Need Based Role of E-Learning in Current Medical Education Environment: Skepticism to Acceptability

1. Assistant Professor, Department of Physiology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India. 2. Director Professor, Department of Physiology, Maulana Azad Medical College, New Delhi, India.

Abstract

E-learning has taken centre stage during this period of social distancing and lockdowns, in the current pandemic, by enabling education to continue. There are perceptibly no limitations to the utility of e-learning tools in the cognitive domain of learning. It complements traditional learning in other domains, namely, psychomotor, affective and communication skill, fairly well. Not only does it ease learning in terms of availability and accessibility, but with the options of asynchronous learning and personalisation of content, it also empowers learners with more autonomy. Despite the limitation of lack of ‘hands-on’ training and experience with e-learning, it has been accepted quite well, although initially both teachers and learners had been skeptical about its applicability and quality. In the ongoing pandemic period, e-learning may assume a bigger role as blended learning in medical education. While this transition may be smooth for the better resourced nations who already have the required infrastructure and resources ready, the resource limited nations may first have to develop the same before being able to implement it. Ensuring the availability of cheap and high-speed internet, computers in various forms (desktops, laptops, tablets and smartphones) within reach of every learner, will enable them to go online.

Distance education, Educational technology, Medical education, Online learning, Virtual reality

The concept of e-learning is well known in medical education (1). Technological advancements have brought in an attractive array of e-learning resources, varying from simple internet sources to the highly advanced augmented reality and telemedicine, these are undergoing innovations and may provide various opportunities in future (2),(3). In the current pandemic, when universities had to suddenly go online for enabling education to continue during ‘lockdown’ gave an opportunity for e-learning to not only meet the emergency need, but also unleashed its tremendous potential and before the word. In the postpandemic period, e-learning is likely to be a definite teaching-learning strategy assuming a bigger role in medical curriculum (4),(5),(6).

However, there are questions that come to mind, which need to be addressed before we begin to rely more on technology. Does e-learning match up to the standards of traditional learning, taking place in classrooms, using chalk and board, books, etc.,? Can it replace traditional teaching and learning? If not, what are the limitations and challenges? What could be done to enrich it?

This paper is an appraisal of the e-learning methods and experiences with it, of both teachers and learners, as perceived by the authors from recently published literature on the same, with respect to its application in a resource-limited medical education environment, where there is paucity of financial support as well as technological advancement.

NEED AND OPPORTUNITIES OFFERED BY E-LEARNING

E-learning has enriched learning and complements the traditional method. It fulfils the unmet needs of learning opportunities that remain unaccomplished by traditional learning methods, including the following:

Overcoming the barriers of time and distance- E-learning has bridged the distance between the learner and teacher. It has, thereby, made possible even real time teaching-learning when the learner and the teacher may be located on different sites on the world map in different time zones, or in remote areas (3),(7).

Overcoming resource limitation- Access to numerous resources of the web, online availability 24×7, are some options that adress the issue of limitation of resources (1). Limitations of space, infrastructure, manpower and finance are taken care of by enabling virtual educational institutions and modules, instead of a physical college or classrooms, libraries and labs (2),(7).

Empowering the potential learner- Asynchronised learning, repeated use of learning modules (reusable e-learning object) and storage of prepared modules so that learners can take their own time to learn without the constraint of time, with any number of repetitions and at their own pace (2),(7),(8).

Enriching the teaching-learning modules: Incorporation of animations, videos, audios, complicated diagrams, virtual hands-on training, augmented reality, etc., have all been made possible with utilisation of various electronic resources (1),(3),(4),(7).

Enabling continued education- E-learning is at the dispense of learners at all stages of life, at all places and at all times. College dropouts, those keen for higher qualifications, those eager to keep abreast with advances in their field of education can easily avail e-learning opportunity without compromising their current employment (2).

Learning opportunity during undesirable circumstances- With e-learning, education and skill development can continue amidst undesirable conditions like that of disease outbreak, unforeseen natural or manmade calamities like violence and war. Both teacher and learner need not expose them to environmental threats and rather continue their endeavour. It may be the only option available as in the times of a pandemic (4),(5).

TOOLS FOR E-LEARNING

Any electronic medium that enables imparting educational resources makes a potential tool for e-learning. The medium may be interactive or non interactive and may or may not enable real time e-learning opportunities (1),(3).

