DOI: https://doi.org/10.21203/rs.3.rs-2323878/v1
To prevent the infection and outbreak of COVID-19, the education method has adjusted the conventional in-person classes to distance learning in recent two years. Most classes were lectures that could go well if the participants were familiar with the online operation and had a stable network environment. Nevertheless, classes such as problem-based learning (PBL) rely on plenty of discussions and still have some limitations for communication and group development. In this research, we surveyed the learning effects of face-to-face (FF) and distance learning (DL) in the medical PBL course at Cheng-Kung University for two individual classes. Tutors and students were requested to give grades for the five key areas (participation, communication, preparation, critical thinking, and group skill). Five factors are used to evaluate the learning effect of face-to-face and distance learning.
Compared with FF and DL methods, our research clarified that student learning effects would reduce participation, communication, and group skills by questionnaire survey. The tutors’ perspective regarded participation and communication ability as reduced at distance learning. But for group skills, one of the two classes showed no difference.
Our research provides an experience for the PBL class focusing on discussion and communication. In the post-pandemic era, whether face-to-face or distance learning, classes should be adjusted properly to let students conduct effective communication in time.
Due to COVID-19, the education method needs to change to conventional face-to-face (FF) methods to prevent the infection and outbreak of COVID-19. The healthy policy suggested that people avoid contacting others and adopt distance communication tools for daily communication in workspaces, education institutes, hospitals, etc. (Qian & Jiang, 2022). Because of the limitations of FF activity, the teaching system has started building up the online distance learning (DL) tooling to upload the classes' movies or teaching in real-time.
In the beginning, “distance learning" means separating teacher and learner in space and time (David Sewart, 1988). In 2002, Ulric Björck first reported information about asynchronous distance learning in social economy PBL class (Bjorck, 2002). Most communication was conducted in texts and can still delivered the information to class members. Brenda Ortiz at Columbia University also discussed distance learning in the PBL class (Ortiz, 2004). They clarified that readiness, interaction, and group development should be considered. However, at that time, asynchronous media were not affordable for everyone, and usually, the institute purchased them for the students. But now, distance learning is not about asynchronous but emphasizes synchronous learning. Synchronous learning means both voice and image can be delivered in time, just like teachers and students have face-to-face interaction on the internet.
Due to the help of global commercial cooperation and the development of the internet (4G and 5G), several distance online media have been released. Internet communication technologies and services present a feasible alternative solution for distance learning, especially when offered free of charge; this provides more choices compared with the hardware systems still offered at an immoderate price (Kotevski & Milenkoski, 2018)
Most classes were lectures that can go well if the participants are familiar with the online operation and have a stable network environment. Nevertheless, some classes rely on plenty of discussions. For instance, this research will focus on problem-based learning (PBL), a student-centered approach, and learning via peer discussion. PBL was initially coined and systematically developed by the Faculty of Health Sciences of McMaster University in the late 1960s in Canada. The University of New Mexico was the first to adopt a medical PBL curriculum in the United States. PBL is wildly promoted in medical courses globally, and this learning is more like self-learning, letting medical students train the ability to find answers via group discussion or knowledge searching and filtering. Several medical courses used PBL in their course design; A global investigation indicated that PBL classes are still conducted during COVID-19 for several medical education (Chang et al., 2021). Several countries need to switch classes online; however, whether learning effectiveness would be reduced or not still needs more investment.
Our research was surveyed during COVID-19, and all workers were conducted at National Cheng-Kung University (NCKU). National Cheng-Kung University started to teach PBL classes in the medicine department and implement the PBL learning style in the course “Introduction to Pathophysiology”. Pathophysiology means abnormal physiological symptoms and usually present in multiple syndromes. With the help of PBL, students can find possible physiological information via group discussion.
The PBL course design encourages students to interact more with the teacher and their class members to make the course close to the students. There are three systems different from the conventional lecture class in NCKU MED, including PBL, case-based learning (CBL), and team-based learning (TBL). The PBL class follows the block course and has corresponding cases. For each semester, in 18 classes, there will be 3 cases for the PBL learning, and each case schedule includes two discussions, a one-time group presentation, and a one-time group mini wrap-up. There will be two tutor meetings for the consensus conference and one reflection meeting in each semester (Fig. 1). It is still the only PBL class continually conducted in the department of medicine at NCKU.
COVID-19 appeared in 2019 winter, but it started to outbreak in Taiwan in March 2021; that is to say, we have approximately one and half-year for preparation. Such a PBL class relies on plenty of discussions requiring some course modification. During the early stage of the global COVID-19 outbreak, schools in Taiwan had delayed opening for two weeks, after which there was no large-scale school closure. To protect students from COVID-19 infection, the Ministry of Education has announced rules for suspending classes prepared and allocating medical supplies to the schools. In addition, schools are required to monitor students’ health conditions, maintain environmental disinfection, and follow up on the activities in which teachers and students have participated (CDC, 2020). The most severe epidemic appeared in May 2021; the Taiwan government announced a “Level 3 Alert” stary, which started from 19 May to 26 July 2021. During this period, all the classes should be proceeded via the internet and avoid face-to-face classes (Fig. 2).
