key: cord-0811929-zo59leg3 authors: Rabbani, Unaib; Sulaiman, Amel Abdalrahim; Aldrees, Anas Mohammad title: Online family medicine training amid the COVID-19 crisis in KSA: A mixed-method study date: 2022-01-21 journal: J Taibah Univ Med Sci DOI: 10.1016/j.jtumed.2021.12.001 sha: 33fcda592d4ece27d0b6dec463cfe5169225ef4e doc_id: 811929 cord_uid: zo59leg3 OBJECTIVE: Literature on the perceptions and experiences of postgraduate trainees and trainers regarding online methods of learning is scarce. We aim to assess the perceptions and experiences of family medicine trainees and trainers regarding online learning during the novel coronavirus (COVID-19) pandemic in Qassim, KSA. METHODS: This was a mixed-method study involving trainees and trainers at the Family Medicine Academy, Qassim. Quantitative data were collected using structured questionnaires. Qualitative data were collected through in-depth interviews with trainees and trainers. Descriptive analysis was performed on the quantitative data, while thematic analysis was performed on the qualitative data. RESULTS: A total of 36 trainees and 26 trainers participated in the survey. Among the trainees, 39% perceived online learning to be less effective. Moreover, 61% and 64% of the respondents were concerned about the motivation and quality of online learning, respectively. Lack of direct contact with other students was the most commonly perceived concern among 80% of trainees. Among the trainers, the majority were either dissatisfied or neutral about participation and interaction, speakers’ and students’ motivation, the quality of online learning, and the online teaching experience. Qualitative data showed that online methods provide the advantages of learning from other institutions and flexibility, as well as a viable alternative during crises. However, there were issues with interaction, participation, and trainers’ online teaching skills. CONCLUSION: Online learning has provided an opportunity to continue training during the COVID-19 crisis. However, there are widespread concerns regarding its effectiveness among trainees and trainers. There is a need to train trainers in online teaching and adopt interactive methods to increase trainees’ interaction, motivation, and participation. Academy, Qassim. Quantitative data were collected using structured questionnaires. Qualitative data were collected through in-depth interviews with trainees and trainers. Descriptive analysis was performed on the quantitative data, while thematic analysis was performed on the qualitative data. Results: A total of 36 trainees and 26 trainers participated in the survey Q5 . Among the trainees, 39% perceived online learning to be less effective Q6 . Moreover, 61% and 64% of the respondents were concerned about the motivation and quality of online learning, respectively. Lack of direct contact with other students was the most commonly perceived concern among 80% of trainees. Among the trainers, the majority were either dissatisfied or neutral about participation and interaction, speakers' and students' motivation, the quality of online learning, and the online teaching experience. Qualitative data showed that online methods provide the advantages of learning from other institutions and flexibility, as well as a viable alternative during crises. However, there were issues with interaction, participation, and trainers' online teaching skills. On 12 March 2020, the World Health Organization (WHO) declared the novel coronavirus (COVID-19) outbreak a pandemic and called for global efforts to contain the infection. 1 To curb the spread of the disease, social distancing was widely promoted globally and nationally in the KSA. This called for changing teaching and learning practices, as well as preventing the spread of the virus among teachers and students. 2, 3 Online teaching, although not new, has become a new norm amid the COVID-19 pandemic. 3 Online methods have been used Q7 sporadically in undergraduate and postgraduate medical education in the past. However, COVID-19 has made it the main medium of education. 4 This is new for many of us; therefore, further investigations are required. Traditionally, online learning is perceived to lack interactivity and have lower student satisfaction compared to face-to-face learning. This is mainly because of a lack of social presence and social interaction. However, online learning has been promoted as being more cost-effective and convenient than traditional educational environments and has been lauded for providing opportunities for more learners to continue their education. 5 However, content that might be easily delivered and acquired in the classroom setting may require more probing and questioning in an online course. 6 Postgraduate medical education requires in-class and bedside teaching, which has to be continued as the training period is specified. 3 In order to continue training family medicine residents during the COVID-19 pandemic, the Family Medicine Academy (FMA) in Qassim adopted online training to facilitate interaction between trainers and residents enrolled at the FMA through videoconferencing and online lectures. Through remote learning, the FMA aims to overcome social distancing and maintain the continuity of educational activities. Studies have been conducted to assess students' perceptions and experiences of online learning during the COVID-19 pandemic. 