Synchronous learning for synchronous teaching: lessons learned from creating an online seminar to help physician educators develop best practices for synchronous online instruction

During the COVID-19 emergency in March 2020, most medical education activities were severely interrupted in teaching hospitals globally. At our institution, a large, urban teaching hospital in the United States, many physicians used video-conferencing tools to maintain educational activities with residents and fellows during the crisis. Therefore, graduate medical education instructional designers created a "pop-up" support seminar to outline and model best practices in conducting synchronous learning for physician educators. A total of 64 physicians attended two sessions of the seminar titled "Instructional Design: Best Practices in Synchronous Learning." While the seminar was designed to provide physicians with sound pedagogical tools, it was also designed to be delivered in a synchronous format to model best practices for this teaching modality. This Practical Tips article aims to be a working template for medical educators who would like to create a support course for physician educators in how to implement a high impact synchronous learning event. We share design challenges for creating online synchronous events, outline the speciﬁcs of our course, and highlight key behaviors and activities that facilitators can take to improve their online teaching.


Introduction
Henry Ford Hospital (HFH), a large urban teaching hospital in Detroit, Michigan, was a major "hotspot" during the Mortimore A, Hoffert M, Kokas M, Air E, Yeldo N, Abreu Lanfranco O, Passalacqua K MedEdPublish https://doi.org/10.15694/mep.2021.000085.1 Page | 2 COVID-19 surge in March-April 2020 (Chapman, Bosman and Eligan, 2020;Nichols, 2020). While medical training is a major activity at HFH, with over 50 residency and fellowship programs, formal teaching activities were severely interrupted in mid-March when the hospital received an overwhelming surge of COVID-19 patients. Because of mandated physical distancing and the need to redeploy residents and fellows to patient care, the hospital declared a Stage 3 pandemic emergency status in late March per Accreditation Council of Graduate Medical Education (ACGME) policy. However, physician educators sought to continue some semblance of formal medical training by using remote delivery methods. Ultimately, this situation turned out to be a lesson in adaptation and was an opportunity to expand teaching skills. One way that physicians maintained teaching activities during this time was with video-conferencing tools.
Using a video-conferencing platform for live, real-time, online teaching is considered "synchronous" teaching, which is different from the online delivery of pre-recorded, formalized lectures referred to as "asynchronous" teaching. Asynchronous teaching is a mainstay of most online educational programs, and the effectiveness of teaching through pre-recorded, asynchronous methods versus live lecture has been studied extensively (Spickard et al., 2002;Browne et al., 2004;Solomon et al., 2004;Davis et al., 2007;Cardall, Krupat and Ulrich, 2008;Brockfeld, Müller and de Laffolie, 2018). While asynchronous teaching is a format that relies on sound, technology-centered instructional design and student motivation/independence (Choe et al., 2019;De Leeuw, Logger , et al., 2019), synchronous teaching is often more informally viewed as a "meeting tool" that differs from in-person teaching mainly in regard to the computer interface. Indeed, the use of synchronous methods for clinical practice and teaching clinical skills has been studied more extensively as "telemedicine" (Roine, Ohinmaa and Hailey, 2001;Bertsch et al., 2007;Jain et al., 2010;Verhoeven et al., 2010;Haney et al., 2012;Brusamento et al., 2019). But it is difficult to compare different e-learning methods head-to-head since there is such a wide range of tools and approaches to using them (Cook et al., 2008) and because technology is constantly being updated and improved.
A 2017 survey of post-graduate medical training program directors revealed that whereas 72% of the 214 responding institutions had used asynchronous methods, only about 40% reported using synchronous methods (Wittich et al., 2017). But with the social/physical distancing measures mandated during the COVID-19 emergency, use of online video-conferencing tools such as Zoom, WebEx, Skype, and others has expanded out of necessity (Greenhalgh, Koh and Car, 2020). HFH has a dedicated team of professional instructional designers who provide support for all graduate medical education (GME) activities. Early in the COVID-19 emergency response, the GME team recognized that physicians were implementing impromptu synchronous teaching and that support for optimizing this teaching modality might be needed. Therefore, the GME team created an online, synchronous teaching module titled, "Instructional Design: Best Practices in Synchronous Learning." The goals of creating this course were four-fold. First, since physicians are generally not extensively trained in teaching methodologies, the course was designed to outline practical pedagogical tools for online teaching. Second, instructional designers wanted to ensure that physicians would be able to maintain educational integrity by using sound educational principles (eg, provide an adequate learning environment, deliver high quality educational content, promote student engagement) despite being unfamiliar with online media platforms. Third, the course was created to discover what faculty experiences with synchronous teaching had been, including what problems they had encountered, what they perceived had gone well, and what they still needed. Lastly, the GME team wanted to model an example of good synchronous methods by performing an effective synchronous event. Importantly, the course was not designed to be a tutorial on specific technologies.
For the 2020-2021 academic year at HFH, in-person teaching has been limited and all teaching activities for groups of any appreciable size are being transitioned to online formats. Nationwide, GME activities have similarly been affected, causing great concern to educators and trainees alike (Gill, Whitehead and Wondimagegn, 2020;Li, Xv and Yan, 2020;Newman and Lattouf, 2020), highlighting a significant need to expand training in using online Mortimore A, Hoffert M, Kokas M, Air E, Yeldo N, Abreu Lanfranco O, Passalacqua K MedEdPublish https://doi.org/10.15694/mep.2021.000085.1 Page | 3 approaches. The aim of this Practical Tips article is to provide a working template for medical educators who want to create their own synchronous learning support course. Additionally, we hope to share the lessons learned from this pilot program, particularly to highlight the commonly perceived barriers to effective synchronous delivery.

