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INTRODUCTION
Important worldwide changes have been caused by the new coronavirus (Coronavirus of Severe Acute Respiratory Syndrome 2 - SARS-CoV-2). On March 11, 2020, a pandemic was declared, with 118,000 recorded cases and 4,000 deaths1 caused by COVID-19. Considering that social isolation is the most important strategy employed in this health emergency, changes occurred in all social fields, including universities and, among them, in medical education. The COVID-19 pandemic caused disruption to hospital routines as a whole, health services, medical schools and other important learning environments for students, in addition to the importance that health professionals have in society to preserve lives2. The systematic cancellation of in-person classes and replacement by those mediated by distance technology has raised major questions regarding medical education for the carrying out of pre-clinical and clinical disciplines2),(3.
The use of information and communication technologies (ICTs) in medical education is not a new thing brought by COVID-19, since it has been used since the end of the 20th century4, with extensive studies on its own protocols and pedagogical debates about these pedagogical strategies5. However, this is not a resource employed in all sectors of medical education, since the in-person model, centered on content and the development of clinical skills, is still prevalent5. Nevertheless, experiences have been recorded in the literature on medical education mediated by ICTs, including in advanced stages of the course, such as medical internship6.
This scoping review aims to investigate which ICT use strategies are employed in medical education in the face of the challenges of the COVID-19 pandemic.
METHOD
A scoping review was carried out using a manual from the Joanna Briggs Institute7, which presupposes the synthesis of results and thematic under development. It is aimed at mapping what is relevant in the literature of the field of interest, a relevant option considering the challenges for medical education caused by the COVID-19 pandemic. The identified research question was
Aiming to systematize the writing of the manuscript, we decided to use the recommendations of PRISMA-SrC, a checklist with 21 specific items to improve the quality of scoping reviews8.
The searches were carried out in Portuguese, Spanish and English, from July 14 to 31, 2020. Four scientific databases were used: Scopus, PubMed, BVS, Scielo; and the Google Scholar portal for the grey literature mapping. The following search key was used in Scopus: (TITLE-ABS-KEY (COVID-19) AND TITLE-ABS-KEY (“medical education”) AND TITLE-ABS-KEY (student) OR TITLE-ABS-KEY (“high education”)) AND (LIMIT-TO (SUBJAREA,”MEDI”)). Two members of the research team independently performed all the steps: search, selection by titles, summary and full-text reading. In case of disagreements, a third party was invited to perform the evaluation.
The inclusion criteria consisted of: focus on medical education; to include at least one teaching strategy used after the beginning of COVID-19, original articles, reports of experiences and comments based on educational initiatives. The exclusion criteria comprised: articles related to the perception of students and/or teachers about the pandemic, articles on preference assessment, studies on the clinical aspects of COVID-19, studies strictly about student biosafety; strictly theoretical considerations, studies that did not clearly show what resources were used to deal with the challenges of the COVID-19 pandemic, articles with considerations only, without pathways or interventions, on teachers’ mental health, on students’ mental health.
For the analysis of the included articles, thematic mapping was carried out with a previous survey of the key topics presented in the results section of the articles, grouping, identification of links between the points and synthesis, classifying and reclassifying the produced material according to the scoping review question.
RESULTS
A total of 321 articles were obtained after the searches performed in the databases, of which 18 were included in the review, after selection by the research team, as depicted in the following figure.
The following table shows the bibliometric data of the included studies.
