Extensive literature exists on the advantages of the closure of educational institutions to decrease transmission of highly infectious diseases, so there was no debate necessary when opting to shut down universities.14,15,16 This ultimately shifted all institutions onto the platform of online education or e-learning. Our study aimed to review the effectiveness of using e-learning to incorporate knowledge in medical students of the Aga Khan University and to explore the experience of these students as they venture on this new journey.
The department of Pediatrics at Aga Khan University, together with the department of Educational Development, devised a plan to proceed with the newly faced challenge of an online module. Online learning is defined as learning experiences in a simulated environment using different devices with internet access and facilitate interactions with instructors and other students.17,18 We set up Zoom meetings of Pediatric faculty and students, included a comprehensive lecture, short "Kahoot" quizzes, pre and post-tests, and compared the knowledge of those who had gone through the rotation already with those only going through it online. It gave us a complete picture of how successful the online module had been in providing the appropriate knowledge and in keeping the students engaged. Though the online system of education is assumed to be a relatively new concept, if it is delivered in the right ways, it will be just as effective as in-person learning.19,20 Our study showed that the medical students were quite relieved that they would be able to continue their learning, and those that had already gone through the rotation agreed that topics were chosen following the normal clerkship. Our quantitative analysis showed that the majority of students were satisfied with the structure of the sessions as it was. Similarly, our qualitative focused group discussions with individuals from each group level of Novice, Semi-expert, and Expert, also approved of the format of the lectures as effective in solidifying concepts. A recent study was done in China that also showed that students perceived online-learning, especially during the pandemic, as useful and highly effective in acquiring relevant knowledge.21
Our results further show that students discovered the greatest advantage of this online module was the engagement and encouraged participation. This level of engagement is not usually present in usual in-person classes or rotations because here, students were called out by name in video-call sessions to partake in discussions and then followed with surprise quizzes. When discussing this in the focused group, students stated that initially, they did not like the level of interaction, as it was out of the norm and made some of them anxious. But as the lesson plan proceeded, a majority agreed that it was the best way to stay attentive during the sessions. Our quantitative results correspond with this same aspect, as a majority of students chose 'agreed' for being engaged during the sessions. Results from a similar study emphasized that for e-learning to have an educational impact, importance has to be given to student engagement and interaction.22 Other studies also stated, to be successful, online programs should be designed in a way that they are student-centered and group-based.23,24 We also implemented this as we divided the students into groups according to their level of expertise. Furthermore, the students also exhibited annoyance at being in the same sessions as their experienced or inexperienced counterparts. Group-based learning proved to be more popular.
A positive impact of our online module was the dedicated and ample time received from faculty. Our quantitative feedback shows that a greater number of students agreed that ample time of interaction was given, and during our qualitative group discussion, students saw it as an advantage to be given such unique exposure to faculty. Under normal circumstances, the students would have exposure to different faculty at different times, and there would be a bias created, as every faculty would have a different way of facilitating or teaching. But through this online format that bias was removed, and all students were exposed to the same teacher. Furthermore, these lectures were recorded, and students were able to go back to see them any number of times and at any given time, but routinely one cannot always bother an attending to review a lesson. A study from India agreed that the "Anywhere-Anytime feature of e-learning" is beneficial for students in all fields.25 Besides the fact that the students had appropriate resources and timing to revise, the benefit was perhaps two-fold, as the facilitators also were better prepared. An overwhelming majority of our students agreed that the facilitators were well-prepared and had a substantial amount of knowledge of the topic they taught.
Regarding our data collected on the test scores, a trend of consistent improvement could be seen among the students in their post-test results compared to the pre-test results. Many students agreed that the tests were the main reason the sessions were successful. It gave them a chance to view their gap in knowledge and fill it with their online class and then re-evaluate themself afterward. This makes the students proactive in reading up before lectures, being diligent during the class, making notes, and then revising for the post-test. Other studies have also shown that testing students’ knowledge before and after online sessions is a very effective way of learning, and most students will always show some improvement in the post-tests.26,27 However, a major error in the tests was the unavailability of answers to the quizzes. Providing students with their answers could help them learn from their mistakes and ultimately enhance the power of the tests as a tool of education. Beyond just for learning, the pre and post-tests results can also be used to assess the competency of the lectures.3 From our results we can judge whether the lecture content was not known to the students before, based on their pre-test scores, and then if it got known or not after the lecture, based on their post-test scores. Since our mean data showed an improvement in all the scores, we can conclude the lectures were useful in providing them the required knowledge.
Additionally, a major concern was if the Expert students have an unfair advantage in this online module, over the other groups, since they had already rotated through the Pediatric clerkship before the pandemic began. But through our ANOVA analysis, this concern was addressed, and it was surprising to note that there was no significant difference between Expert student learning and the learning of the Novice and Semi-expert groups. Hence, we can conclude that all the students got an equal opportunity to learn and that the online module was successful in providing the theoretical knowledge normally received during the Pediatric clerkship. Similar studies in the past have also shown that medical students have accepted online training as an equal or better learning experience than the classroom sessions.28 In the future we can aim to further improve on such online content and be somewhat confident that students will not miss out on any essential lecture teachings they receive in-person.
However, lectures and discussions compose only a minor component of the existing curriculum in medical schools, so just converting it to an online platform is not enough to satisfy a full clerkship. Online content is all theoretical and does not let students apply or practice their learning in real-life situations. When asking our students for suggestions on how to make this online-module more effective, a few suggestions of virtual patients and "tele-clinics" were put forward. During their normal rotation, students would have clinical examination practice sessions and Problem-based-learning group discussions, that were now missing. Finding ways of re-incorporating these into the online module could have proved to be more successful and relevant. Technology has become very advanced and virtual patients, simulations, video triggers, and voice-covers can be easily used to implement real-world scenarios.29
In a meta-analysis done on articles from 2000–2017, to differentiate between online and offline learning via pre and post-tests, 7 articles reported no significant difference between the two teaching methods, and 9 articles reported significant improvement in the online learning groups.30 It might be worthwhile to combine the advantages of online and offline teaching methods and adopt a blended learning technique for future modules.31,32 After all, these students are being trained to become the healthcare workforce of tomorrow and need to be able to deal with real patients, as well as navigate through the latest technology, so that we can better prepare them to face the post-pandemic world.
Limitations
This study only applies to one medical student rotation and equal number of student participation was not present in each session. We had a varied number of student feedback in each session and a low response for suggestions of improvement.