PART 1: Instructional designer observations -Key challenges faced during online synchronous event facilitation
Our institution is somewhat unique in that a team of instructional designers who are trained in adult educational theory and practice work alongside medical professionals to develop effective educational programs. The online "pop-up" support seminar described here was one effort by instructional designers to assist physicians who were struggling with pivoting their teaching online during the COVID-19 pandemic. Below is a brief list of key issues that instructional designers believe will be key for moving forward with online instruction, which is an educational feature that will be prevalent even after COVID-19 is a thing of the past. (Table 3)

Key delivery strategies for online instruction
Skilled facilitation is vital for conducting a successful synchronous learning event. The main challenge is that learners are at a distance, in variable environments, and they face many more distractions than they would within an in-person classroom environment. Therefore, the facilitator has an increased burden for maintaining participant engagement. For our course, we laid out ground rules as a working agreement at the beginning of the event and clearly stated the expectations and outcomes that were expected. Check-in activities, such as signing in via a chat feature, can help increase participant engagement. Our check-in activity also served as an attendance record for continuing medical education credits.
Online events are often impersonal, and suggested guidelines for conducting online meetings have been recently proposed (Rubinger et al., 2020). To keep an "in-person" feel, engaging participants by randomly asking open-ended questions to specific participants (by name) can keep people on their toes. Since most video-conferencing tools allow viewing multiple people on-screen, requiring that people engage the camera option is helpful. Some participants may need to engage classes via telephone, making camera use impossible. And many people are hesitant to use their cameras. However, explaining that participation via full video improves the personal atmosphere of an online event often supports participant compliance.
Importantly, implementing interactive learning methods such as polls, quizzes, small-group breakout discussions, case studies, and others can help create a more intimate, lively atmosphere. Lastly, since the facilitator is also viewing a screen, looking at the device camera instead of the screen can promote a sense of real eye contact with the audience.

Evaluations through the online medium
For synchronous courses designed for teaching medical trainees, learning outcome evaluation is a crucial aspect similar to in-person education. However, best practices for evaluation of e-learning methods requires further investigation (De Leeuw et al., 2018;.

Skills in using ever-changing technology formats -a major barrier
Because video-conferencing and other tools are constantly being created and updated, educational support for learning how to wield specific technologies is paramount. Technological support has been identified as a critical Page | 4 element in the ability of technology adopters to be successful. (De Leeuw, Logger, et al., 2019). Therefore, institutions should wisely invest in technology support staff for physician educators to save time and effort and to reduce frustration. During discussions, the participants in our course consistently voiced their need for help with learning how to use various conferencing software, which was not the focus of our event.
Regarding skill in platform usage, we highly recommend that presenters test their technologies before going live with their programs. Creating an action plan for what to do when unexpected technology issues arise (eg, platform outages, participant technology failure, audio problems) is also highly recommended.

Course material design considerations -not so different from in-person education
Course material design is a key aspect for in-person and online teaching methods alike, and most instructional design considerations are similar. Therefore, recommendations in this realm are like general considerations for any course design. For example, providing learners an outline of course content, learning objectives, and study materials well before the course allows participants to know what to expect. Also, slide deck design is key, and best practices for visual presentations have been covered elsewhere (Mayer, 2010;Daniel et al., 2018).
However, one major difference for a synchronous event is the facilitator's environment: that is, the physical aspects of the room from which the presenter is conducting the course that can affect the quality of live video. Participants of a synchronous events are engaged solely through an electronic screen where they will mainly see the presentation (ie, the slide deck) and the facilitator, or both. When the facilitator is on-screen, microphone placement, background features, and lighting all contribute to the experience of the viewer, and these should be planned strategically. With the rise of video-conferencing tools, many tips and features can be found with a simple internet search, such as the "Zoom Rooms Design Guide Best Practices" (Buell, 2019).
Timing is also key, and for online meetings it is important to factor in extra time at the start of an event, since people may be late for computer-related reasons. Lastly, as with any course, providing tangible takeaways will help participants solidify and implement their learning. These can include offering CME credits (which takes additional pre-planning), a checklist of take-home messages, lists of resources, and study guides. An assessment or survey is also helpful for improving future iterations of a course.

