Number of Citations: 4

Submitted: 14 August 2020
Accepted: 6 November 2020
Published online: 13 July, TAPS 2021, 6(3), 45-55
https://doi.org/10.29060/TAPS.2021-6-3/OA2377

Nathalie Khoueiry Zgheib¹, Ahmed Ali² & Ramzi Sabra¹

¹Department of Pharmacology and Toxicology, American University of Beirut Faculty of Medicine, Beirut, Lebanon; ²Medical Education Unit, American University of Beirut Faculty of Medicine, Beirut, Lebanon

Abstract

Introduction: The forced transition to online learning due to the COVID-19 pandemic has impacted medical education significantly.

Methods: In this paper, the authors compare the performance of Year 1 and 2 classes of medical students who took the same courses either online (2019-2020) or face-to-face (2018-2019), and compare their evaluation of these courses. The authors also present results of three survey questions delivered to current Year 1 medical students on the perceived advantages and disadvantages of online learning and suggestions for improvement.

Results: Performance and evaluation scores of Year 1 and 2 classes was similar irrespective of the mode of delivery of the course in question. 30 current (2019-2020) Year 1 students responded to the survey questions with a response rate of 25.4%. Some of the cited disadvantages had to do with technical, infrastructural and faculty know-how and support. But the more challenging limitations had to do with the process of learning and what facilitates it, the students’ ability to self-regulate and to motivate themselves, the negative impact of isolation, loss of socialisation and interaction with peers and faculty, and the almost total lack of hands-on experiences.

Conclusion: Rapid transition to online learning did not affect student knowledge acquisition negatively. As such, the sudden shift to online education might not be a totally negative development and can be harnessed to drive a more progressive medical education agenda. These results are particularly important considering the several disadvantages that the students cited in relation to the online delivery of the courses. 

Keywords:           Online Learning, COVID-19 Pandemic, Medical Students

Practice Highlights

• The authors report on the forced transition to online learning due to the COVID-19 pandemic.
• The performance and evaluation scores were similar in online delivery vs face-to face. 
• The sudden shift to online education might not be a totally negative development despite the several disadvantages that students cited.

