COVID-19 Pandemics and Impacts on Medical Educators in China


 Background: Education informatization is still in the early stage in China. The sudden outbreak of the COVID-19 pandemic led medical educators passively incorporating information technology for remote medical teaching, in which challenges and opportunities have co-existed.Objectives: The objectives of this study were to (1) explore the medical educators' perception and experience of online teaching in medical education before and after emergency remote teaching (ERT) experience during the COVID-19 pandemic; (2) illustrate the medical educators' satisfaction on the contribution of online teaching on medical teaching, and (3) reveal the main challenges medical educators met when they conduct the ERT during the COVID-19 epidemic, and to demonstrate whether the challenges are a different by age or gender including some other factors.Methods: A web-based questionnaire was disseminated to the faculty of medical education departments at higher institutions in China. The collected quantitative data of the questionnaire were analyzed by using the SPSS software package. Descriptive statistics were conducted on demographic data and the perception and experience of medical educators before and after the COVID-19 were shown as the frequencies and percentages, while the teachers' opinions on contribution of online teaching on medical education were analyzed by descriptive statistics with means and standard deviations. Multiple response analysis combined with crosstabulation chi-square test was applied, and a P-value <.05 was considered to be statistically significant to exams the relationship between age as well as gender and difficulties met in online teaching respectively.Results: A total of 26 medical educators (65.38%, n=17 female and 34.62%, n=9 male) were valid participants. Total 57.69% (n=15) of them had used web-based teaching before the COVID-19 pandemic, whereas 43.21% (n=11) had not. The agreement level on the teaching effect of online teaching was medium, with a mean value of 2.55 (range from 1-5). The first two difficulties medical teachers came across in online teaching were the web-based instructional design (27%), and the unfamiliarity with web-based teaching tools (25 %). No significant difference in the types of difficulties encountered by different ages (P=0.969) or gender (P = 0.873) in online teaching.Conclusions: The majority of medical educators are open-minded to incorporating online teaching into their teaching practice in the future. However, medical educators in China commonly faced shared difficulties when they adopted online teaching during the COVID-19 pandemic. Identify these challenges and proposing some relevant suggestions to promote a further increase in the active adoption of information technology in medical education.


Introduction
The novel coronavirus disease 2019 (COVID-19) is one of the most unpredictable global public health crises of epic proportions in recent years [1,2,3], which has brought a profound impact on higher education [4]. Medical schools have been forced to dramatically restructure teaching and assessment to adapt to the effect of the COVID-19 pandemic [5]. Considering the COVID-19 effect is unstable, medical learners cannot be in a direct clinical environment [6,7]. While it is essential to minimize the spread of a pandemic within medical institutions, medical education and research activities cannot be stalled every time an epidemic occurs [8]. Moreover, practical skills are a crucial aspect in the medical education eld, and the real-life clinical practice experience is hardly optimally replaced by digital virtual simulation learning for the time being. Under the intense pressure of the external environment, medical educators were passively formalizing the application of information technology to teaching activities, which has brought considerable challenges and opportunities for medical educators. Medical teachers were challenged by the inexperience and unforeseen online teaching and inadequate technical aid for ERT under the effect of the COVID-19 epidemic [9]. Therefore, how to quickly adapt to the teaching relationship of space-time separation, adjust teaching methods, and exibly deal with the sudden online teaching situation, conducting a "big test" of teachers' ICT competency.
The accelerated development of information technology nationally and globally in the last couple of years has made a signi cant contribution to support adapting the effect of the COVID-19 pandemic. The use of information technology in medical classes has been increasingly ubiquitous [10,11]. The rapid technology advancement in education has resulted in the adoption of learner-centered methods employed for educational use beyond traditional lectures micro class, massive open online course (MOOC), and ipped classroom, collaborative team learning, problem-based learning (PBL), case-based learning (CBL) [12,13]. Importantly, many digital technologies have been considered or used in the educational eld, such as virtual simulation teaching forms supported by technology [14][15][16][17] and videobased social media platforms [18,19]. In recent years, some studies have proven that augmented reality (AR) and virtual reality (VR) can enhance students' engagement [20,21]. Arti cial intelligence (AI) has revolutionized technical medicine aspects; blending it with medical education can meet post-human demands [22,23]. Under the COVID-19 epidemic, the provision of medical education needs to be maintained in the form of decentralized, remote, and technical support [8,24]. However, it is observed that in China, teachers' information technology application ability is just at the primary level, and the innovation ability of information technology teaching is insu cient [25]. The deep integration of information technology and teaching is currently not enough.
Although institutions that would conduct face-to-face teaching in the classroom or campus may resume the traditional teaching model to a certain extent, the ERT they implemented during the COVID-19 pandemic would leave a lasting trace [26]. The bene ts found in the ERT would prompt further acceleration in the expansion of digital learning in educational evolution. Many researchers have conducted a review or evaluation of the ERT from students' perspective or a re ection of the emergency teaching methods [6, 24, 27, 28] while paying less attention to the educators' aspect. This paper had three main objectives: (1) To explore the medical educators' perception and experience of online teaching in medical education before and after ERT experience during the COVID-19 pandemic; (2) Illustrate the medical educators' satisfaction with the contribution of online teaching on medical teaching; (3) To reveal the main challenges medical educators met when they conduct the ERT during the COVID-19 epidemic and demonstrate whether the difference in age or gender distinguishes the challenges.
Identifying those research questions arising in ERT from medical educators' perspective and evaluating their perception of online medical teaching methods can provide referential suggestions for future medical education reform and improvement.

