Table of Contents  
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 89-96

The online learning in medical education: A novel challenge in the era of COVID-19 pandemic

1 Department of Central Administration/President, Lebanese University, Beirut, Lebanon
2 Department of Urology, Faculty of Medicine, Lebanese University, Beirut, Lebanon
3 Second Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece
4 Lebanese Food, Drug and Chemicals Administration Center, Lebanese University, Beirut, Lebanon
5 Department of Neurosurgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, CEO Al Zahraa Hospital, Beirut, Lebanon

Date of Submission23-Apr-2020
Date of Decision23-Apr-2020
Date of Acceptance24-Apr-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Athanasios G Papatsoris
Department of Urology, Sismanoglio Hospital, 15126, Athens
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/HUAJ.HUAJ_9_20

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Online learning has a well-established role in medical education, and it is well accepted by students. Electronic learning (e-learning) strategy is aimed at improving the quality of medical education by providing students with equal access to quality learning resources. The main advantages of online learning are its flexibility and the capacity for learning to be self-paced. Online learning may be particularly useful for under- and post-graduate medical education. Virtual lectures can substitute conventional lectures in medical education in multiple fields. Online learning has several barriers including lack of time and poor technical skills of their providers, inadequate infrastructure, and the absence of development strategies of the universities. The current COVID-19 pandemic may represent a real challenge to medical education. Online learning techniques can be used to complete the curricula for medical schools during this crisis. This review presents a robust evidence base for e-learning in medical education. Further, it compares online and offline learning methods in medical education.

Keywords: Classroom learning, COVID-19, electronic learning, medical education, online learning, pandemic

How to cite this article:
Ayoub F, Moussa M, Papatsoris AG, Chakra MA, Chahine NB, Fares Y. The online learning in medical education: A novel challenge in the era of COVID-19 pandemic. Hellenic Urology 2020;32:89-96

How to cite this URL:
Ayoub F, Moussa M, Papatsoris AG, Chakra MA, Chahine NB, Fares Y. The online learning in medical education: A novel challenge in the era of COVID-19 pandemic. Hellenic Urology [serial online] 2020 [cited 2022 Nov 29];32:89-96. Available from:

  Introduction Top

Community-based education of medical students has increased vastly.[1] Distance electronic learning (e-learning) refers to the use of technologies based on healthcare delivered on distance and covers areas, such as electronic health, tele-health, telematics, telemedicine, and tele-education. The traditional static concept of medical education can be changed with the help of the novel technologic revolution. Telemedicine is a term for distance medical procedure, of both diagnostic and therapeutic procedures supporting decision-making.[2] E-learning technologies offer learner control of the content and pace of the learning, allowing them to tailor their learning objectives. In diverse medical education contexts, e-learning appears to be at least as effective as traditional instructor-led methods, such as lectures at the auditorium. Students do not see e-learning as replacing traditional learning but as a complement to it.[3] Massive open online courses (MOOCs) are increasingly available in medicine. These MOOCs are offered through various scientific (commercial and noncommercial) online platforms. When offered through reputable institutions, they can provide valuable access to reliable information without constraints of time, geographical location, or level of education.[4] Computer-based teaching and learning are as effective as typical lecture-based teaching sessions for educating postgraduates.[5]

Several factors consist as barriers to online learning: administrative issues, social interaction, academic and technical skills, learner motivation, time and support for studies, and cost and access to the internet.[6] The first meta-analysis to assess the effect of internet-based instruction for healthcare professional (HCP) learners compared with noninternet interventions (offline learning) was conducted by Cook et al.[7] They concluded that the internet-based learning is associated with large positive effects compared with no intervention at all. Effects compared with noninternet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to the traditional methods.[7] Richmond et al. conducted a meta-analysis and comprehensive review to compare online versus alternative methods for training licensed HCPs to deliver clinical interventions.[8] They concluded that online methods may be as effective as alternative methods for training HCPs in clinical interventions for the outcomes of knowledge and clinical behavior.[8]

Utilizing e-learning can result in greater educational opportunities for students while simultaneously enhancing faculty efficiency. However, this potential of e-learning assumes a certain level of institutional readiness in human and infrastructural resources that are not always present in low- and middle-income developing countries. Institutional adoption of e-learning ensures the alignment of new tools to the educational and economic context.[9]

