Medical education requires teaching strategies that promote not only short-term acquisition of knowledge but also long-term retention and application of information. For undergraduate medical students, the accumulation of large amounts of scientific and clinical information within a short time is expected of everyone, and therefore good teaching methods are crucial. Conventional lecture-based teaching is still prevalent as it facilitates the transmission of a great deal of information to a large number of students at once. This method, however, may lead to a semi-passive learning experience for students and may not afford the opportunity for discussion, problem solving, or application of the newly acquired concepts (1-3).

Flipping the classroom has been adopted as a new alternative for learner-centered teaching method. One way to do it is to give students learning materials beforehand and make them learn the basic things on their own. The active use of time in the classroom for case discussions, problem solving, clarifying challenging concepts, peer interaction, and instructor facilitation of knowledge application are all part of this. Flipped learning changes the traditional model of teaching content and teaching methods, striving to enhance the students' participation and maximize the use of class time, and can be summarized as "homework before class, class after homework (4-6).

The potential benefits of the flipped classroom teaching are that students can have control over initial learning pace. Digital resources, such as recorded lectures, reading material, presentation slides and other documents, can be read, heard and watched many times, as needed for each student. Pupils will be able to pinpoint challenging points prior to class and then ask questions in interactive time. This repeated exposure to academic content could help to reinforce understanding and promote deeper processing of material than by passively listening during a traditional lecture (7).

Active participation especially applies to knowledge retention. Retrieval, discussion, explanation and application is more likely to lead to retention of information than passive exposure. Retention is particularly significant in medical education, as much of what students learn in preclinical and early clinical settings is used in future diagnostic reasoning and patient management. A teaching method that enhances test scores right after instruction, but does not help students retain the information in the long run, might not actually have educational value (8, 9).

Flipped learning can also impact other parts of the learning process, like student engagement, satisfaction, self-directed learning and relations with faculty members. Students who prepare prior to class will have the ability to engage in discussions and apply the knowledge in clinical or problem-based situations. Meanwhile it is important that students willingly engage in pre-class learning tasks, that the learning resources are good, that teachers are prepared appropriately, and that they have access to digital technology, all of which are essential for the success of the flipped classroom. So, it is possible to have different levels of effectiveness depending on setting and student population (10, 11).

Despite the growing use of innovative teaching approaches, conventional lectures continue to dominate many undergraduate medical programs, particularly in settings where resources, faculty development, and curricular structures may limit adoption of alternative methods. Furthermore, many educational studies focus mainly on immediate examination scores rather than delayed knowledge retention. There remains a need to evaluate whether the improvement associated with flipped teaching persists beyond the immediate post-teaching period and whether it is accompanied by greater student engagement and satisfaction.

Therefore, the present study was conducted to compare flipped classroom teaching with traditional classroom instruction in undergraduate medical students at Rawal Institute of Health Sciences, Islamabad. The primary objective was to compare immediate knowledge acquisition and four-week knowledge retention between the two teaching methods. Secondary objectives included assessment of student engagement, satisfaction, perceived usefulness, and factors associated with improved retention. The findings may help guide the selection and implementation of effective teaching strategies in undergraduate medical education.

