ARTICLE IN PRESS

Special Report

A Review of Innovative
Teaching Methods
Rebecca T. Sivarajah, MD, Nicole E. Curci, MD, Elizabeth M. Johnson, MD, Diana L. Lam, MD,
James T. Lee, MD, Michael L. Richardson, MD

Teaching is one of the important roles of an academic radiologist. Therefore, it is important that radiologists are taught how to effec-
tively educate and, in turn, to act as role models of these skills to trainees. This is reinforced by the Liaison Committee on Medical
Education which has the requirement that all residents who interact with and teach medical students must undergo training in effective
methods of teaching. Radiologists are likely familiar with the traditional didactic lecture-type teaching format. However, there are many
newer innovative teaching methods that could be added to the radiologist’s teaching repertoire, which could be used to enhance the
traditional lecture format. The Association of University Radiologists Radiology Research Alliance Task Force on Noninterpretive Skills
therefore presents a review of several innovative teaching methods, which include the use of audience response technology, long-
distance teaching, the flipped classroom, and active learning.

INTRODUCTION Didactic lectures are a well-known form of teaching.

However, there are many newer innovative teaching skills,

A
s radiologists, we are adept at interpreting medical
pedagogical techniques, and forms of educational technolo-
images. However, how did we learn this informa-
gy that could also be added to a radiologist’s teaching repertoire.
tion? Some of this knowledge came from the countless
These could be used to enhance lectures radiologists are
hours spent studying radiology books and journals. However,
already giving or be used in addition to the traditional lecture
much of our understanding also came from being taught by
format.
others. Thinking back to the great teachers you had—what
The Association of University Radiologists Radiology Re-
made them stand out? What made them effective teachers?
search Alliance Task Force on Noninterpretive Skills therefore
What interesting techniques did they use to teach?
presents a review of innovative teaching methods. Our goal
This review is relevant because as a radiologist you will find
is to present a practical compendium of useful tools and tech-
you are often called on to teach. Radiologists, especially in
niques that allow education to become more engaging, more
the academic setting, are tasked with the education of fellows,
interactive, and more effective:
residents, and medical students. However, all radiologists, in-
cluding those in private practice, find themselves in some Part I: Audience response technology
teaching role—teaching fellow radiologists, other nonradiology Part II: Long-distance teaching
physicians, technologists, and patients. Therefore, it is im- Part III: Flipped classroom
portant that radiologists are taught how to effectively educate Part IV: Active learning
and, in turn, to act as role models of these skills to trainees.
This is reinforced by the Liaison Committee on Medical
Education, whose Standard 9.1 requires all residents who in- PART I
teract with and teach medical students to undergo training
Audience Response Systems
in effective methods of teaching and evaluation (1).
An audience response system (ARS) is used by presenters to
solicit information from their audience. Many educational ben-
Acad Radiol 2018; ■:■■–■■ efits have been ascribed to ARS, such as anonymity and
From the Department of Radiology, Penn State Health Milton S. Hershey increases in interactivity, participation, engagement, and mea-
Medical Center, Hershey, Pennsylvania (R.T.S.); Department of Radiology,
University of Michigan, Ann Arbor, Michigan (N.E.C.); Department of Radiology,
surable learning performance (2).
University of South Florida, Tampa, Florida (E.M.J.); Department of Radiology,
University of Washington, 4245 Roosevelt Way NE, Seattle, WA 98105 (D.L.L.,
M.L.R.); Department of Radiology, University of Kentucky, Lexington, Kentucky
(J.T.L.). Received January 28, 2018; revised February 28, 2018; accepted March
Background or History
24, 2018. The authors are members of the Association of University Radiolo-
gists Radiology Research Alliance Task Force on Noninterpretive Skills. This The first ARSs were developed in the 1950s by the United
special review is a white paper created by that task force. This research States Air Force and were used to quiz personnel with mul-
did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors. Address correspondence to: M.L.R. tiple choice questions (MCQs), which were embedded into
e-mail: mrich@uw.edu training films (3). In the 1960s, ARSs were built and in-
https://doi.org/10.1016/j.acra.2018.03.025 stalled in lecture halls at Stanford University (1966) and Cornell

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SIVARAJAH ET AL
University (1968) (4,5). These early custom systems were hard-
wired into a classroom and were somewhat costly ($17,000–
$150,000) (6).
By the 2000s, ARS technology had evolved into more af-
fordable systems ($1000–$2000) consisting of portable response
devices (“clickers”) paired with a USB receiver attached to
a computer system (7). Since 2007, smartphones and other
portable computing devices have become increasingly common
among students and instructors, making it possible to use these
as web-based ARS input and receiving devices (8).
Any attempt to publish a comprehensive feature compar-
ison chart of the rapidly growing list of available ARS tools
quickly becomes outdated. However, Awan et al. (9) re-
cently published just such a chart comparing the three most
commonly used ARSs: RSNA Diagnosis Live (Radiological
Society of North America [RSNA], Oak Brook, IL), Poll Ev-
erywhere (Poll Everywhere, San Francisco, CA), and NearPod
(Nearpod, Aventura, FL).
Each different ARSs will usually have its own set of fea-
tures and its own unique interface. Each system will pose its
own learning curve for both presenters and audiences. Some
systems require user accounts, which allow student re-
sponses to be stored and individual performance to be tracked.
Other systems give the presenter the ability to divide the au-
dience into teams and lead them in various teaching games.
Some systems may require the presenter to download an ap-
plication or plug-in to provide integration with Microsoft
PowerPoint (Microsoft, Redmond, WA). Other systems require
special response devices (clickers) and USB receivers. However,
most modern ARSs allow an audience to submit their re-
sponses via the web, either using a specific smartphone
application or web browser. Web-based systems have the ad-
vantage of being able to separately poll an audience regardless
of the presentation software used.
Pedagogy, Not Technology
The feature sets of current ARSs are growing constantly.
