Future Challenges in Medical Education System in COVID-19 Pandemic: Scenario Planning

Background: With the outbreak of the COVID-19 pandemic, all the aspects of educational institutions such as universities have been affected. Trainings have changed from face-to-face and physical to online and digital. Therefor an educational reform has been recognized as a priority toward adaptation of universities with the current situation and transition to third-generation universities in order to synchronize with global trends. This study evaluated the preparedness of universities to manage the outbreak and moving toward a new generation, using the scenario planning approach. Methods: A mixed method design was used including three phases: 1) Identifying the variables affecting the future of medical education, 2) Prediction and building scenarios (future estimates), 3) Building the future (scenario-making). Results: The COVID-19 pandemic represents an enduring transformation in education with the advancement of smart universities, telehealth, adaptive research protocols, personalized and self-controlled learning and �exible approaches to achieve solutions. Conclusions: It is Inevitable that in this situation, the future of this path, must be clari�ed and a joint vision (scenarios) must be created. It is suggested that educational and environmental key factors should be constantly monitored to keep up with the process of managing the situation, globalization and the expansion of entrepreneurial universities.


Background
Universities have a considerable impact on accelerating the growth of society by training and empowering the workforce which is the axis of constant development.In this path universities have always been exposed to internal and external changes affected by economic, political, social, cultural, national and international developments [1][2][3].
With the outbreak of the Corona Pandemic from the end of 2019, all the aspects of personal, social and educational life of individuals were affected.Educational institutions have also been affected and higher education institutions have been closed.Trainings have changed from face-to-face and physical to online and digital.This paradigm, changes all aspects of education Learning, evaluation and researches.Online education, in addition to the many bene ts, has faced with challenges in the educational path due to the unpreparedness for this paradigm, especially in developing countries.These challenges include a lack of digital education infrastructure, computer literacy, faculty readiness, and student readiness to learn online [4,5].
Covid 19 pandemic in addition to all the negative socio-economic effects, has a profound effect on universities.evidence suggests that the Covid 19 pandemic has acted as a catalyst and facilitator in a major transformation at the universities and it has doubled the need to move towards digitalization and create a platform for an interactive model move from their traditional role -merely the production of knowledge (second-generation universities), toward entrepreneurship universities to transform knowledge and ideas into action (Third Generation Universities) [6,7].Hence, an educational reform has been recognized as a priority toward adaptation of universities with the current situation and transition to thirdgeneration universities in order to synchronize with global trends [8].
While the rst-generation university is based on education, second and third-generation universities are based on research, entrepreneurship/business, respectively [9].The third-generation university is composed of education, research, and innovation that is compatible with the needs of the current environment and production of scienti c and technological innovations, to explore and solve the realworld issues.The third -generation universities consider adaptability and creativity as a key driver, enabling students to sell their ideas, contribute to entrepreneurial motivation and the endeavor to generate new knowledge [10,11].Third-generation universities have the ability to innovate, recognize and create opportunities, develop teamwork, take risks and respond to challenges.By doing so, they can compete in global markets by creating economic growth [12,13].
According to the importance of an educational reform toward adaptation of universities with this situation.This study evaluated the preparedness of Shiraz University of Medical Sciences (SUMS) to manage the outbreak and moving toward a new generation, using the scenario planning approach.

