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Karimian et al.

BMC Medical Education (2024) 24:137 BMC Medical Education


https://doi.org/10.1186/s12909-024-05051-8

RESEARCH Open Access

Comparison of the teaching clinical


biochemistry in face‑to‑face and the flex‑flipped
classroom to medical and dental students:
a quasi‑experimental study from IRAN
Zahra Karimian1 , Pooneh Mokarram2*   and Nahid Zarifsanaiey1   

Abstract
Introduction Biochemistry is one of the main courses of basic sciences in the medical curriculum, along with other
difficult subjects that are difficult to learn. The emergence of new technologies has made it possible to test
new methods such as e-Learning. In this study, we compared two methods of Flex-Flipped Classroom (FFC)
and face-to-face.
Method A quasi-experimental research was done which involved both medical and dental students studying
the clinical biochemistry course in the joint semester in 2019. A total of 100 medical students were trained in bio-
chemistry through face-to-face teaching, and 60 dental students were trained in the same course through the FFC
model. Three researcher-made tools were used to compare the two groups to assess the student’s satisfaction, scores,
and self-evaluation. The content validity of the tools was checked using the opinions of 10 experts through the CVI
index. The results were analyzed using one-sample t-tests, independent t-tests, and ANOVA.
Results Both groups scored significantly more than the cut-off-point (Mean > 3.5) in their average scores of the total
and sub-components of the self-evaluation questionnaire (P < 0.05). Face-to-face teaching was viewed more favora-
bly than the FFC teaching except for considering the flexibility (4.14 ± 1.55), but the difference was not significant
(P > 0.05). The students’ knowledge score in the FFC was slightly higher than that in the face-to-face method, but this
difference was not significant(P = 0.758).
Conclusion Both face-to-face and FFC methods were effective according to the students, but the level of satisfaction
with the face-to-face method was higher. It seems that teacher-student interaction is an important factor in students’
preferences. However, the students preferred the flexibility of multimedia. It seems necessary to use the advantages
of each method in a model appropriate to the students’ conditions and available facilities.
Keywords Face-to-face education, e-learning, Blended learning, Flipped class, Flex model, Knowledge, Quality

*Correspondence:
Introduction
Pooneh Mokarram Biochemistry is one of the main subjects of the basic sci-
[email protected]
1
ences in the medical curriculum, which is important for
Department of E‑Learning in Medical Sciences, Virtual School
and Center of Excellence in E-Learning, Shiraz University of Medical
understanding the clinical sciences of the medical pro-
Sciences, Shiraz, Iran fession [1, 2]. Meanwhile, it is one of the hardest courses
2
Autophagy Research Center, Department of Biochemistry, School in basic medicine and an abstract subject that is dif-
of Medicine, Shiraz University of Medical Sciences, Zand Street, Shiraz, Iran
ficult for students to learn [3, 4]. The course content is

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Karimian et al. BMC Medical Education (2024) 24:137 Page 2 of 17

full of biochemical structures, routes, formulas, materi- digital world. For this reason, innovations in instruc-
als, and metabolism [5]. The curriculum for biochemis- tional processes and educational environments are nec-
try is very broad; the time the subject is usually taught essary to meet the needs of these learners [23, 24]. The
is limited, and there are usually a large number of stu- new generation of medical students are more skilled
dents in a class [6–9]. In this context, in most medical in using new technologies. Therefore, teachers should
schools around the world, lecturers are forced to choose provide solutions to help students and guide them to
a lecture style that is often the best way to present a large self-directed learning based on problem solving and
amount of information to a large number of students [6, active participation [25, 26]. Nowadays, there are vari-
8]. However, the one-sidedness and teacher-centeredness ous methods of technology-based learning, and the
of the lecture method diminishes the role of the learner most common term is e-learning, which is sometimes
in delivering information [10, 11]. Lectures are usually referred to as online learning. Nowadays, most educa-
delivered in a uniform manner and pace to all students tional institutions, including schools and universities,
although students have different learning abilities, styles, use various e-learning methods and tools, and gradu-
and speeds [10]. It is difficult for weaker students to fol- ally new terms such as blended learning have been
low in the teacher’s steps. Therefore, not all students can added to it. To explain the dimensions of the issue, the
absorb the content of the lecture in the same way. Thus, concept of e-learning, blended learning, and its vari-
lecturers have limited opportunity to ask questions. Stu- ous models, as well as the models used in this research,
dents are, therefore, forced to take notes, so that they can have been described.
retrieve them later or refer to the curriculum materials
throughout the session, which distracts them from the
presentation of the material [8]. In addition, the quality E‑learning
of speech mainly depends on the experience and skills E-learning is an important type of technology-based
of the teacher. This is due to the teacher’s environment learning, which promotes active learning. Covering a
or personal conditions [8, 12]. If the curriculum is man- wide scope, it refers to the preparation and delivery of
aged in a teacher-centered way, the students will not have educational programs through electronic systems [27].
the opportunity to interact with the professor and learn In the literature of medical education, this term is some-
deeply. times considered synonymous with online learning, com-
In addition to student dissatisfaction and feelings of puter-assisted learning (CAI), computer-based learning
lack of interaction with professors, another negative (CBI), Internet-based learning, learning via multimedia,
consequence of this routine classroom management is and web-based learning [28, 29].
medical students’ boredom and feelings of lack of con- E-learning provides much more flexibility and comfort
nection with basic sciences courses [13]. In some cases, than face-to-face classes [2] as it adapts to the learner’s
students are unable to choose between medical special- circumstances and pace of learning by removing time
ization and biochemistry courses as it requires them to and place restrictions.
communicate with a wide range of abstract and theo- E-learning allows for more practice and repeated expo-
retical concepts [14, 15]. Based on principles of peda- sure, thereby fostering deep learning in students by creat-
gogy, the course delivery must be adapted to students’ ing better conditions for creative learning [29–32].
own needs and circumstances, as well as their speed Powerful interactive online tools can provide opportu-
and learning styles. Thus, students can learn in a self- nities for deep learning, as some studies have shown that
directed way, gaining in-depth understanding because online learning can be as effective as face-to-face learning
it is possible for them to review the course material [33]. Meanwhile, new technologies have created enor-
[16]. This question is especially important because mous potential for the integration of such devices into
biochemistry is one of the foundation courses offered educational settings [34].
to various fields of medical sciences such as medicine, The development of new technologies also allows to
dentistry, pharmacy, nursing which usually engage a diversify student-oriented learning methods, consid-
wide range of students [17] Therefore, teachers should ering the differences in learning abilities of learners to
use new and innovative approaches to enhance student strengthen active learning in a wide range of medical
learning [18, 19]. Considering the development of new fields [35–38]. In spite of its many advantages, e-learn-
technologies in this era, many studies recommend the ing must not be used alone in the absence of some form
use of new technologies in education, especially for of face-to-face interaction. In fact, blended learning is
younger generations, to integrate technology with edu- what has been highlighted as an appropriate method for
cation [20–22]. Today, most of the students are digital teaching and learning today, which is a new educational
natives and must respond to the demands of the new approach that combines face-to-face and online learning.
Karimian et al. BMC Medical Education (2024) 24:137 Page 3 of 17