Table 1 Bibliometric characteristics of the included studies
| Authors | Country | Keywords | Type of article | Journal | Publication month | Focus of the article |
| Birch et al.9 | United Kingdom | Medical students, COVID-19, medical school examinations, online examinations, open-book examination | Original article | Medical Education Online | June/20 | Changes in the teaching and assessment of medical students at King’s College London |
| Mukhtar et al. (10 | Pakistan | COVID-19, Education, Medical, Undergraduate, Online learning | Original article | Pakistan Journal of Medical Sciences | May/20 | Recommendations on distance learning during the COVID-19 pandemic in Pakistan |
| Singal et al. (11 | India | Anatomy education, Body donation, COVID-19, Pandemic, Virtual classes | Original article | Morphology | May/20 | Discuss the effects and solutions to the challenges of teaching anatomy during the COVID-19 pandemic |
| Chao et al. (12 | United States | Virtual surgical education, undergraduate medical education, COVID-19, telemedicine, surgical video capture | Original article | Journal of Surgical Education | June/20 | Development of virtual activities in surgical discipline |
| Rosa et al. (13 | Peru | Educación médica, Educación a distancia, Infecciones por coronavirus, COVID-19, América Latina | Original article | Revista Cubana de Educacion Medica Superior | May/20 | Debate on the main types of distance learning in medical courses in the context of COVID-19 |
| Mishra et al. (14 | United States | Coronavirus disease-2019, Online education, Ophthalmology education, Virtual curriculum | Original article | Ophthalmology | July/20 | Describe the transition from ophthalmology education to a virtual curriculum during the COVID-19 pandemic |
| Gomez et al. (15 | United States | Medical student education, Radiology education, Remote learning, COVID-19 | Original article | Academic Radiology | June/20 | Offer of virtual radiology diagnosis classes due to the COVID-19 pandemic |
| Roskvist et al. (16 | New Zealand | COVID-19, Students, Curriculum, Educational, Electronic learning, General practice, Medical, Models. | Original article | Education for Primary Care | May/20 | Online general medicine internships in national response to the COVID-19 pandemic |
| Krawiec et al. (17 | United States | Assessment in health professions education, COVID-19, Undergraduate medical education | Original article | Cureus | June/20 | Virtual case-based modules for teaching in the pediatric internship in the context of the COVID-19 pandemic |
| Ko et al.18 | United States | Not mentioned | Experience report | Journal of Neuro-ophthalmology | June/20 | To address telehealth in neuro-ophthalmology, including current challenges and opportunities in the context of the COVID-19 pandemic |
| Szmuda et al. (19 | Poland | 2019 nCoV, Coronavirus, COVID‐19, Internet, SARS‐CoV‐2, YouTube quality | Original article | Reviews in Medical Virology | June/20 | Use of YouTube videos in distance learning pedagogical strategy on COVID-19 |
| Huddart et al. (20 | United Kingdom | Not mentioned | Experience report | Medical Education Adaptations | May/20 | Educational strategy using Twitter® on COVID-19. |
| Finn et al. (21 | United Kingdom | Not mentioned | Experience report | Medical Education | May/20 | Educational strategy using Twitter® on COVID-19. |
| Kumar et al. (22 | India | Dermatology practice in shadow of COVID, Changing dermatology practice post COVID | Brief Communication | Dermatologic Therapy | April/20 | Online activities for teaching dermatology in the context of the COVID-19 pandemic |
| Mathieson et al. (23 | United Kingdom | Medical education, Assessment, Open-book examination, COVID-19 | Brief Communication | Medical Education Online | June/20 | In-person medical examinations for the online modality in the context of the COVID-19 pandemic |
| Hofmann et al. (24 | United States | Not mentioned | Experience report | Medical Education Adaptations | May/20 | Adaptation of bedside consultations using videoconferencing during the COVID-19 pandemic |
| Chandra et al. (25 | United States | Not mentioned | Experience report | Medical Education Adaptations | June/20 | Clinical calls allowing live interaction with patients and the development of interpersonal and communication skills. |
| Rose26 | United States | Not mentioned | Brief Communication | JAMA | March/20 | Describe how COVID-19 can affect learning environments in Medicine and its possible implications for the future of medical education |
Four key topics were identified in the literature: (1) Challenges for Medical Education prior to Covid-19; (2) Challenges in migration to distance learning; (3) Strategies to overcome challenges related to ICTs; and (4) Strategies for overcoming challenges related to evaluation strategies.
