Flipped classroom teaching for enhancing critical thinking in postgraduate anaesthesia residents

INTRODUCTION Critical thinking is crucial for anaesthesia residents to interpret complex information and respond effectively in perioperative care and emergencies. Conventional lecture-based teaching is teacher-centred and often leads to passive learning. Active, learner-centred strategies increase engagement and foster deeper understanding. Evidence shows that these approaches enhance critical thinking and long-term knowledge retention in anaesthesia education.[1-3] The flipped classroom model represents a promising pedagogical approach in this regard. Here, residents review pre-class learning resources such as journal articles, recorded lectures, case scenarios, or simulations, which ensures the acquisition of essential foundational knowledge before interactive in-class discussions.[1-3] Several studies have demonstrated the effectiveness of flipped classrooms in enhancing knowledge acquisition and learner engagement across medical specialities, including anaesthesia.[4-6] There is limited research on flipped classrooms in postgraduate anaesthesia training, especially in resource-limited settings. This study implemented a structured model and evaluated its effects on knowledge, retention, critical thinking, and clinical readiness. METHODS A prospective, quasi-experimental one-group pre-test/post-test study was conducted at a teaching institute after ethics approval (IEC/109/02/2024/321, dated 23-04-2024). Twenty-five PGY 1 and two anaesthesia residents participated in a 3-month flipped classroom curriculum covering six core topics, prepared and delivered by four sensitised faculty. Pre-class materials (online video/PowerPoint lectures and literature, 60–90 minutes) were provided for self-study. In-class sessions, held twice weekly (1 hour each), focused on case-based learning, simulations, teamwork, and literature critique, with residents in groups of 4–5 and faculty facilitating. Baseline knowledge tests and self-assessment questionnaires were administered and repeated post-intervention. Faculty assessed clinical reasoning, teamwork, and critical thinking on a 3-point standardised scale (1: below expectations; 2: meets expectations; 3: exceeds expectations). Resident self-assessments and satisfaction used 5-point Likert scales (scores ≥4 = satisfaction). Open-ended responses explored perceptions and suggestions [Annexures 1 and 2]. Sample size was calculated from the study by Martinelli et al., which reported a mean difference of ~6% [standard deviation (SD): 10%] in post-test scores; at 80% power with 10% attrition, 25 residents were enroled.[5] The calculation was performed using G*Power software (version 3.1.9.7, University of Düsseldorf, Germany). Statistical analysis was carried out using SPSS Statistics for Windows (version 26.0, IBM Corp., Armonk, NY, USA). Paired t-tests compared pre- and post-knowledge scores with means, SDs, and CIs. Faculty ratings, student satisfaction, and baseline data were analysed descriptively, while open-ended feedback was thematically analysed. RESULTS This study on 25 PGY 1–2 anaesthesia residents showed significant improvement across all domains. Mean knowledge score increased from 3.20 (SD: 0.80) (95% CI: 2.87, 3.53) to 4.50 (SD: 0.40) (95% CI: 4.33, 4.67); mean clinical reasoning from 3.10 (SD: 0.70) (95% CI: 2.81, 3.39) to 4.40 (SD: 0.50) (95% CI: 4.19, 4.61); mean literature evaluation from 2.90 (SD: 0.90) (95% CI: 2.53, 3.27) to 4.20 (SD: 0.80) (95% CI: 3.87, 4.53); mean evidence application from 3.00 (SD: 0.80) (95% CI: 2.67, 3.33) to 4.30 (SD: 0.70) (95% CI: 4.01, 4.59); mean identifying gaps from 3.40 (SD: 0.70) (95% CI: 3.11, 3.69) to 4.60 (SD: 0.50) (95% CI: 4.39, 4.81); mean communication from 3.50 (SD: 0.80) (95% CI: 3.17, 3.83) to 4.40 (SD: 0.40) (95% CI: 4.23, 4.57); mean time management from 3.20 (SD: 0.90) (95% CI: 2.83, 3.57) to 4.30 (SD: 0.80) (95% CI: 3.97, 4.63); and mean self-directed learning from 3.30 (SD: 0.80) (95% CI: 2.97, 3.63) to 4.50 (SD: 0.50) (95% CI: 4.29, 4.71) [Table 1]. Student satisfaction was high: 92% rated knowledge ≥4, 88% skills ≥4, and 84% overall satisfaction. For improvement, 52% strongly agreed (95% CI: 33.5, 