Participant demographics
207 students responded from eight medical schools: Newcastle University School of Medical Education (n=90); University College London Medical School (n=2); Brighton and Sussex Medical School (n=1); University of Bristol Medical School (n=1); University of Dundee School of Medicine (n=6); University of Glasgow School of Medicine (n=65); University of Sheffield Medical School (n=23); and St George’s, University of London (n-7). One participant preferred not to disclose their medical school. The majority of participants were from Newcastle University, University of Glasgow and University of Sheffield.
172 respondents (83%) were on a 5-year MBBS programme, 10 (4.8%) on a 4-year programme and 25 (12.1%) on a 6-year programme. 179 respondents (86.9%) were undergraduate; 27 (13.1%) were postgraduate. A broad range of year groups were represented by respondents (Figure 3). Most (140, 68.3%) had undertaken clinical placements prior to the March 2020 lockdown; with 90.3% (186) reporting their 2020/2021 academic year would ordinarily include clinical placements.
What types of teaching and learning activities did participants experience?
Clinical on-site learning
58.5% (120/207) of respondents reported they had been on clinical placement during this time, with the vast majority of these students (85.3%) seeing patients both face-to-face and remotely. 3.3% (4/120) saw patients solely remotely. 48.5% (50/103) saw patients predominantly face-to-face. Of students who consulted remotely, 83.8% (104/124) undertook telephone consultations and 37.9% (47/124) undertook video consultations.
Clinical off-site learning
33% (68/207) of students participated in this type of learning. 46.3% (30/68) used telephone consulting while 59.7% (40/68) participated using MS Teams or Zoom. Small numbers used other platforms such as AccuRx or Attend Anywhere. 66.2% (45/68) actively participated in consulting with a clinician observing, 42.6% (29/68) solely observed or listened to a clinician consulting and 39.7% (27/68) consulted without observation. Most students (82.4%, 56/68) were based in their own home rather than a university or clinical location.
Synchronous online learning
96.1% (198/207) experienced this type of learning. Teaching was delivered using a variety of platforms; the most popular being Zoom (77.3%) and Microsoft Teams (74.7%).
87.3% experienced synchronous learning delivered by university faculty, with 94.4% experiencing delivery by clinicians. The majority (75.8% or 150/198) experienced both small group (2-30 students) and large group (> 30 students) sessions.
Asynchronous online learning
94.2% (195/207) participated in asynchronous online learning activities; 92.3% of these students engaged with uploaded PowerPoint slides and 93.7% watched pre-recorded lectures. External resources such as YouTube, quizzes, pre-recorded voice recordings and Moodle resources were also reported. Other sources of asynchronous learning included online learning environments and e-learning modules.
Teaching materials were predominantly developed by university staff (93.3%) and clinicians (87.6%), although materials were also developed by other students (24.2%), third-parties (13.4%) and patients (1.5%). 45.9% reported opportunity for interaction and feedback, which was predominantly via e-mail (61.8%), although other methods such as interactive polls, chat forums, help sheets and written essay feedback were reported.
Other Clinical Experiences
36.4% (75/207) of students undertook additional paid work during the pandemic; including: healthcare assistant, NHS 111 advisor, domestic within healthcare settings, phlebotomy, GP receptionist, online tutoring and working in supermarkets.
13.6% (28/207) students volunteered during the pandemic; including at flu jab clinics, hospices and soup kitchens.
Attitudes of UK medical students towards altered teaching and learning activities during the COVID-19 pandemic
On-site clinical learning
On-site clinical learning was reported as the most useful learning method by the vast majority of students (192/207, 92.6%) despite only 120/207 participating in this method of learning. Many students described clinical on-site learning as ‘crucial’, as they felt it most closely reflected their future role as doctors. This is particularly interesting as 72 students rated it as being the most useful method, despite not experiencing it during the time of the survey, so were not comparing contemporaneous learning opportunities. Students particularly valued opportunities to develop clinical skills, interact with patients and staff, and receive feedback.