Study Design and Participants
The participants were medical educators, who were teaching medicine courses in "211"," 985" (they are top-listed universities in China), or other colleges and universities in China, with an experience of conducting online medical teaching activity under the effect of the COVID-19 pandemic. To ensure the survey's validity and reliability, we delivered our survey to a speci c group of educators deliberately, those who have different background information, i.e., age, gender, and educational background. Thirty online questionnaires were delivered through WeChat or email. Both the English version and the Chinese version of the questionnaire were provided to the participants. The quantitative data collection started on April 14 and lasted for three months.

Questionnaire Development
The online questionnaire was developed through "SO JUMP" and delivered to the participants, involving open-ended and closed-ended questions (see Appendix 1). In this exploratory study, we administered this online survey following different topics with various questions sets: (1) the rst question to ensure volunteer to take part in the questionnaire, and 7 following questions set up for knowing about the personal background information; (2) 12 closed-ended questions with options of "yes or no" multiplechoice questions, and 2 open-ended questions to explore medical educators' perception and experience toward the online teaching method before and after the COVID-19 epidemic, as well as medical educators' perspectives toward further integration of online teaching and medical education; (4) 11 ve-point Likert items on a scale of 1-5 (1=strongly agree, and 5=strongly disagree) were comprised, and choosing "strongly agree" and "agree" represented that medical educators agreed that online teaching has a vital contribution on teaching effect; 5) a multiple question to learn about the main di culties met by medical educators during the pandemic.

Evaluation and Statistical Analysis
The quantitative data were downloaded from the "SO JUMP" platform into a Microsoft Excel spreadsheet. The collected quantitative data of the questionnaire were analyzed by using the SPSS software package (Statistical Package for the Social Sciences, version 26 for Mac, IBM Corporation). Firstly, descriptive statistics were conducted on demographic data with continuous variables--age and gender for the chi-square test later, which were endowed with (male=1, female=2) and (1=age>30; 30<=2=age<40; 40<=3=age<50; 4=age>=50) respectively. The perception and experience of medical educators before and after the COVID-19 pandemic were displayed as the frequencies and percentages. Besides, the data of teachers' satisfaction on the usefulness of online teaching on medical education were analyzed by descriptive statistics (means and standard deviations). Multiple response analysis combined with crosstab chi-square test was applied, and a P-value of <.05 was considered to be statistically signi cant to determine whether there existed a relationship between (a) gender and di culties met in online teaching; and (b) age and di culties met in online teaching.

