12 Chapter 1 the ICAP framework uses overt student behaviors to distinguish the four learning modes (31,36–38). In fact, one assumption of the ICAP framework is that student behavior is a good indicator of student engagement (8). However, critical questions have been raised about this. Verbal participation, for example, is an aspect of behavioral engagement and is typically seen as an indicator of student engagement (39,40). However, to show why this is not a reliable indicator, in one qualitative study, a student described speaking up in class just to get points without much effort (39). This motivation to get points without effort actually aligns with student disengagement. Therefore, being behaviorally active does not necessarily mean being cognitively active (36,41). And it seems that cognitive engagement has the strongest evidence linking it with academic achievement (1,25,30). Fourth, and related to the previous point, student disengagement is common and limits the effectiveness of active learning (26,42). As active learning is typically collaborative in design, it requires students to work together to develop their understanding. When a student does not engage, or even displays disruptive behaviors, they not only reduce their own learning, they can negatively impact the learning of others (25). Factors influencing disengagement are related to both intrinsic and extrinsic factors, such as motivation, unmet expectations, stress, teaching factors, and factors related to the curriculum and institution (26,42,43). Some of these factors may be directly or indirectly under the control of a teacher or of a study program, others are not. This means that although student (dis)engagement can be targeted through interventions, their success is not guaranteed (7). Furthermore, teachers may need to develop their competencies in addressing student disengagement (4,44). One common reaction of teachers experiencing student disengagement is to fall back on more passive learning methods, like lecturing, to avoid such negative situations in the future (45). To summarize, educational literature describes how active learning can be a more effective method to achieve desired student outcomes than passive learning. To be effective, it requires students to engage individually or collaboratively with the course material, preferably in a knowledge-generating way. However, educators should take four important criticisms into account: 1) active and passive learning combined might both be most effective in a learning process, 2) active learning implementation can vary, which affects its potential effectiveness, 3) designing engaging activities and identifying if students are engaged with the material can be difficult, and 4) student disengagement may be difficult to influence and limit the effectiveness of active learning. Thus, active learning can work, but how it is implemented matters. Implementation of active learning in medical education Active learning has been adopted and is increasingly becoming a cornerstone in medical education. The impact of curricular reforms to accommodate active learning is evident in the changing roles of both medical students and teachers within the learning process. Students are less perceived as consumers or clients and are increasingly recognized as partners. Simultaneously, teachers have transitioned from a focus on ‘teaching’ to a focus
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