Can Online Learning Ful � ll the Competence of Medical Study Program Students ?

Background: The Covid-19 outbreak has had a huge impact on education, especially in health education both throughout the world and in Indonesia. Educational institutions are forced to close any access of offline meeting in order to reduce the spread of Covid-19. This is in accordance with the Official Letter of Ministry of Education and Culture Republic of Indonesia. No. 36962 / MPK.A / HK / 2020, the government prohibits universities from holding offline lectures then encourages online learning. Online learning in Indonesia is not popular before pandemic but it must be held. However, the learning goal must still be achieved. The learning process is aimed to achieve the expected performance also improve the quality of education. Quality assurance and personalized online learning are one of the mechanisms that help higher education to achieve planned outcomes. Online learning changes all aspects in the learning process. Both educators and students need to adapt to the online learning process. As a result, students and educators need to adapt quickly to minimize the material backlog. Due to the various reasons above, it is necessary to develop an online learning model that can help the learning process both in the cognitive and psychomotor domains in the Medical Study Program so that the expected competencies can still be achieved. Method: The data was analyzed by using t-test statistic to compare between students’ achievement in distance learning and offline learning. Results: : The results showed that the learning outcomes of students who took online learning methods were higher than those of students who took offline learning. This can be seen from the average learning evaluation score, the number of passing practicum scores, the number of passing skills lab scores and the number of passing blocks (p<0.05). Conclusion: It can be concluded that online learning helps students achieve competence at the academic stage of learning.


Background
The Covid-19 outbreak has had a huge impact on education, especially in health education both throughout the world and in Indonesia. According to [1], it also has negative impact to the education.
Educational institutions are forced to close any access of o ine meeting in order to reduce the spread of Covid-19. This is in accordance with the O cial Letter of Ministry of Education and Culture Republic of Indonesia. No. 36962 / MPK.A / HK / 2020, the government prohibits universities from holding o ine lectures then encourages online learning [2].
The occurrence of the COVID-19 pandemic has fundamentally changed the implementation of medical education. O ine educational activities must be eliminated or replaced with similar activities through other media. The implementation of o ine activities at several universities has been changed to the distance learning. Distance learning utilizes technology in the form of online learning media owned by the faculty as a virtual communication medium to run the learning process. This becomes a challenge in ful lling all indicators of achievement in the aspects of medical education. Actually, online learning is not new thing in this faculty because students can access material related to basic and clinical medical science theory. However, it is totally different with skill aspect which requires direct supervision by the teaching staff to ensure the ful lment of student skills. In addition, practical activities require tools and materials which students do not have. In the aspect of professionalism, the role of teaching staff and educational institutions is very important as a good role model for students.
Evaluation of the professionalism aspect has also become di cult due to the social and physical restrictions during the pandemic. Several solutions have been attempted, for example, making experimental videos to support student practicum activities. However, some things still cannot be replaced by the distance learning, namely direct interaction with patients to obtain objective data as part of clinical skills. In addition, some clinical skills procedures also require detailed supervision from teaching staff. The needs of appropriate distance learning method can help students to achieve clinical reasoning.
It is a quite challenging to do the distance learning in medical education especially in some aspects such as clinical skills, clinical experience with patients, and aspects of professionalism. Evaluation methods in the form of Objective Structured Clinical Examination (OSCE) and patient-based clinical examinations are also di cult to implement because of the social restrictions. Thus, it is not only the di culties in achieving standard competence of Indonesian doctor but also evaluation.
The option that can be considered is extending the study period to achieve competencies that were not achieved during the pandemic. This option seems ideal, but it has an impact on increasing the educational burden that must be borne by teaching staff (lecturers) and students. this choice is not ideal if the pandemic is not controlled. Regarding preclinical education, cognitive aspects can be implemented during the distance learning but the psychomotor and affective aspects are di cult to implement. It is caused by direct contact is needed between teachers and students. Thus, there should be another method to run the learning process in medical education. The policy makers must be very careful in deciding the choice. They should take care of the health protocol which should be implemented by lecturers and students. Openness in the policy-making process is also important, considering that medical education activities cannot be separated from conditions in the eld. Policy makers must also quickly adapt to situations that can change at any time, and provide rm and clear considerations so that the achievements of medical education can still be pursued optimally.
The purpose of this study is to develop a learning model in the Medical Study Program that involves all learning processes, namely lectures, tutorials, practicums and skills labs in order to meet the required competencies when students graduate from the academic stage of education.

Methods
The purpose of learning process in the Medical Study Program is students have cognitive, psychomotor, and affective competence. These three components are a unit of competence that must be possessed by students who have completed their education. To achieve these competencies, the Medical Study Program uses several learning methods including: lectures, practicums, tutorials and skills labs. In normal times, all this learning process is carried out o ine with a block system. This learning model can no longer be implemented in the current pandemic conditions. Therefore, all these learning models will be replaced with an online system that will be developed to meet the competency targets that have been set. The development in this research was online learning model for lectures both synchronous and asynchronous, online tutorial learning model that is implemented synchronously, online skills lab learning model that is implemented synchronously, online practicum learning model that is implemented synchronously, practicum learning assessment model and block evaluation conducted synchronously online, and development of learning videos that support the online learning process both synchronously and asynchronously.
The research sample was students of 2018 and 2019 medical study programs who underwent block learning. The block that was developed in the learning model is the block that runs in the even semester of 2020/2021 chosen randomly. The research was carried out in January 2020 -December 2020. The results of the study compared between the achievement of competence during conventional learning and learning outcomes during a pandemic using e-learning. The data was analysed by using t test statistics.