Medical Education Challenges prior to COVID-19
Most of the included studies pointed out that the discussion on how to structure the medical curriculum and its centralization in a paradigm considered to be poorly articulated with the ICT developments has been debated for a long time, but the issue became more categorical after the need to migrate to online activities9),(11. Moreover, the centrality of the teacher and the clinical space in the training, and the students’ position of little protagonism in the teaching-learning process were characteristics evidenced in the articles, such as the difficulty of migrating advanced disciplines in the courses to other types rather than the experience in wards and outpatient clinics9. An interesting example refers to the discipline of Anatomy, considered the “basis” of medical education, which even with virtual resources and simulations, still finds great resistance to discontinuing the teaching with cadavers11. The professional performance of future doctors is a concern of the academic community, considering the volume of material and spaces necessary for the training of this professional, since in addition to anatomical knowledge, there are developments of technical skills that have few alternatives rather than being present at didactic-pedagogical activities9),(11.
The need to migrate to distance learning has generated great pressure, both on students - concerned with the development of skills - and on educators, who are being forced to venture into unknown territory, for instance, through the digitalization of classrooms14),(15, despite the increasingly present use of electronic resources both in general medical practice and in educational spaces17. Notwithstanding the advanced and powerful technology at universities, including hardware and software, significant advances are still needed to allow effective online learning10, in addition to changing the educational paradigm allowing student participation, which is still very dependent on the classroom and teaching guidance10.
In this sense, it is important to observe that it is common for people to seek health information on platforms such as YouTube®, which is often used as a source of education for greater knowledge about diseases19. At the same time, there have been advances for some years in areas such as teledermatology, an alternative that is readily viable as a measure to solve some aspects of the in-person disciplines in the field22.
Challenges of migration to distance learning
A very important issue that has been raised deals with the possibilities and impossibilities of migration into the virtual space, at least more immediately, with an important division highlighted between the preclinical disciplines, the clinical-theoretical disciplines and the internship10),(12),(13. Additionally, only the first ones and those with a theoretical focus would have a greater vocation for migrating to the virtual space rapidly10, since several skills that are typical of clinical practice are not achieved in the virtual modality. This also seems to be related to the clinical act itself, which demands the presence of both the professional and the patient, in addition to medical training itself11.
There are massive limitations for clinical experiences and those at the surgical environment, in addition to office visits, as well as the impossibility for some surgical specialties to be migrated to distance learning12. While preclinical subjects are easier due to less interaction with the patient, better access to virtual educational material, use of platforms and problem-based learning, clinics have the possibility of migration, provided they use virtual reality simulators and simulated patients13, with due restrictions on both the construction of clinical knowledge and the acquisition of skills14),(15),(20.
Regarding the developed and employed ICTs, there are major challenges in resource-constrained environments, including extensive lack of availability, incorrect diagnosis resulting from poor photo quality, inadequate online patient medical data, communication gaps between the doctor and patients undergoing treatment and problems inherent to the performance of investigations, which can generate irreparable educational damage22.
Strategies to overcome challenges related to the virtual learning environment
Regarding the strategies used for didactic-pedagogical activities, the literature points to the use of video conference platforms, which have been widely used for education and telemedicine10. With the pandemic, it was necessary to diversify its use, for instance with virtual meetings held according to problem-based teaching10),(12),(13. These platforms are highly diversified in distance learning modalities through the use of ICTs13. It is strongly recommended the teaching of small groups, which facilitates interactivity13),(14),(26. The use of the flipped classroom is recommended as a pedagogical strategy, with the teaching staff mediating the contents and information that students must access and dedicate themselves to the study before class26.