“Clinical teaching is so fantastic. It is so much easier to learn in the environment we will be expected to practise in the future, and remembering the content is far easier when we can link cases to real patients we've seen, and appreciate how certain things precipitate in real life on the wards.” - response 70710769
Students do acknowledge variations in clinical on-site learning experiences, for example if they are not able to participate in clinical interactions.
However, sitting in the back of the same clinic is not useful learning but more varied and involved clinical setting is useful like third year rotations. - response 70118621
Off-site clinical learning
Students were more reserved about the benefits of consulting remotely from a non-clinical setting, with only 88/207 (42.5%) agreeing this method was fit for purpose. In fact, 134/207 (64.7%) students rated off-site clinical learning one of the least useful types of learning. Whilst 138/207 (66.7%) recognised it was necessary during the pandemic, only 76/207 (36.7%) students noted the relevance to their future clinical practice.
“The lack of practice in clinical examination will make me less competent when we return to face-to-face settings”- Response 70426922
Whilst a small number of students recognised the educational value and wished for more opportunities to consult with patients in this way, many commented that it was fraught with difficulties. Problems included technological difficulties, lack of access to patient records and patients being unable to use software. 9.7% of students stated they did not believe they would be able to access a private space to engage in the process confidentially because they lived with housemates or partners also working from home. Only 42.6% (29/68) of students who participated in this type of learning had received training on confidentiality and information government for remote clinical learning. Students also cited lack of opportunity to examine patients and practise clinical skills as a major limitation.
Students suggested numerous ways to improve these learning experiences, including: remote consultation training for both students and clinicians - including use of software; access to patient records; and increased feedback from clinicians.
“Training, more widespread use to make clinicians comfortable with it and more likely to get students involved”- Response 70152680
Synchronous online learning
144/207 (69.6%) students agreed this method of learning was fit for purpose, with 178/207 (86%) acknowledging its necessity during the pandemic. However, views regarding continuing this in future were mixed; only 37.2% (77/207) agreed they would like more in future, with 41.1% (85/207) stating they would not.
Students appreciated the ability to interact with peers and tutors, and receive timely feedback, as the main positives. 120/198 (60.6%) students who experienced this learning, reported technological issues which impacted access; some students also reported issues with staff inability to use online platforms.
“Live events are helpful as they give structure to the working day and are usually more concise”- Response 70123098
Students suggested ensuring the sessions are interactive, well-structured and include allocated time to check understanding of subject materials.
“Sync is more suited towards the demonstration type of lectures that allow for interaction and questions when topic is not easily understood”- Response 70123772
Asynchronous on-line learning
Opinions on asynchronous learning activities were mixed. 87/207 (42.0%) felt this learning was of similar educational benefit to synchronous learning, 71/207 (34.3%) felt it was less beneficial and 37/207 (17.9%) found it more beneficial. More than half the students (54.5%) ranked asynchronous learning as least useful overall.
Many students reported struggling to engage due to minimal interaction and the self-directed nature of this learning. Others negatives included a lack of timetable or structure, an overwhelming amount of learning materials and resources being ‘under-developed’ or ‘badly repurposed’.
“Asynchronous is useful for learning the facts but not great for applying information to clinical practice and often felt as though they had been rushed/aimed at the wrong level”- response 70118628
However, some students enjoyed the flexibility afforded from being able to work at their own pace and revisit materials.
“I think the asynchronous online teaching was great for me as a home student, as I saved myself over 2 hours of travel time for lectures that can easily be done at home, and in my own time.” - response 71749835.
Suggestions for improvements included, developing high quality, up-to-date materials and ensuring asynchronous learning activities were supported with an element of synchronous teaching to ensure interaction with, and feedback from tutors.
Widening Participation
A theme of widening participation arose iteratively through the analysis transcending all of the five a priori categories, in which clear differences in students’ ability to access certain learning opportunities were apparent.
