Combined Mode of Courses on Dental Virtual Clerkship During COVID-19 Pandemic for Final-year Undergraduates in Wuhan


 BackgroundOnline teaching is being widely adopted to achieve medical teaching objectives during the COVID-19 pandemic. To explore the dental virtual clerkship so as to continue the education of final-year dental undergraduate interns, combined mode of courses including small private online course, problem-based learning, online dental practice broadcasting and dental practice based on relatives’ or friends’ oral health management were applied for clerkship education for final-year interns.MethodsCombined courses of virtual clerkship was conducted from March to May, 2020 for final-year interns, while online preclerkship curriculum teaching was conducted for non-final-year students. Using the online students’ engagement scale (OSE), Biggs’ revised two-factor version of the study process questionnaire (R-SPQ-2F), student engagement and study process were evaluated for both. Teaching efficacy were evaluated via teachers' sense of efficacy scale (TSES) as well. ResultsStudents’ engagement was higher in final-year students, especially the emotion and participation categories (P<0.01). In the emotion category, 80.95% identified with putting forth effort on lecture and applying knowledge to life. Study approaches on deep motive and strategy were dominated in final-year interns (P<0.01). Teacher’ sense of efficacy also reflected the positive influence on student virtual clerkship. There was no significant difference among three categories including the sense of student engagement, instructional strategies and classroom management (P>0.05).ConclusionThis combined mode of courses on dental virtual clerkship could be potentially applied during the pandemic or be supplementary for traditional by-chair clerkship after the pandemic.


Abstract Background
Online teaching is being widely adopted to achieve medical teaching objectives during the COVID-19 pandemic. To explore the dental virtual clerkship so as to continue the education of nal-year dental undergraduate interns, combined mode of courses including small private online course, problem-based learning, online dental practice broadcasting and dental practice based on relatives' or friends' oral health management were applied for clerkship education for nalyear interns.

Methods
Combined courses of virtual clerkship was conducted from March to May, 2020 for nal-year interns, while online preclerkship curriculum teaching was conducted for non-nal-year students. Using the online students' engagement scale (OSE), Biggs' revised two-factor version of the study process questionnaire (R-SPQ-2F), student engagement and study process were evaluated for both. Teaching e cacy were evaluated via teachers' sense of e cacy scale (TSES) as well.

Results
Students' engagement was higher in nal-year students, especially the emotion and participation categories (P<0.01). In the emotion category, 80.95% identi ed with putting forth effort on lecture and applying knowledge to life. Study approaches on deep motive and strategy were dominated in nal-year interns (P<0.01). Teacher' sense of e cacy also re ected the positive in uence on student virtual clerkship. There was no signi cant difference among three categories including the sense of student engagement, instructional strategies and classroom management (P>0.05).

Conclusion
This combined mode of courses on dental virtual clerkship could be potentially applied during the pandemic or be supplementary for traditional by-chair clerkship after the pandemic.

