Virtual Reality: Medical Students' Thoughts & Perspectives on the Pandemic & Chaos: A Twin City Survey

Background: The COVID-19 pandemic brought about drastic changes in the way we teach medical students. As the universities shut down to contain the pandemic, teachers and educationists were forced to contemplate upon ways and means to continue teaching our vast medical curriculum, while the students stayed at home, having their world turned entirely virtual. As the lockdown eased, social distancing came into play as it became impossible to teach the whole crowd. The objective of our survey was to determine the level of awareness and perspectives of undergraduate medical/dental/physiotherapy students of the twin cities of Pakistan regarding the pandemic, their experience and satisfaction level to the virtual teaching strategies implemented. Methods: A self-designed, validated electronic questionnaire was created using an online application (Survey Planet). The survey comprised of 30 questions and was distributed to students of 8 institutes of the twin cities via email and social media, during the second and third waves of the pandemic. Results: A total of 1490 students responded. Most demonstrated adequate knowledge of the pandemic, implemented good safety protocols, and were hopeful of the situation. Majority were satisfied with the online learning process, and gave positive view of the handling of the pandemic by their institutes. However, most found difficulty in studying at home, felt that precious time had been lost, and feared failure in exams. Internet connectivity issues were face by the majority. Most were in favour of being vaccinated. Conclusions: Twin city students have good knowledge, practices and positive views of online education.


Background
The COVID-19 (novel coronavirus 2019) epidemic erupted suddenly in China in December 2019 and engulfed and overwhelmed most of the world rapidly, in early 2020, as a public health emergency, much to everyone's surprise, fear and dismay [1]. We braced to face our unexpected first and worst pandemic, which saw most governments staggering to implement measures to contain the deadly SARS-CoV2 (Severe acute respiratory syndrome coronavirus 2), by shutting schools, colleges, universities, marketplaces, businesses and even hospitals! This incited chaos and uncertainty everywhere especially for students who were the most susceptible population to suffer at the hands of this pandemic.
In Pakistan, the first case of this deadly virus was reported in Karachi on February 26, 2020 and soon a country wide lockdown was implemented in March, 2020, to contain the first wave of the epidemic [2]. This closure of educational institutes forced teaching authorities to devise ways and means to deliver the extensive medical curriculum while the students stayed away, thus bringing about a culture of online teaching and activities, which had to be both cost effective, reliable and safe [3]. Live, online delivery of lectures by teachers in empty lecture theatres were widely adopted by medical schools in our country, with teachers missing the point of face-to-face teaching and learning, and with minimal student interaction. As the lockdown eased, social distancing came into place to keep students safe. For clinical teaching, the students were segregated further into smaller groups with 50% attendance each day, alternating batches every other day, with social distancing. The exams seemed even more difficult to conduct onsite with the reality of social distancing and safety precautions creeping in. For a developing country like Pakistan, it becomes even more difficult for the Higher Education Commission to provide all educational institutes with the software necessary for online teaching, to train the teachers, inadequate experience in online assessment, the availability of a dedicated information technology (IT) team, the reality of poor or non-availability of internet and low bandwidth for video streaming in some regions, from where the students may hail from, but also working from home also posing a challenge. The lack of a uniform set of guidelines for online teaching and assessment is also an issue [4].
Coming to terms with this ongoing pandemic, medical institutes reopened fully only to see the second wave of the pandemic forcing another shutdown in October, 2020 and a similar situation in the third wave of the pandemic in March 2021. The idea of gathering all students at once in large groups or even smaller groups is bound to have an adverse effect on the controlling of a contagious pandemic, whose curve needs to be flattened by staying six feet apart. As emergency use of vaccines was granted the world over, the reality of a vaccine has brightened the prospects of a full return to original medical teaching and learning [5,6].
The methods of teaching employed during this strange era were online lecturing via various tools, social media groups, video demonstration, virtual sharing of useful links and actual patient teaching in small groups with social distancing and decreasing attendance to prevent spread and crowding. All safety precautions were exercised including masks mandatory for all and masks for patients and COVID-19 testing mandatory for inpatients.
The perspectives of medical students regarding virtual teaching are useful in order to assess our teaching strategies, but also to prepare for future waves or pandemics. The purpose of our cross sectional survey was to bring light to the Twin City (Rawalpindi and Islamabad are frequently referred to by this name due to close proximity) medical, dental and physiotherapy students' perspectives on this seemingly never-ending pandemic, their thoughts, hopes and fears for their future in uncertain times, and also their knowledge acquisition, learning platforms and satisfaction of the strategies implemented during this era.  All methods were performed in accordance with the ethical guidelines and regulation, which is in concordance with the declaration of Helsinki.

Ethics and Consent to Participate
The survey link asks for online written consent of each student at the beginning of the survey before proceeding further.