Blended learning Flipped classroom


Blended learning uses and combines the strengths of The term "flipped class" was first coined by John Bergman
face-to-face training with new electronic technologies. and Aaron Sams, chemistry teachers at a high school in
Research has shown that blended learning increases the 2002, and since then this term has been developed in
students’ satisfaction with learning as learners have a the field of teaching and learning and has been popular.
greater sense of belonging due to their physical participa- Although initially they developed this method for stu-
tion in class [39, 40]. In blended learning, it is possible dents who missed or those who could not attend classes,
to teach with a holistic approach and use a combination today this approach is used in various educational areas
of various learning tools and methods, by considering the and at different levels [48].
individual characteristics of the learner, e.g., attitudes, Flipped class model reverses the sequence of class
beliefs, views, knowledge, skills, and abilities [41, 42]. activities, so that students receive the course content
Blended learning uses a mixture of important learning before attending the class. They go through their learning
strategies such as: lecture, visual and auditory demon- path in a self-directed way through the activities guided
stration, discussion, hands-on projects, with a variety of by the instructor, while the face-to-face class is used for
visual and audio interaction tools. Moreover, it employs research, exploration, and sharing ideas. Inspiration and
collaborative learning activities and learning from peers motivation are accompanied by scaffolding in educa-
[43]. A range of blended learning tools can be used from tion and practical activities, while better quality course
the simplest to the most complex, e.g., electronic mes- content is provided to students [49–52]. Hamdan et. al.
sage, learning management system (LMS), multimedia believes that in the flipped classroom learning model,
and educational videos, podcasts and audio files, simul- teachers take direct learning out of the large group learn-
taneous discussion of text, audio and video, online chat, ing space and with the help of modern technologies, by
video conference, slide sharing, and online resources for transforming it into an individual and individually spaced
a variety of assignments and activities. Learning activities one suitable for students’ circumstances [53]. In several
include self-testing and final assessment, forums, simula- studies in teaching medical sciences, it has been con-
tions, and virtual interactions with patients, while learn- firmed that this method increases learning and satisfac-
ers interact with teachers, peers, and course content [44]. tion and improves students’ performance and academic
Blended learning models are diverse. Horn and Stocker success [48, 51–57]. The flipped learning method par-
(2012) introduced various models of blended learning ticularly strengthens students’ flexibility, active learning,
including self-blended or A La Carte model, enriched and sense of responsibility as it is very effective in making
virtual model, flex model, and rotation models (station- better use of face-to-face classroom time [9, 34]. It poten-
rotation model, lab- rotation model, individual-rota- tially creates a community due to increased productiv-
tion model, and flipped-classroom model) [45–47]. The ity and increases learning, interaction, and engagement
enriched virtual model is mostly offered for virtual and with peers [9]. The course content is presented online
full-time online courses or majors, allowing learners to or via educational videos to save the interaction time for
complete most of the coursework online at home without teachers and students. Research has shown that the use
the need for daily attendance, so that only a few face-to- of interactive tools does not have a negative effect on the
face sessions are sufficient [46]. Self-blended courses (A content and students’ achievement and quality of pres-
La Carte model) are often used for elective courses where entation [34]. In classroom interactions, students are
students can choose units or subjects according to their engaged with the videos, tests, and study work as they
individual interests and conditions [45, 47]. In the Flex participate in problem-solving exercises [58, 59].
method, the main backbone of education is online tools Nonetheless, features of course design are significant in
such as LMS and Moodle. In this method, in addition the online mode. The course content and process should
to attending face-to-face classes according to predeter- enjoy technical and educational quality to encourage stu-
mined class schedule, students interact with their teach- dents to get engaged in learning activities. Otherwise,
ers through an online platform and follow up learning there is little interaction between professors and students
activities [45]. Among the mentioned models, the most because students may not see their professors in person,
common and popular model is the flipped classroom or because of students’ lack of self-regulation, or distrac-
method. The main point in the flipped class method is tions in online environments, even though there is good
to reverse the sequence of classroom activities and home e-content [60–63].
activities [46, 47]. In this research, a combination of two Recent studies have shown that students prefer edu-
models (flex model & flipped classroom) was used. To cational materials produced by teachers [36]. Online
explain this blended concept further, we first discussed video content before class has many advantages over
the definitions of flipped classroom models. textbooks, especially for introductory students who are
Karimian et al. BMC Medical Education (2024) 24:137 Page 4 of 17