Regarding the platforms for the Virtual Learning Environment, the following were mentioned: Microsoft Teams®, Google Meet®, Edmodo®, Moodle®, and Blackboard®(10),(15, while the videoconference platforms are: Zoom®, Skype® for companies, WebEx® and Adobe Connect®(10),(14),(15. Twitter® has also been used as a space for interaction between students and teachers, especially for solving doubts and medical problems, with a wide interaction15),(20. The pre-recording of classes, the use of asynchronous chat and even scheduling synchronous times for supervision and educational-pedagogical support15 have been used.
Regarding the pedagogical strategies for virtual activities, the use of a mind map of the exam, differential diagnosis and management summary stands out, with links to resources to be employed in clinical cases16, as well as asynchronous discussion forums16; a symposium that facilitates social interactions and the teacher’s presence16; a learning portfolio that facilitates aspects of personal goals and reflects the organizational domain16; virtual case presentation by the students themselves17; virtual discussion rounds17; and support for students through synchronous and asynchronous monitoring on social media by specialists18),(21. Online seminars and video conferences based on problem solving, usually accompanied by research results or a long dialogue with the patient, were also reported as strategies22),(23.
In addition to the subjects with the highest theoretical workload, online platforms are also being used for some clinical activities, such as the use of Zoom® for bedside visits17, as well as the recurrence to other electronic sources of contact with the patient, trying to decrease the impacts on the development of clinical skills17. The use of instant messaging for virtual health services, public messages on behavioral modification, epidemiological screening and access to virtual health providers were already in use18.
We found virtual dissection experiments11; use of anatomy11, pathology12 and radiology15 image banks. Additionally, endoscopy, laparoscopy and robotic surgery are also widely used in many surgical disciplines and allow surgical visualization by those who are not directly participating12),(14. Another interesting strategy was the virtual surgery transmitted using a GoPro® camera and real-time, two-way audiovisual communication between the student and the surgical team12. In another experiment, mobile applications validated for components of the neuro-ophthalmic examination were used for the teaching of ophthalmology18. The need for teachers to receive support to carry out virtual teaching and clinical preceptorship is reinforced14.
It is possible to evaluate, manage and care for patients through a video capture device and safe transmission during procedures and the provision of care in a telehealth environment12, just like video surgical review sessions were used with preceptors14 and clinical case sessions were mediated by online platforms through interactive remote workshops and case sessions15.
There have been experiences of visits by a doctor who fixed an iPad Pro and ran the videoconference application24; as well as students’ contact with patients using Zoom®25, laboratory sessions, simulations and bedside ultrasonography sessions, as well as clinical instructions with standardized patients and in authentic patient care environments26.
Strategies to overcome challenges related to evaluations
A very patent concern in the literature referred to the evaluation of the teaching-learning process, since traditionally there is a great focus on memorization, with tests that are focused on content and, in the face of the pandemic, the exams also started to be taken on online platforms10),(26, which required a change of approach22),(23.
Several interesting online assessment strategies were found, including oral assessment through video conference and close communication with students12, oral presentations12, asynchronous assessments with bibliography consultation (5, video recordings of presentations on clinical cases15),(18, evidence-based medicine exercises when evaluating treatments14, open-book tests 23, and randomized questions in the virtual learning environment with an established maximum time for its completion23.
In disciplines that predict the development of clinical skills, there have been considerable advances to allow migration to virtual learning environments, such as the use of an electronic report in which the clinical supervisor assesses the students’ skills16),(19; the use of an instrument to evaluate clinical skills15, online discussion forums and presentations based on cases, assessing critical reflection and the use of literature16; construction of simulated interactive cases, which can be completed asynchronously16),(18; mind maps with links to important documents, podcasts, videos and other resources, and a final section for critical self-reflection and connection to clinical settings16. One activity that stood out was asking students to evaluate the quality of information on YouTube® videos when compared to those that exist in terms of Evidence-Based Medicine19.
In a more integrated way with clinical practice, practical exams were also found in video conference, where real patients were being replaced by scenarios and images of virtual cases22. In another study, preceptors supervised and listened to Zoom®-mediated conversations between students and patients and provided real-time feedback and comments via the software’s chat function and intervened, when necessary. After the call, the students helped to document these call-backs. The preceptors assessed the students’ performance using the same assessment tools as in the traditional internship24.