7e12 However, these were mainly conducted among undergraduate students, and teachers' perspectives were not included. Literature on the use of online learning in postgraduate medical programs is scarce in this region. Therefore, we aimed to evaluate the perceptions and experiences of trainees and trainers at the FMA regarding online learning during the COVID-19 pandemic. This will help improve ongoing online teaching in postgraduate medical education and contribute to better preparation to continue training in the future under special circumstances such as amidst disasters or pandemics. This study was conducted at the FMA in Qassim, KSA. At the time of data collection, there were 62 family medicine residents and 40 trainers. The FMA in the Qassim region is one of the training institutes for the Saudi Board Family Medicine awarded by the Saudi Commission for Health Specialties (SCFHS). Family medicine training in the region started in 2013 as a diploma program that was upgraded to a four-year board program in 2017. In 2019, this program was given the status of being offered by an academy. The study population included residents and trainers at the FMA, Qassim. This study employed a parallel mixed-methods approach, in which quantitative and qualitative data were collected simultaneously. Quantitative data were collected from the residents and trainers using a structured questionnaire. Qualitative data were collected via in-depth interviews with trainers and trainees, using in-depth interview guides. To collect qualitative data, four trainers who had conducted online sessions during the lockdowns were purposively selected. Each batch (level of training) has a group leader who liaisons with residents and administration on various matters related to training. Group leaders, therefore, have insights into residents' affairs and problems. Therefore, we purposely selected trainee representatives from each training level (Year I [ Data were collected using four instruments. The first two were structured questionnaires used to collect quantitative data from trainees and trainers. The third and fourth were indepth interview guides used for qualitative data collection from the trainers and trainees. Tools for this study were developed after a literature review. 13e17 The first questionnaire (trainees' questionnaire) had six sections, which included variables related to socio-demographics, perceptions about online learning, concerns with online learning, experiences with current online sessions, U. Rabbani et al. 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 JTUMED860_proof ■ 21 January 2022 ■ 2/9 preferences about online learning, and weaknesses of and suggestions to improve the online learning experience. The second questionnaire used to collect data from trainers had both closed-and open-ended questions. There were five sections, namely bio-data, perceptions of online teaching, experience with online teaching during this period, weaknesses of and suggestions to improve online teaching, and trainers' online learning preferences. Both tools were reviewed by senior faculty members to solicit expert opinions on the appropriateness of the content. Cronbach's alpha values for the trainees' questionnaire were 0.74 for feasibility, 0.84 for concerns (perception domain), and 0.88 for the experience domain, which indicate acceptable reliability of our tool. These questionnaires were developed as Google forms, and links were shared with trainees and trainers individually. The third and fourth instruments were in-depth interview guides used for collecting data from trainers and trainees, respectively, about their perceptions and experiences related to online teaching. 18 The probes in the interview guides differed for trainers and trainees. The respondents' biodata were noted before starting the interviews. The information gathered included age, gender, current position (consultant/assistant trainer), training level, years of experience, and previous experience with online teaching/ learning. Interviewers took notes during the interviews. The interviews were also digitally recorded to safeguard against any loss of information while taking notes. Indepth interviews were conducted in Arabic to avoid potential language barriers and obtain maximum information. Quantitative data from trainers and trainees were downloaded as Excel sheets and then imported for cleaning and analysis using SPSS version 21.0 . Open-ended questions in the trainers' questionnaires were codified before the analysis. Descriptive analysis was performed to calculate the frequencies and proportions of categorical variables and means with standard deviations for continuous variables. The chisquare test was used to examine differences in experience, perceptions, and preferences with respect to the level of training and gender. Fisher's exact test was used instead of the chi-square test where the expected count was less than five in more than 25% of the cells. Statistical significance was set at p < 0.05. Transcripts of all in-depth interviews were prepared by listening to the audio recordings of the interviews and reviewing the notes taken during the interviews. Transcripts were then compared with recordings to assess completeness, and additions were made when missing information was found. Transcripts were shared with the respondents to confirm whether their messages were correctly transcribed. The researchers then read the transcripts independently multiple times to gain an understanding of the information. Thematic analysis was performed, and two researchers independently identified themes and held group discussions to reach consensus. The information in the transcripts was coded under relevant themes. This study was reviewed and approved by the Qassim Regional Bioethics Committee. Written informed consent was obtained from all participants. The confidentiality of the participants' data was maintained, and no personal identifiers were obtained. Standard precautionary measures were adopted during in-depth interviews. Quantitative data of the participants used smartphones to attend online sessions. Among the trainers, 26 of the 40 trainers (response rate ¼ 65.?