The epidemic of the 2019 coronavirus disease (COVID-19) is caused by a novel virus first detected in Wuhan, China. This virus was previously named as 2019-nCoV. China officially declared the epidemic as an outbreak on January 20 when obvious human-to-human transmissions were ascertained with reagent probes and primers distributed to local agencies.[10] The COVID-19 outbreak has rapidly transitioned into a worldwide pandemic. This development has had serious implications for public institutions and raises particular questions for medical schools. A substantial number of medical students are in the process of preparing for or undertaking assessments that require clinical exposure. The effect of COVID-19 on medical education could, therefore, be considerable.[11]

This current review aims to present a robust evidence base for e-learning in medical education and specifically focus on the e-learning method for medical students and postgraduate doctors. We provide a review of the aims, barriers, and solutions to online learning. In addition, we compare online and offline learning methods in medical education. Furthermore, we present a brief review of COVID-19 disease and its effect on medical education and the place of online learning in these circumstances.

  Aims of Online Learning in Medical Education Top

E-learning can be used to aid the teaching of physical skills. A video showing the technique and explaining the theory by putting it into context could prime learners before they attend the teaching session. One area that has generated interest in medical education is the “virtual patient,” who helps teaching the skills of diagnosis and management through online interaction.[12] E-learning is a viable solution for medical educators faced with many challenges, including promoting self-directed learning, providing flexible learning opportunities that would offer continuous availability for learners, and engaging learners to augment continuous professional development.[13] Students rate e-learning just as highly as other traditional methods of clinical skills teaching and acknowledge its integration in a combined approach. Developers of clinical skills curricula need to ensure that e-learning environments utilize media that encourage deeper approaches to learn.[14]

Compared to conventional learning, e-learning has the advantage that participants can choose the place and time of education themselves. Within a clinical context, the effect of internet-based continuing medical education (CME) programs is comparable to traditional approaches of CME.[15] There are three e-learning modalities that promise great potential for innovative training in the future. These modalities include simulation technology, synchronous learning delivery, and web-based or videoconferencing for standardized patient-based training.[16] There are important implications, too, for globalization in medical education and for the continuity of education from undergraduate to postgraduate and continuing education.[17]

Virtual learning environments (VLEs) can be a compelling and powerful way to support and manage contemporary medical education. A VLE purposively aligned to a course can provide a central access point and reference mechanism for all course components.[18] The provision of e-learning tools or complex-blended learning scenarios depends on an online platform where students and teachers can get access. To address this issue, different forms of learning management systems (LMSs) have been established in medical faculties worldwide. An LMS can be defined as software that automates the administration, tracks all training events, and delivers learning contents rapidly.[19]

  Barriers and Solutions of Online Learning in Medical Education Top

Many factors can influence whether or not an online learning program will succeed or fail, ranging from student-led factors to staff-led factors. Lack of skills, in particular, technical skills, was found to be one of the major barriers met by educators when engaging with the development and implementation of online learning. Medical educators are already under pressure to find sufficient time to manage teaching, research, and maintain a work–life balance. In this context, inadequate time can be a significant barrier. In many cases, the lack of infrastructure and technology can be seen as a barrier in medical education, typically in low–medium-income developing countries. The negative attitude among educators in engaging with new technologies is another barrier to the development and implementation of online learning.[20]

A two-round Delphi study, aiming to identify expectations and barriers to e-learning in primary healthcare education, has been published.[21] Results showed that there was a positive attitude to e-learning, but there was concern about the lack of orientation toward users' needs and the poor development of innovative didactical concepts. In implementing e-learning in primary care, education should be independent of financial influence from the healthcare industry to eliminate conflicts of interest.[21] According to the study, adaptation to a new learning environment is necessary for virtual learning. Many barriers were found to self-directed learning in virtual education, including cognitive barriers (information overload and lack of focus on learning), communication barriers (inadequate coping skills and inadequate writing skills), and educational environment barriers (heavy workload and role ambiguity).[22] An MOOC experience of young family doctors has been published.[23] The limitation of course completion depended on internet connectivity and high English comprehension. First, a fast and reliable internet connection with appropriate bandwidth was needed to watch the videos. Without this, the content did not load properly and affected negatively the learning process. A second limitation was that the weekly modules and videos were in only English.[23] The key challenge is systematic and pedagogical approach to e-learning in which three equally important considerations must be balanced: organization, pedagogy, and technology.[24]