new to complex subjects. Reading a textbook is primarily Since the infrastructure of the LMS existed as the main
visual and conceptual, while video-based and multimedia platform for e-learning in SUMS to share course con-
instruction adds auditory appeal to visual comprehen- tents, learning activities and formative examination, we
sion, language comprehension, and cognitive processes, chose the "Flex" approach. Hence, the contents of bio-
with a stronger emphasis on the importance of content. chemistry topics were prepared as multimedia and pro-
Video assignments are typically more engaging for a large vided to the students before the start of the course via
introductory science course and may stimulate greater the "Flipped classroom" approach. Therefore, the inte-
engagement with the course material [64]. Moreover, grated Flex-Flipped Classroom (FFC) model was used
some studies have shown that providing e-content pre- as the intervention, with the baseline being face-to-face
pared before students attending the class can provide approach, where the usual way of presenting lessons
students with opportunity for practice and repetition includes lectures and discussion. We decided to compare
because of time and place flexibility. Yet, in the absence the delivery of a clinical biochemistry course in face-to-
of face-to-face sessions it may lead to a decrease in live face and FFC model.
interactions between the professor and the students. In this study, there were four main objectives:
The flipped method attempts to solve this problem [62].
There is no single scenario for how to blend the face-to- 1) Comparison of students’ satisfaction with the qual-
face and e-learning classes as there are various methods, ity of course in face-to-face and FFC groups.
but all types of blended learning need to take advantage 2) Comparison of students’ self-evaluation of knowl-
of both face-to-face and online methods [62–66]. edge in face-to-face FFC groups.
3) Comparison of the students’ scores of final exams
(Performance) in face-to-face and FFC groups.
FFC model 4) Investigation of students’ satisfaction of course
As mentioned earlier, biochemistry is widely considered quality after intervention according to demographic
a difficult subject for both students (Learning) and teach- variables.
ers. (Teaching management) It requires a lot of memori-
zation and dedication, which can be challenging for some Method
students. Specially, biochemistry covers a wide range Research design
of topics, including metabolism, enzyme mechanisms, This is a comparative quasi-experimental study employ-
and genetics, which can be overwhelming for some stu- ing two-group pre-posttest design, with a sample of
dents. Despite its difficulty, biochemistry is an impor- medical and dental students in Shiraz University of
tant subject in medical basic sciences that is essential Medical Sciences who were enrolled in the clinical bio-
for many careers in the life sciences, including medicine, chemistry course in 2019. Medical students received
pharmacy, dentistry, nursing, and so on. Flipped class- the conventional face-to-face education, while dental
room and flexible models have been found to be effec- students received blended learning in the form of FFC
tive in biochemistry education. The flipped classroom model with the standard interactive multimedia presen-
model allows students to watch pre-recorded lectures tation via SCORM format on LMS before the classroom
before class, which frees up class time for more interac- beginning. A variety of web-based interactive modules
tive activities such as group work, problem-solving, and such as discussion forums, quizzes, assignments, and
discussions; also, the flex model provides students with exercises were used in the experiment. The students’ sat-
a personalized learning experience that is tailored to isfaction with the quality of education scores, their self-
their individual needs and preferences. To investigate evaluation of their learning, and their final exam scores
the effectiveness of a hybrid model in teaching medical obtained on the end-of-semester test were examined in
students, we decided to use a combination of the flipped both groups after the educational intervention (Fig. 1).
classroom and flex models.
In our initial review, we found that there were few Questionnaire distribution time frame
studies that have investigated blended learning meth- Biochemistry course was held in the academic semester
ods in clinical biochemistry courses. Few efforts have of 2018–2019 from February to July, and the question-
been made to use educational videos in the presenta- naires were distributed and collected at the end of the
tion of laboratory topics in the biochemistry depart- semester before the final exam in person.
ment of Shiraz University of Medical Sciences (SUMS)
[67]. Moreover, there were few cases of using e-content Sample size determination
and multimedia in the presentation of some parts of bio- To determine the minimum sample size in each group
chemistry education. based on previous similar study [66] and using the
Karimian et al. BMC Medical Education (2024) 24:137 Page 5 of 17

Fig. 1 A schematic view of the research design of educational intervention in the two groups

formula below, we estimated the sufficient sample size in In terms of the time of presentation of the course, both
each group. In this formula, the mean and variance infor- groups were enrolled in this course in the same semester.
mation were obtained; the students’ mean scores after Due to the great distance between the two faculties (in
the intervention were μ1 = 15.40, μ2 = 17.46, δ1 = 2.46, and two different parts of the city) and with the necessary
δ2 = 2.36. Therefore, the minimum sample required to explanations to the students of the FFC group, data dis-
enter the study was 32 people. semination between the two groups was made impos-
2
sible. Both groups of students were similar in terms of
z1−α/2 + Z1−β S12 + S22 (1.96 + 1.30)2 × (2.36 + 2.46) academic background.
n= 2
(µ1 − µ2 ) 17.46 + 15.402

However, since all students of both medicine and den- Tools and data collection process
tistry were enrolled in a clinical biochemistry course in The research tools were two researcher-made question-
the semester of the 2018–2019 academic year (Febru- naires for measuring the students’ satisfaction of the
ary to July), it was impossible to split the participants. quality of the course and the self-assessment question-
We could not randomly assign students in a class to two naire of the participants’ knowledge. In addition, clinical
groups due to the possibility of information leakage. biochemistry final exam grades were used to compare
Additionally, from an ethical standpoint, it was not fair the students’ performance. Also, in a part of the ques-
to have students exposed to two different teaching meth- tionnaire, demographic information including gen-
ods in the same classroom as this could potentially affect der, age, GPA of the previous semester, residence status
the comparison of their end-of-term grades. Accordingly, (with family, dormitory, independent house), marital
we decided to select two separate groups of students who status (single, married), employment status (employed,
were at the same level but did not have access to each unemployed), level of access to a personal computer, and
other’s information (Fig. 2). The medical and dental stu- Internet access was also checked. The following are the
dents had similar scientific levels and had taken a similar characteristics of the research tools.
course with the same syllabus. The course content was
the same for both groups, and the instructor was also A. Satisfaction of quality: A researcher-made ques-
the same. Both groups used the same course material, tionnaire was used to measure satisfaction with
quizzes, discussions, and final exam. Given that the stu- the quality of the course from the students’ point
dents of medicine and dentistry fields are almost similar of view. It consists of 21 statements scored using
in terms of grade point average and academic charac- a six-point Likert scale, ranging from strongly
teristics, these two fields were selected for comparison. agree = 6, agree = 5, somewhat agree = 4, somewhat
Karimian et al. BMC Medical Education (2024) 24:137 Page 6 of 17

