We conducted two focus group discussions that involved 4 fifth-year and 7 fourth-year students of CMED (N=11) and 5 semi structured interviews with 5 CMED clinical faculty members.
Discrepancy (understanding the need for the shift to VC)
Theme 1: Perceptions about the university decision and its communication to students
Students were generally satisfied with the college decision to shift to VCs. To one of them, the college response was adequate, and he expressed, “College responded well when online learning was implemented the second week of the lockdown”.
Nevertheless, they were only partially satisfied in the way this decision was communicated to them, and with the slow response from college upon the start of the outbreak. One student mentioned,
“We went to the hospital, we did everything and we didn't hear anything from the college. They only emailed us when we complained. Okay! I'm not sure if we're supposed to complain every time just to get a response.”
Faculty perceived a similar view as one of them expressed, “During the early phase of the shift, no clear communication with students took place regarding how the clerkships will be handled.”
“So none of us was ready. Neither the clinicians nor the patients and nor the students so all of them were not prepared for this. It just happened, you know, suddenly.” [Clinical Faculty 5]
However, all of the faculty members agreed that the college decision to shift to VC was appropriate, quick and reasonable.
“The plan, which has been put to let the students to join again, even for a shorter period of time starting from and taking from all this and grade five, utilize very reasonable. And it goes with this skewed situation.” [Clinical Faculty 3]
Theme 2: A Perceived Lack of clinical experience
Students were disappointed with the sudden change in learning, and felt it will be less beneficial than being in hospital. They realized a huge difference in the way clerkship was being provided, with a total “backward” shift from practice to theory.
“I personally realized a huge part of experience and learning was taken away and with no alternative at the moment. Because at the moment, we're only taking online lectures” [Student 3]
“taking us away from the clinical environment it was like taking us a step back to the college………we just got used to the way of history-taking and physical examination. Basically, our serious education was interrupted at that time.” [Student 5]
More importantly, the vast majority of students emphasized the need for a quick return back to clinical sites. Some students said they were volunteering to compensate for lack of clinical exposure: “I volunteered for the emergency. Therefore, the emergency department volunteering has been really good “, a student expressed.
“We really need to go back, even though it's risky… we would benefit more if we actually go back to the hospital or, for example volunteer or something during this situation. It would be, it would offer a great experience.” [Student 5]
Students also tried to find other solutions by suggesting ways to communicate with patients online. Other Ideas included online consultations, WebEx meetings with patients and small training groups.
“We could have WebEx meetings with patients. Yeah, for example, like doctors can find a good case, they can communicate with the patient, ask him if he wants to participate with us for example and we can see the real patient, we can take history from him”. [Student 10]
All the interviewed clinical faculty members echoed these views.
“I think we cannot replace it by virtual training. It might be in the future.. This is a stimulus in the future. People can do it, but again, it's called practice of medicine. We cannot give it by books.” [Clinical Faculty 3]
Theme 3: Students’ safety (Understanding the necessity of the switch)
Only few (2 students) had positive perceptions towards the VC and felt this move was to keep them and their families safe.
“As well thinking of my family as well. Not everyone has the same family situation that would allow them to actually go to the hospital with the outbreak there and go back home & make sure that everyone there is safe as well.” [Student 5]
One of them also explained that he was expecting that even in the real setting, education would be affected, as the faculty will be too busy dealing with the pandemic.
“… but we need to look at the bigger picture. Okay! Like, the doctors who are taking care of us in the hospital are actually volunteering or concentrating on the COVID situation..., so we won't have enough staff”. [Student 10]
Contrarily, several students perceived that his move to VC might not be necessary because the students could have applied the infection control measures that they got extensively taught, and hence avoided losing the practical training.
“So I feel like, we could have taken the infection control measures that every other doctor, every other nurse, or every other hospital personal could have taken, and we could have avoided getting the infection if we took preventative measures and practiced good practice good hygiene in the hospital.” [Student 4]
Clinical Faculty members gave more importance to the issue of maintaining student safety, than the students themselves did. The majority agreed that moving to VC was the best decision to protect students and patients, and to avoid overwhelming the healthcare system.