Clinical on-site learning
Some students without access to their own transport relied upon public transport to attend clinical placements which was frequently unreliable during this time. In addition, in cases where public transport was available, some felt faced with the dilemma of risking their and their family’s safety against catching the COVID-19 virus by travelling on public transport. A number of students noted that other students who had their own vehicles who they previously shared lifts with were less inclined to do so due to fear of COVID transmission or fear of repercussions for breaking lock down stipulations.
“Public transport is hugely expensive ….and because of medical students giving in names to track and trace… people with cars would often not give lifts to people. I found it hugely discriminated against people who did not have their own cars and the bursary that we got from the medical school to help this does not scratch the surface” - response 70134624
“Due to reduced services and removal of night tube it can be difficult to get in for 8am on the weekends similarly finishing late created a tough decision on how to get home in the dark without the tube” -response 73539388
Some students cited protected characteristics such as disability or shielding status of themselves and family members as impacting their ability to attend placements:
“Taking public transport is difficult due to personal disability, a risk to my partners health as they are in shielding category and it is 1.5hours each way (30 min drive)” - response 71288455
With some students reporting repercussions from clinical staff for lateness due to issues with public transport:
“Timetables for buses and trains are changed with no warning, making students late to placement and then facing backlash for it.” - response 73562956
Clinical off-site, remote asynchronous and synchronous learning
Clinical off-site, asynchronous and synchronous learning interventions were largely delivered via online learning platforms and video-conferencing software. 91% of participants reported using their own personal devices for this learning, 5.3% reported using an NHS supplied device, with 3.8% of students using a device provided by their university.
40% reported issues with accessing remote non-clinical learning opportunities, including poor wifi connectivity (90%), issues with their devices (44.4%) and a lack of private and appropriate space in which to learn at home, whether they live in small spaces with family or student housing.
“Small flat, can’t leave home, share room with partner, all other space communal” - response 70117989
In addition to the above issues which also applied to clinical off-site learning, some students highlighted further concerns with patient confidentiality and issues relating to professionalism, particularly if they lacked a private quiet space to engage within the learning.
“I don't have the luxury of privacy so I'd struggle to maintain patient confidentiality, and also I'd feel unprofessional/uncomfortable using video consulting where a patient could see my own house, especially because it would be my bedroom!!” - response 73562956
These issues affecting all types of remote learning appeared to disproportionately affect those living in smaller accommodation, with housemates or family members working from home, and those who needed to provide childcare during this time:
“I live with my husband and 2 children and my husband also works from home. There isn’t a quiet space in our house where I can work (I work at the dining table, which is in our living room) and my house isn’t big enough for me to consult without my husband's telephone calls being audible in the background. My son has no wrap-around care at school at the moment, so he is home from 3.15 every day.” - response 71329105
Table 1: Barriers and facilitators to student participation
A summary of the reported barriers and facilitators to participation in the different learning activities are outlined in Table 1.
On-site clinical learning
Facilitators
Remote consulting:
- Positive clinician attitude towards remote consulting in general and to student involvement
- Opportunities to discuss cases with clinicians and interact directly with patients
- Training on telephone and video consulting, and relevant technologies
Face-to-face patient contact:
- Access to PPE/COVID-19 vaccinations
- Access to own transport to travel to placement
Barriers
Remote consulting:
- Lack of training on telephone and video consulting, and relevant technologies
Face-to-face patient contact:
- Lack of access to PPE, particularly eyewear (4.3% reported being able to access PPE 'never' or only 'on some occasions')
- Concern they may be a vector of transmission to patients and friends/family
- Students using public transport to attend placement experienced difficulties due to cancellations during the pandemic
|
Off-site clinical learning
Facilitators
- Access to confidential space and able to take measures to manage confidentiality e.g. earphones
- Opportunities to discuss cases with clinicians
- Opportunities to interact directly with patients
- Training on appropriate information governance
- Training on tele-health consulting
- Engaged, organised teacher
Barriers
- Lack of access to clinical details about patients
- Lack of access to confidential space
- Lack of information governance training
- Lack of training in tele-health consulting
- Lack of access to appropriate IT device
|
Synchronous remote learning
Facilitators
- Opportunities for discussion and interactivity
- Opportunities for feedback during and after the session, in a variety of forms
- Well-structured sessions
- Recording to allow retrospective viewing
Barriers
- Difficulties accessing the teaching session, e.g. due to student technical or IT issues
- Tutor technical issues or lack of tutor knowledge of software being used
|
Asynchronous remote learning
Facilitators
- Provision of good quality on-line resources
- Flexibility to manage one's own pace of learning, and to review resources on multiple occasions.