Fig. 2 The Participants’ recruitment flow diagram

disagree = 3, disagree = 2, and strongly disagree = 1, scores ranged from 0 to 20 and the minimum score
with the cut-off line or minimum score being 3.5. to pass the course was 12.
This questionnaire measured the students’ satisfac-
tion in five areas, i.e., "content effectiveness", "active
learning", "questioning", "flexibility", and "general Validity and reliability of research tools
feeling towards education". After the intervention, Validity
this questionnaire was distributed among both To determine the validity of the researcher-made ques-
groups, and its results were compiled. tionnaires, at first face validity was examined using the
B. Self-evaluation of knowledge: In the self-evalu- opinion of five students and five professors. In this stage,
ation questionnaire, some questions were asked eight statements needed to be modified in terms of gram-
regarding the main topics of the course, including mar. Three statements were reviewed in terms of rela-
the five main topics of the content presented during tionship with the components of the questionnaire.
the semester, comparing the students’ knowledge Content validity was evaluated using the opinions of
before and after the course. The Likert scale ques- ten experts in the fields of biochemistry, medical educa-
tions ranged from 6 (very much) to 1 (very little). tion, and e-learning with Content Validity Index (CVI).
This questionnaire was used for both intervention Based on the content validity index provided by Waltz
groups. and Bausell [68], the experts were asked to determine
C. Scores of the final exam (Performance): The scores the status of each item in the three areas of relevance,
of the criterion-based summative examination (final simplicity, and clarity with a four-part spectrum. In the
exam) of the students in the two intervention groups end, we divided the number of experts who chose option
(four-choice questions based on the course content) 3 and 4 by the total number of experts. If the resulting
were the basis for comparing the knowledge gained value was less than 0.70, the item was rejected; if it was
by the students of the two groups. The students’ between 70 and 0.79, it was reviewed. Also, according
Karimian et al. BMC Medical Education (2024) 24:137 Page 7 of 17

to the number of experts (N = 10), if it was greater than Data analysis


0.79, it was acceptable [68]. In reviewing the opinions of For data analysis, SPSS 24 software was used. Frequency,
10 educational and biochemistry experts, three questions percentage, mean, and standard deviation were used to
of the index of clarity and simplicity had a score of 60%, describe the demographic characteristics of the partici-
and according to the items and explanations expressed pants. To compare within-group pre-test and post-test
by modifying the writing style of the items, all the items scores, we used paired t-test, and independent t-test was
were approved with more than 80% agreement. used to compare the scores between groups in terms of
knowledge, satisfaction, and performance, For compar-
ing scores based on background variables, independent
Reliability
t-tests and ANOVA were used.
For internal consistency test, Cronbach’s alpha was used
to determine the reliability of the questionnaires. All
Results
items of the questionnaires were analyzed with 45 sam-
The clinical biochemistry course was a common course
ples. For students’ satisfaction, with the quality of educa-
run for two groups of students including 100 medical stu-
tion questionnaire, the reliability value was 0.928, and for
dents and 60 dental students. The content of this lesson
self-assessment of knowledge questionnaire, it was 0.934.
was the same for both groups. This course was presented
for medical students in a face-to-face format and for den-
Scientific content of the course tal students in a combined FFC model.
The content of the course included the topics discussed In total, 95 medical students and 49 dental students
in the table below (Table 1). All the features of the con- answered the survey questionnaires completely, and all
tent of the two courses were the same except for the students participated in the final exam. Before analysis of
presentation method. In both groups, the clinical bio- the results, the overall characteristics of the two groups
chemistry topics were presented as Case-Based Discus- were first compared. As the results show, the two groups
sion (CBD). In the face-to-face group, it was presented were not significantly different in terms of age composi-
in the form of face-to-face question and answer, and in tion, gender, marital status, employment status, place
the opposite group, it was presented in the form of a dis- of residence, accessibility, GPA of the last semester, etc.
cussion forum. The duration of the lessons was the same. (Table 2).
Both groups were evaluated with the same questions and
on the same day (Table 1). Question 1
Multimedia content was prepared using Flash soft- By comparing the students’ satisfaction with the com-
ware and SCORM 2004 output, which included 5 main ponents of quality of clinical biochemistry education in
topics via standard interactive multimedia. Each content face-to-face and blended groups after the intervention,
consisted of 2–3 speeches (Sco) and at the end of each we found that the average score of the total and sub-com-
speech (Sco) 5 to 7 interactive MCQ questions were ponents was more than expected (Mean > 3.5) and signifi-
presented along with interactive feedback to recall and cant (P < 0.05) as follows: “effective content” (P = 0.001),
review the material. Similarly, it was in the form of short/ “questioning” (P = 0.006), “active learning” (P < 0.001),
MCQ questions in face-to-face class. The content of the and “the feeling of the effectiveness of the course”
questions was similar. The research plan is displayed on (P = 013), respectively. Although both groups scored
the following section. above the cut-off or minimum expected average, i.e., 3.5

Table 1 The content of the materials and the method provided to the intervention groups
Sub-titles F-FC Blended Learning Face to Face
Social Media e-Quiz Forum Multimedia Short Lecture Virtual Class Quiz CBD Lecture
(Time)

Digestion and absorption of fats * * * 40’ 30’ 20 5’ 15’ 70’


Oxidation mechanism * * * 45’ 30’ 20 5’ 15’ 70’
Fatty acid biosynthesis * * * 40’ 30’ 20 5’ 15’ 70’
Cholesterol metabolism * * * 40’ 30’ 20 5’ 15’ 70’
Metabolism of Eicosanoids * * * 40’ 30’ 20 5’ 15’ 70’
Karimian et al. BMC Medical Education (2024) 24:137 Page 8 of 17

Table 2 Comparison of the demographic characteristics of face-to-face and FFC groups


Characteristics of Participants Groups N Sig
Face-to-Face Blended FFC
(Medicine) (Dentistry)

Gender Female 27 20 47 0.139


Male 68 29 97
Total 95 49 144
Age Mean ± St.D 19.15 ± 1.40 20.04 ± 2.41 144 0.057
Marital status Single 93 47 140 0.270
Married 1 2 3
Employment status Employed 7 5 12 0.545
Unemployed 87 44 131
Residency status With Family 44 17 61 0.060
Independent 8 1 9
Dormitory 43 31 74
Access to computers (at Home) Yes 84 37 121 0.056
No 11 12 23
Internet access (at home/dormitory) Yes 92 48 140 0.054
No 2 0 2
Mean Score of previous semesters (Range: 0–20) Minimum 13.70 12.40 144 0.372
Maximum 18.85 18.88 -
Mean ± St.D 16.54 ± 1.23 16.32 ± 1.54 -
< 15 16 9 25
15–17 40 29 69
> 17 32 11 43
Internet usage for scientific activities 0–3 Hours 88 44 132 0.769
4–6 Hours 5 3 8
> 7 Hours 2 2 4
Internet usage for entertainment 0–3 Hours 46 28 74 0.571
4–6 Hours 22 11 33
> 7 Hours 26 10 36

Table 3 Comparison of the average educational quality satisfaction in face-to-face and FFC groups
Components Groups Mean Std. Deviation t Sig