There are several critical success factors for e-learning programs. These include institutional characteristics: organizational support (time allocated for training); cultural support (supportive learning environment); and information technology support (including both technical infrastructure and learner technology assistance). Instructor and learners' characteristics include motivation, positive attitudes toward e-learning, and digital literacy.[25] Students of the online learning program often provide recommendations for strategies to address these issues, such as how to communicate, facilitate teamwork, and optimize time management.[26]

  Online Learning for Medical Students and Fellows Top

Graduate students had a significantly more favorable assessment of the e-learning resources than their undergraduate colleagues. It should not be assumed that all students will choose to use an e-learning resource in the same way and instructional design should enable alternative approaches.[27] A study aiming to evaluate medical students' perception of the usefulness and effectiveness of e-learning was done.[28] Of the participants, 92% found it enjoyable and 95% found the e-learning package useful; 75% perceived it to be effective in increasing their performance; and 91% believed it increased their knowledge in consulting skills.[28]

Early reports in the literature describe using student-generated questions as a method of student learning as well as augmenting question examination banks. However, reports on the performance of student-generated versus faculty-generated questions remain limited. A study was implemented to compare the question performance of student-generated versus faculty-generated multiple-choice questions (MCQs). This study suggests that student-generated compared to faculty-generated MCQs have similar item discrimination scores but are perhaps more difficult questions.[29] There is a gap between medical faculty's positive perceptions of e-learning resources and their low use of such resources. The most frequently selected reasons for not using e-learning resources in faculty members of medical school teachers were the lack of resources relevant to lectures, lack of time to use those resources during lectures, and the unawareness of their availability for learning.[30] The Korean Consortium for E-Learning in Medical Education was formed for the collaboration in providing quality online learning resources for medical schools.[31] This e-learning strategy aimed at improving the quality of medical education at the national level by providing students with equal access to quality learning resources. The consortium also planned to share e-learning content with medical schools in other countries.[31]

Residency programs could be better resourced to integrate e-learning technologies. Asynchronous e-learning was used more than synchronous, mainly because of busy resident schedules and duty-hour restrictions. In a survey of residency program directors (RPDs), it was found that program directors' perceptions of e-learning were relatively moderate and future research should determine whether RPD reluctance to adopt e-learning was based on unawareness of the evidence, perceptions that e-learning is expensive, or judgments about value versus effectiveness.[32] Another survey was done to characterize the educational tools used by surgical residents. Respondents used online textbooks and journal articles most often to investigate timely patient care issues. In contrast, mobile platform applications and online videos/lectures were used least. Fewer than half of the respondents used simulators, limited by clinical duties, absence of feedback/supervision, and lack of working supplies. Simulators remain a required tool for laparoscopic training and incorporation of structured feedback.[33] A surgical postgraduate year (PGY)-1 “Boot Camp” as a preparatory simulation-based training was implemented at the onset of the internship. This orientation process included exposure to simulated patient care encounters and technical skills training essentials. Scientists propose the “Boot Camp” performance measures as parameters for assessment of resident training.[34]

Minimally invasive surgery is a particularly challenging competency training area, requiring significant allocation of resident and faculty time and resources. “Laparoscopy 101” is a resource for the training and assessment of competency residents in minimal invasive surgery. It consists of CD-ROM-based self-paced didactic self-instruction modules, skills laboratories, and web-based testing, evaluation, and reporting. The “Laparoscopy 101” curriculum is well accepted by trainees and yields significant improvement in PGY-2 minimally invasive surgery competencies.[35]

