Students’ opinion concerning alterations to undergraduate medical education during the COVID-19 pandemic: a narrative review

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REVIEW ARTICLE

Hippokratia 2024, 28(3): 83-92

Gournelli M1, Nena E2, Serif-Damadoglou E1, Arvaniti A1
1 Department of Psychiatry
2 Laboratory of Social Medicine
Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece

Abstract

Background: During the Coronavirus disease 2019 (COVID-19) pandemic, various changes occurred regarding undergraduate students’ medical education. Although some research on the matter has been done, to the authors’ knowledge, very few reviews consider medical students’ overall point of view during the pandemic’s first and second years.

Methods: We systematically searched the PubMed database twice using the “Advanced” settings; the last search was on 9th October 2022. The keywords used to search relevant literature included: i) (Distance learning) AND (COVID-19) AND (medical students’ perception) and ii) (medical education) AND (SARS-CoV-2) AND (online learning opinion). All in all, 47 publications met the inclusion criteria for this review.

Results: In most cases, the medical curriculum was modified to an online format, and clinical placements were canceled, which exhibited several advantages for the students, such as more personal time and a sense of flexibility and comfort. Nonetheless, the student’s overall point of view regarding distance learning tends to be rather negative than positive. That is mainly due to the variety of difficulties they faced because of it. The biggest issue that arose at the first (response) and the second (recovery) phase of the pandemic seems to be the lack of interaction between students and their professors and the non-existent student-to-student interactions.

Conclusions: Most students stated that once the pandemic was over, they would wish for either a full return to conventional teaching or the implementation of a blended strategy. Medical students appreciate the ability to continue their education amidst the pandemic. Nonetheless, they expressed various issues that must be addressed if online learning needs to be continued. Medical educators need to be aware of these issues to ensure the best didactic tactics in case a health crisis of a similar magnitude appears in the future. HIPPOKRATIA 2024, 28 (3):83-92. 

Keywords: Distance learning, Coronavirus disease 2019, COVID-19, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, medical students’ perception, medical education, online learning opinion 

Corresponding author: Evangelia Nena, MD, PhD, Associate Professor of Social and Occupational Medicine, Laboratory of Hygiene and Environmental Protection, Laboratory of Social Medicine, Faculty of Medicine, Democritus University of Thrace, Dragana, 68100, Alexandroupolis, Greece, tel: +30 2551030638, e-mail: enena@med.duth.gr

Introduction

The Coronavirus disease 2019 (COVID-19) pandemic has, among other effects, a serious impact on medical education. In most countries, the traditional educational curriculum of medical students is based on lectures and face-to-face teaching. Following the pre-clinical years, students attend clinical rotations and clerkships accompanied by bedside teaching1-3.

During the COVID-19 pandemic, the mode of teaching strategies was modified several times, depending on the periods of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) peak transmission, and numerous changes were implemented regarding medical education for students to be able to resume their theoretical and practical training4-7.

Most available literature focuses on a certain period of the pandemic. This review article aims to explore and display medical students’ point of view on education alterations, referring to both the first and the second year of the pandemic, as both theoretical education and practical training were severely affected. Medical students’ overall point of view should be carefully considered in case a health crisis of a similar magnitude occurs in the future.

Methods

A systematic search of PubMed database was conducted twice using the “Advanced” settings; the last search was on 9th October 2022. The keywords used to search relevant literature included: i) (Distance learning) AND (COVID-19) AND (medical students’ perception) and ii) (medical education) AND (SARS-CoV-2) AND (online learning opinion).

The inclusion criteria for the articles were: i) full text, freely available articles written in English language, ii) both qualitative and quantitative studies reporting medical students’ opinions on changes that took place in the curriculum of Medical Schools during the COVID-19 pandemic, iii) review articles summarizing the above-mentioned changes, iv) articles in the reference list of the previous categories, that also adhere to the previously mentioned inclusion criteria.

We used the following exclusion criteria: i) articles that did not refer to undergraduate medical education, ii) articles that examined health students in general (e.g., School of dentistry, pharmacy, nursing, etc.), and did not focus on and differentiate between medical students’ opinion from others’, iii) studies focusing on research questions that did not concern medical education (e.g., articles about medical students’ psychology), iv) articles not referring to medical students’ opinion on their education but on other matters, and v) specialized articles, for example, students’ opinion on online radiology class.

Results

Initially, 206 articles were identified (96 from the first search combination and 110 from the second one). Out of these, 47 original articles were eligible, based on the aforementioned criteria (Figure 1). The studies were conducted in Asian countries (26), Europe (12), Africa (6), USA (2), and one study was a collaboration between scientists from different continents (Table 1). Regarding their publication date, 17 were from 2020, 17 from 2021, and 13 from 2022.

Figure 1: Flowchart of data collection and study selection process in this review exploring medical students’ point of view on education alterations during the COVID-19 pandemic.