Effective content Face-to-Face (Medicine) 4.96 0.84 3.54 0.001


Blended FFC (Dentistry) 4.37 1.10
Active learning Face-to-Face (Medicine) 4.47 1.01 3.92 0.000
Blended FFC (Dentistry) 3.63 1.48
Questioning Face-to-Face (Medicine) 4.52 1.12 2.81 0.006
Blended FFC (Dentistry) 3.92 1.31
Flexibility Face-to-Face (Medicine) 3.86 1.18 -1.16 0.247
Blended FFC (Dentistry) 4.11 1.25
Feeling Face-to-Face (Medicine) 4.25 1.28 2.50 0.013
Blended FFC (Dentistry) 3.65 1.50
Total Mean Face-to-Face (Medicine) 4.42 0.97 2.44 0.016
Blended FFC (Dentistry) 3.94 1.24
Karimian et al. BMC Medical Education (2024) 24:137 Page 9 of 17

out of 6, the face-to-face group scored higher than the Question 3


electronic method (Table 3). We compared self-assessment scores of students’ knowl-
In the differential analysis of questionnaire items, the edge of clinical biochemistry course topics in the face-
results showed that in most cases the average scores of to-face and blended FFC groups. Having been taught five
the face-to-face method items were higher than those main topics of biochemistry, the students were asked to
of the blended method. Nonetheless, in item 18, which self-evaluate their knowledge before and after the course.
refers to the possibility of adapting to the student’s con- The score range was between 1 and 6, with the cut-off
ditions and time constraints, the score of the FFC group point or expected mean being 3.5. The paired t-test in
was higher (4.14 ± 1.55). (Table 4). the last column (significant level) shows that the stu-
dents considered the amount of knowledge gained in this
course to be significant in all five areas. Comparison of
Question 2 the basic knowledge of the participants before the start
By comparing the students’ scores of final exams in the of the course in the two groups showed a non-significant
face-to-face and blended FFC groups after the interven- difference in the pre-test p value*. In other words, both
tion, we found that although the average achievement groups were equal in terms of basic knowledge. Moreo-
test score of the students in the FFC group was higher ver, as the p value** post-test column shows, the amount
than that in the face-to-face group, this difference was of knowledge gained in both groups was not significantly
not significant (P = 0.758) (Table 5). different in all titles and headings. Given that the average

Table 4 Average satisfaction of students with the quality of clinical biochemistry training in face-to-face and FFC groups
Components Items Face-to-Face Blended FFC
(Medicine) (Dentistry)
Mean Std. D Mean Std. D

Effective content 1. The quality of the scientific content presented was appropriate 5.13 0.970 4.41 1.337
2. Scientific materials were presented in order and sequence 5.11 0.916 4.47 1.138
3. The scientific content covered the educational goals and needs 4.90 1.094 4.41 1.223
4. The teacher gave good examples when presenting the lesson 5.02 1.097 4.61 1.115
5. The volume and speed of presenting the lesson content was appropriate 4.82 1.154 4.24 1.562
6. The good combination of images, text, and … was used to present the lesson 4.55 1.396 3.78 1.598
Active learning 7. There was opportunity for discussion, question and answers in class 4.06 1.343 3.45 1.672
8. It was possible to critique, argue and think about topics 4.16 1.401 3.96 1.353
9. 1. Students actively participated in the learning process 4.33 1.332 3.37 1.654
10. There was ample opportunity to interact with the teacher in class 4.63 1.247 3.88 1.550
11. I did not worry about taking notes and notes in class and focused on the lesson 4.98 1.093 3.80 1.472
12. I learned from the questions and answers and discussions of my classmates 4.30 1.205 3.57 1.633
Questioning 13. The pre-teaching questions increased my attention to the main points of the lesson 4.31 1.383 3.35 1.866
14. Questioning during the class after each topic, was helpful to review and memorize 4.80 1.027 4.10 1.403
15. The short quizzes were helpful in self-assessing and identifying learning difficulties 4.48 1.143 3.82 1.629
Flexibility 16. Before the class started, I read the lesson and prepared for class 4.64 1.320 4.10 1.229
17. After class, I had the opportunity to practice and repeat the lesson 4.47 1.354 3.86 1.414
18. The lesson was presented was adapted the speed of my learning 3.97 1.440 4.14 1.555
19. The presentation method was compatible with different learning styles of students 4.34 1.196 4.22 1.517
Feeling 20. I feel comfortable learning the lesson 4.16 1.401 3.96 1.353
21. I feel more motivated to learn biochemistry 4.31 1.383 3.35 1.866

Table 5 Comparison of students’ knowledge scores of final exams in face-to-face and FFC groups
Groups N Mean Std. D t Sig

Scores of Summative Exam Face-to-Face (Medicine) 100 13.65 2.30 0.30 0.758
Blended FFC (Dentistry) 60 13.77 2.61
Karimian et al. BMC Medical Education (2024) 24:137 Page 10 of 17

scores were more than expected, i.e., 3.5, the results indi- “questioning” (P = 0.015) (Appendix 1). Also, by com-
cated that both methods were effective in improving the paring the mean scores of females and males in the final
students’ knowledge (Table 6). exam in two groups after the intervention, we found no
significant differences although the average scores of
Question 4 females were a bit higher than those of the males in the
We examined the students’ satisfaction of the quality face-to-face education group (P = 0.21) and the blended
of the course and scores of final exams after the educa- learning group (P = 1.64).
tional intervention in two groups as to the background
variables. Academic grade point average
The research population consisted of all the students of We divided the students’ academic grade point average
medicine and dentistry in the 2nd semester; demographic (GPA) into three ranges: 12 to 15, 15 to 17, and above 17.
characteristics of these two groups in terms of mean age, We then used the analysis of variance (ANOVA) test to
grade point average, and year of study did not differ much. compare the total average of the satisfaction scores with
In terms of access to computers and the Internet, most the quality of clinical biochemistry. However, we found
had access with no comparable subgroups. However, it no significant difference (P = 0.255) in the total score and
was possible to investigate the effect of two factors, gen- in the sub-components (P > 0.05).
der, and academic average on the students’ viewpoints.
Students’ free comments
Gender An open-ended question at the end of the satisfaction
By comparing students’ satisfaction with the quality of questionnaire assessed the students’ opinions about bio-
clinical biochemistry courses in face-to-face and FFC chemistry education. We asked the participants to express
groups, we found that gender difference did not have a their opinions about the way the course was presented.
significant effect in the total score (P = 0.255) or in the Table 7 summarizes the opinions raised by the two groups.
sub-components (P > 0.05). However, from the point
of view of the students in the face-to-face group, a sig- Discussion
nificant difference was observed in the average qual- One of the challenges in teaching basic medical sciences,
ity score by gender (P = 0.011), with females giving a including biochemistry, is that it takes much training
higher score to the quality of face-to-face education than time to tackle the large amount of content, the difficult
males. Females also gave a higher score to "content effec- structures, and specialized words. In recent years, basic
tiveness" (P = 0.006), “active learning” (P = 0.029), and science teachers have been seeking creative solutions in