Background
The coronavirus disease 2019 (COVID-19) has great impact on both people's life and medical education [1,2]. Final-year dental undergraduates from School of Stomatology, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China had nished the rst semester clerkship and started winter vacation at the end of January. Later, all teaching activities in classroom of the second semester were cancelled and students will not return for the second semester of the 2019-2020 academic year. The transition was feasible for lectures and group discussion coursework, since large scales of online teaching is being adopted to achieve medical teaching objectives during the COVID-19 pandemic [3][4][5].
Traditional face-to-face learning experiences like dental clinical practice training for nal-year dental undergraduate, however, are much more challenging to adapt to a virtual form [6,7]. During severe acute respiratory syndrome (SARS) pandemic in 2003, the cessation of clinical clerkships, medical formal teaching on wards, exams and electives for students hindered the education of medical students [8,9]. Likewise, the cancellation of clerkships this time could be detriment for both skill acquisition and relationship building [1]. There is uncertainty on how long the pandemic will persist and more and more realize that there may be periods in the future even after this emergency events, in which social distancing or quarantines may still or again be required [3]. At this especial time, Online teaching and e-learning seems to be a proper way to continue clinical practice education for interns. Recent publications reported that, both written and video-based materials were synergistic in promoting ophthalmic knowledge acquisition and clinical skills for undergraduates [10]. The massive open online course micro-video mode was explored to enhancing nurse clinical skills as well during the pandemic [11]. Zooming-out virtual clinical experiences were also tried in an emergency medicine clerkship [12]. Virtual format would do help on clerkship education.
The aim of this study was to nd advantages and disadvantages with combined online teaching approaches in Tongji Medical College for nal-year dental interns. This combined mode could be a necessary temporary replacement for traditional by-chair clinical demonstration during pandemic or could be utilized in "normal" times later as well, promoting teaching e cacy and decreasing cost. Student engagement and study process were very important for preventing online learner dropout and evaluation of students approaches, which could re ect student learning status [13,14]. Different questionnaires were applied for investigation of online learning student engagement and study process at this time, and comparison was made between nal-year interns and non-nal year students who were having online preclerkship curriculum at the same time, so as to evaluate the students' online learning e cacy. Teachers' sense of e cacy on virtual learning for dental students clinical training programs was also evaluated.

General data
All nal-year dental undergraduate interns from a medical college, were enrolled in the study (18 females and 6 males, group 1) with the average age 23.46±0.93. All the students from other grades who are still receiving preclerkship theory curriculum via virtual platform (Chaoxing platform, China) with online learning videos were taken as control group. There were 82 females and 39 males, with average age 21.6±1.48.
Teaching method for nal-year dental undergraduate interns 1. Small private online course (SPOC). SPOC was developed via WeChat broadcasting platform (Tencent, China). Over 17 sessions including 7 sub-majors of dentistry were designed and each session was designed to have 1-2-hour classes with general and main operate technique required for students. Tutors were required to provide both theory and dental practice micro-videos. The PowerPoint and micro-videos were uploaded for review after class. 1-2 quizzes on operation were proposed every week and videos were required to be sent in 20 minutes after the quizzes started.
2. Problem-based learning (PBL). Both case reports and questions were released 2 days before the discussion. The students are split into small groups of around 8-10 students for a single 1-hour tutorial on WeChat group talk platform (Tencent, China). In the discussion, students were the main participators while tutor were required to guide the talk. The group went through each case, revised clinical skills and highlighted important points, clinical knowledge and pitfalls. Questions were raised anytime during the discussion. At the end of the block, assessment was conducted according to the performance and activity during the time.
3. Online dental practice broadcasting. Live broadcast was released on WeChat broadcasting platform (Tencent, China) including type V restoration with glass ionomer and gingiva biopsy when the clinics were reopened in April in Wuhan. Informed consent was signed. Tutors were doing dental practice while commentating.
4. Dental practice based on relatives' or friends' oral health management. This cession was divided into two small parts. Students had to hand over general oral examination on anterior teeth for either themselves or their relatives who lived with them all the time during the pandemic. Those con rmed with COVID-19 disease, any indicators or symptoms related to the disease were strongly inhibited for oral examination. A general oral examination form was lled out. Oral health administration of dental students' relatives was also encouraged. Paper work on the consultation process of dental problem, nal advice and discussion of the case needed to be nished. Final assessment was applied according to the paper work.

Questionnaires
Questionnaires on the students' engagement and study process and teachers' sense of e cacy were converted into online format by using the Questionnaire Star software (https://www.wjx.cn/). Information on gender, age and study year were also required in the questionnaires.