A comparative educational study was conducted at Rawal Institute of Health Sciences, Islamabad, to evaluate the effectiveness of flipped classroom teaching in improving knowledge acquisition and retention among undergraduate medical students. The study period extended from April 2025 to October 2025. A total of 89 undergraduate medical students were included. Participants were divided into two groups: 45 students in the flipped classroom group and 44 students in the traditional classroom group. Students of either sex who were enrolled in the selected undergraduate medical course during the study period and who consented to participate were considered eligible. Students with prolonged absence from teaching sessions, incomplete assessment data, or failure to complete the retention assessment were excluded from the final analysis. Based on the study protocol, students were randomly divided into two groups: the flipped classroom group and the traditional teaching group. Students were randomly divided to be in the flipped classroom group or traditional teaching group in accordance with the study protocol. The same academic, learning, and assessment materials were used, as were similar learning objectives, and the same amount of time was spent teaching. The students in the flipped classroom group were given the learning resources prior to the class meeting. These materials included recorded lectures, reading material, presentation slides and structured learning objectives. Students were asked to prepare for the face-to-face teaching session by reading the learning material. Classroom time was subsequently used for discussion, clarification of difficult concepts, case-based learning, problem-solving activities, and interaction with the instructor. The students in the traditional teaching group learned the subject matter in the traditional way using the traditional method of teaching in the classroom. Instructional lessons were provided in regular classroom sessions, and there were no required prereading sessions or tasks. The learning content was explained by using lecture and presentation slides and there was a brief period for questions and clarification. The learning objectives, topics being taught, teaching time and the level of difficulty of the assessment were matched between the two groups as much as possible to reduce variations caused by teaching content. Knowledge was assessed at three stages. Pre-test was used to get baseline knowledge and to check the comparability between groups before the educational intervention. The immediate knowledge acquisition was evaluated by an immediate post-test after the teaching session. Four weeks after the intervention, a delayed retention test was conducted to assess knowledge retention. The tests were structured multiple-choice questions based on the pre-designed learning outcomes. Although the same content domains were used, similar levels of difficulty were maintained throughout assessments. For each participant, scores were taken in the pre-test, immediate posttest, and 4-week retention test. Knowledge gain was calculated as the difference between score from pre-test and immediate post-test. The long-term knowledge gain was measured by comparing the score obtained before instruction with the score obtained after four weeks' retention. The knowledge loss was defined as the difference in immediate post-test and delayed retention-test scores. The knowledge-retention percentage was calculated as the delayed retention-test score divided by the immediate post-test score and multiplied by 100. Students were also classified based on their levels of knowledge retention, based on a predetermined study cutoff. Along with knowledge outcomes, students' involvement, satisfaction and perceived usefulness of the teaching method were measured by a structured questionnaire. Answers were given on a Likert scale, with higher numbers representing higher levels of engagement and/or satisfaction. Attendance was also recorded in the teaching sessions and attendance rate of 80% or above was regarded as regular attendance. These variables were evaluated as possible factors associated with better knowledge retention. Data were entered and analyzed by the Statistical Package for the Social Sciences (SPSS). All continuous variables (e.g. age, previous academic performance, knowledge scores, engagement scores, satisfaction scores) were given as mean ± standard deviation and all categorical variables (e.g. sex, teaching group, regular attendance, retention categories) were presented as frequencies and percentages. Comparisons of continuous variables between the flipped classroom group and traditional teaching group were conducted using independent-samples t-test, paired-samples t-test was used to test the changes in the knowledge scores between the two groups if it was appropriate. The chi-square test or Fisher's exact test was applied for comparison of categorical variables. Finally, a p value < 0.05 was recognized as statistically significant.

A total of 89 undergraduate medical students were included in the study. In these, 45 students were taught by the flipped classroom method and 44 students by the traditional teaching method. Mean age of the patients was 21.4 ± 1.3 years. No statistically significant difference was observed between the two groups in age (p > 0.05), gender distribution (p > 0.05), year of study (p > 0.05) or previous academic performance (p > 0.05).

Table 1. Baseline characteristics of the study participants

The initial knowledge score for both was also comparable. There was no significant difference in the mean pre-test scores between the two groups (flipped classroom 12.7 ± 2.3 and traditional classroom 12.5 ± 2.4, p = 0.688), suggesting there was no difference in the learning prior to the teaching intervention.

Table 2. Comparison of knowledge scores between the two teaching groups

The immediate post-test scores of the students who taught in the flipped classroom were significantly high compared to the students who were taught in the traditional classroom (18.9 ± 2.1 vs. 17.2 ± 2.4; p < 0.001). The same trend did not occur after four weeks. There was a significant difference between the mean score of retention test in the flipped classroom group (17.8 ± 2.2) and the traditional classroom group (15.4 ± 2.5; p< 0.001). The score of the students in the flipped classroom group increased more than that in the baseline group. The mean improvement of their group was 6.2 ± 2.0 points, which was significantly more than the mean improvement of the traditional teaching group (4.7 ± 2.1 points, p = 0.001). The gap increased when longer term knowledge retention was taken into account.

Table 3. Knowledge retention after four weeks

The students taught by the flipped classroom showed a significantly higher mean knowledge retention percentage of 94.2 ± 7.8%, than the students taught by the traditional teaching method (89.5 ± 9.4%, p = 0.012). In addition, the flipped classroom group showed less knowledge loss between the immediate post-test and the four-week retention assessment (1.1 ± 1.0 points), than did the traditional group (1.8 ± 1.2 points; p = 0.004). The number of students who showed high level of knowledge retention in the flipped classroom group was 37 (82.2%), while in the traditional classroom group, the number of students with high level of knowledge retention was 27 (61.4%). This difference was significantly different (p = 0.028).

Table 4. Student engagement and satisfaction according to teaching method

The students who experienced flipped classroom lessons also gave positive feedback about involvement and satisfaction. The mean score for engagement was 4.3 ± 0.6 for the flipped classroom group and 3.6 ± 0.7 for the traditional classroom group (p < 0.001). Likewise, the satisfaction scores were significantly higher in the flipped classroom group (4.4+0.6 vs. 3.7+0.8; p<0.001).

Table 5. Factors associated with high knowledge retention

Higher knowledge retention was significantly associated with the flipped classroom method, regular attendance, greater classroom engagement, and higher student satisfaction. Students demonstrating high engagement were more likely to retain knowledge than those with lower engagement (p = 0.006).

Overall, the findings showed that the   Students in the flipped classroom group also experienced less decline in knowledge scores over time and reported higher levels of engagement and satisfaction.