However, it can be easy to get caught up in an arms race of
features and technological gimmicks. In contrast to the vast
improvements in ARS technology, ARS techniques have re-
mained relatively static over the past 50 years—the technology
has evolved, but the way it is used has not.
As a pedagogical tool, a depressingly large fraction of ARS
presentations in radiology still consist of peppering the au-
dience with true or false question and MCQs. These same
types of questions have been used since 1926, when the mul-
tiple choice SAT was introduced as a faster way of testing
college applicants (10,11). We may be using computers to do
the work, but we continue to poll our audiences as if it were
still 1926.
There is, therefore, a growing sentiment that it is not the
technology but the pedagogy that matters the most (8,12).
It is about time that we upgraded our ARS teaching tech-
niques to match our ARS technology. Rather than continuing
to force instructors and students to lie in the Procrustean bed
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Academic Radiology, Vol ■, No ■■, ■■ 2018
of MCQ and true or false questions, there are a number of
promising and more modern pedagogical approaches that have
been developed.
21st Century Pedagogical Techniques
1. Bidirectional ARS
ARSs have traditionally operated in only one direction, that
is, the presenter polls the audience. Modern ARSs allow bi-
directional interrogation, so that the audience can anonymously
ask the presenter for additional information or clarification.
In our experience, this two-way flow of questions has been
quite popular. It should be no surprise that an audience that
is shy about answering questions in front of their peers will
also be shy about asking a potentially “dumb” question in front
of their peers.
2. Asking questions on the fly
It can take a considerable amount of time to create MCQs
in advance of a lecture, especially if one also has to enter them
into an ARS. In contrast, if one sticks to questions, such as
“What is the diagnosis?” or “What is the finding?” or “What
is the differential?,” there is no need for this sort of tedious
prelecture preparation. It is amazingly liberating to go into a
case conference knowing that one’s ARS will allow one to
pose naturally occurring questions on the fly and react im-
mediately to questions from one’s residents. For those of us
who love teaching by the Socratic method (13), on-the-fly
questions in a free-text format are the heart and soul of the
process.
3. Peer instruction
Peer instruction (PI) is a technique developed by Eric Mazur
for teaching physics students (14) and exploits student inter-
actions to enhance understanding of difficult concepts. This
can be especially helpful when the ARS poll shows substan-
tial disagreement among students. In this situation, students
are invited to briefly discuss the question with their neigh-
bors and are then repolled before the correct answer is revealed.
Several studies of physics and biology students have shown
that this sort of peer discussion enhances understanding, even
when none of the students in a discussion group originally
knows the correct answer (12,15–17).
PI has also shown benefits when dealing with classes in which
the students have a widely different level of background knowl-
edge about a topic. In general, students with more background
knowledge benefit more during PI than students with less back-
ground knowledge. However, students with less background
knowledge gain as much during PI as students with more back-
ground knowledge gain during traditional instruction (16).
4. Radiology-specific ARS techniques
Traditional case conference
A large part of radiology practice involves going from
the findings to the most likely diagnosis. Traditional case
Academic Radiology, Vol ■, No ■■, ■■ 2018
conferences are used to train this skill. Rather than focusing
on one resident at a time, one can poll multiple residents si-
multaneously. With a web-based ARS, one can poll students
at more than one site.
“Inverted” case presentation
Another large part of radiology practice involves going from
a known diagnosis to generating a list of expected findings.
This skill can be strengthened by “inverting” the case con-
ference. Instead of showing an unknown case and asking for
a diagnosis, one can present a diagnosis and then ask one’s
residents to list the pertinent radiographic findings as free text
via the ARS.
Progressive refinement case presentation
When residents do not know an answer, one can itera-
tively add bits of information that progressively steer them
closer and closer to the answer while repolling them with
the ARS. As one adds progressively more and more facts, it
is fascinating to watch the list of diagnoses quickly converge
to the right answer. For example, a first response from one’s
residents might mention “calcifications” within a bone lesion.
A follow-up question about matrix types might then elicit
“chondroid matrix.” Further hints could lead to a differen-
tial of chondroid bone lesions, a search for other findings,
and an eventual diagnosis of multiple hereditary exostosis
syndrome with degeneration into a chondrosarcoma.
Optimal imaging workup
In the course of a case conference, one can poll one’s stu-
dents as to the optimal imaging protocols for computed
tomography or magnetic resonance imaging. One can also poll
the audience as to the optimal imaging workup for a partic-
ular disease. It is easy to parlay questions such as this into an
interactive teaching session built around the American College
of Radiology Appropriateness Criteria (18).
Differential diagnosis
Real-life cases often lack a single correct answer. It is the
radiologist’s job to therefore pose an appropriate differential
diagnosis in one’s report. A properly designed ARS can
allow students to enter multiple items for the differential
and present all of these responses in alphabetical order. It is
fascinating to see how often the aggregate differential diag-
nosis of a group of residents approaches that of an expert
radiologist.
5. Real-time evaluation of teaching sessions by students
Many radiology faculty currently find themselves on some
variant of a clinician-educator pathway for promotion. A
major tool for clinician-educator promotion is the assembly
of a portfolio documenting one’s teaching activities (19).
Student evaluations of one’s teaching should be a key
element of such a portfolio, although few faculty consis-
tently collect student evaluations. Appropriate use of an
ARS can make documenting these evaluations very easy
(8). One can end each of one’s teaching presentations with
a few ARS questions that ask the students to evaluate the
presentation. Many commercial ARSs will save these evalu-
ations in a session log for each presentation.
INNOVATIVE TEACHING METHODS
Addressing different learning styles
Also, radiologists and radiology residents exhibit a variety
of learning styles. Different styles of learning require differ-
ent styles of teaching, such as the three leading theories of
human learning: behaviorism, cognitivism, and constructiv-
ism (20). If we adapt our teaching to match these different
styles of learning, it follows that we should also use ARS dif-
ferently with each of these styles (8).