Online Students' Engagement scale (OSE)
. Students engagement were evaluated by means of OSE [15,16]. The questionnaire has 19 Likert-type items with skills, emotions, participation, and performance categories. Each of them was scored on ve-point Likert scale. Responses were 1=not at all characteristic of me, 2=not really characteristic of me, 3=moderately characteristic of me, 4=characteristic of me, and 5=very characteristic of me. The Cronbach's alpha coe cients was α = 0.94.
2. Biggs' revised two-factor version of the Study Process Questionnaire (R-SPQ-2F). The questionnaire consists of 20 revised items on both deep and surface learning approaches. Achieving strategy and motive were included in the subscales. There were 10 items for each approach. The R-SPQ-2F is a reliable tool for measuring the learning approaches of students in university [17,18]. It has a 5-point scale including 1= the responses were rarely true of me, 2=sometimes true of me, 3=half the time true of me, 4=frequently true of me, and 5=always true of me. Cronbach's α coe cients for deep learning was 0.86 and for surface learning is 0.77.

Teachers' Sense of E cacy Scale (TSES, long form). The TSES, developed by Tschannen-Moran and Hoy [19] is a valid instrument measuring teachers'
sense of e cacy [20]. It is a nine-point Likert scale (1=nothing, 9=a great deal) with 24 items and three subscales. Subscale "student engagement" is a teacher's sense to make sure students are engaged in learning actively. Subscale "classroom management" means a teacher's ability to instruct the students achieving learning objectives positively, and "instructional strategies" suggests a teacher's ability in applying proper strategies for learning.
Data Analysis: SPSS 23 (Chicago, USA) was used for data analysis, which was expressed as (M ± SD). The counting data were described by numbers and percentage. To compare the mean scores of two different groups, independent t-test was performed. It was taken as statistically signi cant with P-value <0.05.

Study population
Of a total number of 24 students at the nal year, 21(87.50%) completed OSE and 20 (83.33%) completed the R-SPQ-2F. For the TSES, 26 tutors were enrolled in the teaching activity and 23(88.46%) questionnaires were actually recovered. The non-nal-year group was matched with nal-year group for gender and age ±2 years for both questionnaires.
Online Student engagement and outcomes ( getting good scores or do well on examinations. Whereas, compared with students in other grades, the total scores in emotion and participation categories are signi cantly higher than those in other grades (P<0.01, Figure 1A) Biggs' Study Process and outcomes (Table 3, Figure 1B) The mean scores in both deep and super cial learning way are shown in Table 3. Compared with junior students, the scores in deep motive, strategy and approach is signi cantly higher in the nal-year dental students (DA,DS: P<0.001, DM: P<0.01, Figure 1B).
Teachers' Sense of E cacy and outcomes (Table 4) The mean scores for subscales student engagement, instructional strategies and classroom management were 52.00±8.46, 54.09±9.82 and 53.43±9.01 respectively (P>0.05). For the e cacy in student engagement, the number of scores more than 5 which means identifying with the item was above 65.22%, and item 12 has the highest percentage 91.30%, which implied the ability to foster students' creativity during class. For the e cacy in instructional strategies, the percentage were all above 56.52%. For item 7, 10 and 11, which suggested the ability of respondent to di cult questions raised by students, gauging their comprehension and crafting good questions, they had the highest percentage 91.30%. However, for item 17 on ability of costuming teaching for individual students, there were only 13 people (56.52%), who thought they could have some in uence on adjusting their lessons to the proper level for individual students. For classroom management e cacy, item 13 on the ability to get students to follow rules during class had the highest percentage (91.30%) and item 21 on the ability of respondent to de ant students had the lowest percentage (65.22%).