Figure 1. Comparison of mean knowledge scores at pre-test, immediate post-test, and 4-week retention assessment between undergraduate medical students taught through the flipped classroom and traditional teaching methods.

The present study evaluated the effectiveness of flipped classroom teaching in improving knowledge acquisition and retention among undergraduate medical students. The findings demonstrated that students exposed to the flipped classroom approach achieved higher immediate post-test scores and better four-week knowledge-retention scores than students receiving traditional classroom teaching. Although baseline knowledge scores were comparable between the two groups, the improvement following the intervention was greater among students in the flipped classroom group. These findings suggest that restructuring classroom time around active learning and providing instructional material before class may enhance both short-term learning and subsequent retention of medical knowledge (12, 13). Immediate post-test scores were higher in the flipped classroom group, which could be attributed to the chance that students were given to access the learning content prior to the classroom. If students have prior knowledge of the topic they can become familiar with the basic concepts at their own speed and can recognise areas of difficulty in the topic before the face to face teaching. This can then allow class time to be spent on clarification, conceptual application, case discussion and problem-solving, instead of passive information delivery. Multiple exposure to the same academic material across alternative learning tasks can enhance understanding and the encoding of information into memory (6, 14). One of the key results of the present study was the superior results obtained by the flipped classroom group in the four-week post study assessment. Retention of knowledge is especially crucial for medical education as students are expected to not only perform well after teaching, but also recall and apply knowledge during subsequent clinical education. The students in the flipped classroom group achieved fewer percentage drops from the immediate posttest to the delayed retention assessment in this study. The results showed that there has been a positive finding, which is that the use of active learning could result in learning that is more durable than the application of conventional learning in the form of lectures. Independent preparation, class interaction, access to previously reviewed material, and application of knowledge could facilitate deeper/longer term memory formation (15-17). The group in the flipped classroom also had higher student engagement and satisfaction. It is possible that greater engagement played a role in the better academic results that were found in this group. Traditional lecture may restrict students' opportunities to participate in an active way, especially when it is a large percentage of the lecture time that is spent on one-way communication. Compared with the traditional classroom teaching, the flipped classroom teaching method is the opposite, that is, to transfer the classroom teaching time to outside the class, and reserve classroom time for students and teachers to interact. This style can help students to ask questions, discuss challenging ideas, and engage in collaborative learning. Greater satisfaction may also be a result of students' enjoyment of the flexibility to review pre-class material, as well as the ability to re-investigate challenging material as needed (18, 19). Effectiveness of a teaching strategy is also due to the involvement of the students, and regular attendance correlates with increased engagement leading to an increase in knowledge retention. It may not be enough if the students don't work with the material prior to the class. This implies that, the flipped classroom will be successful if the learning objectives are clearly formed and stated, the materials that are presented before the class are manageable, and the teacher provides incentives for preparing before the class, and class activities are designed appropriately. Faculty must also make sure that the material in class isn't presented again in the lecture but that they extend concepts learned prior to class. The considerations are especially important in embarking on the integration of FL into undergraduate medical education (20). The findings have implications for medical education institutions that would like to raise the effectiveness of teaching without significantly increasing the quantity of formal teaching time. It is possible that flipping can use the classroom more efficiently, in which the lower-order cognitive learning can be done by guided self-learning and higher-order cognitive learning can be done in the classroom. Some of its implementation problems, however, may be related to access to digital resources, availability of appropriate learning materials, students' preparedness for self-directed learning, faculty training, and technological support in the institution. Hence, it is necessary to carry out the implementation of the flipped classroom with proper planning, and ensure that the flipped classroom is consistent with the learning objectives and assessment methods of the curriculum. These results must be interpreted with caution due to some limitations. The study was performed in one medical college and the sample size was relatively small (89 students), and therefore the findings might not be applicable to other medical colleges or academic environments. The advantage of the observed knowledge retention was assessed after 4 weeks, which does not rule out whether the presented advantage can be seen for several months or in the application. Students' engagement and satisfaction were also partially assessed by self-reported measures and could be subject to personal preferences or familiarity with digital learning. Furthermore, there may be variations in students' preparation outside the classroom which would have an impact on student learning. The future multi-center study with larger samples, longer follow-up and clinical reasoning evaluation or practical performance evaluation is recommended to determine the wider impact of flipped classroom education on the students' education.

Flipped classroom teaching was more effective than traditional classroom instruction in improving immediate knowledge acquisition and four-week knowledge retention among undergraduate medical students. Students taught through the flipped approach demonstrated higher post-test and retention scores, lower knowledge loss over time, and greater engagement and satisfaction. These findings support the incorporation of appropriately designed flipped learning strategies into undergraduate medical education, particularly when the objective is to encourage active participation and improve sustained understanding of academic content. Further studies involving larger and more diverse student populations and longer follow-up periods are needed to confirm its long-term educational benefits.

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