A study was carried out for comparative evaluation of case-based learning (CBL) aided with mobile phone “WhatsApp” and didactic lectures while teaching a topic to the 2nd-year medical students. CBL aided by “WhatsApp” helped students acquire knowledge, discuss and learn actively, score more, and retain better than the standard lecture.[36] While didactic conferences are an important component of residency training, delivering them efficiently is a challenge for many programs, especially when residents are located in different places. E-conferences (virtual conference) proved to be an effective method of delivering didactics in the residency program. Its many advantages included ease of use, cost-efficiency, and wide availability of equipment.[37] Providing effective multisite didactic teaching in residency programs remains a challenge. In Wayne State University, a synchronous two-way audio and video internet-transmitted distance learning methodology in two sites has been introduced.[38] The didactic sessions were rated highly by both groups, with no significant differences in the resident satisfaction survey. The distance learning method was received positively by learners.[38]

The Area Health Education Centers Program at the University of Arkansas for Medical Sciences sought to deliver high-quality presentations to family practice residents at remote locations, using a two-way interactive video.[39] Four conferences were broadcast to five remote residency programs, and two local programs received identical conferences on-site. The negative attitude shift toward interactive video may have been because it was a new experience, or the preparation of the faculty was inadequate.[39] A study has been done to evaluate the educational effectiveness of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduate medical trainees compared to a traditional lecture-based course of equivalent content. A clinically integrated e-learning EBM course was compared to a lecture-based course among postgraduate trainees at the foundation or internship level in seven teaching hospitals in the United Kingdom (UK).[40] An e-learning course in EBM was as effective in improving knowledge as a standard lecture-based course. The benefits of an e-learning approach need to be considered when planning EBM curricula as it allows standardization of teaching materials and is a potentially cost-effective alternative to standard lecture-based teaching.[40]

  Online Learning for Postgraduate Doctors Top

Postgraduate medical education involves the use of online learning tools. Online learning modules could have an important role in improving the clinical practice of newly qualified doctors. These modules or packages are the tools that consist of key information on a particular topic and may be broken down into several smaller modules. In a study, online learning modules were used by 86.4% of doctors who were in their 1st and 2nd years of professional work after graduating.[41] Newly qualified doctors valued e-learning as an adjunct to experiential and lecture-based teaching, and most preferred it as part of a combined learning program at work or at home.[42] A study has been done to evaluate the possibilities of internet-based radiation protection training among referring physicians.[43] From doctors answering the questionnaires, 75% found e-learning to be an easy way to study. Nineteen percent had previous experience in e-learning. Sixty-one percent found that it saved time, and 57% stated that they learned more effectively using e-learning in comparison to conventional lectures. In conclusion, doctors are very positive about internet-based learning.[43]

A weekly workload of 4.5 h may enable course participation even for busy clinicians.[44] E-learning brings with it new approaches to content development appropriate for postgraduate medical education. Emerging trends include an instructional design based on reusable learning objects and the semantic web. Those technologies will also facilitate online collaborative learning between trainees who are geographically and culturally different.[45]

The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME.[46] A trial was implemented to determine if internet-based CME can produce changes comparable to those produced through live interaction.[47] Physicians were randomly assigned to an internet-based CME intervention that could be completed in multiple sessions over 2 weeks, or to a single live, small-group, interactive CME workshop. Both interventions produced similar and significant immediate and 12-week knowledge gains, representing large increases in the percentage of items correct.[47]

  Online Versus Traditional Lecture-Based Learning Top

Several randomized controlled trials (RCTs) have been implemented to compare the online learning modalities versus offline learning modalities as detailed in [Table 1] and [Table 2]. E-learning may be equivalent to traditional learning regarding knowledge, skills, attitudes, and satisfaction. An RCT concluded that evidence-based online CME could produce objectively measured changes in behavior as well as sustained gains in knowledge that were comparable or superior to those realized from effective live activities.[47]
Table 1: Clinical trials comparing online versus standard offline learning methods

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Table 2: Clinical trials comparing online versus standard offline learning methods