Table 6 Comparison of the students’ pre- and post-test self-evaluation in face-to-face and FFC groups
Lesson outlines Groups Pre-Test Post-Test t Sig
Mean Std. D Mean Std. D

Digestion and absorption of fats Face-to-Face (Medicine) 1.66 0.945 4.09 1.457 -16.32 < 0.001
Blended FFC (Dentistry) 1.49 0.856 3.94 1.566 -12.01 < 0.001
Between Group Sig *P = 0.234 **P = 0.632 - -
Oxidation mechanism Face-to-Face (Medicine) 1.56 0.934 4.06 1.480 -14.79 < 0.001
Blended FFC (Dentistry) 1.41 0.762 3.78 1.403 -12.72 < 0.001
Between Group Sig *P = 0.239 **P = 0.262 - -
Fatty acid biosynthesis Face-to-Face (Medicine) 1.53 0.919 4.13 1.506 -14.97 < 0.001
Blended FFC (Dentistry) 1.39 0.759 3.73 1.411 -12.33 < 0.001
Between Group Sig *P = 0.315 **P = 0.131 - -
Cholesterol metabolism Face-to-Face (Medicine) 1.50 0.852 4.10 1.482 -15.77 < 0.001
Blended FFC (Dentistry) 1.43 0.890 3.84 1.477 -11.24 < 0.001
Between Group Sig *P = 0.570 **P = 0.322 - -
Metabolism of Eicosanoids Face-to-Face (Medicine) 1.52 0.974 3.81 1.771 -12.08 < 0.001
Blended FFC (Dentistry) 1.41 1.059 3.86 1.541 -10.83 < 0.001
Between Group Sig *P = 0.522 **P = 0.866 - -
*P: P-value of the between groups comparison in pre-test
**P: P-value of the between groups comparison in post-test
Karimian et al. BMC Medical Education (2024) 24:137 Page 11 of 17

Table 7 Challenges of face-to-face and FFC methods from students’ free comments
Comments N

FFC Group
• I could not easily use the LMS, many times the system had problems 10
• I had trouble logging into the system and sometimes the ID and password could not be recovered 9
• The text content was not easy to see on my mobile. But the figures were useful (participants who only had a mobile) 18
• Due to the speed of the Internet, downloading files was difficult and time-consuming 18
• The contents were great and useful, but I couldn’t easily download them at the beginning of the semester 14
• The text booklet was downloadable, which was very useful for browsing at home, but downloading multimedia content was not convenient 15
• The e-contents (multimedia) were very useful, and I could repeat them regularly 25
Face-to-face Group
• In biochemistry class, I always worry about taking the handout 8
• The professor taught very fast and sometimes I could not read the entire booklet 9
• We always recorded the teacher’s voice in the class, but it takes a long time to download the voice and set the handout 8

their classrooms by using new technologies. Thus, they Moreover, based on the results of the present research
are in search for more effective classroom methods. As in the learning dimension, the average grades of the stu-
such, they have been turning to e-learning and online dents at the end of the semester as well as the self-evalu-
methods. Nonetheless, little research has been done in ation of the students did not show a significant difference
this regard. between the two groups. In other words, the students in
both groups had similar academic performance.
It is essential to mention in the interpretation of the
In the studies on the dimension of satisfaction, Mirzaei
results that this research was conducted before the
et al. (2012) investigated the attitude of 150 students in
COVID-19 pandemic. At that time, there was not
Yazd University of Medical Sciences towards e-learn-
much experience with e-learning and online edu-
ing in a cross-sectional descriptive study. Much in line
cation, and instructors often used traditional and
with our findings, they found that the students who had
in-person teaching methods. Therefore, students
experienced some sessions of biochemistry lessons in
did not have much skill in working with LMS and
a blended learning context had a positive view towards
other related technologies. As a result, a portion of
this type of teaching method [65]. In most of the simi-
the FFC method’s grade was influenced by students’
lar studies, the presence of e-content and resources are
computer skills."
often noticed and welcomed by students in terms of the
confidence and educational support it creates. As in the
It is possible that if this study were conducted now,
part of free comments of students, the face-to-face group
after the COVID-19 pandemic, the results would be
showed that some students were worried about notetak-
significantly different. The pandemic has led to the
ing, while the students in the FFC training group believed
strengthening of students’ computer and electronic
that the presence of pre-prepared content would allow
skills, and the skills of the instructors in utilizing
them to review and repeat the material. In line with our
electronic infrastructures have improved.
findings, Varghese et al. (2012) investigated the opin-
In the present study, we attempted to compare face-to- ions of students about the use of e-resources of univer-
face and blended FFC methods under similar conditions sity MOOCs in a study in a medical college. In the survey
of academic content and the lecturer. Examining the conducted, 98% of the students had used the provided
dimension of satisfaction, we found that the participants e-resources in different cases. Most of them found the
in face-to-face and FFC blended learning were satisfied provided e-resources useful and of high quality. Most of
with either method; however in the sub-components, them used these resources to get prepared for the mid-
the participants were more satisfied with the face-to-face term and final anatomical assessment in the course. The
method than FFC. This difference was especially higher use of these resources increased steadily as the academic
in the "active learning" subcomponent, but there was year progressed, and the students (83% of the respond-
no significant difference in the "flexibility" component ents) stated that, due to using these resources, their
between the two methods, where the participates rated comprehension had improved. Likewise, 86% of the
the FFC method a bit more favorably. respondents stated that their ability to answer questions
Karimian et al. BMC Medical Education (2024) 24:137 Page 12 of 17