Future technology
For the most part, ARS technology has transitioned to web-
or cloud-based technology. Vendors no longer depend on au-
dience to have “clickers” or the presenter to have a dedicated
receiver. Future ARS may involve monitoring the audi-
ence’s nonverbal response to a presentation. These future
systems may take advantage of wearable technology moni-
toring heart rate or blood pressure. Cameras on personal
computing devices may also be used to follow pupillary di-
latation and eye gaze direction. Additionally, the definition
of “audience” will continue to evolve. Social media and live
streaming technology continue to challenge our traditional
understanding of audience response.
Today’s technology allows an affordable voting system—
an electronic, group version of the Socratic method—that
facilitates interactive teaching and enhances lecturing in med-
icine. In our experience, this modality improves the quality
of clinical learning and deserves further evaluation (13). ARS
provides an excellent tool for improving interactive learning
in radiology residents. However, it is not the technology but
the pedagogy that matters the most (12). It is long past time
to upgrade our ARS teaching techniques to match our ARS
technology. It is time to move on to more innovative ARS
techniques that are well adapted to radiology and its differ-
ent styles of learning.
PART II
Long-distance Teaching
Long-distance teaching can be accomplished by means of many
conventional Internet tools, such as email, text messaging, and
web forums. There are also a variety of online courseware
platforms such as WizIQ (WizIQ, Gurgaon, India), Black-
board (Blackboard, Washington, DC), and Moodle (Moodle
HQ, Perth, Australia). However, for purposes of this review,
we will focus on remote conferencing systems, which allow
real-time streaming of online meetings with audio, video, and
screen sharing.
Daily or weekly didactic conferences are a major compo-
nent of most radiology residency programs in the United States.
For programs with residents rotating at multiple sites, or for
affiliated programs that combine their didactic curriculum, trav-
eling constraints and clinical responsibilities can complicate
conference scheduling and physical attendance. Remote meeting
technology has become increasingly popular, allowing speak-
ers and audiences at multiple geographic locations to participate
in conference. Teleconferencing or videoconferencing from
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SIVARAJAH ET AL
multiple sites not only increases residents’ exposure to expert
faculty teaching but also saves residents’ time and expense from
commuting between sites for conference (21). Shah et al. re-
ported many positive outcomes following implementation of
a remote conferencing program (22). Time savings achieved
by the residents resulted in increased efficiency and reduced
workload for faculty members, as eliminating commute time
saved the remote participants up to 60 minutes. Residents who
are post-call or unable to leave clinical areas can participate,
as well as those attending professional meetings out of town.
There are some disadvantages of remote conferencing. For
example, many programs experience decreased participation
of remote residents in the conference, which limits interac-
tive discussion. Previous studies investigating the use of remote
conferencing described a sense of exclusion felt by remote par-
ticipants (23). In addition, technological issues such as poor
audio transmission or loss of image quality can be problem-
atic (21).
The number of web-based video conferencing services (VCS)
available at a given time waxes and wanes as start-ups rise and
fall and as new companies are taken over and absorbed by
the older ones. Any comprehensive listing of such services
will therefore be somewhat obsolete by the time it reaches
print. A 2017 review by PC Magazine posted a detailed feature-
comparison table of 10 different VCSs popular at the time
of publication (24).
Web-based tools work on all major platforms (Mac OS X,
Windows, Linux, iOS, and Android). Although many of these
tools have developed stand-alone apps, they can be used with
no software other than a web browser. These browser-
based services include ClickMeeting (Gdańsk, Poland), Zoho
Meeting (Pleasanton, CA), GoToMeeting (LogMeIn, Boston,
MA), Adobe Connect (Adobe, San Jose, CA), Skype
(Microsoft, Redmond, WA), WebEx (Cisco, San Jose, CA),
and others (24). Provided features differ among tools; some
allowing users to speak to each other through their comput-
ers’ microphones, whereas others teleconference through a
telephone bridge. Prices vary depending on the number of
desired participants. For example, GoToMeeting prices start
at $29/month for up to 50 people or $199/month for up to
500 people. It runs on most computer and smartphone plat-
forms. Collaboration tools include screen sharing with mouse
and keyboard controls, multiple presenters, text chat, mobile
access, and video conferencing. Additional features such as
polling and survey capability, postmeeting metrics, and re-
cording options are available (23,25,26).
Hardware Considerations
Regardless of the computer platform used, the sound quality
can be greatly improved by the addition of a high-quality mi-
crophone. For single user sites, a headphone with built-in
microphone is often ideal. For multiple users in a physical con-
ference room, an omnidirectional microphone makes it easier
for all voices to be heard. A powered speaker with a built-
in amplifier can make it much easier for all listeners in the
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Academic Radiology, Vol ■, No ■■, ■■ 2018
room to hear those speaking online. To enable adequate screen
sharing in a physical conference room setting, a large TV screen
or a computer projector is key.
With a large system of interlinked microphones and powered
speakers, a bit of audio feedback is inevitable. This can usually
be alleviated by careful placement of one’s microphones with
respect to one’s speakers, as well as adjustment of the volume
controls. One can also greatly minimize audio feedback by
having each member of the conference voluntarily mute them-
selves when they are not speaking. Another annoying source
of audio feedback occurs when two people in the same room
connect to a conference on two different devices. A final source
of audio feedback comes from a feature offered by many
conferencing systems: allowing audience members to connect
by telephone. Some conferencing systems allow little or no
control or muting of the audio of those connecting via tele-
phone. In a very few cases, this has led to cancelled conferences
due to badly behaving telephone audio. For this reason, we
no longer enable telephone call-ins to our conferences, and
our audio feedback issues have been greatly reduced.
The Pedagogy of Online Conferencing
Most of the web conferencing services offer the same basic
functionality. Given that, it is not so much the technology
but once again the pedagogy that matters the most (8,12). We
will therefore now focus on techniques for optimizing edu-
cation with an online conferencing system. In a decade of
experience with online conferencing, the authors have amassed
a long list of technical and social tips for running a success-
ful online conference (25).
