Active learning in Medicine: what it is and how to use it

In an experiment in introductory physics courses, students randomly assigned to active classes learned more than those who attended expository classes taught by very well-rated instructors, with the same content and the same material (Deslauriers et al., 2019). Even so, those in the active classes had the feeling of having learned less (Deslauriers et al., 2019). The authors suggest that the greater effort of active learning is read, at first, as a sign that one is learning worse (Deslauriers et al., 2019).

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This text explains what active learning is in Medicine, which strategies are most studied, what meta-analyses show when they are compared with the expository class and how to apply the idea to studying alone and in a group. The study routine has its own text about how to fit games into the routine, and the effect of testing yourself is in the text about reviewing by playing.

Main points

• Active learning is learning by doing something with the content: answering, explaining, discussing, solving and correcting, instead of just listening or rereading.
• The feeling of learning is usually lower in active classes, even when learning is greater (Deslauriers et al., 2019).
• In the flipped classroom, the content is seen beforehand and the class becomes practice; in the health professions, it had a better result than the traditional class in a meta-analysis (Hew and Lo, 2018).
• TBL, peer instruction and peer teaching are group formats with evidence in medical education, with limits worth knowing.
• Alone, the student applies the idea by answering before reading, explaining out loud and checking the error.

Summary

• What active learning is
• What the meta-analyses show
• The most studied strategies
• How to apply it alone
• How to apply it in a group
• Where NEXO comes in
• Frequently asked questions
• Active learning checklist

What active learning is

In this text, active learning is any form of study or class in which the student does something with the content and thinks about what they did: answers a question, explains a mechanism, discusses with a colleague, solves a problem or corrects an error. The opposite is passive reception, such as listening to an entire class without interacting or rereading a summary.

Active does not mean agitated

Active learning does not depend on technology, on an elaborate activity or on a special room. A one-minute pause in a class to answer a question and discuss with a colleague already counts as an active strategy, as the peer instruction example further on shows. What defines the strategy is the type of effort it asks of the learner.

Learning by practicing, testing and correcting

Active strategies usually combine three movements:

1. Practice: use the content to solve something, such as a problem, a case or a question.
2. Test: try to remember or answer before looking at the answer. The basis of this effect is in the text about reviewing by playing.
3. Correct: compare the answer with the answer key and understand the error. The record of errors has its own text about error notebook.

The working definition and the three movements are a synthesis of the Editorial.

Why it seems harder

In the experiment by Deslauriers and colleagues, students were randomly assigned between active classes and expository classes, with identical content and material, and the instructor did not try to convince them of either method (Deslauriers et al., 2019). The authors warn that evaluating teaching by students' perception can unintentionally favor passive methods (Deslauriers et al., 2019). They also note that students may discover the value of the active class on their own over a semester, but that learning at the beginning may suffer (Deslauriers et al., 2019).

The same mismatch between feeling and learning appears in individual study, as the section on the feeling of knowing in the text about routine shows.

What the meta-analyses show

The classic comparison between active learning and lecture-based classes in science, technology, engineering and mathematics courses is summarized in the text about study routine. Here, the focus is on studies that look at who benefits and at the health professions.

Who benefits the most

A meta-analysis in science, technology, engineering and mathematics courses gathered data from test grades in 15 studies, with 9,238 students, and from failure rates in 26 studies, with 44,606 students (Theobald et al., 2020). On average, active learning reduced the grade gap between students from under-represented groups and the others by 33%, and the gap in pass rates by 45% (Theobald et al., 2020).

The important detail is the dose: only the classes with high-intensity active learning, with more class time dedicated to activities, reduced these gaps (Theobald et al., 2020). The authors propose that the reduction only happens when the course combines deliberate practice with inclusive teaching (Theobald et al., 2020).

Flipped classroom in the health professions

A meta-analysis of 28 comparative studies in the health professions found an effect in favor of the flipped classroom compared with the traditional class, with a standardized mean difference of 0.33 (Hew and Lo, 2018). The studies included medical students, residents, physicians, nurses and other professionals, and in all of them there were videos recorded before the in-person meeting (Hew and Lo, 2018). The flipped classroom was more effective when the teacher applied a short test at the start of each meeting (Hew and Lo, 2018).

