INTRODUCTION

Medical education in India is undergoing a paradigm shift, with increasing emphasis on learner-centered and competency-based teaching strategies.[1] Conventionally, teaching has relied heavily on didactic lectures where students passively receive information. While structured and time-efficient, this method often falls short in fostering critical thinking, clinical reasoning, and active engagement– skills that are essential for modern medical practice.[2] The introduction of competency-based medical education (CBME) by the National Medical Commission reflects a growing recognition of the need for innovative methods that align with adult learning principles and promote deeper understanding.[3]

While the concept of the flipped classroom (FC) was first described decades ago by educators such as J. Wesley Baker in the early 2000s, its practical implementation remains relatively underutilized in Indian medical colleges.[4] In the FC approach, students are first exposed to new material outside the classroom through pre-recorded videos, readings, or digital modules.[5] Classroom time is then devoted to higher-order learning tasks such as group discussions, case-based analysis, and problem-solving, with faculty acting as facilitators. This model shifts the focus from passive absorption of content to active participation and knowledge application, encouraging student autonomy, collaboration, and reflection.[6]

Recent studies have shown that FC improves both academic performance and student satisfaction in various subjects across medical education.[5] Various authors have reported a statistically significant increase in post-test and end-of-module scores among students taught through FC, with 82% finding the method more engaging.[7,8] Similarly, Bhavsar et al. (2022) observed higher post-test scores and positive perceptions related to engagement and flexibility.[8] Although some studies did not find significant differences in academic scores, student preferences consistently favored the FC model due to its interactive and learner-friendly structure.[9]

Despite growing global evidence, limited research has explored the implementation of the FC model in Indian medical colleges, particularly among Phase III part I MBBS students and within the Forensic Medicine curriculum.[8,9] To address this gap, the present study aims to evaluate the effectiveness and student perceptions of FC versus traditional didactic classroom (TDC) teaching methods in a cohort of Phase III part I MBBS students. Using a crossover interventional design, this study contributes to the emerging body of literature on active learning strategies in the Indian medical education context.

MATERIAL AND METHODS Study design

This study was designed as a prospective, interventional, crossover study aimed at evaluating the effectiveness and student perception of the FC method compared to the TDC approach. The crossover design was employed to ensure that all participants experienced both teaching methods, thereby minimizing individual bias and enhancing the reliability of comparisons. The study was conducted within the Department of Forensic Medicine at a tertiary care teaching institution.

Participants and grouping

A total of 100 undergraduate students enrolled in the Phase III part I MBBS course were included in the study. Participants were randomly divided into two equal groups of 50 students each, designated as Batch A and Batch B. Randomization was achieved through a simple random technique using computer-generated numbers. Inclusion criteria encompassed all consenting students regularly attending the Forensic Medicine classes. Students who were absent on the day of any of the sessions or assessments were excluded from the final data analysis.

Selection of teaching topics

Two topics from the Forensic Medicine curriculum were selected for instructional intervention, chosen for their suitability for both FC and TDC modalities. For this study, the topics selected were:

Forensic identification: Methods and determination of age, sex, and race for medicolegal purposes - a conceptually rich area suited for analytical thinking and classroom discussion.

Medicolegal aspects of wounds: Types, significance, and differentiation between antemortem and postmortem injuries - a practical, policy-driven topic ideal for interactive engagement and role-based learning.

Intervention protocol

The study was conducted in two phases (Module A and Module B), each consisting of instruction on one selected topic. In Module A, Batch A received instruction on Topic 1 using the FC approach, while Batch B received the same content through the TDC method. In Module B, the groups crossed over; Batch B was taught Topic 2 using the FC approach, and Batch A received the TDC method. This crossover ensured that every participant experienced both instructional modalities on two distinct topics.

FC instructional approach

For sessions utilizing the FC method, students were provided with curated pre-class learning resources 1 week in advance. These materials included:

Pre-recorded video lectures

Topic-specific handouts

Relevant excerpts from textbooks

Supplementary digital resources and links.

Students were instructed to review these materials independently before attending the class session. During the classroom sessions, time was devoted to active learning strategies such as:

This model allowed classroom time to focus on applying and integrating knowledge rather than passive content delivery.

TDC method

Students taught using the TDC method attended conventional lecture sessions led by faculty. These sessions were conducted in a typical classroom setting using PowerPoint slides, chalkboard illustrations, and verbal exposition. Students were passive recipients of information, with limited opportunity for interactive engagement or collaborative learning. No pre-class material or active assignments were provided under this format.

Assessment strategy

Student performance was evaluated using three types of assessments:

A pre-test, consisting of multiple-choice questions (MCQs), was administered immediately before each instructional session to assess baseline knowledge.

A post-test, also comprising MCQs, was conducted at the end of each teaching session to evaluate immediate learning gains.

An end-of-module test was conducted after both modules to assess cumulative understanding and retention of the taught content.

All tests were validated by subject experts and reviewed for content reliability and difficulty balance.