Increasing Interactivity
While one can use video conferencing systems to give tra-
ditional didactic lectures, we prefer to spend our valuable contact
time with our students with presentations that are much more
interactive. Therefore, most of our online conferences are given
in the unknown case conference format, using some type of
ARS. Many VCSs include an online chat function that allows
viewers to send messages to other viewers or to the entire
group. These features were found to be extremely useful in
a weekly, multi-institutional case conference (25). In this con-
ference, attendees take turns presenting interesting cases from
their own practices. The usual presentation format involves
the presentation of an unknown case, with findings and dif-
ferential diagnosis elicited from the other attendees. The answer,
if known, is then presented, followed by a short slide-based
discussion of the relevant diagnostic and treatment aspects of
the case, plus a few salient references. The VCS control panel
allows the moderator to switch among presenters and to control
other aspects of the conference.
The main disadvantage of a built-in VCS chat function is
that it does not anonymize the attendees. For many of our
resident case conference, we therefore use ARSenic, a simple
online ARS that anonymizes the users and their responses (8).
With ARSenic and other online ARSs that allow free-text
Academic Radiology, Vol ■, No ■■, ■■ 2018
responses, one can use the ARS in a bidirectional fashion,
allowing users not only to give anonymous answers but also
to ask anonymous questions to the presenter. This
bidirectionality has been very popular with our residents.
If there are multiple users who wish to speak at the same
time, audio collisions are inevitable. These collisions can be
minimized with the appropriate use of some of the features
built into the user interface of many VCSs. In one of our online
case conferences, those wishing to present cases state their in-
tention in the chat window. The moderator then transfers the
screen sharing to each of these presenters when it is their turn.
This flow of control can also be enhanced using the tiny video
windows shown for each user in the user interface of many
VCSs. When one wishes to make a statement or ask a ques-
tion, one can signal this by raising one’s hand.
Social Aspects of Online Conferencing
There is great potential for strong social aspects to online
conferencing. This initially took us somewhat by surprise. In
retrospect, this is not so surprising. One of the major reasons
for attending any medical meeting is to spend time with one’s
friends and colleagues. One of us has hosted an online mus-
culoskeletal (MSK) case conference for over 9 years. We quickly
found that meeting once a week was a lot more fun than
meeting three or four times a year. This simple enjoyment
is probably one of the major reasons for the growth and en-
during success of that conference.
We also greatly value seeing the wide range of pathology
from other institutions and the ability to confer with col-
leagues on difficult cases (Fig 1). Our conference has also
spawned several collaborative educational projects, such as an
online journal club, a published book of conference cases, peer-
reviewed case reports, and an online MSK hardware atlas.
Our Friday conference has turned out to be a great “one
size fits all” conference for medical students, residents, fellows,
Figure 1. Sites that have joined one of our weekly online conferences as of January 2018.
INNOVATIVE TEACHING METHODS
and attending radiologists. This type of conference is an
especially good training tool for our residents and fellows. Many
of our cases are presented by fellows, who will end their year
of training with a collection of dozens of cases fully worked
up in slide form.
This project has turned out to be an enjoyable conference
with regulars who attend zealously. As an index of its pop-
ularity, we held the conference last year on the days right after
Thanksgiving and Christmas. As academicians, we are bemused
that after spending years struggling to get trainees to come
to conferences, we have finally stumbled into a conference
format that people want to attend, even on their days off.
We suspect that this conference has also some value as a
recruiting tool, not only for academic positions but also with
the private practitioners who regularly attend our confer-
ence. We often schedule visiting applicants for fellowship and
faculty members on Fridays so that they can attend our con-
ference. We hope that potential applicants viewing our
conference will come away with a favorable idea of what it
would be like to work at our institutions.
We value the chance to pick the brains of our colleagues
at other institutions. We often show cases for which we have
no answers and ask for their assistance. We always hope that
someone else will be able to tell us the right answer or suggest
ideas for further workup. However, even when no one knows
the answer, it is very comforting to know that one is among
such good company in ignorance.
Our conference allows us to enrich our experience with
disorders not seen locally. For example, one of our sites has
a large experience with MSK tumors but little exposure to
trauma. Other sites see huge trauma volumes but have few
tumors. Our current mixture of sites makes for a rich mix
of most areas of MSK practice.
Occasionally, cases coming up in our conference are har-
bingers of new disorders or treatment modalities. For example,
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SIVARAJAH ET AL
a case of aseptic lymphocyte-dominated vasculitis-associated
lesion presented at our conference was the first time many
of us had heard of this phenomenon. The condition, an intense
lymphocytic response to a certain type of metal-on-metal hip
prosthesis, is now the reason for a large, nationwide recall of
this particular implant (27).
Several private practitioners regularly attend our confer-
ence. In some cases, they are the sole person with MSK training
in their group and are delighted to spend an hour per week
with friends who actually care about and enjoy discussing
Mazabraud syndrome (28,29). They also value the academic
input from 10 to 20 other MSK specialists reading the liter-
ature and reporting on new and interesting concepts. They
also find it helpful to see how orthopedics is practiced in dif-
ferent parts of the country.
Unexpected Spin-offs From Video Conferencing
Although our conference was originally envisioned as a case
conference, several related educational activities have subse-
quently evolved over time.
Early on in the course of our conference, we decided that
it would be helpful to periodically gather the best cases from
our weekly conference into some permanently accessible format.
We decided to do this in the form of an electronic book. In
exchange for providing case write-ups to the book, our con-
tributors gain authorial lines on their curricula vitae. Our first
book of 50 cases, Intergalactic Online MSK Conference: Cool Case
Book 1 (30), was published in May 2011 and is currently avail-
able on Amazon’s Kindle store, Apple’s online bookstore, and
Barnes & Noble Nook store. It has been joined subse-
quently by three other volumes of cases (31–33).
A number of the cases shown in our conference have suf-
ficient appeal and teaching points that we encourage their
authors to write them up for a formal peer-reviewed case
report in journals such as Radiology Case Reports (https://
www.journals.elsevier.com/radiology-case-reports/). Gath-
ering similar cases from multiple institutions for case reviews
and other projects has been another natural outgrowth from
our online conference.