Results
The learning process in the Medical Study Program during the pandemic is carried out in a blended learning. The entire lecture process is carried out online using e-learning media, the practicum process is also carried out online 100% and the skills lab learning process is carried out in a blended. The learning outcomes of each activity can be seen in the following table: From Fig. 1 it can be seen that the average score of learning outcomes in each block with the online learning system is higher than the learning outcomes with the o ine learning system (p < 0.05). Based on the calculations, it is known that the results of the online learning evaluation are signi cantly different from the o ine learning evaluation results Based on Fig. 2, it can be seen that the passing of each block using online learning was higher than the passing of each o ine block (p < 0.05). The results of statistical calculations show that passing blocks using online learning is signi cantly different from passing blocks using o ine learning. From Fig. 3 it can be seen that the minimum value of the learning evaluation results in the block that uses online learning is higher than the minimum value of the block that uses the o ine learning system (p < 0.05).
The maximum score obtained by students in block learning using online learning is higher than the score obtained by students using o ine learning but this difference is not signi cant (p = 0.600) For practicum activities, the average value of practicum response, the average nal grade of practicum and graduation of practicum students who take online learning is higher than students who take o ine learning, this can be seen in Fig. 1 (p < 0.05).
The results of the skills lab learning can be seen in Figs. 5 and 6, where the images show that the average OSCE score of students who take online learning is higher than those who take o ine learning. This has an impact on students whose remediation of online learning lab skills is less than online learning. Discussion E-learning is mostly used in the learning process of the Medical Study Program during the pandemic. Lectures, practicum, skills lab and tutorials all done in the learning process. During the pandemic, the lecture learning process is carried out online, both synchronously and asynchronously. Synchronous learning either using MS Team or Zoom applications. Tutorials are carried out directly using the MS Team which are divided into small groups and facilitated by a tutor.
Based on the results, it is known that the average score of the learning evaluation test in online learning is higher than the results of the o ine exam learning evaluation with a value of p = 0.024 this has an impact on the number of blocks passing which increases in online learning when compared to o ine learning. The average online practicum response score is also higher than the o ine practicum response test average score, this also has an impact on increasing the number of practicum graduations in the online learning process. The skills lab learning process is given synchronously and asynchronously.
Before the synchronous meeting, students are given a video about the skills that students will do through MyKlass. They can access the video independently before synchronous learning is implemented.
Although the skills lab learning process is carried out online, the assessment process is carried out o ine. Surprisingly the result show that the OSCE score of students who take online learning is higher than students who take o ine skills lab learning. This result is in accordance with the results of previous studies which stated that online learning outcomes were higher than o ine student learning outcomes [3]. This is also supported by research conducted by [4] which states that students are satis ed with the learning system that uses e-learning during the pandemic. The existence of satisfaction will increase con dence and foster student motivation to learn. Attitudes, motivation, self-e cacy, and the use of technology play an important role in the cognitive engagement and academic performance of students which will later affect their learning process [5]. The learning process using e-learning is in accordance with the PBL learning method used in the Medical Study Program because this method requires students to become independent learning [6], the delivery of lessons can be in the form of simulations and real cases (Hartanto et al., 2020) and can ensure lifelong learning [7], and students can also access and learn without being constrained by place, space and time [8].
The learning process using technology, especially e-learning during the pandemic, is one of the alternatives chosen by various institutions, because this learning has many advantages, including 1) having relevant content to the learning objectives; 2) using instructional methods, for example presenting examples and exercises to improve learning; 3) using media elements such as words and pictures to convey learning materials; 4) allows direct teacher-centred (synchronous e-learning) or designed for independent learning (asynchronous e-learning); 5) build understanding and skills related to learning objectives either individually or improve group learning performance [9]. Although learning using elearning has many advantages, there are 4 dimensions that can hinder its implementation, including (Naveed et al., 2017): students, among others, lack of motivation [5,7,10], self-e cacy [5] low bandwidth due to limited quota [11][12][13][14], do not have adequate online learning support facilities [12]. The second dimension is instructors, including not all educators can use technology in online learning [12], the techniques used are less varied [15]. The third dimension is Infrastructure and Technology, including inappropriate infrastructure, inadequate bandwidth and support personnel [16]. The last dimension is institutional management, including lack of funding and training support, unsupportive policies, and inappropriate instructional designs [16]. Therefore, so that the learning process using e-learning can be effective, the existing obstacles must be overcome. In addition, in developing this learning, cultural and contextual learning must be considered [17].
Conclusion E-learning conducted in the medical study program can support the achievement of student competencies during the pandemic. In order for the learning process to run properly and effectively, the existing obstacles must be overcome.

Declarations
Ethics approval and consent to participate Ethics approval was obtained from Faculty of Medicine and Health Sciencies UMY No.521/EP-FKIK-UMY/X/2019 All methods were performed in accordance with the relevant guidelines and regulations. Permissions from the administration of all participants. Information sheets containing study objectives with written consents had been explained and the informed consent obtained from all respondents prior to completing the research, in which the participation in this study was entirely voluntary.

Consent for publication
Not applicable.
Availability of data and materials All data and materials are available from the corresponding author by request.