in assessments had improved. Meanwhile, 73% of the enthusiasm had a positive effect and led to better stu-
respondents also said they found biochemistry interest- dent–teacher communication, though overall the face-
ing, and 59% stated that they felt motivated to study the to-face method was significantly more effective [66],
subject [8]. perhaps because the quick feedback and two-way inter-
In another study, Münch-Harrach et al. (2013) investi- action between the professor and the students created an
gated the delivery of a medical biochemistry course using active learning environment in the classroom. Similarly,
audio podcasts and individual study by UKE University we found that face-to-face classroom was more facilita-
students in the period from 2008 to 2012. They found that tive of active learning and discussion and questions in the
the students were very satisfied with this method. Pod- classroom.
casts were prepared on a practical biochemistry course In a quasi-experimental two-group study carried out
on lipoproteins. The quality of the course was meas- in 2015, Jensen et al. compared active flipped classroom
ured by indicators such as comprehensibility of content, and regular active classroom. They found that the flipped
preparation for practical parts, preparation for exams class did not necessarily lead to increased learning or a
and preparation for course quizzes, and "preparation for better attitude than the face-to-face class. Students per-
practical parts" received the highest score [4]. Shanthiku- formed equally well in the exams and in a final compre-
mar (2009) found that in the blended method, the use of hensive exam. In addition, students’ satisfaction with
pre-prepared podcast content was effective in enhancing the class and achievements of scientific reasoning abil-
the learning of medical students when presenting lec- ity were equal in both conditions [73]. The results of this
tures [69]. In addition to experimental and semi-experi- study were inconsistent with ours in terms of satisfac-
mental studies, Birgili (2021), in a descriptive analytical tion, but in terms of achievement test scores, they were
study of the content of articles related to the results of consistent with ours. Jensen believes that when active
the flipped class from 2012 to 2018, reported positive learning methods such as discussions and question and
impact cognitive, emotional and soft skills as well as answer are used in the teaching methods, there will not
academic performance [48]. In 2021, Balakrishnan et al. be much difference between the flipped class and the
also showed in a meta-analysis of 20 studies on blended face-to-face class, so the determining factor is the type of
learning in the field of pharmacy that the blended learn- interaction created.
ing approach had a positive and significant effect on the Malekigorji et al. (2020) presented the innovative
knowledge and skills of learners [70]. Moravec et al. in model of super blended teaching, taking into account that
2010 showed that in large biology classes, the groups that sometimes socio-cultural differences and limited teach-
studied the large part of the content before the class, i.e., ing time in large classes prevent students from interact-
flipped class where the time the face-to-face class was ing and actively learning. In this model, he presented a
dedicated to questions and answers, quizzes, and doing teaching and learning model by combining accountabil-
homework, better grades were obtained [71]. ity system in the classroom with the flipped classroom
Blended and flipped classrooms ensure that the con- and team-based learning. It also allowed students to use
tents of the course are available before or parallel to their smart devices (e.g., phones, tablets, and laptops) to
teaching, in addition to student educational support. answer a variety of numerical, multiple-choice, short-
Hence, they create more flexibility in terms of the possi- answer, and open-ended questions presented during
bility of reviewing the course regardless of time and place classes through the CRS classroom response system to
limitations. This point was confirmed both in the results encourage them to do class activities. The Flipped-CRS
of the free comments of students. However, in the review approach requires students to pre-read e-learning mate-
of previous research, the findings of Vaona et al. (2018) rials and watch the recorded lectures before meetings and
are also worth considering. In a systematic review, they use their knowledge in the classroom. TurningPoint CRS
found that the results and effectiveness of using e-learn- software makes it possible to answer questions individu-
ing depended on the research conditions. His study ally or as a team. They found that the learners positively
showed that e-learning was associated with many posi- viewed F-CRS. Moreover, the super-blended teaching
tive effects when compared to lack of intervention, and and learning model increased the students’ cooperation,
that e-learning showed less or similar effectiveness com- motivation, engagement, attendance, and academic per-
pared to traditional educational interventions (without formance, especially when using F-CRS method in teams.
access to e-learning) [72]. The ultra-blended approach enables the teachers to mon-
In a quasi-experimental pre- and post-test study on 60 itor student participation throughout the year, facilitates
medical students who had taken the biochemistry course, formative assessment, and helps teachers predict raw
Jafari (2012) found that blended method increased satis- classroom performance in summative assessments [9].
faction and motivation. He also reported that students’ In a study inconsistent with our findings regarding the
Karimian et al. BMC Medical Education (2024) 24:137 Page 13 of 17