PART III
Flipped Classrooms
What Is a Flipped Classroom?
In a traditional classroom or learning environment, learning
is centered on a didactic teaching method. A teacher stands
at the front of the classroom and delivers a lecture, and then
assignments and problem-solving exercises are performed at
home. In a flipped classroom, the order of events is “flipped.”
Educational material and instructional content is delivered before
the class session via online lectures, videos, or readings which
the student can access and review at their own pace. The class
session is then dedicated to more active learning processes with
interactive application of knowledge through problem solving,
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case-based scenarios, or interactive discussions—all under the
guidance of the teacher (34).
The basic elements of a flipped classroom are as described
previously. However, experienced educators have devel-
oped the four pillars to describe flipped learning, a more specific
form of the flipped classroom. To implement flipped learn-
ing, educators must integrate the following additional
components into their practice utilizing the acronym F-L-I-
P: a Flexible teaching environment, a shift in Learning culture,
Intentional content, and a Professional educator (35,36).
Flexible environment: Flipped classrooms allow a variety
of learning modes including group work, independent
study, research, performance, and evaluation.
Shift in Learning culture: In the flipped learning model,
there is a deliberate shift from a teacher-centered class-
room to a student-centered approach, where in-class time
is meant for exploring topics in greater depth and creat-
ing richer learning opportunities. Students become the
center of learning.
Intentional content: Flipped educators evaluate what
content they need to teach directly and they continually
think about how they can use the flipped learning model
to help students gain conceptual understanding.
Professional educators: In the flipped learning model,
professional educators are vital. During class time, they
observe students, provide relevant feedback, and decide
how to maximize the face-to-face time between teach-
ers and students.
Proponents of Flipped Learning Believe That It
Enhances the Learning Experience—but Why?
With traditional learning, when students are doing home-
work or applying what they learned in class, it is usually at
home. If they have a question, a teacher is not available to
help. In comparison, in a flipped learning environment, when
students are applying new knowledge and concepts, the teacher
or professional educator is present to answer questions because
this work is being done in the classroom.
In a flipped classroom, students are doing lower levels of
work (gaining knowledge and comprehension) outside of class
and focusing on higher forms of cognitive work (applica-
tion, analysis, synthesis, or evaluation) in class where they have
the support of peers and the instructor.
In a flipped classroom, teachers are therefore able to spend
more of their face-to-face time supporting students in deeper
learning processes such as knowledge application, assimila-
tion of information, and problem solving instead of just being
content disseminators. A teacher’s interaction with students
in a flipped classroom can be more personalized with more
individual support (36,37).
A second advantage of a flipped classroom is that students
can review lecture materials at their own pace and review and
replay parts of the lecture as many times as they need. It also
allows students who may have missed class to still view the
lecture content (38).
Academic Radiology, Vol ■, No ■■, ■■ 2018 INNOVATIVE TEACHING METHODS

Does a Flipped Classroom Model Work? developed: preclass content delivery, student centered in class
learning activities, and then assessment of student learning (46).
The flipped classroom approach has been shown to be ef-
Creating preclass content: The goal is to provide key
fective in secondary schools. In 2011, educators in Michigan’s
information to the students before class that can then be re-
Clintondale High School flipped every classroom. In one social
inforced with in class activities. This could take the form of
studies class, two classes with identical material and assign-
recorded video lectures or textbook or journal readings. An
ments were run: one flipped and one conventional. The flipped
easy way for a first-time “flipper” to develop video content
class had many students who had already failed the class. After
may be to record the lectures they are already giving and archive
20 weeks, students in the flipped classroom were outper-
these lectures. Recording a lecture could be as simple as using
forming students in the traditional classrooms. No students
a recorded PowerPoint narration using PowerPoint’s built-
in the flipped classroom scored lower than a C+. In the pre-
in narration. There are also many screening casting software
vious semester, 13% had failed. The traditional classroom
packages available to help with this. Specific to radiology ed-
showed no change (36,39).
ucation, there are a variety of e-learning modules that could
The flipped learning model has been shown to be effec-
supplement these lectures including RadCasts, RadTorials, and
tive in the postgraduate and medical educational community
RadGames.
as well. At Stanford, the biochemistry curriculum was rede-
When designing and delivering preclass content, it is im-
signed following the flipped education model, with class time
portant to provide clear learning objectives for each class session
used for interactive discussions of clinical vignettes and out-
so students know how to prepare. It is important to focus on
of-class time used to view online presentations made by the
key foundational concepts that students must understand so
instructors. Positive course reviews increased and atten-
that they can they can then practice applying these concepts
dance increased from 30% to 80% (40).
during class. Efficiency is important and experts in flipping
Use of flipped classroom during delivery of a renal
have found that shorter lectures (10–15 minutes) are more
pharmacotherpy module improved student’s performance com-
effective than longer lectures (34,43).
pared to performance of students the previous year that
Design in-class activities: The purpose of the in-class
underwent the same module in a more traditional setting
activities is for the student to take the information taught in
(34,41).
the preclass assignment and engage in activities that rein-
In 2016, The University of Vermont Robert Larner College
force and apply these concepts. It is important to avoid just
of Medicine became the first US medical school to commit
relecturing content that was already provided in the preclass
to flipping its entire required curriculum (42).
assignment. Sometimes, a 1- to 3-minute micro-lecture is
When a flipped classroom approach was used in a medical
helpful to reinforce learning or address an apparent gap in
school radiology elective, the flipped classroom learners achieved
knowledge identified when engaging in the in-class activity.
higher pretest to posttest improvement compared to other
The in-class activities should promote higher orders of think-
teaching strategies, and students enjoyed the components of
ing and application. Many of the in-class activities incorporate
the blended learning sections over traditional learners (43).
active learning and some examples of active learning exer-
Another study tested the effects of flipped learning in a ra-
cises that could be used are as follows (47):
diology medical clerkship to explore whether it would better
facilitate fact learning and development of clinical decision-
Individual Activities
making skills (44). Subjects who participated in the flipped
learning cohorts had greater interest in learning, increased en-
• Individual exercises: These provide an opportunity for the
joyment, and higher task value than the traditional didactic
students to practice skills. This could include labeling, rank
instruction cohorts. In addition, the change in posttest vs pretest
ordering, multiple choice, problem solving or true or false,
scores was 10.5% higher in the flipped learning group than
and completion.
in the didactic instruction group.
