key: cord-0928149-9p6o1xzu
authors: Cheng, Xin; Chan, Lap Ki; Cai, Hongmei; Zhou, Deshan; Yang, Xuesong
title: Adaptions and perceptions on histology and embryology teaching practice in China during the Covid-19 pandemic
date: 2021-02-18
journal: nan
DOI: 10.1016/j.tria.2021.100115
sha: 149bc1b3141650714583812e78a8e0a25937755a
doc_id: 928149
cord_uid: 9p6o1xzu

Backgroud Under the circumstance of school closures caused by the coronavirus outbreak, medical schools in China began implementing online teaching, including histology and embryology (HE) beginning in the middle of February 2020. The changes in HE education in responding to the pandemic in China needs to be determined, for further adaption of online teaching delivery or blended learning. Methods A nationwide survey of the major medical colleges was conducted via WeChat. Results In total, 83 medical schools (one respondent per school) were invited to survey, 78 medical schools responded which represented most medical schools across all the provinces in mainland China, as well as Hong Kong and Macao. The results revealed that 77% (n = 60) and 58% (n = 45) of the responding schools had conducted HE theoretical and practical online teaching, respectively, prior to the pandemic; however, 27% (n = 21) of the medical schools had temporally suspended practical sessions at the time the survey was completed. During the pandemic, 73% (n = 57) and 29% (n = 23) of the medical schools delivered HE theoretical and practical sessions by synchronous live broadcasting, respectively; 65% (n = 51) of the medical schools increased virtual microscopy using during practical sessions. During the pandemic, 54% (n = 42) of the medical schools implemented teaching activities promoting active learning; meanwhile, online assessment was implemented in 84% (n = 66) of the responding medical schools. With regard to the satisfaction with the effectiveness of online teaching during the pandemic, 64% (n = 50) of the medical schools gave positive answers and considered that it was a good opportunity to develop novel and diversified teaching methods. Despite various difficulties such as work overload and unstable online teaching environments, most medical schools are willing to continue or increase theoretical online teaching after the pandemic. Conclusions Medical institutes in China were the earliest of closing campuses and having complete online teaching experience during the pandemic. This paper presents overall HE teaching situation extracted from the survey, to assist other medical schools optimizing the transitions to quality online teaching within a short time, and to serve as reference for schools that demand essential knowledge in online teaching methods, infrastructure construction, and platform integrations.

distribution of the completed surveys covered the 23 provinces, 5 autonomous regions and 4 174 municipalities in mainland China, as well as the two special administrative regions of Hong 175

Kong and Macao. 176

The 337 main cities in mainland China are classified into six-level city tier system, which 177 are the first, new first, second, third, fourth and fifth-tier cities, according to the degree of 178 commercial resources aggregation, city junctions, citizen's activities, diversities of livings, and 179 future plasticity (http://www.199it.com/archives/1057872.html). Hong Kong and Macao are also 180 categorized into first tier cities because of their international status. Based on the locations, 33 181 surveyed medical schools are situated in first-tier and new first-tier cities. There is only one 182 medical school in the fifth-tier city. Therefore, the medical schools in the fourth (n = 13) and 183 fifth-tier cities (n = 1) are combined as one group for further correlation statistics. "Double 184 first-class" -the newest government assessment criteria to categorize universities in mainland 185

China, means "world-class universities" and "first-class disciplines". There are 42 world-class 186 universities and 95 universities having first-class disciplines [23] . Based on this criterion, 21 of 187 the 78 medical universities/schools in this survey are qualified as "double first-class". 188

The value for Cronbach's alpha for the 15 single-answer items in the questionnaire was 0.376. 189

The results of Kendall's tau b test showed the correlation coefficient amongst cities classification 190 and the items in the questionnaire (Table 1) platforms, e.g., Tencent classrooms/meetings, 36% (n = 21) of them used teaching management 203 platforms with live broadcasting capability, e.g., Rain Classroom, Xuexitong, and 31% (n = 18) 204 of them used social software, e.g., QQ and WeChat. During synchronous live broadcasted 205 theoretical sessions, the vast majority of the surveyed medical schools (83%, n = 47) used less 206 than half of the class time to interact with their students, and real-time interactive communication 207 via voice (91%, n = 52) or text (89%, n = 51) was the most commonly used means of interaction. 208

Other interaction forms, such as real-time on-screen comments (Danmu) and online voting (44%, 209 n = 25), real-time online answering questions based on PowerPoint plug-ins during the 210 synchronous live broadcasting class (51%, n = 29), and organizing online discussions among 211 student group members (39%, n = 22), were also adopted by some schools. 212