Ethical Considerations
Ethical permission for the research was obtained from the human research ethics committee (HREC) of the University of Hong Kong. The reference number indicated in the letter of approval for ethical clearance issued by the HREC is EA1909007. Medical teachers were informed the research purposes, con dentiality and their right to quit the survey. To safeguard the con dentiality of the participating teachers, the names of teachers will be coded as teacher A, B, C.

Result Demographic Information of Participants
A total of 26 valid responses were received, involving 17 female and 9 male medical educators, out of the total 30 questionnaires delivered. The demographic background information of those 26 participants were statistically summarized in the descriptive Table 1. 50% of them were 30-40 years old, and at the age range 40-50 and over 50 shared the same percentage that was around 23%. Both clinical educators and basic medicine educators had equal share. 58% of participants have been teaching less than 10 years, while 27% of them have been teaching over 20 years. The participant form "211" university took up 81% approximately. As for the highest educational background, 70% of educators own a doctoral degree, and both those who got a master's degree and a post-doctoral degree have the same 15% proportion. The medical educators who have had or had not an oversea learning experience share an equal percentage. When it comes to the future prospects on online teaching, all medical teachers (100%) believed that online teaching will be more and more widely used in medical teaching methods in the upcoming decade, and 24 (92.31%) of them think that online teaching needs to be integrated into all aspects of the institution and the curriculum with co-operation between departments and between software providers and trainers.

Prospects
Do you think online teaching will be more and more widely used in medical teaching methods in the next decade?
26(100.00) 0(0.00) Do you think online teaching needs to be integrated into all aspects of the institution and into the curriculum with co-operation between departments and between software providers and trainers? 24(92.31) 2(7.69) Two single multiple questions explored the online teaching hours per week and the percentage of online teaching in the total teaching activities of medical educator during the COVID-19 pandemic (Figure 1 &   Figure 2). Among the 4 medical teachers who regularly used online teaching before the COVID-19 outbreak, 3 of them used online teaching for teaching less than 2 hours every week, only 1 medical teacher used it for more than 10 hours every week, and the online teaching occupied 15.75% of the total teaching time. After the COVID-19 outbreak, all 26 medical teachers participated in online teaching, in which 5 (19.23%) of them used online teaching for less than 2 hours, 13 (50%) of them used online teaching for 2-6 hours every week, 6 (23.08%) of them used online teaching for 6-10 weeks, 2 (7.69%) of them used online teaching for ≥ 10 hours, and the online teaching occupied 85.81% of the total teaching time.

Medical educators' opinions on contribution of online teaching on medical education
The descriptive statistics of medical educators' opinions on the contribution of online teaching on medical education was shown in Table 3. The agreed level on the teaching effect of online teaching was just around the medium level, with an average mean value of 2.55 (range from 1-5). The highest one was that online teaching is conducive to the development of new teaching methods (mean=2.00), while the lowest one located at the item that facilitates students' classroom focus (mean=2.92). Stacked-Column for the responsive proportion of 13 Likert items on a scale of 1-5 (1=strongly agree, and 5=strongly disagree), which indicated that most of choice were located at the "Agree" and "Neutral" level ( Figure 3).

Di culties in the ERT for Medical Educators under the COVID-19 Pandemic
The medical teachers stated the major challenges that they met in the online teaching in COVID-19 pandemic ( Figure 4). The rst two di culties medical teachers came across in online teaching were the web-based instructional design (14/26, 27.00%), and the unfamiliarity with web-based teaching tools (13/26, 25.00%). Only one person (2%) thought that leaders do not pay attention and support online teaching method. Multiple response analysis combined with crosstab chi-square test was applied to tested whether there existed relationships between two variables (gender and age) and di culties met in online teaching respectively (Appendix 2), considering a P-value of <.05 was considered to be statistically signi cant. No signi cant difference in the types of di culties encountered by different ages (P=0.969>.05) or gender (P = 0.873 > .05) in online teaching.