• Role play: Students are given a situation and a role to play
In a Mayo Clinic Internal Medicine Residency Program,
of a character in the situation.
a study was conducted to determine whether the flipped class-
• Questioning strategies: Questions which the students will
room approach would improve the quality improvement
be asked are planned by the instructor before the lecture.
knowledge of the residents. They found that the residents who
Each question is written out and is related to a learning
participated in the flipped classroom approach demonstrated
objective. In case of no response or incorrect responses,
improved quality improvement knowledge compared to the
the instructor will also be prepared to ask easier or lower
control group (45).
learning level questions, which will lead the student to
answer the original question.
• Personal vignette: Given a topic or learning objective,
How Does One Begin to Implement Flipped Learning
Into Their Classroom or Learning Environment? the students are asked to relate it to their real experiences
(personal or professional) by telling a brief story about it.
Experts in flipped learning stress that there is not just one • Progress quizzes: Short self-tests that are not graded. Answers
way to “flip.” There are three components that need to be are provided to the students after completing the quiz.

7
SIVARAJAH ET AL
Group Activities
• Buzz/Brainstorm sessions: A small group of students work
within a determined time limit to answer a question or
solve a problem and come to a conclusion.
• Group work exercise: Students are given a problem or sit-
uation to solve in a 5–10 minute period of time.
• Problems: A group of students works on given problems
within a specified time. The instructor discusses the correct
answers at the end of the activity.
• Complete case studies: These are real-world descriptions
of problems with all accompanying data. Groups are asked
to resolve the problem within a given period of time. Each
group makes recommendations while the instructor acts
as moderator.
• Diagnostic sessions: Groups diagnose a problem, situa-
tion, process, etc.
• Pyramiding (Snowball groups): Given a problem, stu-
dents first work alone, then in pairs, and finally in foursomes
(maximum) and compare, refine, and revise their con-
clusions and recommendations.
Activities to Promote Class Discussion
• Controlled discussion: This is used after a lecture. Stu-
dents ask questions and make comments while the instructor
controls the process which goes on for a prescribed period
of time.
• Choices: Given data on an event and several choices, stu-
dents are asked to discuss all choices. They may select a
choice, justify it, and give the consequences.
• Debate: This is an organized and civil argument moder-
ated by the instructor.
• Discussion of handouts: These are special documents,
reports, pictures, etc., that are discussed.
• Simulation: This presents cases, problems, scenarios, etc.,
in which the students must role play. A critical situation
is discussed and analyzed, and decisions are made about
how to resolve the situation.
• Read and discuss: This is a short reading followed by a
discussion.
Assessment of Student Learning
The teacher can use a variety of methods to provide feed-
back about student learning. These could include a preclass
or preactivity learning assessment (which helps the teacher un-
derstand which concepts from the preclass assignment may
need additional review), real-time assessment during the in-
class learning, and graded assignments or projects that test the
ability of the student to not only memorize information but
also analyze, synthesize, and evaluate concepts.
In summary, the flipped classroom approach is a novel way
to teach students, allowing the valuable teacher-student in-
teraction time to be used to review higher order educational
activities instead of just used as a time to lecture and dissem-
inate information. It has been shown to be an effective tool
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Academic Radiology, Vol ■, No ■■, ■■ 2018
across many learning environments and may have a place in
radiology education.
PART IV
Active Learning
Active learning is an approach to instruction in which stu-
dents engage the material they study through reading, writing,
talking, listening, and reflecting. Active learning is basically
“anything course-related that all students in a class session are
called upon to do other than simply watching, listening and
taking notes” (https://www.cte.cornell.edu/teaching-ideas/
engaging-students/active-learning.html).
We all can remember those great lectures that we attended—
ones where the hour passed without us realizing and we were
actively engaged throughout the lesson. Unfortunately, we
can also all remember lectures where we struggled to keep
our eyes open, often leaving the lectures with “sleepy notes”
or finding ourselves distracted. The problem with the tradi-
tional model for education is that it has been primarily teacher-
centered, with the student as a passive learner as information
is provided in a 50- to 60-minute lecture without engage-
ment of the students.
However, studies have shown that this is not the optimal
way for students to learn (48). Instead, an active learning model
that is more student-centered and requires active participa-
tion of each student has been shown to be most effective. The
two main goals of active learning (46) are to
1. shift focus from the teacher to the learner
2. promote higher order cognitive tasks through active en-
gagement with course content
Advantages of Active Learning
In a review of the literature on active learning, Prince found
broad support for the core elements of active learning (49),
with improvements in both short- and long-term learning com-
pared to the standard didactic lecture. Some advantages of active
learning include the following:
Improved student attention: It has been shown that
after an initial settling-in period of 5 minutes, students
readily assimilate material in a traditional lecture for the
next 5 minutes. Ten to 20 minutes into the lecture,
however, assimilation falls off rapidly. Active learning uses
skills that help break up the lecture and keep students in-
terested and focused.
Higher order learning skills used: Active learning is
also better at integrating higher level learning skills
such as applying, analyzing, and evaluating compared to
passive listening which utilizes lower end skills of remem-
bering and understanding. This allows learners to develop
better problem-solving skills and improves retention of
information.
Academic Radiology, Vol ■, No ■■, ■■ 2018
More motivating: Active learning can be more moti-
vating and interesting to learners as it often requires them
to apply knowledge learned to clinically relevant situa-
tions. It also allows more frequent and immediate feedback
to students.
Helps perfect additional professional skills: Active
learning also provides opportunities to learn and practice
skills for professional work such as team skills, commu-
nication, negotiation, and peer assessment of performance
(46).