Regarding asynchronous theoretical sessions, Powerpoint presentation screen capturing is 213 most commonly used for HE online teaching. However, 61% (n = 22) of the schools adopted 214 without teachers appearing in recorded videos, 27% (n = 10) of the schools did postproduction Xuexitong, Rain Classroom, and Blackboard, to release the videos, while 24% (n = 9) of the 218 schools used online courses platforms, e.g., Chinese University MOOC, PMPH MOOC, and 219

Zhihuishu, and 19% (n = 7) of the schools used social software, e.g., QQ and WeChat. In regard 220 to the contents of HE theoretical sessions, 38% (n = 30) of the responding schools completely 221 redesigned their teaching materials for online delivery, while 36% (n = 28) of the schools only 222 slightly modified their content, and 18% (n = 14) of the schools did modify their teaching 223 materials at all. 224 225

The HE online practical sessions were implemented at a much lower rate if compared with the 227 theoretical sessions. The survey showed that 58% (n = 45) of the responding schools had 228 experience with implementing online HE practical sessions using the MOOC (9%, n = 7), flipped 229 classroom (15%, n = 12), or blended method (33%, n = 26). During the pandemic, HE practical 230 sessions were temporally suspended in 21 responding schools (27%) at the time the survey was 231 performed. For the schools that still conducted online HE practical sessions, 40% of the schools 232 used synchronous live broadcasting (n = 23), 12% of the schools used asynchronous recorded 233 broadcasting (n = 7), and 30% of the schools used both live and recorded broadcasting (n = 17). 234

Fifty percent of the responding schools (n = 39) showed an increased use of virtual microscopy 235 in online HE practical sessions by more than 50%, 15% of the schools (n = 12) showed an 236 increase of less than 50%, and 35% of the schools (n = 27) reported no change in their use of 237 virtual microscopy in online HE practical sessions. Among these schools, 49% (n = 28) used 238 virtual simulation platforms built by their own institutions, while 36% (n = 21) and 15% (n = 8) 239 J o u r n a l P r e -p r o o f of the schools used national or provincial virtual simulation platforms, respectively, which are 240 virtual resource-sharing platforms recognized by central or local governments. It was found that 241 65% (n = 35) of the responding schools used less than 50% of the class time for interacting with 242 students, and 30% (n = 16) of the medical schools used more than 50% of the class time as 243 practical time. 244 245

The students-centered teaching strategies were also employed during HE online teaching, but a 247 sizable reduction could be observed. Before the pandemic, 82% (n = 64), of the responding 248 schools had active learning sessions (e.g., flipped classroom, small group discussion, 249 problem-based learning (PBL), and team-based learning (TBL), individualized tutoring). Among 250 them, 46% (n = 36) continued these sessions during the pandemic, while 36% (n = 28) of the 251 schools suspended them. Interestingly, 8% (n = 6) of the responding schools initiated active 252 learning during the pandemic although they had never done so before (Fig. 1A) . The active 253 learning sessions included individualized tutoring, flipped classroom, small group discussion, 254 PBL, TBL, etc. (Fig. 1B) . The platforms for running these sessions were mainly teaching 255 management platforms such as Rain Classroom, Xuexitong, and Blackboard (86%, n = 36), 256 although 52% (n = 22) of the responding schools utilized social media, e.g., QQ and WeChat. 257

Other platforms including "Panopto (Panopto, Seattle, WA)", "Zoom" and "Duifene (Duifene, 258 Shanghai, China)" were also used by some teachers (others, 10%, n = 4). 259

One particular challenge for educators switching to the online format from traditional 260 teaching is how to implement assessment. Before the pandemic, 72% (n = 56) of the responding 261 J o u r n a l P r e -p r o o f schools had experience with using online assessments. Among them, 65% (n = 51) of the schools 262 continued their use during the pandemic, while 7% (n = 5) of the schools suspended their online 263 assessments during the study period. The remaining 28% (n = 22) of the responding schools did 264 not have experience with online assessments before the pandemic. Among them, 19% (n = 15) of 265 these schools initiated online assessments during the pandemic (Fig. 1C ). Among the responding 266 schools that carried out online assessments, the vast majority of the medical schools adopted 267 online tests, while the others utilized peer assessments for homework, attendance for online 268 sessions, and subjective assessments by teachers (Fig. 1D ). Some other applications (APPs) e.g. 269 "Mentimeter quiz (Mentimeter AB, Alströmergatan, Sweden)", "Sojump", were employed for 270 online assessment, mentioned at "others" option. 271 272