A more cautious meta-analysis

Another meta-analysis gathered 46 studies, with 9,026 participants, comparing the flipped classroom with the lecture-based class in higher education (Chen et al., 2018). The flipped classroom had a better result in test grades and in final course grades, but not in OSCE grades (Chen et al., 2018).

The advantage did not appear in the randomized trials, and the risk of bias was high in 36 of 37 articles assessed (Chen et al., 2018). The authors ask for caution in the interpretation because of the diversity of methods and the risk of bias (Chen et al., 2018).

Study	What it compared	Main result
Deslauriers, introductory physics	Active class against lecture-based class, with random assignment (Deslauriers et al., 2019)	More learning in the active class, with a lower feeling of learning (Deslauriers et al., 2019)
Theobald, science and exact sciences	Active learning against lecture-based class, by student group (Theobald et al., 2020)	Smaller differences between groups, only with high intensity (Theobald et al., 2020)
Hew and Lo, health professions	Flipped classroom against traditional class (Hew and Lo, 2018)	Effect in favor of the flipped classroom, greater with a test at the start (Hew and Lo, 2018)
Chen, higher education	Flipped classroom against lecture-based class (Chen et al., 2018)	Better in the tests, the same in the OSCE, with no advantage in the randomized trials (Chen et al., 2018)

What can be concluded

As an editorial reading, the set points in the same direction: doing something with the content tends to teach more than just receiving it, with effects that vary according to the format, the intensity and the quality of the studies. For the student, the practical lesson is that the discomfort of answering without consulting is part of the method.

The most studied strategies

Each strategy organizes the effort in a way. The table summarizes what each one asks of the student; the details and the evidence come next.

Strategy	What the student does	Where to apply it
Flipped classroom	Studies the content beforehand and uses the meeting to practice	Courses with prior material
TBL	Prepares alone, takes an individual test and then a team test, and applies the content to problems	Large classes divided into teams
Peer instruction	Answers a question alone, discusses it with the colleague and answers again	Pauses within the class
Peer teaching	Teaches a colleague or learns from a more advanced colleague	Tutoring, student leagues and study groups
Elaboration and self-explanation	Asks "why?" and explains the mechanism in their own words	Individual study
Cases and problems	Uses the content to solve a clinical case	Discussions and individual study

Summary table of the Editorial; the evidence for each strategy is in the following sections and in the linked texts.

Flipped classroom

In the flipped classroom, the expository part leaves the class: the student watches videos or reads beforehand, and the meeting is used for exercises, cases and discussion (Chen et al., 2018). In the health professions, the flipped classroom paid off more when there was a short test at the start of each meeting (Hew and Lo, 2018). As a practical suggestion, arrive at class having already answered some questions about the prior material.

TBL, team-based learning

In TBL, the student prepares alone, takes an individual test, repeats the test in a team and then applies the content to problems. A systematic review found 118 articles on TBL in the health professions, almost half of them with undergraduate medical students (Reimschisel et al., 2017). The authors conclude that there is plenty of literature on the effect of TBL on traditional performance measures, but that student engagement and the pattern of engagement within teams have been little studied (Reimschisel et al., 2017).

A meta-analysis that compared TBL and problem-based learning included 10 studies, with 752 participants (Zhang et al., 2024). TBL had higher grades on theoretical exams, with a standardized mean difference of 0.37, and improved teamwork (Zhang et al., 2024). There was no difference in practical skills grades, interest in studying or understanding (Zhang et al., 2024). The difference between case and problem in teaching is in the text on case-based learning.

Peer instruction

In peer instruction, the class is interrupted by a question: each student answers alone, discusses with classmates and answers again. In a respiratory physiology class with 256 first-year medical students, the 50-minute classes were divided into three or four short presentations, each followed by a multiple-choice question (Rao and DiCarlo, 2000). Students had 1 minute to think and record the answer and 1 minute to discuss with classmates (Rao and DiCarlo, 2000).

The proportion of correct answers increased after the discussion, both in memory questions and in those that required reasoning (Rao and DiCarlo, 2000). The study had no control group, but it shows how an active strategy can fit into a large class, with just a few minutes.

Peer teaching

In peer teaching, one student teaches another, usually a classmate from the same year or a more advanced year. A systematic review selected 19 studies on medical students as teachers, 10 of them with random allocation (Yu et al., 2011). In selected contexts, peer teaching had short-term results comparable to teaching by teachers, and those who taught also benefited (Yu et al., 2011).