DISCUSSION
The removal of students from clinical internships can have significant implications for the future planning of the workforce27. However, the COVID-19 pandemic made issues that were already debated in medical teaching more evident, such as the role of the student, the focus on training through clinical experience and the challenges generated by a traditional model - such as the medical model - in the face of the contemporary world and technological advances. Also, the centrality of the students’ role and not the teachers’ in the teaching-learning process became clearer as an important issue for the pedagogical decisions of medical courses28.
At the same time, the articles point out that there are great differences in the general disciplines of the health sciences, the specific medical pre-clinic ones and the medical clinics, leading to the understanding that different measures should be taken, thinking about possibilities of integral change for the use of ICTs, mixing, reducing the in-person load and even postponing, if deemed significant for training, considering five approach possibilities: continue, postpone, adapt, discard, add other forms29.
The use of video conferences is a possibility to compensate for the abandonment of clinical classes held daily. A webcam and a microphone become important for classroom work30. Mixed learning, defined as the combination of conventional classroom learning and asynchronous or synchronous teaching, has increased rapidly and is now widely used in medical education30. Additionally, the use of webinars, discussion forums, clinical study clubs, social media in general, and other forms that allow interaction between students, teachers and medical experts31.
The issue of training the teachers to use ICTs, as well as the development of infrastructure resources, has been defended by the literature for a long time, becoming even more important in the context of the COVID-19 pandemic. At the same time, several strategies for overcoming challenges related to the learning environment, evaluations and exams were adopted in an interesting manner by the teachers in the articles included in this study, bringing inspiration for their immediate implementation and for future developments.
Due to the emergence of COVID-19 and its broad effect on society, which required the reconfiguration of teaching worldwide, the present study has the potential to present what was possible to be published in the international scientific literature regarding the strategies employed to continue medical education in the face of the pandemic limitations. However, the limitations are evident, since the impact of COVID-19 is a recent one, and there has been no time for all experiments in this field to be published in the literature, including the time necessary for more robust studies to be developed, synthesized as a scientific publication, submitted, evaluated and approved by peers, in addition to the publication process in scientific dissemination vehicles. Nevertheless, the findings of the present scoping review are important as a guide for future actions and adaptations in terms of medical education during the COVID-19 pandemic, and future studies are required to see whether these strategies will be modified, or even if others will appear as medical courses are faced with the challenges brought on by the health and educational context.
CONCLUSION
In this scoping review, the reported experiences of medical education during the Covid-19 pandemic suggest the need to adapt the training focused on the presence of the student in clinical-laboratory environments, for a situation mediated by ICTs. In this sense, the old challenges of medical education in the face of changes in the contemporary world, such as the existence of the possibility of teleconsultation, started to be resignified as possibilities of certain learning aiming to minimize the losses arising from the social distancing required as a sanitary measure. The role of the student in the teaching-learning process must also be rethought, with a certain centrality in autonomy, given the characteristics of remote teaching. In a way, it can be concluded that the educational strategies employed in medical education in the face of the COVID-19 pandemic are related to four possible paths:
Maintain the pedagogical strategies that were already used online, such as activities and classes previously mediated by technology;
Adapt classes, exercises and clinical simulations that were held as in-person activities and then became possible through online technology mediation;
Adapt clinical visits and consultations, with mixed strategies, in which a professional takes part in the in-person contact with patients and transmits (and sometimes interacts) to students via online technology;
Postponing to the future the elements that are irreplaceable - both clinical and in procedures, which has a practical and a contact aspect, in addition to the humanization issue.
To some extent, there are possible approaches to more clinical and contact areas with cases and medical procedures, but there is a strong and important question about the extent to which these adaptations can be used without damaging the development of skills and competences of future medical professionals.