Feedback and perception evaluation

Following the completion of both modules, students were asked to fill out a structured feedback questionnaire designed to capture their perceptions of the FC method. The questionnaire consisted of both closed-ended items rated on a 5-point Likert scale and open-ended questions for qualitative feedback. Areas assessed included student engagement, content clarity, perceived learning outcomes, motivation, and overall satisfaction with the teaching method.

Statistical analysis

Quantitative data obtained from test scores were entered into Microsoft Excel and analyzed using the statistical package for the social sciences software version 25.0 (IBM Corp., Armonk, NY). Pre-test and post-test scores within each group were compared using paired t-tests to assess the improvement in knowledge after each intervention. Between-group comparisons of mean scores were conducted using independent sample t-tests. A P <0.05 was considered statistically significant. Descriptive statistics, including means and standard deviations, were calculated for student perception scores. Open-ended responses were analyzed thematically to identify recurring feedback patterns and insights.

RESULTS Participant overview

Out of the 100 students enrolled in the study, all completed both modules and were included in the final analysis. Each group–Batch A and Batch B–consisted of 50 students. No dropouts or exclusions were recorded during the study [Table 1].

Table 1: Baseline characteristics of study participants (n=100).

Characteristic Batch A (n=50) Batch B (n=50) Total (n=100) Age (years) 20.3±0.5 20.5±0.7 20.4±0.6 Gender (%)   Male 26 (52) 26 (52) 52 (52)   Female 24 (48) 24 (48) 48 (48) English medium schooling 45 (90) 43 (86) 88 (88) Urban background 33 (66) 33 (66) 66 (66) Average attendance>75% 47 (94) 46 (92) 93 (93) Prior exposure to FC 5 (10) 7 (14) 12 (12) Knowledge assessment scores Module A

In Module A, Batch A was taught using the FC method and Batch B using the Traditional Didactic method for the topic Forensic identification: methods and determination of age, sex, and race for medicolegal purposes. The comparison of pre- and post-test scores is shown in Table 2.

Table 2: Comparison of pre-test and post-test scores between FC and TDC groups.

Group Pre-test Mean±SD Post-test Mean±SD Mean difference P-value Batch A (FC) 6.42±1.32 13.88±1.76 7.46 <0.001 Batch B (TDC) 6.36±1.48 10.52±2.03 4.16 <0.001

Independent t-test comparing post-test scores between Batch A (FC) and Batch B (TDC) showed a statistically significant difference (t = 8.42, P < 0.001), indicating superior performance in the FC group.

Module B

In Module B, the topics were switched-–Batch B received the FC method, and Batch A received TDC for the topic Medicolegal aspects of wounds: Types, significance, and differentiation between antemortem and postmortem injuries. Results are shown in Table 3.

Table 3: Comparison of pre-test and post-test scores between FC and TDC groups in the crossover session.

Group Pre-test Mean±SD Post-test Mean±SD Mean difference P-value Batch B (FC) 7.02±1.25 14.21±1.58 7.19 <0.001 Batch A (TDC) 6.88±1.40 11.10±1.97 4.22 <0.001

Again, the FC group (Batch B) demonstrated a significantly higher gain in post-test scores compared to the TDC group (t = 7.64, P < 0.001).

End-of-module test scores

An objective structured test was administered to all students after completion of both modules to assess cumulative learning. The results are summarized in Table 4.

Table 4: Comparison of end-of-module test scores between flipped classroom and TDC methods.

Teaching method Mean score±SD P-value (vs. TDC) Flipped classroom 27.9±3.1 <0.001 Traditional didactic 23.1±3.5

The FC method resulted in significantly higher overall scores in the end-of-module assessment (t = 7.12, P < 0.001).

Student perception and feedback

Out of 100 students, 98 submitted completed perception questionnaires. The results are summarized in Table 5.

Table 5: Student perceptions regarding the FC method.

Statement % Agree/Strongly agree The FC method was more engaging than traditional lectures 87 I was able to understand the topic better through FC 82 Pre-class materials helped me learn at my own pace 85 I would prefer more topics to be taught using the FC approach 78

Analysis of qualitative feedback revealed several recurring themes highlighting the perceived strengths and challenges of the FC approach. A majority of students appreciated the interactive and collaborative nature of the in-class sessions. They expressed that the opportunity to participate in group discussions, solve case-based problems, and engage in peer learning made the sessions more dynamic and intellectually stimulating compared to traditional lectures. This collaborative environment fostered deeper conceptual understanding and encouraged active participation, especially among students who were typically less vocal in conventional classroom settings.

Another frequently mentioned advantage was the flexibility offered by pre-class preparation. Students valued the ability to learn at their own pace by accessing pre-recorded videos, handouts, and supplementary materials before the classroom sessions. This allowed them to revisit complex concepts multiple times, pause and reflect during their study, and arrive in class with a baseline understanding, thereby making in-class activities more meaningful. Many students felt that this autonomy improved their ability to manage their own learning and promoted self-directed study habits.