Survey question	Theme	Quote
Advantages of online teaching and learning in comparison to face to face teaching and learning	Time flexibility with asynchronous learning	“Better scheduling that allows us to sleep and rest at night in order to wake up better prepared to ace those PowerPoints” (S9) “Easier to manage our time” (S18)
	Control of learning pace with VOP	“Being able to speed through slides/concepts we already understood and pausing and replaying concepts that we have trouble with makes the whole learning process a lot more efficient and focused” (S27)
	More wellbeing	“Less time to commute which allows more time to rest and take care of oneself” (S9) “Having a very healthy diet with my family in the village” (S12) “The [exam] performance is better and stress in minimal” (S23)
Disadvantages of online teaching and learning in comparison to face to face teaching and learning	Potential for procrastination and loss of motivation	“Less motivation, harder to follow the schedule, requires strong time management skills” (S5) “Face to face teaching helps me organize my day better” (S4) “Being at university with other students around studying during the day motivated me” (S26)
	Bad internet connection	“Internet connection in our country is not stable to hold a class or an exam, so we are resorting to 3g/4g. This leads to a lot of extra expense” (S3) “Time consuming” (S2) and “Sessions would run for more than their original allocated time” (S3) “Longer exams might coincide with the times of the electricity shut offs. This would automatically freeze Respondus and the student will have to restart their computer and so on. Although we are given extra time this adds a lot of stress to an already stressful situation” (S19)  “Asking questions are much more difficult and needs much more time” (S7) “WebEx needed a stronger Wi-Fi in some sessions which leads to a harder way to grasp the information” (S18) “The internet connection everywhere in Lebanon is not the best, sometimes we have trouble listening. Sometimes it also gets really crowded when everyone wants to talk at the at the same” (S21)
	Home environment less conducive to learning	“Not everybody has the privilege of adjusting their environments to their liking, whether that be because of their dog barking or their family members not respecting their study time” (S28) “This experience helped my appreciate how much I concentrate better in the library” (S9)
	Loss of interaction with teachers	“No direct interaction, harder to communicate directly with professors” (S2) “Face to face interaction was lost: no clues to non-verbal clues, no gestures seen” (S17)  “It is true that we can always email the doctors for any additional questions but that does not compare to in person interactions” (S19)
	Loss of interaction with students	“not being able to interact with my friends” (S12) “Students lose their social skills as they interact less with each other-more into introversion” (S17) “You feel there is a barrier between you and the students” (S17)
	Lack of immediate feedback	“One problem is during exams not being able to see my mistakes” (S15) “Not correcting our exam and not seeing our mistakes was a huge disadvantage for the online learning” (S18) “Restricting questions to only emails” (S11) and “some professors don’t respond to emails” (S16) and “the response may be delayed” (S29)
	Loss of hands on experiences	“No hands-on experience for courses like clinical skills” (S3) “Mainly missing out on clinical skills” (S22)
	Faculty’s lack of IT knowhow or experience	“Professors have different abilities and effectiveness in knowing how to do a VOP/online lecture” (S11) “Most Drs. don’t know how to use zoom or WebEx” (S6) “Many instructors are not technically inclined or are outright aversive to it” (S13) “So much time is wasted on technical issues” (S19) “Professors sometimes don’t see the raised hands and sometimes it doesn’t even work. In some lectures we had to wait for the professor to give us access, so we spent time waiting while they didn’t see that some people are trying to access the lecture” (S21) “One of the disadvantages is using the live WebEx sessions. Some professors are losing their recordings, others have a poor connection” (S23)
	Effect on faculty’s teaching skills	“Some professors …just read instead of teaching” (S7) “Many professors are not exactly cooperative in terms of explaining mainly because they read their PowerPoints” (S23) “Can’t explain a topic and be passionate about it if talking to a screen or microphone” (S23)
Suggestions to improve the current online teaching	Technical support and knowhow	“Train the staff on the proper way of utilising the platforms” (S2) “Make IT staff more readily available to help instructors” (S16) “Agree on one way to give the lecture via WebEx as some professors used WebEx team, where we had to ask permission for access, and it was kind of chaotic. It would also be better if the professor agreed on one way to have the questions asked to avoid interruptions and multiple people talking at the same time” (S21)
	More VOPs and less WebEx for lectures	“I think VOP is a much safer option and a less tiring one” (S23) “Revert from live WebEx sessions to VOP” (S3)
	More interaction and immediate feedback	“Open forums for discussion” (S3)  “Adding analytical questions in PowerPoints” (S9) “See exams and mistakes” (S15) “If the professors want to use WebEx … then they should allow questions at all times and not only at the end of the session” (S11) “Include small assessment questions (clicker like questions) at the end of each major concept so that the students can assess their understanding” (S19) “Recording voice over PowerPoint for lectures, with every group of lectures followed by a WebEx session where the professor answers questions” (S24) “Review/Q&A session once a week” (S25)

Table 1. Themes Generated from the Three Survey Questions with Selected Representative Quotes

VOP: Voice Over PowerPoint

As shown in Tables 2 and 3, there were no statistically significant differences in the MCAT scores between any two classes that were compared. The performance of the Year 1 students on the CMM course during the current academic year (online) was higher than that of students during the previous year (face-to-face); however, the passing grade for the two courses was slightly different.  When the passing grades were equalised, there was no longer a difference between the two classes. Similarly, there was no difference in the performance of the Year 2 students on either the CMM course they took in Year 1, or on The Kidney and Urinary System course between the current class and the previous year’s class (all face-to-face).

With regard to The Blood course, the grade on the final examination was significantly lower for current students (online) relative to their predecessors (face-to-face); however, the passing grades on these examinations were different, with the current year’s examination having a lower passing grade than last year’s. When the passing grades were equalised, there was no longer a difference in the performance on the final examination.

The performance of the students in the Human Development and Psychopathology course’s final examination was almost identical in the online group compared with their predecessors (all face-to-face). Interestingly, the passing grade on this year’s examination was lower than that on last year’s examination, such that when the passing scores were equalized, the current class had better performance on the final examination than last year’s class.