Background of medical education during the pandemic

The highly contagious COVID-19 disease urged the need for radical reform of undergraduate medical education during the pandemic. The literature search showed various curriculum changes were applied; online lectures and digital training activities replaced in-person training activities4,8. Most universities postponed their academic calendars for several weeks to achieve an e-learning’ implementation9. The two forms of online medical education during the acute phase of the pandemic described in the available literature are synchronous and asynchronous e-learning.

Synchronous e-learning consists of real-time live transmissions and virtual student-teacher interactions. Small group classrooms offering interaction, active participation, and live large group teaching and chat rooms have often been utilized10,11. The most used platforms for online learning are Zoom, Microsoft Teams8, Google Meet, Skype for Business, Adobe connect12, WebX10, Google classroom12, and WhatsApp Groups13. Asynchronous e-learning primarily consists of online articles, slide decks, and pre-recorded slide-based lectures14.

Students were also suspended from university hospitals, as they posed potential targets and transmitters of the virus2,15. Their practical courses were either postponed or indefinitely cancelled2,9,10. To continue their practical education, practical training was reestablished online2,16. To do that, universities used virtual patient cases and online case simulations, allowing students to practice using them2,10,17-21. Teachers also introduced online videos of patient examinations, as well as remote patient care environments and telemedicine10,22-24. Case-Based, Problem-Based, and Team-Based learning were also used, as well as “gamification” (a concept involving game attitudes to influence learning-related behaviors in non-game contexts)13,25-27. Even before the COVID-19 pandemic, many universities had already begun applying telemedicine or hybrid learning in their curriculums (such as phone triage, ambulatory electronic visits, conferencing platforms, email, and phone calls), facilitating the implementation of e-learning1,3,6,12,21,28–31.

According to the literature, the education of final-year medical students was prioritized in some countries. No changes in their education were applied. Instead of providing digital training, several teaching hospitals relied upon medical student trainees to cope with the constantly increasing healthcare problems arising from the evolving pandemic14.

Several studies showed that final-year medical students’ assessment was accelerated, and they were promoted to their career’s next step before completing the required medical education. This was reported in some countries, such as Italy, the United Kingdom (UK), the USA, and Brazil, and was due to the essentiality of these students to the understaffed healthcare systems5,8,14,32.

Following the suspension of face-to-face education, exams were also conducted online. Objective clinical skills examinations were either postponed or cancelled1,4,5. The exams usually consisted of multiple-choice questions, theory examinations (pen-and-paper), and oral tests. Some universities applied Open Book Examinations5. A significant challenge for the universities was finding fool-proof examination systems so students could not cheat during their exams33,34.

Additionally, hospitals in some countries attempted to reinforce their health staff, enlisting medical students by calling them out to perform tasks according to their level of knowledge; that could be considered an alternative way for students to gain clinical competencies2,33. Students had to volunteer of their own free will and fulfill a number of tasks under supervision33. 

Moreover, medical students offered their help to healthcare workers and community members during the first year of the COVID-19 pandemic35,36. Apart from volunteering in call centers, some students chose to help citizens by assisting them with their shopping, educating peers, patients, and communities regarding the SARS-Cov-2 virus via social media2, providing social services such as support and assistance to senior citizens, offering free childcare and pet care, running errands, as well as collecting personal protective equipment (PPE) and donating it to health care centers and hospitals in need35. Medical students also assisted in contact tracing, applied their lab skills in research, and volunteered in centers that provided information on the SARS-CoV-2 virus. Some examples of students’ volunteering groups are Harvard’s Medical Students Response Team #GetMePPE, Co-op, and Covid sitters33,35.  As stated, medical students have realized that the education procedure does not solely involve classes and clerkships. It is a relatively constant learning that integrates different principles and constantly adapts to changing circumstances35.

Medical student’s opinion concerning the new teaching methods enforced due to the high prevalence of the SARS-CoV-2 virus

Medical students’ point of view on the changes that the COVID-19 pandemic enforced were diverse; students pointed out both positive and negative aspects of them. The following section summarizes the advantages and disadvantages of online medical education, as assessed by the students.

Advantages of online medical education versus conventional education

I. Studies showed that online medical education eliminated the need for leaving home and driving long distances. As a result, it improved students’ time management and personal productivity36,37. This fact also reduced expenditures and contributed to better financial handling20,38. The reduction in air pollution was another positive aspect of tele-education based on the literature38.

II. Medical students utilized the resulted extra free time to undertake new hobbies and spend time with their families. Moreover, they studied for their classes and residency tests, prepared for clinical placements and improved their physical and mental health14,20,39,40.

III. Furthermore, students studying abroad had the chance to return home20, observed at a large scale in universities with great numbers of international students, such as universities in the UK or China41. E-learning was also helpful for international students due to the flexibility of the provided asynchronous learning, resulting in the ability to keep up with their classes while being in a completely different time zone20.

