Opportunities and pitfalls within student-directed e-learning
Our survey shows that the COVID-19 induced short-term conversion to a purely digital education was associated with great difficulties in many places which is in line with other studies on this global issue (Al-Balas et al. 2020; Alkhowailed et al. 2020; Chatziralli et al. 2020; Mian and Khan 2020; O’Byrne et al. 2020; Tabatabai 2020). It would actually have been expected that in a world that has been digitalised in many areas, a rapid conversion to a virtual teaching environment should be relatively easy to master. Nevertheless, several unforeseen issues had to be overcome during the digital SS 2020. The evaluation of the free text comments in our survey revealed that through the use of asynchronous teaching methods, the direct contact between students and educators was missing and as a result the otherwise often familiar relationship between students and teachers, which builds up over time, could not develop properly. Non-verbal aspects of communication cannot be perceived and responded to as well or at all in a digital setting as in a direct face-to-face relationship (Bambaeeroo and Shokrpour 2017). Not only the teachers but also the students had to adapt to this new teaching method. The teaching content is now no longer taught centrally and synchronously, which can be an advantage since the students are now flexible regarding their own learning pace, but it also means that it is the responsibility of the students themselves to organise their individual learning units. The motivation for self-study is an aspect that should not be underestimated and is often characterised by the students’ postponement behaviour (Tillmann et al. 2016).
Although asynchronous teaching enables students to work independently at their own pace (independent of time and place), regular, personal contact between students and educators, as well as individual feedback, must still be guaranteed. In addition to content and method, students value reliable structure, organisation and support in the virtual environment. However, students need certain self-regulation strategies so that online courses are not accompanied by boredom and less enjoyment compared to face-to-face units (Stephan et al. 2019). Self-regulation can be promoted, for example, through portfolio work (Gläser-Zikuda et al. 2018). Asynchronous, digital blended learning/inverted classroom concepts can strengthen clinical teaching (Engel et al. 2019; Northey et al. 2015). Students work together on case studies and projects and apply their knowledge from the synchronous lecture in more complex contexts. The students’ motivation can be increased through the self-determined selection of topics. In interactive small groups, the solutions worked out can be presented and mutual feedback exchanged. The focus shifts from passive content transfer to interactive handling of content. Additionally, some faculties have introduced weekly quizzes to increase student motivation and also to check their “presence” on the relevant learning platforms. Virtual lectures can be designed to be more exciting through integration of small quizzes or surveys.
Challenges of distance online examinations
The corona pandemic and the associated distance and hygiene regulations affected not only face-to-face teaching in medical education, but also the examinations required for assessing students’ performance. At many universities these could no longer be conducted in large cohorts. Since no generally applicable rules were established, very different individual solutions were found in the various faculties across Germany. While most surveyed institutions adhered to presence-based written examinations and divided large cohorts into small groups in several examination rooms or used large premises, such as canteens, for the examination of large cohorts, almost 20% (n = 11) of the respondents in this study switched to distance online examinations. Due to the uncertainty in dealing with the hygiene and distance regulations, the examination format was changed in many places. Some have moved away from electronic written examinations (tablet-based, desktop-based) back to paper. The reasons for this were relocation to non-computer-based premises or the risk of virus transmission during final cleaning of equipment after use. Others indicated that there had been a switch from paper-based examinations to electronic examinations. This change of medium could have been accompanied by a switch to distance online examinations. The implementation of distance online examinations is a challenging task and also requires faculties and universities to impose and develop a range of procedures, policies and activities to overcome unequal opportunities Both digital teaching and digital examinations can lead to the exclusion of students due to non-existent access to equal opportunities for digital or blended learning formats. It is difficult to ensure equal opportunities for all students, because the quality of technical equipment of the students is very diverse and thus advantages due to newer or better hardware or disadvantages due to poorer internet connection emerge. In order to overcome unequal opportunities, universities could provide technical equipment or the possibility to conduct online examinations on university premises, if necessary (Fuller et al. 2020). Inadequate technical equipment must also be taken into account in the legal certainty of examinations. What happens if a student with poor performance intentionally leaves the online examination and blames it on a lack of internet connection? Attempts at fraud are of similar importance. How can it be ensured that the correct student takes the examination and does not attempt to cheat? Certainly there is a wide range of technical software tools that are designed to prevent attempts at deception by means of so-called proctoring (Camara 2020; Guangul et al. 2020). Often it is handled in such a way that the students need two devices with cameras to transmit a picture of themselves at the workplace as well as of their surroundings. Of course, this immediately entails the legal risk that the students’ privacy is not respected. Furthermore, the use of such programmes can disturb the trust and relationship between teachers and students as it is already assumed in advance that fraud could take place (Mellar et al. 2018.).