%) participated in the study. Their mean age was 42.? AE 9.96 years, and slightly more than half (53.8%) of the trainers were female. Nearly two-thirds (61.5%) of the trainers had more than five years of teaching experience (Table 1) . Two-thirds (66.7%) of the trainees agreed that online learning is effective; however, only 44.?% perceived online learning as a pleasurable activity. Only 50.?% wanted online teaching for other courses. Compared to face-to-face learning, approximately 39.?% perceived online learning as less effective, while 50.?% viewed it as equivalent. The most effective means of online engagement were simulations and group projects (75.?%), followed by posting on online message boards (64.?%). About 61% were somewhat to moderately concerned with learners' motivation and focus during online teaching. Approximately 64.?% of respondents were concerned with the quality of online learning. Poor/inconsistent contact with the instructor was a concern for 69.?% of respondents. Among the trainees, 80.?% perceived lack of direct contact with other students as a concern (Table 2). Regarding current online learning experiences during the COVID-19 pandemic, about 89.?% found it easy to use online portals, and 86.?% agreed that information was clearly communicated. Only 25.?% rated interaction as good, while the rest rated it as either poor or neutral. Approximately 80.?% of the trainees were either very or extremely satisfied with online learning (Table 3) . Among the trainers, the majority were either dissatisfied or neutral about participation and interaction, speakers' and students' motivation, the quality of online learning, and the online teaching experience. However, approximately 46.?% of the trainers were satisfied with the ease of use of online teaching and learning. Online learning is considered to be less effective than face-to-face learning (Table 4) . Regarding online learning preferences, email (89.?%) and text messages (61.?%) were the most preferred channels among trainees for receiving class updates. Scores and specific feedback on individual items were the most preferred Family medicine training and COVID- 19 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 . For 88.5% of the trainers, a small group discussion board was the preferred interaction method (Table 5) . We did not find a significant difference in trainees' perceptions and experiences with respect to gender. However, a significantly higher proportion of female trainees preferred to receive class updates through the learning management system (p ¼ 0.001), while a higher proportion of male trainees preferred interacting via voice-generated messages (p ¼ 0.003), real-time videoconferencing (Fisher's exact p ¼ 0.008), and video-generated discussion Q16 (Fisher's exact p ¼ 0.003). With respect to the level of training, overall satisfaction was higher among juniors (R1 and R2) than among seniors (R3 and R4) (Fisher's exact p ¼ 0.011). The weaknesses in the current online learning methods, as reported by trainees, were poor interaction, less discussion Q17 , trainers' unpreparedness for online teaching, unclear slides, poor Internet connection, poor trainee participation, absence of mechanisms to ensure whether trainees are actually attending the sessions, and covering two entirely different topics in one session. On the other hand, trainers reported a lack of interaction and difficulties with evaluation as the main concerns. Other weaknesses were the need for more time for preparation and technical issues with the Internet and equipment. However, trainers named flexibility, a good alternative in crises, and lower cost as advantages. Trainees' suggestions to improve the online learning experience were as follows: Trainers should prepare well before the session and increase interaction with trainees, small group discussions should be incorporated, a suitable time should be chosen for sessions, all attendees should use a camera and microphone, only related topics should be covered in a single session, and the length of the online sessions should be reduced. Suggestions from the trainers included offering training for online teaching instructors; using multiple methods such as case discussions, problem solving, videos, animations, and small groups; instituting a rule whereby trainees must always have their camera on; providing real-time feedback; and increasing the duration of sessions. Four and three in-depth interviews were conducted with the trainees and trainers, respectively. The duration of the interviews ranged from to 25 to 45 min. Among the trainees, three were male and one was female, while among the trainers, two were female and one was male. Most of the themes were shared by both groups; themes included interaction, technical issues, residents' interest, flexibility, trainers' role, alternate approach, and online teachers' Family medicine training and COVID-19 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 training