(Table/Fig 1) summarises the various e-learning tools that are available. E-learning resources are applicable in all domains of learning, including cognitive, psychomotor, affective and communication skills domains (9),(10). There are perceptibly no limitations to the utility of e-learning tools in the cognitive domain of learning (1). However, the same cannot be said to be equally valid for learning in other domains (1),(2),(3),(7),(8),(11),(12),(13).

All these e-learning modules may be classified as static, advanced, interactive online and class modules. Static online modules include online textbooks, video based teaching, flashcards, etc., (1). The interactive online modules webinars, virtual video classrooms, chat rooms, conference transmission etc. (3). Online teaching-learning tools may be further classified as synchronous and asynchronous activities (5),(8).

The choice of e-learning modality is determined by the learning objectives of the course content, whether they can be effectively achieved using the modality or not. Implementing the e-learning tool will require redesigning of the content such that it is deliverable as well as learnable through the e-learning tool. The institute may want to adopt a Managed Learning Environment (MLE) or a Virtual Learning Environment (VLE), ‘Learning Management System’ (LMS) or ‘Course Management System’ (CMS) as a platform for regulating the teaching learning activities. This may be commercial, proprietary ones like Web CT or blackboard or open source like moodle or sakai. The LMS utilises a single window application software to dispense the medical curriculum (8),(12). Besides internet based, local area network based and non networked computer-based e-learning interventions can also be used. Once both the course content and delivery system are decided, an additional requirement is assessment of activities and exercises. The e-assessments could be done for knowledge, using Multiple-Choice Question (MCQ) and extended matching questions, and quizzes. Evaluation of skills or performance-based assessment can be done using Objective Structured Clinical Examination (OSCE) and using virtual patients. Similarly, attitude can be tested by discussions or peer assessment. Logbooks and portfolios are generally used for practice-based assessments.

The common modes of e-learning being used in the recent pandemic situation have been webinars and virtual classrooms, which are explained as (Table/Fig 2), (Table/Fig 3). For using an appropriate e-learning modality: target audience is identified; a relevant topic is selected, and most appropriate learning and assessment tools are chosen that may be used with the e-learning modality, resource personnel are identified, and communicated to (subject experts, administrative staff, technical assistants), floating of the learning modality is planned- date, time, schedule, resource material is collected and rehearsed, the audience and resource persons are formally notified and given timely reminders, audience is enrolled, the modality is put to use as per plan/schedule and assessment of learning of audience is done and a feedback of the e-learning activity is collected from them for further improvisations. Setting up virtual classroom using LMS requires: setting up an e-learning facilitation team having technical and academic committees; developing a road map with time line, identifying learning model and goals, identifying target learners and teachers to deliver the learning resource materials, identifying both learning and teaching needs to fulfil with the e-learning experience, identifying the appropriate e-learning tools, selecting the appropriate learning system management to deploy the tools as per customisation options, technical support and security provided, licensing needs, cost, user load, etc, setting up the LMS and registering the users; having a test run of the LMS before the actual use, training the faculty and students in using the LMS, developing the learning resource material for use with available teaching learning tools at LMS, roll out of the LMS with, parallel technical support; and system analysis for further training, improvisations and more customisations as may be required.

IS E-LEARNING BETTER THAN TRADITIONAL CLASSROOM LEARNING?

Benefits offered by e-learning are very lucrative and seem to be the answer to every limitation and criticism of the traditional learning. But is that really so? The two modes of learning, traditional learning and e-learning, are compared in (Table/Fig 4) (1),(2),(5),(7),(8),(13),(14),(15):

Studies comparing traditional learning and e-learning have found mixed results, some conclude e-learning to be at par or even superior (16) and some caution against it (11). E-learning appears to have a clear edge in ‘information dissemination’ in any domain of medical education-cognitive, psychomotor, affective and communication. Various interactive artificial intelligence-based tools of assessment effectively analyse theoretical learning and comprehension. Virtual skill labs may be useful in imparting cognition related skills. But traditional learning with hands-on experience is indispensable for actually putting that information to use in patient care and advancement of medical science (8).