“It's, it's the best why it's the best for their safety is the best for the health care sector as a whole because of the need the need and the demand of the PPEs and for the patients as well.” [Clinical Faculty 5]
Other faculty members argued that instead of a total shift to VC, students should better maintain at least some limited exposure to clinical settings during the pandemic.
“So, it's a bit difficult situation, but I'm still believing even limited clinical exposure was good idea even in the presence of the epidemic.” [Clinical Faculty 4]
Yet, some clinical faculty emphasized a need to provide students with more understanding of why such a shift is needed in order to make them embrace such a major change in their learning.
“they are still young and that is the point that we need to address to make sure that students know exactly why we do this new format and make sure that they're always objective.” [Clinical Faculty 1]
Theme 4: Students’ role as members of the medical team facing the pandemic
Students perceived that they could have helped out in the pandemic and that would have been a major source of motivation for learning.
“When we used to go to the hospital, you feel motivated when you take care of the patient and you are a part of the team, whereas when you're home and you just have a lecture.” [Student 1]
”I think we could have helped and learned a lot if we were in the clinical situation.” [Student 4]
Clinical faculty views were widely concurrent with those of students. They stated that students would better be practicing in hospitals because this would be their duty as future doctors during a pandemic.
“…. how to use The PPE [personal protection equipment], how to limit the chance of getting the infection once you’re a doctor, you cannot say no sorry I got kids. Well, everybody got kids. It's our job. We are like soldiers and you cannot say, no I can't fight the enemy because I got kids. [Clinical Faculty 4]
Appropriateness
Theme 5: Quality and design of VC and the skills it offered
The majority of students from CMED explained that they benefitted less from this clerkship compared to being in the hospital, as it did not provide them with the essential clinical skills. One student expressed, “Online lectures, not as useful as hands-on training and the lectures don't work for me… since the pandemic started, I didn't really gain any clinical experience.” All students agreed that the VC was mainly theory and knowledge-based, and could never compensate for the actual clinical placement, which is an integral part of their learning.
“we need to communicate with the patients, take the history ourselves. after we do the physical, we can go discuss it with a supervisor and the doctor will comment on what we did, this kind of interaction you cannot replace it with online lectures”. [Student 10]
-
Students negatively perceived the design of the VC. They felt that the VC was less appropriate than on-site training because doctors were busy and were not able to deliver education that optimally matched with the university’s program requirements, and one of them expressed, “Doctors are busy, and some have a gap in education based on the college blueprint.”
-
Students believed the low number of patients seen during the pandemic deeded a compensation mechanism, such as frequent formative assessment.
“Surgery was the only rotation that I did not observe any patient in it. I feel if we take assessment. Daily assessment, regarding each topic in order to fulfil all the gaps regarding surgery, for example for us people who did not attend their rotation”. [Student 2]
Students who were through their first semester in clerkships had to go through medical rotations for ten weeks and a surgical rotation for s similar period. The disruption coincided with the beginning of the second rotation and hence affected the introduction to those rotations. That was perceived by some students as lack of clear goals for the clerkship
“The first four weeks we were lost, because we don't know what is E-value we don't know what we're expected to do. We don't know what are the goals!” [Student 6]
On the other hand, students opinions regarding the extent of interaction and engagement during the online sessions were variable. Some students felt that online lectures were missing the interactive component. However, others valued the efforts that clinical faculty exerted towards overcoming this issue. They explained how faculty applied several techniques to enhance the appropriateness of the VC by making the lectures more interactive and engaging.
“After the lecture, some doctors used to put a lot of questions, like, more than ten questions after the lecture to summarize the points that they’re raising….
Doctors made us all join with the camera and the Mic, and also he [faculty member] was asking us to participate by the name. So, in this way, it was more engaging”. [Student 2]
Clinical faculty members’ stressed on the importance of students physical presence in clinical settings and that it is irreplaceable.