Research on Active Learning
In a review of research, Prince examined the evidence for
the effectiveness of active learning and found broad but uneven
support for all forms of active learning (49). A meta-analysis
of 225 studies comparing traditional lecture to active learn-
ing in university STEM (Science, Technology, Engineering,
and Math) courses found that active learning reduces failure
rates from 32% to 21% and increases student performance on
course assessments and concept inventories by 0.47 standard
deviations (48). In another study, the impact of two types of
active learning, team-based learning and case-based group dis-
cussion, was evaluated in a medical school pathology course.
The study found that students in the lower academic quartile
showed better examination performance after using a team-
based approach (50,51).
How to Perform Active Learning
Active learning is achieved when students interact with the
educational content in any way that can promote active thought
which encourages them to think about the material rather than
just transcribe the content (52). There are many active learn-
ing techniques that can be used.
Interactive Lectures
In its simplest form, active learning can be integrated into
already designed lectures. Therefore, it can even be utilized
in large lecture room settings. Activities can be done during
the lecture that help students actively think about the mate-
rial being taught and recognize areas with which they may
need more help. These techniques are brief activities, which
can be used to break up a traditional lecture helping to engage
students throughout the entire lecture time. Some examples
include the following:
The testing effect: Give a test at the beginning or end
of the class. Students who took tests (even if they did not
count toward their overall grade) were found to have better
long-term retention of material (53). To implement this,
an ARS could be used. To further increase the active learn-
ing, a teacher could have the students come up with the
test questions themselves, based on the lecture material.
Pause and clarify/update notes: Student attention span
starts to dwindle about 20 minutes into a lecture. To break
this time up, the lecturer can pause every 15 minutes or
INNOVATIVE TEACHING METHODS
so, taking a break for 2–3 minutes. During this time, the
teacher can allow students to compare their class notes
so far to other students. This not only keeps the atten-
tion of students but allows learners to clarify their own
understanding and compare their perspectives to their
partner (54).
One minute papers: In this technique, in the last 10–
15 minutes of class the lecturer asks the following questions,
“What is the most important thing that you have learned
today? Write one to two questions that you have regard-
ing the lecture. What subject would you like to know
more about?” Have students write down answers.
Student summary of another’s answer: Have one
student (ie, lower level resident) answer a question about
the lecture and have another student (ie, higher level
resident) summarize that answer and then add or elaborate.
Stage setting: Give questions at the beginning of class
and instruct them to listen for answers within the lecture.
Recall material: At the beginning of class, have stu-
dents take 3–5 minutes to write down the most important
concepts from a previous class lecture or reading assignment.
Active review: After the instructor summarizes the class,
ask students to spend 2–3 minutes reading through notes
to identify points of confusion.
Muddiest point: Instructor has students respond to the
following question: “A question I still have about this
topic but have been afraid to ask is . . . (ie muddiest point).”
Have them write the questions down and then turn in
(47,54).
Relevance: Students retain more information when it
seems more clinically relevant. In medical education, a per-
sonal clinical scenario or case could be discussed. The lecture
could even include a live patient.
Active Group-based Techniques
More active or complex tasks can also be used during lecture
time which require more group-based activities. Examples of
these activities include think-pair-share and jigsaw.
Think-pair-share: A thought-provoking question is posed
by the teacher to the class. Students think of an answer and
write it down (think). Students then form pairs and discuss
responses (pair). Students then share answers with a team, group,
or entire class (share) (Fig 2). This is believed to enhance student
problem-solving skills and enhance their ability to see errors
or insights into the thinking of others (46).
It may be helpful to present a brief example of the think-
pair-share technique applied to radiology. One abundant source
of case material for this sort of exercise is an online journal
such as Radiology Case Reports (https://www.journals
.elsevier.com/radiology-case-reports/). For example, one might
give the students the history of an otherwise 56-year-old healthy
woman presenting with atraumatic bilateral ankle pain and
bilateral Achilles tendon lesions, as shown in Figure 3 (55).
After pondering this information, students write down their
thoughts and then pair up with another student. Each pair
will likely decide that the patient has lesions in both Achilles
9
SIVARAJAH ET AL
tendons, but will have differing opinions as to the cause of
these lesions. When the pairs meet as a group, these differ-
ent opinions will merge into a collective differential diagnosis
list, including items such as normal variant, tumor, infec-
tion, or trauma. The group will also be struck by the bilateral
nature of the findings and the lack of any significant trauma.
At this point they will come up with a list of further ques-
tions they need to answer. Some students will then compare
the findings in the images to those of various tendon dis-
eases in a radiology text. Others will do a PubMed search for
causes of bilateral tendinopathy. Yet, others will search the
patient’s history for further clues. Eventually, the group may
learn of the phenomenon of drug-induced tendinopathy
and conclude that this patient’s bilateral tendon tears are a
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Academic Radiology, Vol ■, No ■■, ■■ 2018
Figure 2. Think-pair-share technique.
Figure 3. T1-weighted magnetic reso-
nance images demonstrate small foci of
increased signal in the medial-posterior
margins of both Achilles tendons, consis-
tent with small partial width tears.
complication of the fluoroquinolone antibiotic she was given
for her pharyngitis.
Jigsaw: In a jigsaw, a topic is divided into separate but related
pieces and requires the learners to become experts in a subject
area and then teach that topic to peers who have become
experts in their topics. The class is divided into teams and each
member of the team is assigned one piece. She or he then
works to understand and become an expert on her or his piece.
Then, each person teaches the other team members about what
he or she knows about that piece—thereby putting together
the jigsaw puzzle (Fig 4). This could also be used in a slightly
different way—where the class is divided into groups and each
group is given a piece. The groups work together to under-
stand their piece. Then, the class is redivided into mixed groups,
Academic Radiology, Vol ■, No ■■, ■■ 2018
with one member from each group in each new group. Each
person in the group teaches the rest of the group what he or
she knows—again forming the puzzle.