Discussion
Despite reporting some issues with "virtual clerkship", which is challenging in providing real patients experiences for medical students [3], combined mode of course on dental virtual clerkship seems to provide enough e cacy for both teacher and students and to be a key substitute component under this circumstance. 80.95% nal-year students performed well on emotion category, suggested the strong desire to learn and apply the knowledge. Compared to non-nal-year student who were also having online theory courses, score of the participation category was also higher which suggested the better engagement in this combined mode than that of non-nal year online learners (Table 2, Figure 1A). Increase in DA in nal-year students suggested the study process was performed well, meanwhile, the students were adapting to the online and student-centered learning gradually with the application of combined courses [21] (Table 3, Figure 1B). The self-e cacy of tutors was high and consistent with other research [22], indicating that tutors had good sense of the e cacy and the ability to direct the learning process of their student [23]. The majority of the respondents have a high e cacy in all three sub-dimensions of self-e cacy with no signi cant difference (Table 4).
The student engagement of online course is very important for the retention of online learners [24,25]. With analysis of feedback on student engagement, it can be concluded that nal-year students were interested in learning. Students thought they engaged in activities, focused on teaching materials, try their best, and deserved good scores [26]. The attitude towards grades on item 15 and 16 suggested that the expectation was higher than reality (Table 1). Some students re ected that there were many quizzes, which might be the reason for low score for item 15 and 16. Teaching assessment should be re-assigned and designed for students.
Learning approaches were usually indicated of learners' perceiving, interaction with and responding to the learning environment [27]. Proper teaching methods are involved which could be applied allowing students to learn most effectively [26]. If students' learning approaches have been identi ed, proper teaching formats could be implemented and applied [28]. In this study, mean scores of deep approaches including learning motive and strategy were found higher among students in years 5 (Table3, P<0.01). Our study is consistent with Newble and Gordon's study, which reported that high scores were found on DA in senior medical students [29]. The observed higher DA score in years 5 students might suggest a carry-over from post-graduate examination that is both externally and internally driven and education background might be a key factor for learning approaches [30]. Different format of teaching might be another explanation [31]. Lectures in other grades are mainly micro-video class for theory, which was uploaded onto the online platform. Whereas, in the years 5, various types of study and teaching mode were carried on so as to simulate clinical practice as much as possible and some of them were PBL, which was proved to increase in a deep learning [32,33]. In addition, workload or other factors, may be more as determinants than course type as well [21].
Though traditional by-chair clerkship is irreplaceable, the advantage for this combined virtual clerkship mode are as follows (Table 5). Taking SPOC, which could be repeatedly watched by the trainees, could greatly improves training effect [11]. The application of PBL and the exploration and practice of health management has been widely applied in Tongji Medical College [34], especially the dental health management and consultation from family or friend, making the role of dentist impressive. The clinic was reopened on April 8 th , which make the live broadcasting available. Self-perceived student-to-tutor interaction was kept constant in both face-to-face and live broadcast [35]. Student Combined mode of SPOC, group talking, live broadcasting, health management for dental students' relatives is utilization of network tools to present clerkship courses, which could simulate to the maximum of by-chair clinical practice, providing patient medical histories, oral examinations, medical recording, and the art of detective conversations.
We learned several lessons as well. First, make sure all potential users could use the application. It's very challenging on the willingness of faculty to embrace the new technology [40]. Anything, including poor connection, or unfamiliar with apps operation should be taken into consideration rst. With the re ection of such problems, teaching assistants helping both teachers and student to solve problems which often disrupt the ow of the class. Second, videos are encouraged to use for both teachers and students, which may improve the sense of interacting and engaging for both speakers and listeners. However, it's better to blur the participants' background for privacy protection, while unintended interruptions should also be avoided.
Di culty in teaching dental practice via internet is still the main limitation. To learn these techniques, simulated patients are needed. Traditional by-chair learning is still a more effective way for medical education [7].
As social distancing is needed during pandemic, the combined virtual mode has signi cantly changed the way of teaching and engaging with our dental interns. Additionally, it has helped us to foster a sense of attenuating intern's burnout and to some extent promote dental wellness especially during or after the isolation. Combined modes of courses on virtual learning program may play a important role in medical clerkship education during or after the pandemic.

Conclusion
With combined mode of courses on dental virtual clerkship, the student engagement and study process of nal-year students were more improved than those of non-nal-year students. This mode could be potentially applied during the pandemic or be supplementary for traditional by-chair clerkship after the pandemic.

Availability of data and materials
Data are available from the corresponding author with reasonable request.

Ethics approval and consent to participate
The online courses study was conducted with prior approval from institutional ethics committee (IEC,20200406), which has waived the informed consent since it's a part of training program.

Consent for publication
Not applicable

Competing interests
No con ict of interests