IV. This flexibility of the e-classes was helpful for the majority of the students regardless of their origin. Asynchronous learning especially offered students the ability to organize their schedules independently and attend their classes from almost anywhere (with most students feeling more relaxed from the comfort of their homes)8,12,20,38,39. Several students stated that they had the chance to develop time management skills8,14,20. Medical students also reported more straightforward access to a significant quantity of information they could explore at their own pace during their e-learning experience38,39,42. E-learning was a self-directed educational process and a student-centered way of gaining knowledge20.

V. Lastly, the pandemic provided medical students with volunteering opportunities14,20,33,35. Students reported that by volunteering, gaining medical knowledge was easier due to the lack of performance anxiety. In some cases, the reduction in the clinical personnel of the hospitals offered the students the opportunity to a better training of their practical skills in a real-life setting14.

Disadvantages of online medical education against conventional amphitheater and bedside teaching

I. At the beginning of their e-learning experience, students faced serious problems regarding technological equipment and other technical issues, such as lagging e-learning platforms. Studies showed that the most commonly reported problems were a range of technical difficulties12,20,21,38,39,43. Students reported an inability to access the online lectures at the beginning of e-learning training. Problems such as poor internet connectivity, software failure, and audio problems during e-classes disturbed the students as well as their professors39,44,45. Outdated equipment and poor computer literacy on behalf of the teaching stuff were also mentioned14. After a month of online teaching, though, most students gradually got sufficiently equipped with electronic means. Subsequently, the earlier technical problems were substituted by the lack of learning motivation39,46–48.

II. Furthermore, medical students, in the clinical years of their education, expressed a rising concern about the reduction of their clinical skills. They voiced the opinion that online learning was insufficient in providing them with clinical knowledge and competencies12,14,20,33,39,42,49-52. To be more precise, students mentioned that there were defects in the online discussion sessions of clinical cases during e-classes14. Problem-Based, Team-Based, Case-Based learning, clinical skills practice, and physical examination could not be successfully taught online39. Medical students’ dissatisfaction with clinical skills e-classes was also expressed because their opinions concerning e-learning were influenced by their year of study. Students in advanced years (clinical or closer to clinical years) were less satisfied with e-lectures compared to students from earlier years4,53. In addition, even students who were having clinical rotations in hospitals were often left unsupervised49.

III. Another major drawback of e-classes was the poor student-student and student-professor interactions. Specifically, many students mentioned that during e-lectures, communication with their teachers worsened4,14,20,38,39,54,55. Class interactions, discussions, and chances for students to express their questions demanded great effort14,56. Medical students also missed peer interaction, peer instruction, and face-to-face Team-based learning12,39. Many people mentioned that they also missed body language, something that troubled kinesthetic learners a lot39. Articles showing rates of students who were asked about interactivity are listed in Table 2.

IV. Additionally, many students experienced financial issues during the pandemic. It is important to keep in mind that university students are a financially vulnerable socioeconomic group. They had to purchase expensive technological equipment to participate in their classes, which may have worsened their economic situation and caused them anxiety10,57-59. Some students were even afraid that after the pandemic, they would no longer be able to afford college costs32, especially those living in developing countries where high-speed internet packages and technological means such as computers and phones are expensive to buy57,60.

V. Many students also felt the flexibility afforded by the e-learning status was harming them, as they had problems with self-motivation and self-discipline. As a result, they found it hard to manage their time correctly and to study the content needed10,21,61. Students also faced problems finding a quiet place to study, participate in their classes, or take exams. They were easily distracted by their parents or other family members12,20,39,46,49. Especially those students trying to manage children, siblings, or elders who are present at the house at the same time, who seemed to have experienced a significant amount of difficulty32.

VI. Students also experienced adaptation stress to the electronic means unfamiliarity with them and technophobia, even if scarcely mentioned39,62. The higher workload was mentioned, too, provoking laziness or burnout syndrome20,39,63. Furthermore, a feeling regarding the insufficiency of online medical education to replace their in-person classes was highly expressed42.

VII. Other disadvantages of e-learning were the following: patient discomfort and detached interaction with the students via e-visits, difficulty in maintaining academic integrity during e-exams due to the resourcefulness of the students when it comes to cheating, problems with the timing of the tutorials and its frequent change on behalf of the professors20,39.

It is notable that the majority of the students, when asked, stated that in the future, they would either prefer a full return to traditional teaching methods or integrate a hybrid strategy13,32,44,64-66. A smaller proportion expressed their wish to continue participating in distance learning techniques32,44,64.