Survey
We developed a 30-question online survey, available in English via the Survey Planet application. The survey was developed by the first two authors and was analyzed critically by senior faculty members before final approval. The survey was validated in a pilot study. Its Cronbach's alpha was 0.853. Sample size calculation was done with Raosoft sample size calculator etc. population size 5574 students, confidence level of 99%, 5% margin of error, 50% response distribution. Sample size estimation was 594.
The survey consisted of queries pertaining to basic demographic characteristics; gender, year of medical schooling, and different multiple choice questions, dichotomous ('yes/no') questions, scaled response via a Likert scale, as well as brief essay type questions, regarding knowledge, thoughts, hopes, fears and perspectives of students on the SARS-CoV2 pandemic experience and future plan as well. Questions regarding the students view on their colleges' handling of the pandemic, safety measures employed, methods of teaching during lockdown and ease of lockdown, motivation and problems faced via online learning were included in the last portion of the survey. Lastly they were asked upon their willingness to receive a vaccine. For some quantitative survey questions, the option of an open-ended qualitative feedback was provided with a comment box, if they wanted to answer it. The survey was piloted by a medical education consultant prior to distribution.

Recruitment and survey distribution
We recruited collaborators via email and phone from each willing participating institute. The respondents, as well as student representatives, and class teachers agreed to disseminate the survey to their respective students' population of their home institution, via email and social media, which was strictly online.
The collaborator and willing representatives then spread the survey with a brief in English and the link to access the survey to all the medical students at each institute, with one reminder sent again before the survey was closed. A total of 5574 were sent the online survey link, from the 8 participating medical schools and 1490 of them responded with free will and anonymity, resulting in a response rate of 26.7 % of our survey.

Statistical analysis
We calculated the descriptive statistics (frequencies and percentages) for each survey question using Survey Planet application which automatically calculates the responses obtained. A word cloud was generated for question 6 [What is the one word that comes to mind when you think of the pandemic?] using a word cloud application [Available from: https://www.wordclouds.com/] Figure 1: Word cloud depicting one word that comes to mind while thinking of the pandemic. This image is our own generated with our own survey data of Question 6 using wordclouds.com application which provides us copyright to use it freely

Results
The results of our survey have been tabulated in Table 1  885 (59.4%) felt they might fail their next exam due to the pandemic. 1300 (87.2%) showed consent to receiving the vaccine, the rest had either received 1 or 2 doses, or were reluctant due to side effects like hypersensitivity, blood clots, efficacy against multiple strains, unclear clinical trial data, herd immunity, or to allow vulnerable populations to be vaccinated first, but a few were scared of the chip implantation instead of the vaccine, current vaccine availability and waiting for other vaccines to arrive.

Discussion
Our study was a collaborative survey carried out in 8 medical colleges of the twin cities of Pakistan, O'Byrne et al have highlighted the need for future pandemic preparedness in order to minimize adverse psychosocial effects on medical students due to gross restructuring of the curriculum, exam and clinical teaching [28]. Early graduation and open book examinations in UK have led to reduced student anxiety according to Sandhu  Our study has had two limitations, the first of which is the response rate of 26.7 %. The survey was taken by free will and choice of each participating student and in times of uncertainty it is difficult to achieve a response.
Also there is selection bias as our survey represents only the twin cities' institutes and not all institutes have consented to the survey and not all medical colleges of the whole of Pakistan. This shows that the majority of institutes of twin cities have satisfied their students with their teaching strategies.
These are unprecedented times. As medical teachers, it is our duty to make the most out of what we have, to deliver our curriculum with the best possible methods, whilst keeping the safety of our students and also ourselves as a top priority. Student feedback is also important to evaluate our teaching methods and strategies and also to further enhance the teaching and learning process [35]. It is our job as teachers to deliver the best under any circumstances, favourable or unfavourable.

Conclusions:
To conclude, our survey revealed that Twin city students have good knowledge, practices and positive views of online education.

Declarations:
Ethics approval and consent to participate All methods were performed in accordance with the ethical guidelines and regulation, which is in concordance with the declaration of Helsinki.
The survey link asks for online written consent of each student at the beginning of the survey before proceeding further: "Hello! We hope you are safe & well. Please take a few minutes out of your precious time to share your thoughts on the Pandemic. By taking this survey, you give consent on sharing your thoughts. Complete anonymity is guaranteed!" Available from: https://app.surveyplanet.com/preview/5fbe4d8f08b8f57bbcaff644

Consent for publication
Online written consent was obtained from each participant for the survey before participating in the survey.

Availability of data and materials
The survey was completely online and its data along with results can be viewed at the Survey Planet application webpage from the following link: https://app.surveyplanet.com/results/5fbe4d8f08b8f57bbcaff644 The datasets generated were analysed by the Survey Planet application itself.
For Question number 6 in the survey: What is one word that comes to mind when you think of the Pandemic? ; we took out all the words and converted them into a word cloud with the help of the webpage: [Available from: https://www.wordclouds.com/] Figure 1: Word cloud depicting one word that comes to mind while thinking of the pandemic. This image is our own generated with our own survey data of Question 6 using wordclouds.com application which provides free copyright to use it freely

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

Funding
No funding was provided to us during the survey or afterwards.

Authors' contributions
"SN 1 is the author of the article. SI 2 is a strong collaborator involved in validation and data procurement. UH 3 , SI 4 and ZA 5 are institutional collaborators who have helped in data collection. All authors read and approved the final manuscript."