Teachers were also aware of the importance of their perceptions on this high-impact online 274 teaching experience. Only approximately 50% (n = 39) of the responding teachers estimated that 275 their online sessions during the pandemic helped students achieve 80-100% of the intended 276 learning outcomes, while 36% (n = 28) claimed a 60-80% achievement rate, 11% (n = 9) claimed 277 a 30-60% achievement rate, and 3% (n = 2) claimed a <30% achievement rate ( Fig. 2A) . In 278 addition, 15% (n = 12) and 49% (n = 38) of the responding schools reported that they were "very 279 satisfied" and "satisfied", respectively, with the effectiveness of their online teaching during the 280 pandemic (Fig. 2B) . The average values of Likert scale for satisfaction was 3.79±0.69, if 1-5 281 rating scale from "very dissatisfied" to "very satisfied". They reported that the top two gains teachers were reported as "difficulty grasping students' progress and learning outcomes" and 285 "unstable online teaching environments, platforms and tools" (Fig. 2D ). Some teachers said the 286 first week of online teaching was much difficult to adapt, and the students' firsthand experience 287 was irreplaceable for medical practical science. When asked whether they were willing to 288 continue their online teaching after the pandemic, 58% (n = 45) of the responding teachers said 289 they were willing to continue to implement theoretical sessions online, but only 1 medical school 290 would continue to implement practical sessions online, while 17% (n = 13) of the respondents 291 said that they would like to switch back to face-to-face teaching. 292 293

The correlation analyses were carried out between the items in the questionnaire and various 295 classifications of medical schools (Table. 1). It showed that the satisfaction of online teaching 296 effectiveness was correlated with the city tier system (r = 0.206, P = 0.034, n = 78), with 297 significantly higher satisfaction of the first-tier cities than others ( One important way to constantly improve active learning online is to set up an effective 415 online assessment system in a real-world context, which is one of the difficult aspects of 416 of the responding medical schools that have implemented online assessments during the 418 pandemic, in which some timely feedback might be included. Similar to the aforementioned 419 findings regarding "the biggest difficulties encountered during implementing HE online 420 teaching", 55% of the respondents said it was "hard to grasp students' progress and learning 421 outcomes". Therefore, it is understandable that the number of online assessments increased 422 during the pandemic since the teachers desired to learn about the students' perceptions about 423 online teaching from time to time. 424

Online learning has been somehow controversial topic among teaching academics in higher 425 education under normal conditions [31, 42] , although there is no doubt that it is a growing trend. 426

In the context of the pandemic outbreak and school closures, both teaching academics and 427 students had little choice but to embrace this format. The first step of online education during the 428 pandemic was how to shift to online teaching successfully for most educators. And the 429 evaluation about whether the switch was gained on less tangible effects could be lagged. 430

Learning outcome is a crucial indicator for judging the success or failure of online teaching. This 431 survey showed that approximately 50% of the responding teachers estimated that their online 432 sessions during the pandemic helped students achieve less than 80% of the intended learning 433 outcomes. The reason for this outcome is probably related to the limitation of hardware, because 434 51% of the respondents mentioned that "the biggest difficulties encountered during 435 implementing HE online teaching" was "unstable online teaching environments, platforms and 436 tools". Some medical schools introduced corresponding measures for implementing online 437 teaching at the very beginning of the online teaching period (e.g., providing assistance for 438 effectively delivering online instruction designs, engineering adequate support to students provided by teaching academics, establishing a contingency plan for unexpected incidents of 440 online education platforms, etc.) [43] . However, this approach might not be good enough for 441 coping with the situation in which millions of students nationwide are using online courses 442 simultaneously. 443