70.0) and 40% agreed (95% CI: 23.4, 59.3) on knowledge, while 40% strongly agreed (95% CI: 23.4, 59.3) and 48% agreed (95% CI: 30.0, 66.5) on skills [Table 1, Figure 1].Figure 1: Agreement with improvement in knowledge and skills among studentsTable 1: Summary of self-assessed cognitive skill improvements and satisfaction levels among students and faculty following the flipped classroom interventionFaculty assessments across eight domains using a 3-point scale indicated residents consistently met or exceeded expectations in every domain. Strong inter-rater agreement was found in 75% of domains, with an overall mean SD of 0.36. Perfect consensus was noted in ‘Analysis of evidence’ [3.00 (SD: 0) (95% CI: 3.00, 3.00)], while ‘Collaboration with peers’ showed greater variability [2.80 (SD: 0.72) (95% CI: 2.50, 3.10)]. Faculty noted improvements in clinical reasoning, evidence appraisal, teamwork, and high engagement satisfaction [Table 1]. Qualitative feedback revealed that residents initially expected interactive sessions to enhance knowledge, reasoning, and teamwork. Post-intervention, they confirmed that these goals were met, with case-based learning and peer discussions noted as most effective for improving clinical reasoning and decision-making. DISCUSSION This study evaluated the flipped classroom model for postgraduate anaesthesia residents, showing significant improvements in pre- and post-intervention knowledge and skill scores (P < 0.001). These results align with earlier reports of enhanced knowledge, skills, and exam performance among anaesthesiology residents exposed to flipped learning.[4-6] Faculty ratings indicated that residents exceeded expectations in critical thinking and application of evidence, with mean ratings above 2.7 out of 3, reflecting strong faculty satisfaction. Prior studies have similarly highlighted gains in learner engagement and cognitive skills in flipped classroom settings.[4,7] The study also highlighted the importance of faculty development for effective implementation. Phillips and Wiesbauer reported that educators may need to invest 127% more time in developing and maintaining flipped classrooms compared with traditional lectures.[2] Although our study did not measure this workload, faculty feedback echoed the challenge. Resident satisfaction was high, with over 84% satisfied, comparable to Martinelli et al.,[5] who found that 82% of anaesthesia residents preferred flipped over traditional lectures. In addition, 92% of residents agreed that the flipped format improved knowledge, and 88% reported skill enhancement, consistent with other studies showing high satisfaction and engagement.[8,9] Both residents and faculty further perceived that the flipped classroom format enhances learning, skill development, and classroom interaction, consistent with the observations of Marchalot et al.,[10] who reported similar benefits in anaesthesia education. Limitations include the small sample size (25 residents), short duration (3 months), and single-centre setting, which limit wider applicability. Future multicentric, longer-term studies are required to confirm generalisability and assess sustained clinical outcomes. CONCLUSION The flipped classroom is an effective strategy for postgraduate anaesthesia residents, improving knowledge retention, critical thinking, clinical readiness, teamwork, and participation. Broader adoption and multicentric studies across diverse settings are needed to strengthen evidence and optimise its role in medical education. Presentation at conferences/CMEs and abstract publication None Study data availability De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared upon request. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI. Declaration of use of permitted tools The scales, scores, figures, and tables are freely available and not copyrighted. Authors contributions LG: Concept, Design, Data Analysis, Manuscript Preparation, Editing, Review, Approval. KNS: Design, Editing, Review, Approval. KC: Literature Search, Data Acquisition, Editing, Review. MA: Design, Editing, Review, Approval. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Supplementary material This article has supplementary material and can be accessed at this link.