This research was a retrospective study of distance learning during the COVID-19 pandemic from 2020 to 2022 in the department of Medicine, Cheng-Kung University. In this research, participants were medical students in their fourth year and joined the “Introduction to Pathophysiology” PBL class. This research project has been certified for exemption from Human Research Ethics Committee at National Cheng Kung University (NCKU HREC -Exempt- No. 111–511) (Suppl. Figure 1).
Due to the tutors composed of clinical doctors and professors for the college of medicine, they have known the epidemic process. They agreed that PBL needs to change the teaching methods (environment, setup, learning platform) in the 2020 tutors’ reflection meeting. We designed a guideline for online learning in March 2020 and let students practice during the class. In this research, three different class members were joined (Fig. 2): the class-2022, the class-2023, and the other class-2024. The class-2022 is the class that will graduate in 2022, and the class-2023 is the class that will graduate in 2023. The class-2022 started their PBL when there was still no pandemic in Taiwan. In their spring semester (Feb 2022), COVID-19 become more severe in other countries. Taiwan was still kept safe at that time and had no COVID-19 cases. The class-2023 started their PBL class Sep 2020, and they had experienced several online class tools and had an additional chance to practice the online platform of the class. The class-2024 experienced the serious COVID-19 period and post-COVID-19 time.
In the beginning, even though no COVID-19 case appeared in Taiwan, class tutors had already started the draft of the precautionary teaching methods. NCKU PBL teaching group tried to draft the teaching guideline for online teaching and reconsidered many items and setups which should be changed. Unlike the conventional lecture class, the components of the PBL course include a meeting room and a whiteboard to record the discussion. Nevertheless, all instruments cannot be achieved in the web class due to the prohibition on coming to school. Building the online environments for PBL needs more steps and measures for execution.
In the following new semester, our teaching group planned a rehearsal for online testing for all the tutors and students. The first problem is which online media we should choose. A more accessible and freer platform, or do we need to select a more reliable platform NCKU has already purchased to get more function and security? Compared with the traditional and web classes, some choices can find alternative approaches, but we need to test some options in real (Table 1).
Table 1. Comparison of traditional face-to-face (FF) and distance learning (DL) methods
| Objects | Traditional face-to-face | Distance learning |
|---|---|---|
| 1. Place | Meeting room | Google meets* / Cisco WebEx / Microsoft Teams |
| 2. Discussion | Directly talking | Microphone / webcam |
| 3. Record media | whiteboard | Typing texts / iPad writing application / Google draw* |
| 4. Handout | Papers | Electric pdf file / Mobile application (LINE OpenChat) |
| 5. Group presentation (< 12p) # | meeting room/projector | Google meets* |
| 6. Mini wrap-up (< 24p) | meeting room/projector | Google meets* |
| 7. Final presentation (> 100p) | lecturing hall/projector | Cisco WebEx* / Microsoft Teams |
| *Means most groups prefer to use; # p means how many participants are in the discussion. | ||
To evaluate whether online teaching affects the learning outcome during the COVID-19 period, in this research, we surveyed the learning effect of face-to-face (FF) and distance learning (DL) learning methods. After class, tutors and students were required to finish the online survey; the survey will not record the respondent’s name. The survey form referred to medical education research at Hong Kong University (Foo, Cheung, & Chu, 2021). Both tutors and students need to give grades for the encompassing five key areas (participation, communication, preparation, critical thinking, and group skill). Five factors are used to evaluate the learning effect of face-to-face and distance learning. The data (mean, SD, N) was imported and used one-way ANOVA for comparison. Furthermore, the final data will use GraphPad Prism for further statistical analysis.
Two classes’ data were collected in this research (class-2023 and class-2024). For class-2023, we collected 13 tutors and 84 students to finish the grading survey; for class-2024, 15 tutors and 76 students finished the grading survey. The final data were analyzed using GraphPad Prism. The data (mean, SD, N) was imported and used one-way ANOVA for comparison.
The class-2023 students are about 22 to 23 years old (22.5 ± 1.3), and the class gender composition is 53 males (53/84, 63.1%) and 31 females (31/84, 36.9%). For the class-2023, data have similar statistical results between tutors (Fig. 3A) and students (Fig. 3B), and three points have significantly different between FF and DL (including participation, communication, and group skills). Compared with the referred research, Foo’s study showed three criteria were significantly different between FF and DL (P < 0.0001), including participation, preparation, and group skills. These two independent data show that critical thinking is no different between FF and DL. In general, face-to-face get more average scores than distance learning in all criteria.
