In Reply to Willett

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We appreciate Dr. Willett’s analysis of our research1 and agree that a limitation was our use of a historical control group that, unlike the study group, was not participating in quality improvement (QI) projects at the time of the study. We agree that this limitation should temper assumptions regarding the potential meaning of between-group differences.
However, we do not agree that this limitation would preclude the ability to draw conclusions from our study. As stated in our article,1 the control group participated in a longitudinal QI curriculum that included active learning across their training. Throughout their first year of residency the control group participated in QI projects, and during their second year they evaluated patient outcomes through use of a systems analysis that involved conducting stakeholder interviews, generating fishbone diagrams, developing problem statements, and creating an intervention plan.
Furthermore, many of our findings stemmed from analyses of the intervention group in isolation. A systematic review of published medical education research revealed that comparison groups are not frequently incorporated, and a majority of studies are based on single-group designs.2 While single-group studies have many limitations, they are recognized as experimental research.3 Our study revealed that residents who experienced a flipped-classroom QI curriculum valued the in-class application sessions more than the online component; that residents in the flipped-classroom QI curriculum demonstrated improved, postcourse QI knowledge and attitudes towards flipped classrooms; and that residents who had not been previously exposed to flipped classrooms were more likely to show improvements in QI knowledge following participation in a QI curriculum.
Finally, we would highlight that criteria2 for education research quality extend beyond study design to comprise other measures which, pertaining to the current study, include participation rate, objective outcome measurements, validated scales, inferential statistics, and outcomes at various levels, including both reaction (Kirkpatrick Level 1) and learning (Kirkpatrick Level 2).
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