evaluation of teaching metabolism in the biochemistry FFC method, we can point to the way the course is pre-
course to undergraduate students, Booth et al. (2021) sented. In our study, the e-content was prepared based
found that simulation-based methods with the possibility on the standard multimedia principles, but the duration
of feedback and correction, along with a blended course, of each multimedia content was often close to 40 to 45
in a dynamic model and Online Computational Systems min, which caused an increase in the size of the file. Fur-
increased cognitive skills and abilities of students com- thermore, the students complained about the low-speed
pared to the group that received simulation training in a Internet or the cost of downloading files. This problem
non-blended learning course [74]. They concluded that in might have caused limitations for students; as stated in
interactive teaching methods, especially those with feed- the review of the opinions of the qualitative part of the
back, time was a vital factor. The face-to-face classroom study, the students mentioned operational problems such
is facilitative of teacher’s care and supervision of the stu- as low Internet speed and problems downloading files.
dents, unlike the flipped classroom method. They con- Moreover, the type and format of the e-content file are
clude that if there is a way to communicate and interact also important in making it easier for users. For exam-
with the students in the flipped classroom, this method ple, it is more difficult to download files with a large
may be more effective. It should also be noted that Booth volume on a mobile phone, or some file formats cannot
et al.’s research was conducted in 2021 and after the be viewed on a mobile phone (for example, EXE format
Corona pandemic. Considering the suddenness of the files). It is important, and it would be better to consider
COVID-19 pandemic and its quick and binding effects the user’s conditions. To solve this problem, it is recom-
on changing educational methods, after the pandemic, mended that a micro-learning approach to developing
the students and professors became skillfull in working course contents should be adopted, especially in com-
with electronic and computer tools, leading to a better munities that face more limited network infrastructure or
use of blended learning and content. low Internet speed. In this regard, Prakash et al. (2017)
However, in terms of the learning scores or academic reported that three-to-five-minute audio podcasts were
performance, the results of our research showed that accepted by students as a useful and convenient sup-
both the students’ self-evaluation score and the end-of- plementary tool. They reported that students used pod-
semester score of the students in the two face-to-face casts for coursework, general reviews, and quick revision;
and combined methods were not significantly differ- most of them felt that podcasts helped them improve
ent, which is in line with Jensen et al.’s research in 2015. their understanding of the subject matter, clarify con-
[73]. In a similar study, Sajid et al. (2016) examined the cepts, focus on important points, and prepare for exams.
effectiveness of web-based blended learning. They found Approximately 49% of the students felt that the duration
that from a total of 127 students, about 22.8% felt that of three minutes was optimal, and the rest described the
the professors’ lectures should be given in a face-to-face duration between three and five minutes as optimal [77].
context, but almost 35% felt that one-fifth of all lectures In a study in 2017, Herbert et al. tested over 250 under-
should be given online. Students expressed satisfaction graduate students of UNSW Sydney faculties of medical
with blended learning as a new and effective learning sciences using the flipped teaching method in teaching
approach. Most students reported that blended learn- pathology. The researchers changed the duration of class
ing was useful for test preparation and concept clarifica- lectures to about 12–18 min online and designed and
tion. However, the comparison of grades did not show a held the course content in the form of short courses in
statistically significant increase in the academic perfor- the form of slides, animations; highlighting the main
mance of students taught through the blended learning points; and containing interactive questions and tests,
method [75]. and e-content. ispring software and PowerPoint were
Rabiepour et al. (2016) reported that the post-test used with Scorum output. Interaction and participation
scores of midwifery students in the blended learning and feedback in large groups were possible through an
method in the fetal health assessment course were sig- Echo360 (ALP) platform. They concluded that the flipped
nificantly better than their scores in the pre-test, indicat- method and short modules increased the students’
ing a significant increase. However, the post-test scores understanding and strengthened active learning. Mod-
of the students of the face-to-face group were higher ules were enjoyable, and this combination was effective
than the average scores of the blended learning group in increasing the students’ satisfaction and learning [32].
[76]. They concluded that the difference might be due to It should also be noted that although most students
demographic variables, level of activity and feedback, and have access to mobile phones, not all students have
interaction in face-to-face classes. access to laptops or computers. Thus, it is necessary to
However, in explaining the reason for the higher use the combination of image and sound more than text
mean score of the lecture method compared to the and sound in the creation and production of e-content.
Karimian et al. BMC Medical Education (2024) 24:137 Page 14 of 17

After all, on the mobile page, the writings are smaller and and Dentistry). Although we could not divide one class of
sometimes not readable, while the images are better seen. students into two groups to prevent data dissemination,
This point was also mentioned in the qualitative com- we tried to choose a distant field with similar initial char-
ments of the participants in this study. In a similar vein, acteristics. We suggest that in future studies, compari-
Khojaste et al. (2022) reported that the level of students’ sons should be made randomly and from the same group
access to electronic tools and devices affects their satis- of students.
faction with the quality of the course [78].
Conclusion
Limitations of the study Both face-to-face and FFC blended learning methods
The important point in the analysis of the results is that were effective in enhancing the students’ knowledge
the data of this research was collected before the Covid- and satisfaction with a similar effect on their academic
19 pandemic. Shiraz University of Medical Sciences performance, but the students in the face-to-face group
is one of the most important and largest universities of showed more satisfaction than those in the blended
medical sciences in Iran and has more than 17 main fac- learning group.
ulties and 54 research centers. In 2009, the virtual edu- It seems that factors of "interaction " in face-to-face
cation center of the university was launched, offering teaching have a greater impact on students’ preferences.
basic infrastructures such as LMS and e-content develop- Moreover, the students acknowledged that e-content had
ment center. However, due to easy access to classrooms a better fit with their learning needs and provided greater
and students, faculty members often use the traditional "flexibility" in their learning process. Blended learning
and face-to-face methods, rarely using online methods has the merit of advanced preparation of e-content and
in the delivery of their courses. Thus, both professors educational support for students, but the face-to-face
and students had very limited experience in e-learning; method has the merit of live human interactions, lack
therefore, the computer and electronic skills of students of intermediaries, punctuality, and the direct care and
in working with e-learning tools were limited. As men- supervision of students by the professor. They are espe-
tioned in the free comments, initially a large number of cially important for new students or those with lower
students had problems of working with LMS and did not educational levels. In addition, it seems that various fac-
have sufficient mastery. Another limitation that future tors such as the type of interactions and classroom activi-
researchers need to pay attention to is that the junior ties; type, volume and time of e-content; facilities and
students participating in this study were in the second conditions of students; and type and extent of access to
semester, and they need to work with their professors electronic tools and devices have an effect on the effec-
face-to-face. It is possible that if this study were con- tiveness of teaching methods. Therefore, in the educa-
ducted on senior students, the results would be different. tional design of courses, it is necessary to set appropriate
Also, we used two different groups of students (Medicine plans according to different conditions.

Appendix 1 Comparison of male and females’ views on quality components in face‑to‑face and FFC model

Components of Gender Face-to-Face (Medicine) Blended FFC (Dentistry)


Quality
N Mean Std. D t Sig N Mean Std. D t Sig

Effective content Female 26 5.34 0.55 2.83 0.006 20 4.20 1.14 -0.87 0.387
Male 65 4.81 0.89 29 4.48 1.07
Active learning Female 27 4.82 0.75 2.22 0.029 20 3.23 1.57 -1.61 0.112
Male 64 4.32 1.07 29 3.91 1.37
Questioning Female 24 4.93 1.01 2.47 0.015 20 3.58 1.55 -0.96 0.339
Male 67 4.30 1.07 29 4.00 1.42
Flexibility Female 24 4.12 1.052 1.24 0.216 20 4.03 1.24 -0.36 0.716
Male 66 3.72 1.22 29 4.17 1.28
Feeling Female 25 4.60 1.10 1.57 0.118 20 3.30 1.58 -1.38 0.174
Male 66 4.12 1.32 29 3.89 1.41
Total Mean Female 18 4.91 0.76 2.61 0.011 20 3.67 1.31 -1.15 0.255
Male 58 4.25 0.98 29 4.09 1.22
Karimian et al. BMC Medical Education (2024) 24:137 Page 15 of 17

Abbreviations Students Using the Traditional Teaching in Combination with Group


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Thompson K. Teaching Biochemistry to Students of Medicine, Pharmacy
& Dentistry: 5th International Conference of the Association of Biochem-
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