key: cord-0886910-e94ax060
authors: Chao, Chia-Ter; Tsai, Chiao-Lin; Lin, Mong-Wei; Yang, Chih-Wei; Ho, Chao-Chi; Chen, Huey-Ling; Hsu, Chiun; Sheu, Bor-Ching
title: Fully digital problem-based learning for undergraduate medical students during the COVID-19 period: practical considerations
date: 2021-11-29
journal: J Formos Med Assoc
DOI: 10.1016/j.jfma.2021.11.011
sha: e42f76285b5f8cc4c50e07a3dbd61cae42a95374
doc_id: 886910
cord_uid: e94ax060

Digital problem-based learning (PBL) was originally introduced as a means to improve student engagement and increase flexibility. However, its use becomes mandatory during the coronavirus disease 2019 (COVID-19) period, accelerating changes in medical education. Few elaborated on the implementation details of digital PBL curricula. Technical guidance can be important but under-recognized prerequisite of a successful digital PBL session. In National Taiwan University College of Medicine, we established a digital PBL curriculum and previously validated a confidence questionnaire for surveying undergraduate students receiving digital PBL sessions. In this opinion piece, we gleaned multiple procedural details from our experiences based on students’/tutors’ feedback, which we summarized in a 5”W” recommendations, (Who), timing/duration (When), location (Where), software/hardware/topics (What), and evaluation aspects (Why). Suggestions on how to optimally prepare for digital PBL session are also provided. We believe that these tips can further facilitate the wide adoption of digital PBL.

Digital problem-based learning (PBL) was originally introduced as a means to 2 improve student engagement and increase flexibility. However, its use becomes 3 mandatory during the coronavirus disease 2019 (COVID-19) period, accelerating 4 changes in medical education. Few elaborated on the implementation details of digital 5 PBL curricula. Technical guidance can be important but under-recognized 6 prerequisite of a successful digital PBL session. In National Taiwan University 7

College of Medicine, we established a digital PBL curriculum and previously 8 validated a confidence questionnaire for surveying undergraduate students receiving 9 digital PBL sessions. In this opinion piece, we gleaned multiple procedural details 10 from our experiences based on students'/tutors' feedback, which we summarized in a 11 5"W" recommendations, (Who), timing/duration (When), location (Where), 12 software/hardware/topics (What), and evaluation aspects (Why). Suggestions on how 13 to optimally prepare for digital PBL session are also provided. We believe that these 14 tips can further facilitate the wide adoption of digital PBL. 15 16 Keywords: digital learning; problem-based learning; medical education; online 17 education; technology-assisted education; undergraduate education 18 19 J o u r n a l P r e -p r o o f Effective learning for health professionals is an important task in this era of 20 information explosion. Technology-assisted education provides recipients with a 21 better subjective efficacy compared to traditional pedagogy. Students prefer this 22 education strategy due to its flexibility, high accessibility, and ease for tool usage. 1 Table) . 7 During course design, we 48 involved multiple stakeholder groups including both junior and senior facilitators, 49 course designers, medical school administrative staff, and experts from the Graduate 50

Institute of Medical Education and Bioethics for course digitalization. The materials 51 and themes were the same as those of face-to-face ones but the delivery platform was 52 digitalized. We encountered challenges when implementing the pilot digitalized PBL 53 curriculum, including two categories, potentially suboptimal learning efficacy among 54 medical students and technical issues. For the former category, we used to assess 55 medical students' confidence in satisfactorily completing the digital PBL curriculum 56 and compared results with that in completing the traditional face-to-face PBL. 7 57