PART 2: Key features of the PowerPoint slide-deck design
Because our seminar was a synchronous event that aimed to model how to perform a synchronous event, a great deal of thought was put into instructional design. Table 2 and the list below highlight key features of our PowerPoint slide-deck. Note that all slides were designed to minimize text and optimize visual cues, per best practices in creating visual presentations (Mayer, 2010;Daniel et al., 2018). The presentation contained 42 slides in total, and the presentation was judiciously animated to create an adequate pace to the session.
The course was conducted two times in May 2020, with 42 physicians in attendance for the first session and 22 in the second session. Instructional designers took notes during the course and created a Learning Guide that was made available after the event for the participants. The class consisted of didactic explanations, video-recorded testimonials from medical faculty, a live discussion panel, and live question and answer time. Select slides are shown in Supplementary File 1.

Welcome Slide:
The first slide shown on the screen when participants joined the meeting said "Welcome." Key Feature -This slide was placed as a link in the Chat room at the beginning, in the middle and at the end of the seminar to guarantee that attendees had access to it. Importance -To promote an open, friendly atmosphere, and to list several key directions for attendees, paraphrased below: Upon arrival, introduce yourself in the chat room by sharing name and program Those who need CME credit should include badge number in Chat room or email to facilitator Please turn on video and mute audio Note that a link for an online learning guide will be posted in the Chat room Program start: At the start of the program, a title slide was briefly shown to reiterate the formal title of the course: "Instructional Design: Best Practices in Synchronous Learning." The first active slide contained embedded video of the Program Director of the Emergency Medicine residency program answering the question, "When was the moment you realized that medical education would never be the same for trainees?" The question was included as a feature of the slide. Importance -To engage participants with a peer's experience regarding the topic and to highlight the importance of multimedia in synchronous learning. Using multimedia (eg, videos, polls, panel discussions) is a key approach for establishing participant engagement early in the event and to break up didactic sections.
Objectives Slide: Three target objectives and a note on what the course did NOT cover were outlined. Importance -To clearly state ideal outcomes of the course.  First advanced slide after Welcome -starts the presentation Introductory Video Short video of a person who has been asked a key question to set the tone. Question: "When did you realize that medical education would never be the same?" Objectives (sub: Targets) Three clear, achievable target objectives for the course, includes one disclaimer on what is NOT covered Working Agreements Clearly states expectations of participant behavior during online session (eg, active participation, attention, keep airtime brief, technical difficulties) Agenda More detailed descriptions of study topics Agenda Item #1 -Types of Synchronous Learning Intro slide to Part 1 -transition slide followed by 5 animated content slides Panel Discussion on Successes and Challenges in using Synchronous Learning Introduction to panel speakers, pictures of speakers on screen during intro. Followed by 2 slides with specific questions for panel. Active group discussion during panel discussion. Questions for panel discussion: • What do you think is going well for you in your practice of synchronous remote learning? • What questions or challenges have you faced in conducting synchronous remote learning? Tips and Tools: Best Practices in Synchronous Learning • Introduces a section on things to do before, during, and after your synchronous learning event. Following slides outline the specific Tips and Tools for Synchronous learning that were covered Mortimore A, Hoffert M, Kokas M, Air E, Yeldo N, Abreu Lanfranco O, Passalacqua K MedEdPublish https://doi.org/10.15694/mep.2021

PART 3: Teaching by example -Key aspects of course delivery
A crucial goal for this course was to model best synchronous teaching methods. Therefore, the presenters not only prepared and practiced ahead of time, but also performed key activities and behaviors during the session. Table 3 below lists some key behaviors and activities that the event facilitator can adopt to address the key challenges outlined in Part 1. Send out pre-session correspondence with course outline and specific advice/parameters for how to set up a home space • Encourage students to use the "Chat Room" to make comments and ask questions • Chat rooms engage students without interrupting the flow of the presentation • Use polls or breakout sessions if technology allows Sample question: "In the Chat Room, indicate which aspect of synchronous learning you will find most difficult: Speaking into a computer camera, planning materials, engaging students, other"

Lessons Learned & Challenges
Key skills for designing and conducting online synchronous teaching are similar to in-person teaching, but the computer interface creates some key considerations that are uniquely challenging. Engaging the audience is difficult because of the need for technical skill and the impersonal nature of the video interface. Incorporating interactive methods within synchronous modules is challenging but can increase participant engagement. More training and technological support are needed for physician educators.

Take Home Messages
Conducting an online synchronous event has a range of challenges that are unique from in-person teaching because of physical distance and an online interface. Practicing ahead of time, implementing active learning, redesigning visual presentations to include an introductory slide with directions, and making eye contact with the camera are helpful behaviors. Strategies for keeping participants engaged during synchronous learning include: beginning with a working agreement, requiring participant use of the video option, including active learning, using impromptu openended questioning, and having the facilitator make eye contact with the camera.