ACCEPTABILITY OF E-LEARNING

In the present-day context of competency-based curriculum, the computer aided course instructions are required to meet the expectations of a medical graduate (17),(18). In one study, students perceived that e-learning was used more by students who were self-regulated but it needs to be ascertained if it was associated with deep learning (19). Similarly, another review has suggested e-learning to be superior to traditional learning for both knowledge gained and skill learning, although the review highlights that there are many contradicting views of the studies done for this evaluation (20). A recent systematic meta-analysis and review supports the advantage of e-learning over the traditional methods in terms of enhancing undergraduate knowledge and skills and its analysis did not find any study reporting that offline was better than online method of learning (16).

What puts E-learning on the Back Foot?

Simulation may compensate for but never replace utilisation of three senses, namely smell, touch and taste. The smell of the dissection room, stains in labs, disinfectants, operation theatre, wards and OPD, all which incorporates into the aura of a medical student, is missing and cannot be compensated for. Also, the touch of patient’s skin, while doing examination, how the enlarged liver feels, and all palpatory and percussion procedures cannot be effectively learnt. Attitude and communication can be learnt but its practice, assessment and feedback require a real time environment. Hands-on training of practical exercises and operative procedures cannot be compared to the traditional method and will always be insufficient (7),(11).

So ‘E-learning’ alone is ‘not competent enough’. What about Blended Learning?

The solution to overcoming the limitations of both e-learning and traditional learning lies in blended learning, which involves the use of the various tools of the two modes in an appropriate manner to an advantage to achieve the e-learning outcomes with promising results (20). However, there are contradictory reports whether blended learning is favourable compared to traditional method of teaching with points for and against it and a lot depends on the motivation of both students and faculty, digital literacy and infrastructure (21),(22),(23),(24).

Present Status of E-Learning

E-learning tools have yet not been incorporated formally into the medical curriculum in many parts of the world (25), although in the face of the current pandemic, medical education across the globe had to switch to virtual classroom teaching. Many analyses and feedbacks conclude achieving partial success in continuing medical education by using the e-learning during the pandemic (26),(27),(28). Few studies highlight that students are keen to adopt e-learning tools as supplemental tools to traditional learning but are skeptical about the infrastructure and training professionals in their university (29), (30). Models for e-learning should be evaluated for their knowledge gain, time frame and convenience and financial viability (31). With the availability of cheap and high-speed internet, and smart phones, tablets and laptops within reach of every learner, they are all set to go online.

Barriers to Adopt E-Learning in Medical Education

Postpandemic, we may look forward to e-learning tools being incorporated into medical education curriculum; however we need to overcome the barriers to increase its feasibility. These include inadequate technological infrastructure in institutions, limited availability of continuous power supply and high-speed internet at certain locations. Current curriculum designs and course content may not include e-learning tools in its teaching methods. Faculty training is another issue and learners, teachers and other stakeholders are still sceptical about reliability and validity of e-learning. The entire cost-effectiveness in terms of time, efforts and money has to be worked out for its economic viability and this may be more of an issue in low and middle income group countries (5),(7),(10),(20),(29),(32).

Future of E-learning

Recent research also upholds the role of e-learning in competency based medical education (33). E-learning is here to stay and medical education institutes should upgrade their information and technology departments to facilitate it. The faculty too should develop their training tools. It is important to understand that this involves remodeling of the current medical curriculum and faculty development (1),(9),(20),(32). A recent publication has highlighted that, in Korea, many schools are collaborating to develop learning resource material (34). The concept of personal learning environment is also coming up, whereby an individual uses the e-learning platform to direct his/her own learning goals (35).

Conclusion

E-learning is a need today. Not only shall it upgrade, standardise and universalise medical education, provide more autonomy to the learner, but it shall also make us prepared for any other future pandemics and disasters. For quality assurance, the infrastructure preparation in medical colleges, development of teaching-learning modules and validation of assessment tools with a good utility is what is needed in present circumstances. The students shall accept the e-learning activities once we as faculty and our institutions are ready.

DOI and Others

10.7860/JCDR/2021/49281.15243

Date of Submission: Mar 04, 2021
Date of Peer Review: Apr 26, 2021
Date of Acceptance: Jun 19, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 20, 2021
• Manual Googling: Jun 17, 2021
• iThenticate Software: Jul 13, 2021 (2%)

ETYMOLOGY: Author Origin