Methods
A mixed method design was used in this study.The scenarios for SUMS in moving to the third-generation university were developed using the exploratory futures approach and attitude towards past trends [14].
This study was carried out in three phases: Phase 1: Identifying the variables affecting the future of health education A structured interview was used to collect data and identify the variables affecting the future of health education.Participants (n = 15) were managers of the vice-chancellor for research of SUMS, instructors and specialists in health education, and health policymakers.Snowball sampling with maximum diversity and consistency was used (First, the most known individuals were identi ed, followed by the recognition of other experts).Participants were chosen based on their expertise/experience in the relevant area, and their familiarity with the factors affecting health education.Objectives of the study and the interview questions were provided to participants, and consent was obtained.All interviews were recorded and transcribed.Transcribed texts were shared with the participants and their feedback was received in order to validate the data.
Data analysis was performed deductively and via a ve-step analysis of the framework, including familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation [15].Familiarization stage carried out through repeated listening to the audio les/reading of the transcripts, to identify the general perspectives, key ideas and overlapping themes.STEEPV and SWOT frameworks were considered as the framework for environmental analysis in three main categories of instructor, student, policy and infrastructure, to generate the conceptual framework.In the third stage (indexing), the manuscripts were studied line by line and based on the conceptual framework, and parts of the data that were related to the particular theme were identi ed and indexed.Following that, the identi ed codes were summarized in the form of tables.Data analysis was performed using MAXQDA-11 software.The method designed by Lincoln YS, Guba EG was exploited to evaluate the quality of analysis, while considering four criteria of credibility, transferability, consistency/dependability, and con rmability [16].
Phase 2: Finalizing key factors for prediction and building scenarios (future estimates) Cross-impact analysis and future signals sense-making framework were applied to select the most important factors identi ed in the previous stage (expert interviews), using a square matrix questionnaire.
Afterwards, experts shared their views of the level of mutual impact of factors on each other, selecting the most important proponents after determining the role of each factor (based on a Likert scale).In addition, the future signals sense-making framework was exploited to determine the impact and probability of occurrence of identi ed factors.In this technique, new domains and latent key factors that make changes in the domain were identi ed, and a list of information about the future of the environment around the organization was provided (Table 1).The researcher achieved participants' consent for sending the questionnaire (reminder emails were sent, in case of no response).After the completion, the mean views of responders for each question were estimated to analyze the questionnaires (the factors with the most impact and the highest probability of occurrence were selected).It should be noted that megatrends designed in this area in the Iranian Academy of Medical Sciences, as well as upstream documents and education transformation documents, were applied to nalize the key factors for predicting and constructing scenarios in health education (see Table 1.Future Signals Sense-Making Framework (FSSF)).Scenarios were developed and strategies and requirements for the implementation of the scenario were explained to build future plans.Cross-impact balance analysis was exploited to construct scenarios for moving toward third-generation universities (entrepreneurs).In this method, the probable situation (ranging from desirable to unfavorable status) of the selected factors was considered, based on the opinions of experts.Afterwards, another matrix questionnaire was designed, in which the effect of the occurrence of each situation on the occurrence or lack of occurrence of another situation was determined, according to experts' opinions and based on three features: strengthening, ineffective, and restrictive (scores between − 3 and 3).Scenario Wizard software was used for analysis.

Results
The results of this study are presented based on three phases shown in the methodology section [17].
Figure 1 showed the process of foresight in health education.
Phase 1: Monitoring and identifying effective factors In the rst phase, we recognized the effective variables and factors in health education at SUMS (with regard to the pyramid rule in the above model).At this stage, based on SWOT analysis, four categories of strengths, weaknesses, opportunities, and threats were identi ed, based on experts' comments.These categories were categorized into four levels: instructor, student, policy and infrastructure (Table 2).In the second phase, the effect and probability of occurrence of any of the factors affecting the future of health education in SUMS, which were identi ed in the previous stages, were evaluated.Five factors which had high impact and possibility of occurrence were selected as the nal key factors in the movement of SUMS toward the third-generation university (Table 3).These include: funding; stabilization of long-term policy-making towards the realization of third-generation university; cultural and attitudinal infrastructures; improving hardware (equipment) and software (educational contents and processes) infrastructures.
Table 3 Impact and the probability of occurrence of factors affecting the movement of health higher education at SUMS toward a third-generation/entrepreneur university

Factors Impact Probability
The ability of the system to nancially support the university in order to realize third-generation universities 5 3 The decision of the ministry of health for moving toward an entrepreneurial and third-generation university 5 5 Cultural and attitude infrastructures of instructors, students, and the staff of university in order to realize third-generation universities 5 3 Distance education to decrease the government custody charge 5 3 Improving the hardware (equipment) and software (educational processes and contents) facilities and infrastructures in order to realize third-generation universities 5 3 System's inability to create motivation 4 3 An improper awarding system that leads to a lack of meritocracy 4 3 The inability of long-term planning 4 3 Emigration of elites abroad 3 3 Stop of associate degrees and MScs and creation of specialized and subspecialized courses 2 2 Inaccurate and uncontrolled use of new technologies 2 3 Instability in economic issues 4 3 Educations be (Education is?) divided into two normal and subspecialized classes for elites 4 2 Private (with costs) and public (free of charge) educations 3 3 The mitigating effects of the ministry of health and medical education on education: the nature of the pro tability of treatment and the lack of pro tability of education 3 4 The coherent, robust and planned training system 4 2

Excessive centralization 3 3
Lack of localization of imported models 2 2 Disregarding interdisciplinary sciences 3 3 Excessive attention to subspecialized training and disregard for the needs of the community 3 3 Changing the evaluation and rating of instructors in line with third-generation universities 2 3