On the other hand, however, such examinations must also stand up to legal certainty and also be represented in the examination regulations of the respective federal states. The changing nature of teaching and examinations due to the coronavirus pandemic requires a revision of academic standards and formalities adapted to this extraordinary situation, including the examination regulations of the respective federal states and institutions (Sandberger 2020). In Germany, there are regulations in this respect both at federal state level and at the level of the corresponding higher education institutions, but general, concrete rules for online examinations still need to be defined. Bavaria was one of the first of the federal states to amend the Bavarian Higher Education Act (For detailed information see section 63 of Bayerisches Hochschulgesetz, 2006) on 24th July 2020 including distance online examinations and was even valid retrospectively for the whole SS 2020. Also, the Higher Education Act of North Rhine-Westphalia (For detailed information see Higher Education Act of North Rhine-Westphalia 2020, p. 207-302) was revised and distance online examinations are now possible. The above-mentioned challenges, which occur in written distance online examinations, are easier to handle in oral online examinations. This could explain why a higher rate of online examinations was achieved in this examination format. In contrast to written examinations, these are held individually between students and examiners via video conferencing tool, so that an identity check can be easily carried out. Equal opportunities aspects also play a rather subordinate role, as the exchange of information is verbal.
Digital teaching and testing of practical skills
Many of the competences required for the later practice of medicine, dentistry or veterinary medicine can be transferred well into a digital setting. The importance of these skills for decision-making within patient care is well summarised in the following statement by Guerrero-Dib et al. (2020):
“Promoting and experiencing academic integrity within the university context has a twofold purpose: to achieve the necessary learnings and skills to appropriately perform a specific profession and to develop an ethical perspective which leads to correct decision making.”
However, the digital conversion of practical skills poses a challenge for clinical practical skills and particularly at the beginning of the COVID-19 pandemic practical courses were discontinued (Fig. 2C) leading to an associated loss of essential skills for the later working life of physicians, dentists or veterinarians. Digitalisation of physical examinations on patients is simply not possible. These still have to take place in person, but can be carried out with the best infection prevention measures in place (Boursicot et al. 2020). However, there are also some practical clinical skills for which a well-thought-out digitalisation strategy can partly replace classroom teaching. One example is the skills that are acquired through bedside teaching. During bedside teaching, students can practice medical activities in direct contact with patients, such as taking a medical history, performing a physical examination or introducing a patient (Aldeen and Gisondi 2006; Kroenke et al. 1997). The contact with the patient can take place via a video conference, so that students have the opportunity to follow the examination at the patient’s bedside and, if possible, to get involved (Hofmann et al. 2020). Complete digitalisation of bedside teaching is a good substitute, but it can only replace direct contact with the patient to a limited extent (Pudritz 2021). The learning of interprofessional and communicative competences is an important and essential part of medical education (Bagnasco et al. 2014; Buring et al. 2009; Hean et al. 2012). Concepts involving simulations, telemedicine or virtual patients, have proven suitable for learning and testing these skills digitally (Abdelaziz et al. 2021).