Discussion

This review of the literature aimed to investigate medical students’ point of view regarding the necessary changes in undergraduate medical education during both years of the COVID-19 pandemic worldwide. The pandemic has had a severe effect on medical education. Its curriculum was, in most cases, radically transformed. In-person lectures were replaced by online learning. This fact led to a wide range of mixed reactions and feelings. Medical students have mainly appreciated the chance to continue and/or complete their education amidst the pandemic. They identified a variety of advantages of the changes, such as reduced commuting costs, increased personal time, returning to their homes, comfortability, and flexibility afforded, and voluntary activities available for them at the time12,14,20,21,33,39.

Nevertheless, students described the significant difficulties resulting from the integration of online teaching techniques. These can mainly be summarized as the reduction in students’ clinical exposure, poor student-student and student-professor interactions, financial issues, problems with self-motivation, as well as technical issues10,39,64. Concerning the latter, though, hope abides in that most of the survey respondents belonged to the millennial and post-millennial generations, resulting in an increased familiarity of the students with the usage of electronic means, as only a limited number of the responders admitted having insufficient computer skills (2 %)31.  Increased familiarity with advanced technology and computer science simplified the use of online medical learning31,66.

Concerning the interactivity of online lectures, most students expressed that during e-classes, the communication between them and their professors worsened. Students were also concerned about their significantly reduced interaction with the patients in real-life clinical settings. Even though some stated that interactivity was achievable through electronic means, communication during e-lectures still posed a challenge for several students (Table 1).

Interestingly, the available literature presents some major areas of agreement and disagreement. Some studies document the free time students gain due to online learning and the opportunity to organize their own time as a positive aspect14,36-38, while there is also evidence that other students had difficulties managing their time without supervision and could not focus sufficiently on their lectures10,21. Furthermore, even though most students were pleased to return to their homes8, they eventually started feeling uncomfortable due to lack of personal space, slow internet connectionetc2,12,20,31. Nonetheless, the existing studies agree that due to online classes, medical students have lost the opportunity to practice their clinical skills, resulting in rising anxiety among them20,31,33,39,49–52. Also, many studies note the lack of technological infrastructure at the beginning of online learning as an important aspect12,20,21,31. Interestingly, papers written in developing countries express rising concern about online learning, as internet packages are very expensive and not everyone can access them, causing a considerable economic burden on universities and students in these countries57,60. Therefore, a question arises regarding whether online learning is, in fact, accessible to everyone. What is intriguing, though, is that the available literature seems to agree mostly on the negative aspects of medical education during the COVID-19 pandemic and to contradict itself regarding the positive ones.

The previously mentioned disadvantages led to a sense of rising anxiety among students regarding their skills and concerns about wasting time that could be dedicated to mastering clinical knowledge5,10,12,14,20,31,33,59.

The results of this review demonstrated that the vast majority of the students prefer the traditional teaching methods or a hybrid strategy to e-learning. A small percentage of students prefer to continuously join distance learning methods, which is intriguing, as young adults prefer electronic teaching over face-to-face. Results proved medical students’ urge to return to in-person education and attend lectures in the classroom. They also wish to integrate the knowledge they earned during e-lectures into their future learning strategies. Undoubtedly, medical universities and teaching hospitals should properly integrate digital learning methods into a well-structured teaching curriculum. The aim of this change should be to combine the advantages of in person and e-learning methods and improve the quality of medical education globally13,32,44,64,65-69. Universities across the world should also be able to adapt to different circumstances without affecting the quality of education.

This review article has several strengths and limitations. The strength of this paper is the fact that the findings are based on a large number of papers published during the pandemic. Also, it considers the literature on the first and second years of the COVID-19 crisis, which is important as the medical students’ overall point of view on the matter is being presented. Regardless, the current study’s design is subject to limitations; only the PubMed database was searched, and methods of statistical analysis used by the article’s authors were not considered. Further studies need to be conducted to report and compare medical students’ perceptions concerning medical education during the different stages of the COVID-19 outbreak, aiming to develop a high-quality medical education program in the post-COVID-19 era.

Conclusions

During the COVID-19 crisis, medical education underwent many changes, most demanding innovative technological infrastructure, as well as medical students’ and their professors’ willingness to participate in them. Most of the available literature agrees on the negative aspects of the pandemic on medical education. The fact that medical students’ opinion regarding their education was more likely to be negative than positive is in line with that. The greatest disadvantage of tele-education, implemented by the universities during both years of the pandemic, is the lack of student-teacher and student-patient interaction. All in all, the majority of medical students tend to agree that after the COVID-19 crisis is over, they prefer either a full return to conventional classrooms or the implementation of a blended strategy. The university education system should develop new technologies and innovative educational strategies for similar future crises.

Conflict of interest

The authors declare that they have no conflicts of interest. 

Acknowledgements

We would like to express our gratitude to Professor Paschalis Steiropoulos MD, PhD (Professor of Pulmonology, Medical School, Democritus University of Thrace) for his valuable guidance and support.

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