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A randomized study assessed whether web-based learning was superior to face-to-face problem-based learning (PBL) in the setting of a 6-week cardio-respiratory course.[48] While virtual collaborative learning was as effective as traditional PBL regarding the acquisition of clinical reasoning skills, it was less well accepted than traditional PBL.[48] A study comparing online versus traditional classroom-based methods for teaching scientific writing was done. It was demonstrated that online scientific writing instruction was better than standard face-to-face instruction, in terms of writing quality and student satisfaction.[49] Subramanian et al. concluded that the StepStone Interactive Medical Software (a web-based medical learning modality) modality demonstrated a significant improvement in student learning retention compared to the traditional didactic lecture format.[50] Yeung et al. failed to demonstrate a better contribution of the computer-assisted learning module to the understanding of spatial anatomic relationships of the cranial nerves in novice students.[51] In particular, no significant difference was identified between the computer-assisted module and the traditional text-/image-based learning supplements.[51]

The web-based tutorial was at least as effective as the traditional didactic lecture for teaching the knowledge and skills essential for learning ultrasound-guided vascular access. Participants expressed high satisfaction with this teaching technology.[52] Computer lectures in basic ultrasound and the extended focused assessment with sonography for trauma (EFAST) versus classroom lectures were compared.[53] Computer-based lectures were not inferior to classroom lectures and may represent a worthwhile substitution in subjects without prior ultrasound training.[53] Web-based ultrasonography and the EFAST didactics are comparable to traditional classroom lectures and result in similar knowledge retention in a study of two German emergency departments.[54] When training anesthesiologists to perform lung ultrasound for the exclusion of pneumothorax, it was found that web-based training was not inferior to traditional classroom-based training.[55] A study of web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains.[56] An RCT was implemented to compare the effectiveness of traditional and online teaching methods for educating anesthesiology residents in the principles and practice of difficult airway management.[57] It concluded that online teaching formats may be a valid alternative for teaching residents the principles and practice of difficult airway management.[57]

In an RCT study, nurses from hospitals and primary healthcare were randomized to either e-learning or classroom teaching.[58] The learning outcome and risk of error were compared after a course in drug dose calculations with the two methods. The study showed no differences in learning outcomes or risk of error between e-learning and classroom teaching in drug dose calculations.[58] E-learning using the Computer-Enhanced Visual Learning platform significantly improved preparedness, confidence, and comfort with percutaneous closed reduction and pinning of a pediatric supracondylar humeral fracture by residents.[59]

Therefore, online methods are as effective as standard methods for training healthcare professionals in clinical interventions for the outcomes of knowledge and clinical behavior.

  Covid-19 Disease and Its Effect on Medical Education Top

The COVID-19 outbreak rapidly transitioned into a worldwide pandemic. This development has had serious implications for public institutions and raises particular questions for medical schools. The effect of COVID-19 on medical education is therefore considerable. Several teaching hospitals in the UK have reported cases of COVID-19, with some hospitals suspending medical and observer students from attending.[11] The initial reaction in many countries was for healthcare facilities to reduce or even cease many clinical services, including the closure of clinics and postponement of medical appointments and elective surgeries. As a result of the pandemic, hospital activities (e.g., research and education) and virtual e-learning platforms are increasingly being explored to eliminate physical meetings.[60] As COVID-19 is identified worldwide, governments have imposed quarantines and travel restrictions on an unprecedented scale. The COVID-19 pandemic imposes restrictions on the mobilization of medical students, with classes being canceled and the teaching hospitals operating with “on-duty” shifts only, focusing on COVID-19 cases. This pandemic represents a unique challenge to education and healthcare services.[61]

Social distancing is the most effective preventing strategy until the development of a vaccine. This precludes medical students from gathering in auditoriums or group rooms. In response to COVID-19, medical education faculty have quickly transitioned the entire preclerkship curriculum to online formats that include content in the basic sciences, health systems sciences, and behavioral sciences. Small-group formats convene online in virtual team settings. Clinical skills sessions occur online or, in some cases, may be deferred. Examinations have also transitioned completely to relevant online settings.[62]

  Conclusion Top

Online learning has the potential to make important contributions to medical education. Web-based training is an effective and efficient method for medical education. Distance online learning is expanding and replacing the traditional method. As the revolution of e-learning has begun, universities should develop e-learning materials to improve the learning experience, knowledge, and skills acquired by their students. In the era of COVID-19 crisis, it is important that the medical schools and academic centers worldwide learn from the experience and prioritize planning for virtual e-learning for medical students and residents.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]

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