“I think this time of training, they need to see patients themselves, they need to put their hands on the patients. And this honestly has been jeopardized...…Again, I think they need to start from the way they sit in that clinic from the way the sit on the chair, introduce themselves to their patients…... It's very difficult. Because if they read it, they will forget it. It's a practice. They should do it when they sit in the clinic…” [Clinical faculty3]
To faculty, the VC created a need to re-structure the standard tests of clinical skills and the Objective Structured Clinical Examination (OSCE) mode of assessment. They expressed that different learning outcomes were expected from different rotations, and such specific outcomes and objectives should have been better clarified to students from the beginning in order for them to make realistic expectations from the VC.
“In the clinical clerkship, we did the structured case discussion. It went fine, but our expectation did not match what the student have and I think is the major thing, because we cannot, based on assessment, without knowing exactly what the students have gained through their clinical training…, there should be a clear objective and by the end you achieve it.” [Clinical Faculty 1]
Efficacy
Theme 6: Belief in own ability to succeed in the VC
Only one student felt confident that students will succeed in this move to VC and expressed, “Being the first batch we’ve been through so many changes and we adapted to them… I have faith in the college”. However, the majority of students felt discouraged and unsatisfied with the lack of hands-on-training and one of them explained, “Online lectures, not as useful as hands-on training and the lectures don't work for me”. Another student added, “It is a little bit discouraging at times, so I find it a struggle to get back to reading things without knowing I'll ever see those things or experience them in the hospital. “
Theme 7: Confidence that VC would reach its goals
The vast majority of students felt that the lack of gaining clinical skills along with the lack of staff availability and lack of organization during the pandemic would not help the program achieve its goals.
“making the doctors and the faculty aware that we have a program and these are the goals one, two, three, and these are the expected learning outcomes and the students need to perform one, two, three, four and we may receive assistance from the doctors and the hospital administration for that we are able to do a few things, but in a lot of circumstances, we lose that chance.” [Student 6]
Conversely, faculty held more positive views about students’ efficacy towards taking the VC. They mentioned how a condensed training program was given to students, at least for some rotations (such as the pediatrics rotation), which was an efficient way to make the VC achieve its goals.
“I am confident in what they [students] had in terms of information by the end of the rotation and actually, see the difference between the first week of rotation and the last week of the rotation and it shows while they are doing the oral presentations” [Clinical Faculty 2]
Faculty also had confidence in student’s abilities to carry the VC based on their positive attitude and attributes. According to them, students built the needed knowledge, were motivated to learn and were highly adaptable.
“…The attitude is very important that I think because we could make sure that students are motivated enough, and they are working towards and proceeding their rotation, make sure they have a clear objective”. [Clinical Faculty 1]
“Overall. They were good. Some of them were very enthusiastic about learning …They are confident, they are very good”. [Clinical Faculty 2]
They also valued how this millennial generation of students accommodated the shift to virtual learning, since they possessed high computer and technological skills.
“I think the students also, I was astonished, the way the absorb the... how they understood the system and they had no problem about the online teaching at all” HCP4
Valence
Theme 8: New enhanced learning approaches
Almost all students appreciated some short-term benefits from VC that were not feasible in the context of on-site trainings. They explained how they were offered extra sessions and revisions and how the clinical staff were always approachable to answer questions over the phone. It is worth indicating that attempts to standardize clinical lecture across different remote clinical sites wasn’t possible due to the lack of IT infrastructure in place. That lead to the same lectures prepared and provided by different faculty each in their own hospital which was always a source of students dissatisfaction before the pandemic. Once these lectures moved online during the pandemic, students started receiving each lecture by a single faculty regardless of the location of their clinical placement, which they appreciated and considered as an enhanced in learning approaches in addition to the fact that faculty started including case-based learning in some online sessions. One of the students mentioned:
“The online lectures. It's much better compared to the lectures that we take in hospital… I feel that our lectures in hospital can be replaced with online lectures to be much better even if we can take it evenings, or even at night”. [Student 9]
”Doctors would give us the lecture then give us like, cases and we resolve questions. So, it's kind of like seeing a patient and discussing.” [Student 1]
The majority of students also agreed that the VC helped them allocate more time for studying and revising patient cases.
“.. It was really difficult to study after a whole day of the training, which is from seven to three. You are very tired, you’re not motivated to study or do anything for five days, it's only the weekend when you have the opportunity to the study or to revise what you saw at the hospital. ” [Student 9]
Faculty members’ views coincided with views of students.