Factors Impact Probability
Increasing the interactions between a university with industry and branding and patents 4 2 Possibility to continue postgraduate and doctoral studies 3 3 The high number of articles and citations 2 3 The existence of scienti c and advanced research poles 3 3 The existence of completely updated laboratory equipment 3 3 The ability of activities of foreign students 3 3 The unfavorable political condition of the country in training elites: bureaucracy, slow working process 3 4 Resistance to change 3 2 Excessive government roles 3 3 Phase 3: Building the future (Scenario-making) The ve key factors presented in Table 4 were used to structure research scenarios.The basket of scenarios was compiled from the combination of different states of these factors and their possible situations using a cross-impact balance analysis.Four compatible scenarios, a network of direct and indirect effects and possible situations which were not rejected by experts, were extracted using the Scenario Wizard Software (Table 4).

Unfavorable
The rst scenario: quick movement toward the third-generation universities.This scenario is the most desirable future for SUMS, in which conditions and strategies have been described in detail as following.
The second scenario: opening the wing of e-learning and virtual schools.
The third scenario: turtle movement, indicating very slow progress of university.
The fourth scenario: danger of moving backward to rst-generation universities.

Discussion
Universities have one key principle in common, which is meeting the needs of the community by creation of knowledge-based wealth, and articulating entrepreneurship.In this regard, third-generation universities have opened up new horizons in the eld of entrepreneurship, de ning new career areas and creating wealth for the society [18,19].The results of the study showed that there are four different scenarios and challenges in Medical Education System in COVID-19 pandemic.
First Scenario: quick movement towards third-generation universities In this scenario, the focus of teaching and learning is on nurturing entrepreneurial and creative students.This requires more collaborations between universities, and industries for research and development.In this case, universities will be creators of new ideas, new jobs, and pro t.In this way the COVID-19 epidemic may represent an enduring transformation in medicine with the advancement of telehealth, adaptive research protocols, and clinical trials with exible approaches to achieve solutions [20].
The Covid19 Pandemic Crisis has facilitated the digitization of universities.Under normal circumstances, this path toward achieving this goal has required more time and the complex administrative rules and bureaucracy.But in this special condition the potential to move universities towards digitalization and the importance of information technology has increased [21].
Some evidence suggests that students' attitudes toward e-learning are not positive.The most in uential variables are learning environment, the degree of interactivity of the learning platform, students' knowledge and information about online communication.It seems that the growth of adopting approaches to correct these attitudes can be helpful [22].
The strategic actions for the success of this scenario are: Reform in nancing educational system, both private and public Reform in recruitment of faculty members, on the basis of entrepreneurship and modern knowledge of electronic marketing Re-design of the educational curriculum (specialized courses in entrepreneurship, creativity, critical thinking, innovation, marketing, project management)