Totally 110 medical and pharmacy students voluntarily participated, and a recalibrated 58 confidence questionnaire was administered, followed by exploratory factor analyses 59 and dimension reconstruction. We found that a single session of digital PBL 60 significantly attenuated students' confidence in completing the curricula, while 61 repeated practice up to 3 consecutive sessions might partially restore it. 7 For the latter 62 category, we synthesized technical issues and made recommendations according to a 63 5"W" categorization (Supplementary Figure 1) , based on feedbacks from medical 64 students and tutors/facilitators, in Table 1 pre-registered or real-time updated agenda to place them in queue. Presentation style 80 also needs to be modified using pre-course slide-sharing with in-course verbal 81 explanation, electronic chalkboard, or even social media forums, etc. Digital etiquette 82 is another important element for a successful digital PBL, in which participants 83 assume digital citizenship following two web manner principles, technical details and 84 communication guidance. 9 The former refers to asking participants to turn on 85 cameras/speakers for framing at session beginning, since the transmission of 86 visual/auditory messages may be compromised. Participants should avoid covering 87 their face and look at the camera but not images on the screen. We notice that periodic 88 checkups with audience regarding the clarity of words/images is helpful. Slower 89 movements and wider gestures increase message clarity. The latter refers to the 90 content and message organization. Presenters are expected to speak slower with 91 terminology explained in details. A brief but concise summary at presentation end 92 places the audience at a better position to absorb content. Both digital PBL tutors and 93 students are expected to be more patient than in face-to-face PBL sessions. There are 94 students being "digital natives" (better adapted to the technology-assisted 95 communication), while others are "physical natives" (used to face-to-face 96 interactions). 10 We can enhance students' engagement if communication route, 97 schedule flexibility, device accessibility and ease of usage, etc. is taken into 98 consideration. In our experiences, students of Asian origin might be self-effacing and 99 tend to wait for others to express themselves. Autonomy in learning behavior assumes 100 importance during digital PBL curricula. We encourage students' proactiveness and 101 appraise them for such attitude. 102

When? Timing and duration should be carefully adjudicated for digital PBL (Table  104 1). We think that maintaining high concentration on visual/verbal information 105 assumes importance. In our experiences, students reported intermittent inattentiveness 106 owing to the monotonous background, while distracting exposures are not uncommon 107 including environmental noise, side-chat, or connection interruption. Studies from 108

United Kingdom identified that one-fourth medical students complained of family 109 distraction during digital curricula. 11 We recommend that the duration of a digital 110 PBL session ideally ranges from 1 to 2 hours. A shorter duration is not recommended, 111 as time-consuming technical issues frequently emerge during online sessions, and 112 shorter sessions than 30 minutes preclude effective interactions. In contrast, prolonged 113 digital PBL sessions impair students' concentrating capacity, since sessions longer 114 than 2.5 hours decreased students' satisfaction, leading to negative perceptions. 12 115

Finally, we believe that mid-session breaks similar to those in didactic lectures may 116 sometimes be helpful for restoring students' concentration. We can extrapolate experiences from other forms of online learning 14 , with 3 domains 146 identified including organizational capacity, effectiveness learning and assessment, 147 and human resources. For organizational capacity, there should be an accountable 148 organization/course leader that is supportive and willing to lead the designer process, 149 allocate resources, and implement relevant regulations. 14 For learning effectiveness, 150 components need to be inspected including digital course design, delivery, and 151 student evaluation. 14 For human resources, stakeholders including faculty, students, 152 and administrative staff, should all be considered. 14 153 154 We next provide period-dependent recommendations for implementing digital PBL, 155 divided according to the timings, before, during, and after digital PBL (Table 2) . 156 From the 5"W" categories, students mostly reported difficulties related to the "Where" 157 and "What" categories; that is, their comments frequently involved how to secure 158 places with adequate internet connection, the selection of a suitable conference 159 software, the style of presentation, etc. Feedbacks from the facilitators, on the 160 contrary, spanned from "Who", "When", "Where", "What" to "Why". Prior to the first 161 session, we can ask each group to assign a moderator to lead, organize, and streamline 162 the preparation, avoiding blank period, awkward silence, speaker jamming, or 163 crowding messages. Studies indicate that moderators can guide others to perform 164 better if their ties to the moderators are strong. 15 Feedback from tutors should be instantaneous and avoid losing catch of messages. All 172 should turn off/silent other applications such as emails or recreational ones. We 173 identify several options to ensure students' concentration ability (Table 2) 

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Education. Farewell, lecture?

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We are grateful for the assistance of Mrs. Yin-Li Tsao from the