The authors note that most participants were volunteers and that the long-term effects are still little known (Yu et al., 2011). As editorial reading, tutoring sessions and well-organized study groups seem a reasonable option, and teaching is also a way of studying.

Elaboration and self-explanation

Asking "why?" and explaining a mechanism in your own words are active strategies that fit into individual study. They were described in the text on the basic cycle, in the section on asking and explaining to yourself, with examples in Physiology and Biochemistry.

How to apply it on your own

Most of the strategies above were studied in the classroom, but the principle holds for individual study: do something with the content, with feedback. The suggestions below are from the Editorial.

Before reading, ask

As a practical suggestion, before opening a chapter, write three questions you think it answers and try to answer them however you can. After reading, go back to the answers and correct them. It is the logic of the test at the start of the meeting, which worked in the flipped classroom (Hew and Lo, 2018), applied to reading.

While reading, explain

At each section, close the material and explain out loud, or in writing, what you have just read, as if it were for a classmate from the previous year. Where the explanation gets stuck, that is the point to reread.

After reading, solve

End the session with questions or a short clinical case on the topic, without consulting the material. Check the answer and note the reason for each mistake. The link between games, books, Anki and questions is in the text on how to fit games into your routine.

A one-hour study session

As a practical suggestion, an active one-hour session can look like this:

1. Questions first: write and try to answer three questions about the topic.
2. Reading in blocks: read a section and explain it without looking; repeat until the end.
3. Questions or case: solve without consulting.
4. Correction: check, note the reason for each mistake and go back to the right passage.
5. Memory summary: write what you remember about the topic, without looking, and compare it with the material.

Common mistakes when studying alone

• Confusing familiarity with mastery: recognizing the text when rereading is not the same as being able to explain it.
• Skipping the correction: answering without checking loses the feedback part.
• Giving up because of the feeling: the greater effort can be read as a sign that you are learning worse, as in the Deslauriers study (Deslauriers et al., 2019).
• Leaving practice for the end: saving all the questions for the eve of the exam removes the feedback along the way.

How to apply it in a group

The group formats studied in medical schools can be adapted for the class, the league or the study group.

A pause with a question

As a practical suggestion, in a study group, stop at each topic for a question: each person answers alone, in writing, discusses with the colleague next to them and answers again. It is the structure of peer instruction (Rao and DiCarlo, 2000), with the time the group has.

A pocket TBL

As a practical suggestion, agree on a topic and a material for the week. At the meeting, take a short individual test, repeat the test in pairs or trios and then use the remaining time to solve a case with the content. The difference between the individual answers and the group answers shows what needs more study.

Teaching to learn

As a practical suggestion, divide the topics and agree that each person teaches one of them to the group in a few minutes, followed by questions from the colleagues. The review by Yu and colleagues shows that those who teach also benefit (Yu et al., 2011). For those who teach, the best preparation is to answer the questions the group is likely to ask.

Cases in a group

Discussing a clinical case in a group brings together several strategies: answering first, explaining the reasoning and correcting with the colleagues. How to study cases alone and in a group is in the text on case-based learning.

Where NEXO comes in

NEXO trains the hypothesis actively: each case arrives in up to six clues, one at a time, and you guess the diagnosis with the data you have up to that point. Each guess shows the proximity in ICD-10, and the explanation of the case, at the end, is the time to correct.

Answering before seeing

The Daily brings one case per day, the same for everyone, and the Archive gathers the previous cases to review an area. Multimedia brings cases with image, audio and other exams. As a practical suggestion, before each guess, write in one line why you chose that hypothesis; at the end, compare it with the explanation of the case.

In the class

Since the Daily case is the same for everyone, it serves as a common question for a study group: each person plays alone and then the group compares the hypotheses for each clue, in the pause-with-question format. The ranking allows you to compare the case of the day with the class, and the streak and achievements track consistency. To turn what was missing into a card, the Anki button is described in the guide on spaced repetition. The game elements and what the evidence says about them are in the text on gamification in medical education.

To research, bring to the class and create

If you research active learning and want to propose studies with NEXO, check out NEXO Researcher. To bring NEXO to the medical school, the league or the residency, there is NEXO Closer. Doctors who review the cases in their specialty take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is active learning in Medicine?