Enhancing university internationalization
Second scenario: laying the foundation for e-learning and virtual Schools This scenario focusing on expanding virtual health education into diverse elds and with more advanced equipment and facilities.The university could then expand its virtual school and extensively collaborate with universities in other parts of the world to hold joint courses.This will enhance the opportunity for more enrolments, nationally and internationally, and enhance the exchange of knowledge and ideas.Expanding e-health courses are paramount due to emerging megatrends in health education, such as: expansion of borderless health care, improvement of health/bioinformatics information technology, development of fourth-generation smart hospitals with advanced intelligence and management systems in clinical and non-clinical settings.In this situation online education is a possibility that should be considered compatible with or replaced by face-to-face and physical education.Bene ts such as the exibility of online education, personalized and self-controlled learning, and cost savings cannot be ignored.Therefore, the implementation of smart universities will bene t all stakeholders.These smart universities will not only be more cost-effective than traditional one, but will also be more useful for students because a wider range of courses will be available compared to traditional universities and then different career paths are created [23].Evidence suggests that the challenges of online education, especially in developing countries and low-income countries are lack of adequate Internet infrastructure, teachers' lack of competency in online education, and students' low knowledge in this regard.Meanwhile, medical and clinical education has more challenges especially in teaching hospitals due to the health of patients that the constant presence of an observer is a basic need.
This issue emphasizes the importance of conducting researches in this eld and reducing administrative bureaucracy for an effective transition toward e-learning [24].Potts in his study suggested that allow and foster greater use of tele supervision were adopted by the ACGME Board of Directors in February 2020 were to become effective July 1, 2020.As the pandemic unfolded in the US, it became clear that tele supervision of residents/fellows could positively affect the delivery of care to patients while mitigating the risks to those residents, fellows, and other healthcare providers [25].
The strategic actions for the success of this scenario are: Changes recruitment based on the expertise in e-health Incorporate information communication literacy in the curriculum as well as investing in intelligence information systems Increase online courses and support for the production of electronic curriculum content Third Scenario: Turtle Movement This scenario is similar to the current situation, including some main issues, such as: low motivation, inappropriate system of payment to educators, lack of evidence-based teaching and learning.This situation discourages those who are actually competent and scienti c references in their own specialized elds to contribute to the area of policy-making and targeting (lack of meritocracy).
In this scenario, there will be an expansion of an industrial approach to medicine, which could have the following consequences: unbridled and non-expert use of new technologies; excessive increase in costs; harm to the spiritual relationship between physicians and patients; disregard for the spiritual dimension of human beings; lack of attention to ethics; violation of patients' privacy; and lack of localization of new educational models, approaches and technologies will lead to the backward movement of the university in terms of achieving scienti c authority in health education.
It is notable that even under these conditions, there can be opportunities to enhance the quality and improve the situation.with regard to the strategic geographical location of the universities in south of Iran and presence of experienced instructors in these universities, there will be proper conditions for growing and expanding medical tourism industry, which will lead to import of currency and improvement of nancial support of the university.
The strategic actions for the success of this scenario are: Society-based education tailored to the needs of community members and the use of indigenous models in education.
Improve the support and motivational system for distinguished students to maintain and reduce their migration (e.g., offering nancial and intellectual support for converting innovative industrial-scale ideas; patent registration; international conferences attendance).
Monitoring the purchase and evaluation of advanced health and education technologies.The lack of proper rules and adequate supervision for the suitable application of advanced technologies or referrals tailored to the patient's treatment process causes a heavy nancial burden on healthcare system, patients and families.
Fourth Scenario: Alert for Moving Backward to First-generation Universities Along with the Covid-19 pandemic, unstable economic and political conditions, Universities will not be able to nance a new educational system, research projects, support staff and national/international students.University may be unable to establish the distance education in more diverse elds, and the inability to use more advanced teaching technologies.This process will lead to less collaboration among university and industries, less staff retention, and ultimately poor education, and ineffective future human resources.In this regard, a case study by WSB (Visa Skola Biznisa) proposed a model that is a product of the joint investment with the National Louis University.In this model, the key mission of entrepreneurial universities is to help create the opportunity and capacity for local and regional development, create a knowledge-based society, encourage the development of industry, commerce, services, urban development, and technological citizenship in an active and action-oriented form [26,27].Moreover, the results obtained by Etzkowitz showed that the goals of entrepreneurial universities will be realized when the results and achievements of some particular research or innovation are revealed.In addition, it was noted that value-adding occurs by the university itself operating the result of the research or innovation [28].

Conclusions
It is Inevitable that in this situation, the future of this path, The COVID-19 epidemic, must be clari ed and a joint vision must be created.It is suggested that educational and environmental key factors should be constantly monitored to keep up with the process of managing the situation, globalization and the expansion of entrepreneurial universities.By doing so, the authorities will be able to make more appropriate decisions about the future with a clearer vision.Also they will lay the foundation for developing opportunities to establish an electronic global market, attracting students and researchers seeking the best occupational opportunities in the global academic market.On the other hand, this COVID-19 crisis represents an enduring transformation in medicine with the advancement of telehealth, adaptive research protocol and clinical trials with exible approaches to achieve solutions.In this way students should improve their ability to ful ll themself through electronic learning tools and social media and other online models. Figures

Figure 1 Process
Figure 1

Table 2
SWOT analysis (Strengths, Weaknesses, Opportunities, and Threats) to identify effective factors on health education at SUMS InfrastructureThe coherent, strong and planned education systemThe high number of articles and citations Presence of the Health Sciences Research Center Presence of supportive educational groups The existence of fully updated laboratory equipment and departments, such as virology and immunology Weaknesses Instructor Lack of transparency in job descriptions and promotion and nancial issues Being under pressure from three sides of education, research, and treatment, and neglecting education, which has fewer pro ts for instructors Injustice in payments to clinical and basic sciences instructors, which causes a lack of motivation Lack of openness to criticism Student Disruption of the pyramid of human resource training (our freshmen are very vulnerable and weak)

Table 4
Key Factors and Possible Situations of Each Factor in 2020 Vision