According to our study, a digitalisation of practical assessments (OSCEs) was not feasible at surveyed faculties. Interestingly, the University of Heidelberg conducted the first virtual OSCE including simulated actors in SS 2020 as part of the Master of Medical Education (MME) course of studies. The virtual OSCE was administered via videoconferencing tool and designed (Cantone et al. 2019) to specifically assess medical interviewing and interprofessional competencies (Pante et al. 2020). Also other universities and institution changed to a digital OSCE format (Cantone et al. 2019; Craig et al. 2020; Hopwood et al. 2020; Lara et al. 2020; Lawrence et al. 2020). Within these virtual OSCEs, competencies such as history taking, knowledge of physical examination manoeuvres, problem solving, decision making and counselling could be assessed. Nevertheless, in all the proposed variants of a virtual OSCE, no physical examinations could be carried out on patients and thus these skills of the students cannot be assessed digitally and require face-to-face assessments.
Recommendations for the conversion to a digital semester
No individual solutions - digital transition is a collaborative task
At the beginning of the COVID-19 pandemic, all educators faced the same challenge: The entire analogue teaching had to be converted to digital formats in the shortest possible time without a preparation phase. For many educators working exclusively in face-to-face teaching, however, this digital conversion was entirely new territory and digital competences had to be acquired to a great extent first. From our point of view, one of the most fundamental tips is to manage the digitalisation as a community together intra- as well as inter-institutionally. Avoiding individual solutions may sound banal at first, but it can make a huge difference, especially when a change is necessary at short notice. The digital transformation is a collaborative task and requires lasting cooperation and a constant exchange of knowledge. In this way, experience can be exchanged and future developments can be jointly considered. Digital teaching should not be understood as a temporary task, but as a permanent goal. Accordingly, central structures must be established on institutional level and be sustainably financed. As a first instance educators should contact the respective support facilities at their universities or faculties. Most institutions have central support structures established that can be contacted for technical and didactical questions. Additionally, contact and exchange with educators who are experienced in e-learning has also proven successful. For this purpose, digital possibilities such as forums, platforms, etc. have been created at various universities so that educators can inform themselves, exchange information and network. Students were also integrated into the process and supported educators in the transition to online teaching (Abler et al. 2020). de Jong et al. (2020) published 12 tips on how to integrate digital teaching units into one’s own teaching.
New didactical concepts over technically simplest solution
The unexpected introduction of online teaching in March 2020 was very spontaneous for educators, without a phase of preparation and careful selection of didactically suitable methods and techniques. For teaching content to be communicated as quickly as possible, many educators relied on the technically simplest solution, while didactic concepts were neglected, often unwittingly. Initially, video conferencing and online seminars were primarily used, while didactic diversity was lacking. However, the learning content and learning objectives should still be in the centre of attention and the focus should not be on the technology but on the content-related competences. Reflecting on the motivations for previously used face-to-face teaching methods to impart skills, competences and knowledge could provide conclusions on which virtual teaching units need to be revised in order to bring didactics to the fore by means of good blended learning alternatives. Akin to teaching also the why, who, when and what of assessments need to be rethought (Fuller et al. 2020). In our opinion, it is difficult to transfer several hours of face-to-face teaching one-to-one into an online format. In this case, it is advisable to divide the teaching unit into several shorter units in order to avoid rapid fatigue or reduced attention of the students. For further reading on didactic teaching methods, we recommend the literature review by Challa et al. on modern techniques on teaching and learning in medical education (Challa et al. 2021).