- Materials well-suited to be delivered in an asynchronous remote format
- Perceived reduced need to travel, and benefits associated with this, e.g. reduced cost
Barriers
- Poor-quality teaching resources
- Excessive amounts of on-line asynchronous teaching material
- Few opportunities for discussion and feedback
- Difficulties with accessing the teaching materials e.g. due to problems with internet
- Requirement for student self-motivation and time management skills to engage effectively with unscheduled learning
- Lack of peer interaction
|
Views on ‘Essential Worker’ Status
Despite government guidance, the majority (117/207, 56.5%) of students did not view themselves as an ‘essential worker’ with strong and contrasting views about this status, including that they don’t deserve it. Some students described essential worker status as a ‘privilege’ and an ‘honour’ which afforded them the opportunity to attend placements whilst many people in society were instructed to remain at home.
“We're treated as essential workers, but do no essential work. The patients clearly are uncomfortable as are the nurses and support staff.” - response 70121849
However, many felt conflicted, stating that whilst placements were essential for their learning, they did not feel their role was ‘essential’. Some felt their presence was a ‘bother’ to staff; considering their roles as ‘learners’, as opposed to ‘service providers’. Students often described weighing up the risks and benefits associated with attendance of placements; questioning whether it was appropriate to risk themselves and others, whilst feeling they were not helping patients.
“I don't think it is fair on patients to put them at additional risk from a student who cannot contribute to their care in any meaningful way”- response 70118488
Students’ sense of value and worth as an essential worker appeared to be influenced by their access to certain resources. For example, PPE, lateral flow testing, vaccination and participation in ward based activities. Students who encountered difficulties accessing these ‘rights’ seemed less likely to identify as an essential worker. Some students felt undeserving of being given these privileges; with some describing themselves as an ‘imposter’.
“I don’t think we are ever considered a part of the team. Therefore, no one guides us on where to find PPE … instead of equipping us with the PPE we need ... [the university] ... just cancelled the placement” - response 71653063
Students describe not being part of the team, or not being able to help with clinical tasks, or being expected to do so.
“If we're essential workers it would be great to be treated as such. If we're essential on the wards I would love to help the FY1s (Foundation Year 1 Doctors) with their tasks ‘’ - response 71746605
Many students identified as essential workers for extracurricular paid or unpaid roles, but did not for their role as medical students. This was because their additional work was seen by them as contributing to patient care or the pandemic efforts, whereas time on placement was not.
“I don't class myself as an essential worker on placement because the hospital/GP (general practitioner) doesn't need me there, however when I am at my paid job, I would consider myself an essential worker.” - response 71680145.
Students got involved in various paid or unpaid roles, including roles in which they were expected to provide care to patients and roles which allowed them to contribute to the pandemic efforts.
“I worked as a note summariser initially ... [and] ... created weekly COVID research and guideline updates for primary care staff across a health board. These were brilliant jobs and I'm so glad I got involved despite strong resistance to the idea by my medical school as I gained a lot of experience in medical education, put my undergraduate degree to use and made a genuine difference based on the feedback I received. I felt like I was actively contributing in the pandemic and I'm proud of the work I did.” - response 70231678
“[I] worked as an HCA (health care assistant) in A&E (accident and emergency) at the local trust, where I am now on clinical placement. Really good experience which helped me develop my skills during a time when there was no teaching from my course.” - response 71329105