“we believe now that we can do a lot of things without presence physically. And one of the things that you are doing your job now, even from other places, I think we become more accessible to our students by this telecommunications…” [Clinical Faculty 3]
Theme 9: Acquired skills
During the VC, students developed some skills like adaptability and problem-solving, which are very important skills.
“They teach us how to adapt to situations quickly even the college everyone had to adapt to the situation thrown at them very quickly, find solutions to every problem. So, everyone had to look, think quickly and change”. [Student 8]
Theme 10: Preparing students for new types of practice in the future
Faculty members perceived that the VC as an opportunity with long-term benefits for students, such as preparing them for virtual teaching and practicing telehealth in the future.
“…. the online teaching, there will be a, it has a lot of future. So, they can use it in the future themselves to teach somebody else we can give lectures online.” [Clinical Faculty 4]
“I think this will be a major change in the healthcare system, the appointments and the frequency of the appointments, and having the virtual evening clinics will be a great change”. [Clinical Facutly 5]
Principal Support
Theme 11: Academic support and communication with faculty and college
Students were satisfied with the positive attitude of faculty, their availability and willingness to help at any time. “The [clerkship] director is always approachable”, one student described. “The attitude of the professors and of the doctors have been really good. They've been really friendly. They're really keen on teaching us”, another student explained.
“I feel like we had a lot of support from them. The staff are willing to give extra sessions and revision sessions and willing to take questions at any time. They have given us their contact numbers as well.” [Student 4]
On the other hand, a few students felt uncomfortable with the level of communication and they asked for clearer and more frequent communication about academic issues from the college. These students asked for better organization and more collaboration within the program in a way that facilitates better and efficient communication regarding assessments, curriculum and resources available during the VC. One student explained how this would also allow more depth while studying a specific topic.
“So when I'm studying, I want to know how much in depth should I go so I can read a sufficient amount on it. If you say abdominal pain, there could be a lot of topics under that. So having a specific depth you want….that's the issue I'm facing with the blueprints at the moment”. [Student 8]
Students also expressed that they did not receive sufficient guidance nor regular feedback on their performance and thus demanded more frequent assessments. They also asked for more support from college by assigning staff from the college as student mentors.
“We need motivation, guidance and kind of follow up, which is actually the role of mentors… So, if we had, for example, mentors from the college, this would be much better.” [Student 9]
Faculty shared the same positive views as the students regarding the easier access to faculty members during the VC.
“…all what you can do now is actually a plan easy to access to faculty. Students have the right to ask questions, find their faculty, even if we have answers for extra time” [Clinical Faculty1]
In concordance with students’ views, clinical faculty members’ demanded more administrative support from college.. Clinical faculty members indicated that some disorganization and insufficient communication existed, and were mainly caused by the lack of administrative and technical support from training sites.
“We do need admin support, because I can describe how much we struggled with that at Sidra/ Hamad. Because I am working with two groups here and there, it is like, I do not know, print the schedule. I like to print the schedule sitting in my office. So I can allocate which student is rotating where or whatever phone I get. I know where they are. We have beautiful schedules made by XXXX colorful and last month, when I asked the nurse to print this paper for me, she said no colored printers.” [Clinical Faculty2]
“I think quite possibly build the station in the medical education where the faculty can go to, full prepared studio, good mike for example, with more advanced computers in order to make sure that we deliver the best possible medical education.” [Clinical Faculty1]
Theme 12: Psychological support to students
Faculty members perceived a need to provide students with more specialized psychological support to lessen the anxiety that student might have in relation to the pandemic and its impact on their education. They indicated that faculty communicated well with students about this issue. The college also assigned a student representative board, but no student counsellors, to work closely with students, help them understand the need to change the nature of their trainings.
“Having these representatives of students, provided psychological support to the students that we are listening to. We are there… having a very close communication between the students and the college at this critical situation… the more the communication, the more students have trust and confidence towards the faculty and the college…” [Clinical Faculty 5]
“I would suggest, in terms of coping strategies and coping mechanisms, that the university provides a counselor on the phone, or WebEx, or some hotline...not because of the COVID alone, but to this age group.” [Clinical Faculty2]