needs. Only trainees mentioned the accessibility of other learner opportunities, while trainers raised attendance and the future of online teaching. Trainees reported opportunities to attend various online workshops and courses anywhere in the world. "I was able to attend a lot of teaching activities outside my region without having to travel and within the comfort of my home" [R1]. "I had a chance to attend an online course from Riyadh, which helped me in Flexibility is another commonly cited advantage of online learning. The temporal and spatial flexibility virtual learning offers makes attendance easier. "Other colleagues preferred the online method because first, it is comfortable, especially for people who come from [a] far distance. We are more flexible with regard to time online" [R1]. Trainers, on the other hand, also cited flexibility and ease of performing online activities as main advantages: "easy accessibility, good alternative, including many residents, less cost Q26 /cheap, quieter and more self-confidence" [female trainer]. Both groups equally emphasised trainers' role in effective online learning. "Some trainers actively try to elevate the session by themselves or through the presenter (trainees), while others do not" [R3]. "Some residents do not have (good) presentation skills, so they just read their slides. In this situation, I expect my supervisor to intervene and generate a discussion. Only a few trainers tried that, with some of them failing." [R2]. "Trainers can adopt various ways to improve the Q27 interaction and participation by using interesting tools of teaching Q28 such as case discussion, problem-solving, videos, and animations" [male trainer]. Theme: An alternative during the COVID-19 pandemic During the COVID-19 pandemic, online learning is regarded as the best alternative to continue learning without exposure to the risk of infection. "We are glad that we avoided physical contact by using online learning" [R1]. "Even if we used infection control measures at that time the pandemic was in its beginning Q29 , and recourses were Q30 available to conduct the sessions online. (So) it was a safe option" [R4] . "It is difficult to make an online presentation, but it is useful, especially in an unusual situation like COVID-19" [Female trainer]. Theme: The need for online teacher training Trainees stressed the need for training for trainees and trainers to acquire the appropriate skillset for online teaching Q31 . "Getting a lecture from someone who specialises in online teaching is very important, especially in audience engagement" [R3]. "Training on online presentation would be nice, especially on how to gain and maintain the attention of your audience, i.e. how to make your presentation interactive and so There were mixed responses regarding future use of online learning. One trainer said, "My overall experience with online learning was good, but I like traditional teaching". Another said, "If we strengthen online learning, it will be more valuable than [it is] now". This is the first study of its kind in the region to assess the perspectives and experiences of trainees and trainers regarding online learning and teaching in a postgraduate medical program amid the COVID-19 pandemic. We found that about two-thirds of the trainees perceived online methods as an effective way of learning, while only half thought that it was as effective as face-to-face sessions. These findings are similar to those from a study in Malaysia where a little less than half of medical physics students perceived online learning as superior. 7 Another study involving medical students from Pakistan, however, reported that an even lower proportion (16.?%) of students perceived online learning to be as effective as face-to-face sessions. 8 This lower perceived effectiveness of online methods could be due to a number of associated limitations such as lack of focus/attention, teaching quality, Internet issues, and virtual communication, which have been reported in our study as well as in several other studies globally. 7, 10, 12 Our qualitative results support these conclusions, as both trainees and trainers identified poor interaction and lack of interest as common issues in online learning. These factors require attention when planning and implementing online learning methods. Regarding trainees' online learning experiences during the COVID-19 pandemic, only 25.?% rated interaction during sessions as good, while 47% agreed that online sessions are useful. These findings are similar to Q34 those of studies from Pakistan and Malaysia, where nearly 50.?% of the students considered online sessions to be useful. 7, 9 About 80.?% of the trainees in our study were satisfied with online learning. This is higher than the 69.?% reported by a study involving undergraduate medical students in Pakistan. 11 Among the trainers, only 15.?% and 19.?% were satisfied with interaction and quality of learning, respectively. Nearly one-third of the trainers who conducted online sessions were satisfied with them. This trainer satisfaction level is lower than that among trainees, possibly because trainers may have had higher unmet expectations of online teaching. During the in-depth interviews, trainers raised concerns about their Q35 interest in online sessions, which may have been a source of disappointment. Both trainers and trainees preferred email as the medium for receiving class updates, while text messages and announcements on the learning management system were the other preferred means for trainees but not for trainers. Official emails are the standard means of communication with trainees and trainers. However, with the advent of new applications, other means are also preferred, especially among new generations. 