IV. DISCUSSION

Medical education scholars have been increasingly disseminating opinions about sudden transitioning to online education to COVID-19 and the adaptations that are being implemented. Few studies have documented the actual institutional experiences, the perspectives of students, and the lessons learned in different medical courses or curricula such as TBL (Gaber et al., 2020), anatomy (Srinivasan, 2020) and continuing medical education in obstetrics and gynaecology (Kanneganti et al., 2020). Only one report from Wuhan, China, evaluated nursing interns’ outcomes on emergency medicine theoretical and practical examination scores (Zhou et al., 2020). The current paper is the first to examine the impact of this abrupt transition to online learning, which occurred in numerous countries worldwide, on the performance of our medical students in knowledge-based examinations. It reveals that the sudden shift to full online learning that our medical school had to adopt did not have a negative influence on the students’ knowledge acquisition as judged by their performance on final examinations. It also did not affect their overall reception and evaluation of the courses. These results are particularly interesting and important considering the many disadvantages that the students cited in relation to the online delivery of the courses. 

Many of the limitations and disadvantages of online education cited by students had to do with technical and infrastructural matters and with faculty know-how and IT support. These are problems that can, theoretically, be easily remedied. The more challenging, however, limitations had to do with the process of learning, what facilitates or hampers it, the students’ ability to self-regulate and to motivate themselves, the negative impact of isolation, loss of socialisation and interaction with peers and faculty, and the almost total lack of hands-on experiences. 

These limitations did not affect the students’ ability to achieve learning, at least in the domain of knowledge acquisition and application. It is clear that students in the three classes that were examined had, at baseline, a similar level of achievement meaning that any differences in student performance in the courses that were given online this year cannot be ascribed to differences in the academic performance or ability of the students. Therefore, the lack of difference in performance between classes taking the course online versus those taking it face-to-face suggests a consistency in performance that was not affected adversely by the sudden transition to online learning.

One reason for this lack of difference in performance between online and face-to-face delivery of the courses may be that the outcomes that were being sought and assessed were essentially knowledge acquisition and knowledge application. This agrees with the overall results of multiple studies that compared online vs offline learning in medical school, and which, in fact, tended to favour online learning (Pei & Wu, 2019). Indeed, even before our sudden shift to total online education, many of our students had adopted their own approaches to achieve the knowledge learning outcomes. Even though lectures were not available online, attendance at face-to-face lectures (which was not mandatory) was never complete, and for the majority of students, the rate of attendance ranged between 25% and 75% (unpublished data). In fact, the students indicated that they depended instead on notes and voice recordings made during the lecture that were shared by their classmates or predecessors, and that they used several Web-based resources. In contrast, attendance at TBL exercises and other interactive and small group sessions is mandatory at our school, and students uniformly participated in them, as they did in the online Zoom-based sessions. Thus, our students were probably well prepared for this sudden shift. In line with this view, Ferrel and Ryan (2020), in a recent editorial on the impact of COVID-19 on medical education, predicted that many medical students in their didactic years may perceive little change in their study schedule, since many of them already use outside resources and watch school lectures after they have been presented.

The lack of significant differences in scores and attitudes may also attest to our – and indeed all – medical students’ resilience and adaptability to difficult situations, for they are high-achieving and resourceful students who have been selected from among an exceedingly competitive group of applicants, and likely have the cognitive powers and non-cognitive qualities to meet such challenges.  Ferrel and Ryan (2020) also emphasised the need for medical students to adapt and be innovative during the pandemic, and to devise ways by which they can exhibit their skills, work ethics and teamwork. In fact, one of the advantages of the online shift that our students cited was the flexibility this approach afforded them in managing their time, setting their schedules, controlling their pace of learning and achieving better self-care. Nevertheless, some of them found it challenging to do so, and to regulate their environment and motivate themselves; rather, they seemed to require external cues or assistance to get into a learning mode, and found difficulty in establishing boundaries between work and home, as suggested recently by Rose (2020). In this context, it is noteworthy that our students preferred asynchronous to synchronous learning, and this is consistent with Daniel’s recommendation to use this approach because it gives teachers “flexibility in preparing learning materials and enables students to juggle the demands of home and study” (Daniel, 2020).