Team-based Learning
Team-based learning (TBL) is an evidence-based collaborative
learning teaching strategy designed around units of instruc-
tion, known as “modules,” that are taught in a three-step cycle:
preparation, in-class readiness assurance testing, and application-
focused exercise (http://www.teambasedlearning.org).
Before implementing TBL, classes must be divided into
groups or teams (usually five to seven members). Every effort
should be made to ensure the teams are diverse with the goal
of equally distributing intellectual talent among the groups.
Groups are fixed throughout the entire course and are ideally
determined by the teacher (not student selected).
Preclass preparation: During the preclass preparation,
learners independently study material that has been preas-
signed by their teacher (ie, reviewing a chapter in a book,
reading articles, viewing PowerPoint slide presentations, or
viewing prerecorded lectures). The goal of the preclass prep-
aration is to review fundamental concepts that will help the
learner solve problems during the in class activity. Learning
objectives should be clearly defined by the teacher.
Readiness assurance phase: At the beginning of class,
students take an individual readiness assurance test, which is
designed to assess their individual preparedness for class (usually
5–20 MCQs). They then take the same test with their groups,
called the team RAT. However, groups must determine a con-
sensus answer for each question. The answers to the questions
are revealed immediately to the group using a special Feed-
back Assessment Technique card (groups scratch off an answer
and a star is revealed if the answer is correct). Both tests usually
count toward the student’s grade. The cards are collected and
INNOVATIVE TEACHING METHODS
Figure 4. Jigsaw technique.
the instructor then focuses a short mini-lecture to review con-
cepts that are still confusing to the students.
Application exercise phase (usually about 75% of the
class time): In this phase, students demonstrate their ability
to apply the knowledge they have just prelearned by working
in groups to complete an assignment. All groups complete
the same assignment or exercise which usually involves de-
termining the best solution to a given significant, relevant
problem. The assignments should promote collaboration among
students in each group and use the phase 1 and 2 knowl-
edge. At the end, teams then reveal their collaborative group
answers to the entire class, and the teacher facilitates a class-
room discussion between teams to explore the topic.
Team-based learning implementation is based on four un-
derlying principles:
1. Groups should be properly formed and are fixed through
the whole course.
2. Students are accountable for their prelearning and for
working in teams
3. Team assignments must promote both learning and team
development
4. Students must receive frequent and immediate feedback
Games
An education game is defined as “an instructional method re-
quiring the learner to participate in a competitive activity with
preset rules (56).” Educational games have been used in medical
education as a way to review specific medical topics and try
to make the learning process more active and fun (57,58).
Medical jeopardy is an example of a quiz-type educa-
tional game in which students are presented with general
knowledge clues in the form of answers and they must then
phrase their responses in the form of questions. A PowerPoint
11
SIVARAJAH ET AL
version of this game allows educators to create their own jeop-
ardy style game using a free downloadable template (59). One
study compared medical student’s performance, satisfaction,
and retention of knowledge on a jeopardy game format teach-
ing method vs a didactic lecture format (60). They found that
both groups showed a significant improvement in their knowl-
edge on an immediate posttest compared to the pretest.
However, on a posttest performed 2 months after, retention
of knowledge was significantly better in the game format
group.
Breast Imaging Bingo is another example of an educa-
tional game that has been developed to supplement traditional
didactic lectures (61). The game incorporates popular music
to reinforce memory retention, with lyrics designed to be similar
to the correct answer or principle that the question assessed.
A session of this game was played at the 2015 American Os-
teopathic College of Radiology Breast Imaging Innovation
Conference. Participants found the game enjoyable and felt
they would use this format to supplement their conference
or lectures.
A wide variety of medical board and card games have also
been developed to aid in teaching medical concepts. These
games range from the common “2 stage” quiz games where
a question has to be answered, the answer is evaluated in some
way, and the next question follows to more complex 4 stage
games which also requires abstraction of the issue and then
planning the next step. A detailed review of medical games
is provided in an article by Bochennek et al. (62).
Medical puzzles such as crosswords and anagrams are ad-
ditional educational games that can be used to help reinforce
medical concepts. These puzzles can be done individually or
in groups to incorporate small group learning. In one study,
crossword puzzles were given to small groups of undergrad-
uate medical students. Students reported that the crossword
puzzles were beneficial in helping them identify key con-
cepts, contributed to their learning, and engaged them in
collaborative practice (63).
In summary, incorporating active learning into education
has been shown to be beneficial. Active learning has been
shown to engage students and improve their attention. It has
also been shown to improve retention of information by de-
veloping higher order critical thinking skills, and it can also
foster communication and cooperative learning skills. Active
learning can take many forms. As described previously, active
learning can range in complexity from adding a few simple
active learning techniques to an already established lecture to
development of a complete team-based learning curricu-
lum. Active learning can also incorporate fun elements such
as games. When developing a teaching curriculum for radi-
ology residents or medical students, active learning strategies
should be kept in mind.
CONCLUSION
We have reviewed four innovative teaching methods that could
be implemented into a radiologist’s teaching practice. These
12
Academic Radiology, Vol ■, No ■■, ■■ 2018
educational skills go beyond the routine didactic slide lecture
format and help actively engage students in learning. ARSs
were described and examples of how they could be used during
a lecture to encourage interactive learning were reviewed. ARSs
now allow students to anonymously ask questions to the lec-
turer in real time and allow teachers to ask “on the fly” open-
ended questions as most systems allow free-text answers from
students. Techniques for optimizing long distance education
were also discussed. Through an example in MSK radiolo-
gy, it was shown how an online conference could promote
increased interactivity between radiologists of all levels at many
difference institutions. The flipped classroom approach is a
novel way to teach students, allowing the valuable teacher-
student interaction time to be used to review higher order
educational activities. It has been shown to be an effective
tool across many learning environments, including radiolo-
gy education. The final innovative teaching method to be
reviewed was active learning, which engages students and im-
proves their attention through using engaging techniques such
as working in groups and reflecting during the lecture. We
encourage radiology educators to incorporate innovative teach-
ing methods, such as the four described in this paper, into
their pedagogy as they have been shown to enhance the learn-
ing process.
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