Principal Findings
The results illustrated that the information technology for medical teaching had not been widely used before the outbreak of the COVID-19 epidemic, the teachers' ICT competency was generally insu cient, and the web-based teaching mode was imperfect in medical education. To adapt to the effect of the COVID-19 pandemic, educators had tried their best to redesign the curriculum and have adopted information technology in teaching. However, in doing this, medical educators have been faced with many challenges. Some medical educators recognized that the online teaching method was just a shortterm teaching approach under the temporary pandemic situation. It may be the fundamental reason that led to the satisfaction of the online teaching method's contribution presented slightly better than the medium level. Nevertheless, they still believed that it would be a de nitive trend of integrating information technology with medical education in the future and holding a positive attitude towards it. Although the current circumstance of the integration is still in the early stage, the COVID-19 pandemic has accelerated the evolutionary scheme of medical education informatization to a reasonable extent.
The 26 participants of the study with varied demographic backgrounds have covered different age groups, length of teaching, and university a liation types. It can enhance the study's reliability, creating a bene t for carrying an evaluation of the di culties linked to ICT competency between different ages and different gender. However, the result demonstrated no signi cant relationship between the technical challenges and the diversity of age or gender. In other words, the main challenges medical educators met when they conduct the ERT during the COVID-19 epidemic would not be distinguished by the difference in age or gender. This result was slightly out of expectation because it was generally believed that the older people are, the more di culties they may encounter in using information technology. The di culties and challenges faced by medical educators in the use of emergency distance learning are universal. The biggest challenge for medical educators in ETR was web-based instructional design, which revealed that redesign the o ine course would need medical educators' much effort and time, particularly for the clinical course, which is hard to be replaced by the online teaching model entirely. Therefore, in the future, the reformation of clinical courses would likely combine an online and o ine teaching method. For instance, the o ine teaching method will be conducted for medical students' practical demands, while the online teaching method will be conducted for the theoretical learning demand. The second biggest challenge was unfamiliar with the online teaching tools, which was reasonable under the unpredicted pandemic situation. The effect of COVID-19 led to the large-scale closure of medical colleges and emerged a sudden shift to online teaching, which limited the time for medical educators to get familiar with these new pedagogical online techniques. Fortunately, this di culty can be solved by further training or within a long-term regular online teaching pattern. The next three di culties were the challenging online teaching environment, the insu cient online teaching resources, and the limited ICT competency, respectively. Three of them shared a similar percentage, which indicated that all of them were the secondary challenges in the ETR, and they can be overcome through further training for educators and improvement in the online teaching circumstances. The least challenging one was the higher authorities or leaders giving no adequate attention to the ERT or supporting it, which intimated that the school supported medical educators to tide over the di culties faced on online teaching.
Although many di culties are encountered in ERT, they also co-exist with opportunities. When medical educators try to solve these di culties, they promote the improvement and reformation of medical education. Comparing with medical educators' experience towards online medical teaching before the COVID-19, around half of them conducted online teaching for the rst time, which enhanced the covered level of medical education informatization and identi ed more issues in online medical teaching. The time spent on online teaching dramatically raised though it was an external environment forced to conduct online teaching. The more they used the online teaching method, the more familiar with it. Most medical teachers utilize online multimedia platforms to ensure the interaction with students. As for their perceptions, a majority of them believed that the online teaching method was bene cial for work-life balance and enhanced exibility of the courses, study methods, and the interactive communicating way.
Although the online teaching was new to most medical teachers, they regarded the contemporary information technology in online teaching as current accessible, reliable, and worthy. However, because the ERT shorten the preparation process of online teaching, in medical educators' opinions, the contribution level of online teaching method in medical education was average posited at the level of a little higher than the medium level. It has been undeniable that the ERT helped develop a new teaching method, and the online teaching method did contribute to medical education to adapt to the effect of the pandemic situation.
Based on the challenges and opportunities that have been discussed above, some suggestions are proposed for future medical education reformation. Firstly, emphasizing knowledge and experience, the clinical clerkship course is an essential part of medical education. Unlike the traditional clerkship that happened in a physical place or hospital, the current online teaching was not advanced enough to provide the same clerkship experience on an online platform, which waves the demand for an advanced and standardized online medical teaching system in China. It would be helpful if China can refer to some other advanced countries' practices or suggestions in online medical education [25]. For example, in the UK, they have proposals for a "networked" medical school based on district general hospitals and the corresponding community [29]. Although facing many challenges in online teaching, medical educators still hold a strongly positive attitude towards the medical education informatization in the future and believed that the broad application of modern technology in medical education needs the cooperation and joint efforts of various stakeholders to promote the application of digital technology in medical education reformation. Concrete leadership and practical policy are essential for the implementation of modernizing medical education. We believe that catastrophes like the COVID-19 pandemic may repeatedly come and pass in the future, just like all human history records. What can we do to reduce the damage to the medical education system? We believe that developing an advanced and better online teaching system is one of the answers.
All in all, students and teachers generally accept the online teaching of medical courses during the pandemic period because of its advantages of exibility, information accessibility, global reach, and e ciency. However, online education also has shortcomings, including the lack of teacher-student interaction, the presence of distractions, and the decrease of students' self-discipline. Especially for online medical education, there is still a problem of technological constraints. Students cannot participate in the laboratory and clinical practice. As to teachers, a big challenge for them is that they are not adapted to change of teaching methods well and dissatis ed with the construction of some online course platforms, which is the main reason that affects the teaching quality. The paper focuses on the current situation and future trend of online education in medical courses, consistent with earlier ndings showing that online courses will play an essential role in many schools' long-term survival. However, our analysis neglects several potential conditions. An important direction for further work might be to study how to realize remote clinical practice teaching better. Online education will continue to play an important role, an emerging trend, and become the next normal in the post-COVID-19 pandemic. The results of this research may help educators to progress current education form. By incorporating arti cial intelligence and mobile education, online education will co-exist with traditional education to provide more education options, promote education equity, and enhance education innovation.