Our findings also raise questions about certain assumptions regarding student learning and the optimal teaching approaches for knowledge-based objectives, such as the value and benefits of face-to-face interactions among students and with faculty in a didactic context. Our results suggest that students can achieve these knowledge objectives without the personal interaction and contact with faculty. This, of course, does not address the non-cognitive learning outcomes that might be negatively affected by pure online learning. As summarised by Fawn et al. (2020), while content may be covered well in such abrupt transitions to online learning, we cannot be sure that the valuable non-cognitive learning that happens as a result of the “social activity, the relationship-building, the problem-solving, the dialogue and generation of ideas and the students’ own discovery of other content that has not been pre-defined by the teacher” has been achieved.

We cannot make definite, long-term conclusions from this single account that is restricted to 2 courses in the preclinical years, a brief period of time, and one institution, and a low response rate for the survey questions, but the results are encouraging, and may have implications for educational practice. The lack of decline in cognitive performance may suggest that the sudden shift to online education might not be a totally negative development. If our findings are reproduced or generalised, one can use them to validate what progressive medical educators have been advocating for years, that: online educational technology must change the way we educate our students; didactic lecturing should give way to flipped classrooms; and valuable teacher time must be expended to help students apply knowledge rather than to simply transfer information in scheduled lectures. Quoting Ezekiel Emanuel (2020), who in a recent article stated that the reconfiguration of medical education, fuelled by online educational technology, seemed inevitable, Wolanskyj-Spinner (2020) suggested that the coronavirus epidemic appears to be an inflection point that is forcing a disruption in how we teach medicine. At AUBFM, we have long pressed the faculty who teach medical students to record their lectures and use the scheduled class time thus saved to implement flipped classrooms, employing small-group-based, problem-solving and interactive sessions. While many responded, many also hesitated, objected, and even resisted. The following two additional comments provided by two students illustrate their frustration with the resistance of faculty and their hopes to move in that direction: 

“I really hope we can make online learning standard coming out of this phase … There was an attempt a few years ago but many instructors refused to be recorded or to fiddle with computers; we must seize the opportunity now.”

“Please never stop recording lectures, regardless of the status of live classes!”

Ahmed et al. (2020) recently reported that during the 2003 SARS epidemic in China, novel online problem-based learning techniques had to be implemented in one medical school that proved to be so popular that they were applied as part of the regular curriculum in later years. We believe that medical educators can harness the current disruption in how we teach medical students, and make use of to implement novel and sound educational practices and adopt a wide variety of valid approaches and tools that, otherwise, might have been resisted by unwilling individuals with entrenched ideas.

V. CONCLUSION

In conclusion, rapid transition to online learning did not affect student knowledge acquisition negatively. As such, the sudden shift to online education might not be a totally negative development and can be harnessed to drive a more progressive medical education agenda. These results are particularly important considering the several disadvantages that the students cited in relation to the online delivery of the courses. 

Notes on Contributors

Nathalie Zgheib developed the concept, collected and analysed data, and wrote the first draft of the manuscript. Ahmed Ali also developed the concept, performed the literature review, and revised the manuscript write-up. Ramzi Sabra also developed the concept, collected and analysed data, and revised the manuscript write-up. The three authors read and approved the final version of the manuscript.

Data Availability

The data that support the findings of this manuscript are available from the corresponding author upon reasonable request.

Ethical Approval

This is a report of experience with educational practices. It was confirmed by our Institutional Review Board (IRB) that the activities described in this article do not constitute human subject research.

Acknowledgments

 The authors wish to thank AUBFM faculty and medical students for their support, diligence and flexibility during the COVID-19 pandemic.

Funding

This study did not receive any funding.

Declaration of interest

The authors do not have any conflict of interest to declare.

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*Ramzi Sabra
Department of Pharmacology and Toxicology,
Faculty of Medicine,
American University of Beirut,
PO. Box 11-0236, Riad El Solh,
Beirut, Lebanon
Tel: +961-1-350000 Ext: 4848
Email: rsabra@aub.edu.lb