It is learning by doing something with the content: answering, explaining, discussing, solving cases and correcting mistakes, instead of just listening or rereading. It includes class formats, such as the flipped classroom and TBL, and forms of individual study, such as answering before reading.

Does active learning work better than lecturing?

In the flipped classroom in health professions, a meta-analysis found an effect in favor of the flipped classroom (Hew and Lo, 2018). Another meta-analysis found an advantage on exams, but not on the OSCE or in randomized trials, and calls for caution due to the risk of bias (Chen et al., 2018).

Why does active learning seem to deliver less?

In a physics experiment, those who had active learning learned more and, even so, felt they learned less (Deslauriers et al., 2019). The authors suggest that the greater effort is read as a sign of worse learning.

What is a flipped classroom?

It is the format in which the student studies the content beforehand, with videos or readings, and the meeting is used for exercises, cases and discussion (Chen et al., 2018). A short test at the start of the meeting increased the effect in health professions (Hew and Lo, 2018).

What is TBL?

It is team-based learning: individual preparation, individual test, team test and application of the content to problems. Compared with problem-based learning, it had higher scores on theoretical exams in a meta-analysis (Zhang et al., 2024).

What is peer instruction?

It is a pause in the class with a question: each student answers alone, discusses with classmates and answers again. In a first-year Medicine physiology class, the proportion of correct answers increased after the discussion (Rao and DiCarlo, 2000).

Does teaching a colleague help you learn?

The review by Yu and colleagues found academic benefits for the students who taught, in addition to short-term results comparable to those of teaching by teachers for those who learned (Yu et al., 2011).

How do you apply active learning when studying alone?

Write questions before reading and try to answer them, explain each section without looking at the material, finish with questions or a case and correct each mistake. The one-hour session described in this text is a starting point.

How does NEXO help with active learning?

Each NEXO case arrives in clues, one at a time, and you take a guess at the diagnosis before seeing everything; each guess shows the proximity in ICD-10, with the explanation of the case at the end to correct. The Daily case, the same for everyone, also serves as a common question for the study group.

Active learning checklist

1. Did I write questions before starting to read?
2. Did I try to answer before seeing the answer?
3. Did I explain in my own words each part of the content?
4. Did I solve questions or a case without consulting the material?
5. Did I correct each mistake and note down the reason?
6. Did I accept the effort as part of the method, without going back to just rereading?
7. Did I arrive at the flipped class having already done the prior material?
8. Did I discuss with a colleague at least one question on the topic?
9. Did I teach a topic to the group this week?
10. Did I summarize from memory what I studied today?

References

1. Deslauriers L, McCarty LS, Miller K, Callaghan K, Kestin G. Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proc Natl Acad Sci U S A. 2019. https://pubmed.ncbi.nlm.nih.gov/31484770/
2. Theobald EJ, Hill MJ, Tran E, et al. Active learning narrows achievement gaps for underrepresented students in undergraduate science, technology, engineering, and math. Proc Natl Acad Sci U S A. 2020. https://pubmed.ncbi.nlm.nih.gov/32152114/
3. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018. https://pubmed.ncbi.nlm.nih.gov/29544495/
4. Chen KS, Monrouxe L, Lu YH, et al. Academic outcomes of flipped classroom learning: a meta-analysis. Med Educ. 2018. https://pubmed.ncbi.nlm.nih.gov/29943399/
5. Reimschisel T, Herring AL, Huang J, Minor TJ. A systematic review of the published literature on team-based learning in health professions education. Med Teach. 2017. https://pubmed.ncbi.nlm.nih.gov/28664760/
6. Zhang W, Wei J, Guo W, Wang Z, Chen S. Comparing the effects of team-based and problem-based learning strategies in medical education: a systematic review. BMC Med Educ. 2024. https://pubmed.ncbi.nlm.nih.gov/38388937/
7. Rao SP, DiCarlo SE. Study on peer instruction and performance on short in-class questions (original title in English on PubMed). Adv Physiol Educ. 2000. https://pubmed.ncbi.nlm.nih.gov/11209565/
8. Yu TC, Wilson NC, Singh PP, et al. Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract. 2011. https://pubmed.ncbi.nlm.nih.gov/23745087/