The class-2024 students (Fig. 4) are about 22 to 23 years old (22.6 ± 1.6), and the class gender composition is 50 males (50/76, 65.8%) and 26 females (26/76, 34.2%). For the class-2024, two points significantly differ between FF and DL (including participation and communication) in both students (Fig. 4A) and tutors (Fig. 4B). But for tutors, one difference is the point of the group skill.
Three parameters (participation, communication, and group skills) have fewer scores due to the unfamiliarity with online tools. Another one is the delay and asynchronous communication due to the limitation of the internet. The online-meeting media will shortly shut down the video camera to prevent frozen errors and thus maintain good talking fluency. Also, even if the camera is working, members do not always look at the camera or wear masks; thus, the online meeting lacks eye contact and facial expressions.
PBL class is led by students, not by tutors. A key man is the "chairman," who takes responsibility for leading the PBL discussion. The chairman should ensure all the conversation is conveyed to all members. In this step, if there is some interruption from the internet, it will interrupt the discussion fluency. Another role in the PBL group is the recorder, who writes down the discussion and ideas on the whiteboard in the conventional class. Recorders need to convert the words into online media or write via an electric whiteboard (such as an iPad) in the online course (Suppl. Figure 2). As shown in the table (Table 1), the chairman and the recorder should be familiar with the operation and the stability of the internet to ensure the discussion's efficiency and fluency. In our research survey, tutors (class-2024) who have experienced more online classes and are familiar with online tools show no difference in group skills. These results infer that group-based learning courses can go well even in the DL class.
Due to the challenge of COVID-19, education institutes worldwide have started to emphasize the importance of web classes and updating the environment. From 2020 to 2021, the global outbreak increased dramatically. This situation caught schools off guard and urged schools to make the change. For example, in the past, the demand for the internet requires more cover range to let everyone easily connect to the school Wi-Fi, but in the COVID-19 period, more stable internet is more important than cover range.
In our research, we also had a text survey for the students to collect opinions; interestingly, some students gave positive feedback on distance learning. For example, some students prefer the electric writing board over the traction whiteboard. Reasons included that the electric writing board can be projected onto every member’s laptop or mobile phone. Both texts and figures can easily change locations for the recorder and be imported for the online source.
New learning should transform face-to-face and online distance classes in the post-pandemic era. We suggest that classes in recent years should let students and tutors be familiar with these online tools before entering the PBL discussion. Suggesting a fast online-class guideline and letting people get the point quickly is still necessary in recent years. There would be two approach selections for online teaching; first, when in the infectious disease outbreak period, all members are suggested to attend online and prevent face-to-face interaction. Second, if only few members were affected by COVID-19, in-person classes are still conducted but held an online discussion at the same time.
In this study, compared with face-to-face and distance learning, we clarified that learning effects would be reduced in participation, communication, and group skills by questionnaire survey. Our research provides an experience for the class focusing on discussion and member brainstorming like in PBL class. PBL class is crucial for medical students to establish communication and critical thinking. In the post-pandemic era, whether face-to-face or distance learning, classes should be adjusted properly to let students conduct effective communication in time.
Ethics approval and consent to participate
Students received written information about the data collection survey that participation was voluntary, anonymous, and unrelated to grade performance. Informed consent was obtained from all students and tutors. The research has gotten the permission of all participants, and all the data collection would not disclose any personal information. All methods were carried out in accordance with relevant guidelines and regulations and were reviewed and certified by Human Research Ethics Committee at National Cheng Kung University (NCKU HREC -Exempt- No. 111-511) (Suppl. Figure 1).
Consent for publication
Not Applicable
Availability of data and materials
The original data has been uploaded in the supplementary information (Suppl. Table 1-4). The datasets generated or analyzed during the current study are available from the corresponding author or the first author on request.
Competing interests
Authors declare no that they have no competing interests.
Funding
This study did not receive funding support.
Authors contribution
Dr. Chih-Hsien Chi is the main person in charge of the PBL class, gives the research idea, and held the PBL teaching tutor meetings twice a year. Both Ms. Chen and Mr. Wu are the teaching assistants in the PBL classes. Ms. Chen helps to collect survey data from both students and tutors. Ms. Chen helped to finish the background survey and wrote the main article manuscript. Mr. Wu designed the online learning guideline of the class and constructed a survey table and a statistical model (Figure 3 and Figure 4).
Acknowledgements
Thanks to all PBL tutors of the “Introduction to Pathophysiology” class for guiding PBL groups and individual discussions. PBL tutors include teachers from the Institute of the Medicine of Cheng-Kung University and doctors from the National Cheng-Kung University Hospital.