Unexpectedly, 65% of the responding schools were either satisfied or very satisfied with the 444 learning outcomes of online teaching during the pandemic. It was found that only 64 (82%) of 445 the surveyed schools redesigned or adjusted the teaching content after shifting from "face-to-face" 446 to fully online teaching. This ratio was fairly higher than that of gross anatomy, 51 (68%) of the 447 responding schools, although the two disciplines reported the similar data on medical schools 448 using synchronous live broadcasting (for gross anatomy, 35 surveyed schools; for HE, 31 449 surveyed schools; the data of gross anatomy comes from our another parallel survey). It can 450 partly interpret the higher satisfaction with learning outcomes of HE when compared with the 451 one in gross anatomy, except for the advantage of relatively perfect digital-resources of HE than 452 gross anatomy. Synchronous live broadcasting ranked the most popular of online teaching, which 453 implies that most of the online teaching might simply follow the "face-to-face" teaching 454 strategies. This phenomena can be understood as strategies coping with emergency, but the 455 teaching strategies and methods should be changed when switched to online teaching. We must 456 re-consider and focus on post-pandemic online teaching from now on. Moreover, both the 457 evaluation of teaching effectiveness and the satisfaction with learning outcomes in this survey 458 were from internal evaluation since they were assessed by teaching academics themselves, so 459 that the extrinsic evaluation indisputably is required. with experience in implementing online courses. As a consequence, when the pandemic emerged, 496 these HE academics could deal with the unforeseen alterations to the existing teaching model 497 rather than being caught off guard. A negative finding is that there are still many teaching 498 academics who lack online teaching experience. Thus, there was an increased workload due to 499 suddenly moving traditional didactic lectures to online courses, as well as the presence of 500 insufficient infrastructures prior to the pandemic; therefore, some medical schools suspended 501 their practical sessions during the pandemic temporally. Hopefully, both teaching academics and 502 students, as well as administrators of higher education, can learn lessons from the global disease 503 outbreak so that our higher education can ultimately make considerable progress when the 504 outbreak is over. 505 

The COVID-19 pandemic in the USA: What might we expect?

COVID-19 in Europe: The Italian lesson

Clinical course and risk factors for mortality of adult inpatients with

COVID-19 in Wuhan, China: A retrospective cohort study

China Novel Coronavirus Investigating and Research Team

A novel coronavirus from patients with pneumonia in China

The psychological effects of quarantining a city

Senior medical students in the COVID 19 response: An opportunity to be 548 proactive

School closure and management practices during 550 coronavirus outbreaks including COVID-19: A rapid systematic review

Covid-19 and community mitigation strategies in a 553 pandemic

Going virtual to support anatomy education: A 555 STOPGAP in the Midst of the Covid-19 pandemic

Improved teaching of microanatomy

An efficient technique for teaching microanatomy

Histology and embryology education in China: The current 561

Virtual histology in the classroom and beyond

Virtual versus light microscopy for teaching histology

Virtual microscopy-The future of teaching histology in 572 the medical curriculum?

Web-Based Virtual Microscopy Platform for Improving

Academic Performance in Histology and Pathology Laboratory Courses: A Pilot Study

Uses and gratifications of social media: A comparison of microblog and 578

Privacy trust crisis of personal data in China in the era of big data: The survey 581 and countermeasures

Online questionnaire, examinations and voting platform

Daily medical education for confined students 590 during COVID 19 pandemic: A simple videoconference solution

Trends in histology laboratory teaching in United States 593 medical schools

Using web-based animations to teach histology

Examining issues of e-learning practices in Chinese higher education: A 597 comparative study of Mainland China, Hong Kong and Taiwan

Enhancing course grades and evaluations using 599 distance education technologies

Online learning in higher education: A review of research on interactions 602 among teachers and students

Mixed methods student evaluation of an online systemic 607 human anatomy course with laboratory

Unprecedented pandemic, unprecedented shift, and unprecedented opportunity

Forced disruption of anatomy education in Australia 612 and New Zealand: An acute response to the Covid-19 pandemic

The virtual anatomy laboratory: Usability 615 testing to improve an online learning resource for anatomy education

Strength, weakness, opportunity, threat 618 (SWOT) analysis of the adaptations to anatomical education in the United Kingdom and 619 Republic of Ireland in Response to the COIVD-19 pandemic

Traditional and virtual microscopy compared experimentally in a 622 classroom setting

Dermatopathology education during the COVID-19 624 pandemic: Virtual simulation of the multi-headed microscope

The effectiveness of the problem-based learning teaching 627 model for use in introductory Chinese undergraduate medical courses: a systematic review and 628 meta-analysis

Integration of histology lectures and practical teaching 630 integration of histology lectures and practical teaching in China

Problem-based learning in online vs. face-to-face environments

Strategies shift as coronavirus pandemic looms

Adopting web based learning and teaching: A case study in 637 higher education

COVID-19 and online teaching in higher education: A case study of Peking

J o u r n a l P r e -p r o o fThe authors would like to thank all of the survey respondents who helped to complete this 508 survey. 509

Attitudes on online teaching Positive 6 (12%) "HE possesses certain advantages in teaching online.""Combining online education and face-to-face teaching can lead to better learning outcomes." Neutral 4 (8%) "Online teaching is not recommended except in very special circumstances.""The consistency and integrity of knowledge framework was difficultly delivered via online courses."Strong desire to share premium online resources among medical schools