19 A study in the United States reported significantly higher use of social media among students compared to faculty. 20 Assessments and monitoring of academic progress pose issues in online methods of learning. 11, 21 In our study, trainers preferred scoring and overall feedback, whereas trainees preferred scores with specific feedback on individual items. This may indicate that trainees' positive attitude about assessments is an important component of training. Evidence suggests that trainees' and trainers' perceptions about evaluations affect the effectiveness of the evaluation process Q36 . 22 Implementing appropriate evaluation methods to cope with the challenges of distant learning during crises such as the COVID-19 pandemic is therefore recommended. 23 Interaction and social contact have been widely reported as limitations of online methods in recent studies. 10e12 Planners need to identify strategies for improving interaction and social contact. We found that small-group discussion boards and small-group projects were the preferred means of interaction among classmates. Small groups provide an interactive and dynamic way of learning 24 and are therefore rated highly among students and trainees. 25 Among the weaknesses discussed earlier; trainees also pointed out unprepared faculty as an additional weakness. Similar findings were obtained from the qualitative data, where trainees and trainers emphasised skills and training for online teaching. With the widespread use of online learning methods, it is recommended that teachers learn about technology and develop online teaching skills. 26 This calls for formal training of online instructors as an essential part of faculty development. Suggestions from both groups to improve the quality and outcome of online learning methods were as follows: remote teaching/learning training for students and faculty, small-group sessions, and a camera-on policy. Trainees, on the one hand, suggested reducing the duration of online sessions, whereas trainers suggested increasing sessions' duration. In this regard, various quality improvement strategies can be used. Researchers from China reported the use of the planedoe checkeact (PDCA) cycle to implement, manage, and improve the quality of postgraduate medical education during the pandemic. 27 This study is unique in that it assesses the perspectives and experiences of trainees and trainers in a postgraduate medical program. We used a mixed-method strategy to increase the validity of the findings. However Q37 , certain limitations should be considered when interpreting the results and discussion. First, this study was conducted at a single regional family medicine training centre, which may limit its representativeness. However, we assume this to have had a limited impact on the generalisability of our results because all family medicine training centres in the KSA are accredited by the Saudi Commission for Health Specialties, which ensures standardised infrastructure and processes. Second, although a sequential design is preferred, we used a parallel mixedmethod design due to limited time and resources. Nonetheless, the qualitative data in our study helped confirm the findings derived from the quantitative surveys and yielded an in-depth understanding of the respondents' perspectives. We found that overall satisfaction with online learning was lower Q38 for both trainers and trainees. There were concerns regarding effectiveness, interaction, participation, motivation, and quality of learning. To make online methods more effective, there is a need to train trainers to use online teaching methods and involve trainees in planning online activities to help increase their motivation and participation in online learning. This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to declare. This study was reviewed and approved by the Qassim Regional Bioethics Committee (approval number: 1441-1717686, dated 21-09-1441 H). Written informed consent was obtained from all the participants. UR and AAS conceptualised the study and developed the study tools. UR and AAS analysed the quantitative data for trainees and trainers, respectively. AAS and AMA conducted and transcribed the in-depth interviews with the trainees and trainers, respectively. UR, AAS, and AMA analysed the qualitative data. UR wrote the final manuscript, with contributions from AAS and AMA. 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Perceptions of unprofessional social media use by medical students and faculty Med school final exam plagued with technical issues after moving online due to COVID-19 Toward meaningful evaluation of medical trainees: the influence of participants' perceptions of the process Postgraduate medical training and COVID-19 pandemic: should we stop, freeze, or continue? The use of small group tutorials as an educational strategy in medical education Small group tutorials in radiology: a pilot study COVID-19 and changes to postgraduate medical education in Canada Application of PDCA cycle management for postgraduate medical students during the COVID-19 pandemic We thank the study participants for their time. We would also like to extend our thanks to the administration of the Family Medicine Academy, Qassim, for allowing us to conduct the study.