Recommendations for conducting digital assessments
Prior to the corona pandemic, examinations at German universities were only partially conducted electronically. At the beginning of the pandemic, many individual solutions for online exams were created which was also an outcome of our survey. In the support facilities of many institutions, the main focus was on questions of legal security (38%) and functioning technology (30%), but also on related topics such as acceptance and fairness of digital forms of examination (Dreyer 2020). Software-based monitoring of students within online examinations by means of proctoring is considered rather critical and problematic. In our follow-up survey, it became clear that cheating attempts by students in online exams could hardly be detected. Guerrero-Dib et al. (2020) state in their work that academic integrity is much more than avoiding dishonest practices and is essential in any teaching-learning process focussed on achieving the highest standards of excellence and learning. According to a survey by Reedy and colleagues, both students and staff believe that deterrents to cheating behaviour are proctoring, student beliefs, question design, exam duration and marking practices (Reedy et al. 2021). Given these statements the focus should be less on the assumption that cheating could take place and the use of a monitoring system in online exams and more on the trust in students that they do not intend to cheat. Vučković et al. (2020) showed in their study that most students are capable in identifying ethical misconduct which also includes cheating in examinations. But they also state that not all ethical issues are clear to students and universities should organise trainings to increase the awareness of ethical misconduct. So, a first step in minimising fraud attempts is good ethical education of the students. Secondly, the exam format and question types should be adapted specifically for online examinations. Probably the simplest way to prevent students from copying each other’s answers is to randomise the exam questions. On the one hand, the order of the questions could be randomised and on the other hand, different examination questions could be used. However, these would have to cover an analogous subject area and be comparable in terms of difficulty in order to ensure a homogeneous and fair examination for all students. For this reason, the future should focus more on new examination formats that make the use of proctoring software obsolete. One example is the Open Book approach (Sarkar et al. 2021; Zagury-Orly and Durning 2020). In the OpenBook examination approach, cognitively and thematically demanding examination tasks are made available to the students on a fixed date. Afterwards, a certain amount of time is set aside for processing. The use of analogue and digital aids is explicitly permitted. Such approaches are well suited, for example, to test transfer skills. In this case, however, the questions must be chosen accordingly and be directed less towards knowledge-based and more towards application-oriented task types, such as multiple-choice questions with case vignettes or media content. Pettit et al. (2021) did a worth reading literature review on virtual exams, which looked in depth at the challenges of online examination. They describe different possibilities to assess clinical skills in virtual exam and offer question design strategies to mitigate cheating behaviour (Cluskey Jr. et al. 2011; Pettit et al. 2021) One must bear in mind that the development and formulation of new question types is usually resource intensive, which is why it is unfortunately still a vision for the future at many universities.
Outlook and conclusions
This study examined the influence of the corona pandemic on digitalisation in medical education in German-speaking countries. It can be said that, especially with regard to digital teaching, immense progress has been made and new, innovative teaching methods have found their way into a field in which e-learning has only been used sporadically despite advancing digitalisation (Handke 2015). However, the quick conversion to distance learning also presented many hurdles and, for example, technical problems had to be solved in many places (Table 1) (Veasuvalingam and Goodson 2020). Even though the switch to a digital semester was successful after some start-up difficulties, many educators and students are lacking more direct ways of communication usually occurring in face-to-face teaching units and thus the otherwise existing trust between educators and students. For this reason, a critical selection of the experience gained in this digital semester should be made in order to ensure future development of teaching with adequate digital teaching content. The future switch to partially digitally taught teaching content was also formulated by some of the survey participants to have both the benefits from distance teaching as well as face-to-face teaching. In conclusion, it can be said that even after two digital semesters, a didactically meaningful transfer to digital teaching methods has not yet been fully achieved and distance online examinations cannot be implemented at many universities. Nevertheless, the COVID-19 pandemic took the digitalisation of medical education a decisive step forward.
Limitations of the study
There are some limitations to our study: We only questioned UCAN partners of German-speaking countries, which is leading to the circumstance that only health professions are regarded in our survey and the outcome could be different in other programmes of study. Due to the rather low number of responses, it was not possible to categorise the answers by respondent characteristics, such as location, state or type of UCAN partnership. Another limiting point is that we did not take into account the students’ point of view in this survey. This could still be done in the future and we might identify further aspects that are needed for the successful digitalisation of education in the healthcare system.