Limitations
We acknowledge that this study has limitations, which related to the aspects of the participants. The number of the participants may not be signi cant enough, and a limited amount of young medical teachers. Our participants were mainly from the Guangdong province of China, and most of the medical teachers enrolled work in top-listed universities in China ("985" or "211"). Therefore, our analysis may not be representative of all medical educators in China.

Conclusions
In conclusion, this study provided quantitative evidence for online medical education under the COVID-19 pandemic from educators' perspectives. The permission/approval for the study and data collection at Jinan University in this study was obtained from the Human Research Ethics Committee (HREC) at the University of Hong Kong, with a reference number issued by the HREC of EA1909007. The informed consent was obtained from all subjects, and all subjects are over 18 years old. The participants were informed about the study's purpose, their anonymity and withdrawal rights, and all other ethical principles were observed. Before the conduction of experiments on humans, informed consent is obtained from the participants. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication
Informed consent for publication was obtained from all the participants. All data included in the manuscript are applicable for publication. All authors of the manuscript have read and agreed to its content and are accountable for all aspects of the accuracy and integrity of the manuscript in accordance with ICMJE criteria. The manuscript is original, has not already been published, and is not currently under consideration by another journal.

Availability of data and materials
The datasets used or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
No funding was used for the conduct of this study.
6. Author's contributions MC and W-KM contributed to the original conception of the study and the administration of the project.
MC and SZ contributed the rst draft version of the manuscript. SZ and W-KM made online questionnaire.
MC, SZ and SW contributed to the quantitative data collection, analysis and interpretation. BA and W-KM reviewed the manuscript. All authors contributed to the interpretation of the results and the nal manuscript. All authors discussed and agreed on the implications of the study ndings and approved the nal version to be published. Figure 1 Online teaching hours per week The percentage of online teaching in the total teaching activities  Main challenges medical educators came across during the COVID-19 pandemic

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