However, a recurring concern among some participants was the increased effort and time required to prepare adequately for the flipped sessions. A few students noted that the initial adjustment to the FC model demanded greater discipline and time management, especially when balancing other academic responsibilities. While some perceived this as an added burden, they nonetheless acknowledged that the approach led to better engagement, improved retention, and a stronger grasp of the subject matter. Students also emphasized that the real-world application of knowledge through cases and examples made the content more relevant and easier to recall during assessments.

Overall, while a minority expressed a preference for the predictability of traditional lectures, the overwhelming consensus supported the integration of the FC approach for select modules, particularly those that benefit from conceptual clarity, analytical thinking, and active discussion.

DISCUSSION

The findings of this study demonstrate that the FC approach significantly enhances student learning outcomes compared to the TDC method in the context of Forensic Medicine for Phase III Part I MBBS students. Students taught through the FC model consistently scored higher in post-tests and endof-module assessments. This outcome echoes the conclusions of several prior studies, adding weight to the growing evidence-based advocating for active learning models in Indian medical education.

The results are notably consistent with Angadi et al.[7] (2019), who conducted a similar interventional study among 2nd-year MBBS students and reported a statistically significant increase in both immediate and summative assessment scores following FC sessions. In that study, 82% of students strongly agreed that the FC model was more engaging and supported deeper understanding. Similarly, Bhavsar et al.[8] (2022) applied a crossover design among 1st-year students and found that students taught using FC scored significantly higher (14.77 ± 2.16 and 11.26 ± 1.76) compared to their counterparts in the TDC sessions (12.16 ± 2.05 and 10.03 ± 2.57). Student feedback in that study further highlighted improvements in critical thinking, participation, and retention–—trends that were mirrored in the current research.[8,10]

Our findings also align with the results reported by Nanjundaiah and Anuradha,[10] who found a significantly higher mean academic score post-FC session among Phase II students. Their mixed-methods study revealed that students appreciated the exploratory nature of FC, improved comprehension, and increased classroom interaction–similar sentiments reflected in the qualitative feedback of our participants. Interestingly, Malhotra and Bhagat[9] (2023) did not observe a statistically significant difference in cognitive test scores between the FC and TDC groups, yet reported a strong preference for FC among students. In that study, 80% of participants favored FC due to the interactive and collaborative environment, self-paced pre-class learning, and improved engagement during classroom discussions. This suggests that while the quantitative outcomes may occasionally vary, the qualitative benefits of the FC model– such as enhanced student motivation, communication, and classroom dynamics–remain consistent.

Furthermore, the findings of Vaddatti et al.[11] (2022) underscore the differentiated impact of FC based on academic performance levels. Their analysis showed that FC was more beneficial for both high and low achievers, with a statistically significant difference in scores (P = 0.0001), indicating that FC is an inclusive teaching strategy adaptable to diverse learner profiles. Our study, while not stratified by performance level, supports the broader efficacy of FC across the cohort.

Despite the advantages of the FC model, it has notable limitations. It requires substantial faculty effort to prepare quality pre-class materials and demands greater student discipline. In large groups, facilitating active participation is challenging, and the format may not align well with content-heavy summative assessments. These factors often limit its sustained adoption despite proven benefits in select modules.

The strengths of the present study include its randomized crossover design, which allowed each student to experience both teaching methods and thereby control for individual learning style variability. In addition, the integration of both quantitative metrics and qualitative feedback enabled a holistic evaluation of the teaching methods. However, limitations must also be acknowledged. The study was conducted in a single institutional setting, which may limit generalizability. The short duration of the modules restricted the assessment to immediate learning outcomes, without insight into long-term knowledge retention or clinical application. Moreover, although multiple-choice tests offer objectivity, they may not fully capture nuanced improvements in analytical thinking or soft skills nurtured by FC strategies. There exists a potential for acquiescence bias in the perception survey, as positively framed statements may have encouraged agreement, especially in hierarchical settings. Future surveys should use balanced phrasing, including neutral or negative items, to minimize this bias.

Despite these limitations, this study adds to the growing evidence that FC can be an effective, student-centered pedagogy in medical education, particularly within the CBME framework. The model’s emphasis on preparation, collaboration, and application aligns well with the competencies required of the modern Indian Medical Graduate and supports a transition away from purely content-heavy, lecture-driven instruction.

CONCLUSION

The present study provides compelling evidence that the FC model is a more effective teaching strategy than the TDC approach in enhancing academic performance and student engagement among Phase III Part I MBBS students. Students exposed to the FC method demonstrated significantly higher post-test and end-of-module scores, along with overwhelmingly positive perceptions of the learning experience. The active, student-centered nature of FC promotes deeper understanding, encourages self-directed learning, and aligns well with the goals of CBME.

Given the positive outcomes and student receptivity, the integration of FC into undergraduate medical curricula– particularly for topics that require conceptual clarity and analytical thinking–should be strongly considered. However, given the resource-intensive nature of FC and the structural alignment challenges it poses, we advocate for a blended learning model–where FC is integrated selectively for topics requiring deeper engagement. Future research should explore long-term knowledge retention, clinical application, and faculty perspectives to further refine the implementation of FC across disciplines.