key: cord-1021014-x4r9cvo7 authors: Cho, Min-Jeong; Pio, Joon title: The Emergence of Virtual Education during the COVID-19 Pandemic: The Past, Present, and Future of the Plastic Surgery Education date: 2021-01-10 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2020.12.099 sha: 9642f669907ce0fe389496ce1a7b46a44837a465 doc_id: 1021014 cord_uid: x4r9cvo7 BACKGROUND: : Since the global outbreak of COVID-19, plastic surgeons were forced to transition from traditional didactics to virtual lectures to practice “social distancing.” As this method of education continues to be widely used, understanding the current trend of its usage is critical. In this study, we performed a survey study of virtual lecture attendees and presenters to determine current usage and general consensus on virtual lectures in plastic surgery education. METHODS: : An electronic survey was sent to attendees and presenters of virtual lectures using Google Forms. Demographic data, webinar usage patterns, and views on virtual lectures were collected. RESULTS: : A total of 417 surveys were received. Prior to the COVID-19 era, 39.1% of attendees did not use virtual lectures, and 45.6% of presenters did not give webinars at all. Both groups reported that the lack of opportunities and need were the most common cause of no use. After the outbreak, 35.4 % of attendees now use virtual lectures daily, and 51.4% of presenters give lectures weekly. Over 90% of the study population reported a positive experience with the virtual lectures due to increased interaction, convenience, outreach, and usability. Finally, over 75% stated that virtual lectures might replace classroom lectures in the future. CONCLUSION: : Our study shows that a majority of plastic surgeons have begun to use and give virtual lectures daily after the COVID-19 outbreak. Virtual education is a powerful and versatile tool that has great potentials, and it may continue to serve as a part of surgical training in the future. The authors have no financial interest to declare in relation to the content of this article Since the global outbreak of COVID-19, plastic surgeons were forced to transition from traditional didactics to virtual lectures to practice "social distancing." As this method of education continues to be widely used, understanding the current trend of its usage is critical. In this study, we performed a survey study of virtual lecture attendees and presenters to determine current usage and general consensus on virtual lectures in plastic surgery education. Forms. Demographic data, webinar usage patterns, and views on virtual lectures were collected. A total of 417 surveys were received. Prior to the COVID-19 era, 39.1% of attendees did not use virtual lectures, and 45.6% of presenters did not give webinars at all. Both groups reported that the lack of opportunities and need were the most common cause of no use. After the outbreak, 35.4 % of attendees now use virtual lectures daily, and 51.4% of presenters give lectures weekly. Over 90% of the study population reported a positive experience with the virtual lectures due to increased interaction, convenience, outreach, and usability. Finally, over 75% stated that virtual lectures might replace classroom lectures in the future. On December 2019 at Wuhan, Hubei province, China, what is now known as the Coronavirus Disease 2019 (COVID-19) outbreak has started 1 . The virus has rapidly spread around the globe, inflicting up to 2.2 millions of people by mid-April of 2020 2 . COVID-19 is known to spread by person-to-person, and it can remain on the surface of plastics up to 72 hours 3, 4 . Due to its high transmission rate, governments across the globe executed orders to ban leaving the home for anything other than essential activities such as grocery shopping 5 . Meanwhile, plastic surgeons have stopped any elective surgeries to preserve personal protective equipment (PPE)s and joined the fight against the COVID-19 by taking care of critically ill patients at the Intensive Care Unit (ICU)s 6 . As the COVID-19 outbreak continued, the question of how to continue plastic surgery education during the outbreak arose. Plastic surgery trainees at North America traditionally attend classroom didactics, followed by online modules on the American Society Plastic Surgeons (ASPS) Education Network (EdNet) [7] [8] [9] . In addition, trainees have visiting professors, participate hands-on courses, and attend national conferences 7 . In contrast, offline learning maybe limited to countries without an established plastic surgery community and resources to train a large number of residents. In these countries, online platforms such as social media and online community are widely used to seek guidance and learn from the experts online [10] [11] [12] [13] . To adhere to the rules of "social distancing," plastic surgeons have rapidly transitioned from teaching offline to online. American Council of Academic Plastic Surgeons (ACAPS) now provides a combined calendar that shows lectures provided by multiple societies 14 . Webinars are given by experts almost daily, and the participation of these lectures has been increasing exponentially 15 . As this method of education continues to be widely used, understanding the current trend of its usage will help determine how the specialty can better implement and identify its risks. Therefore, the goal of this study was to determine the current virtual lecture usage and general consensus on virtual lectures in plastic surgery. Statistical analyses were performed using the SPSS (version 24; SPSS, Inc., Chicago, IL) software. Nonparametric data were described with frequency and percentage. Descriptive analyses were conducted using chi square tests, and a p-value of <0.05 was considered statistically significant. Of the 465 attendees, we received 345 total responses. Of these, 2 responses were discounted due to technical errors in the survey (Table 1 ). Therefore, we had a total response rate of 74.1% (345 out of 465). Of the 343 attendees, the majority of the study population is from Asia, followed by Europe, North America, South America, Africa, and Australia ( Figure 1 ). The majority of respondents are in practice, followed by fellowship, last year of residency, mid-residency, early years of residency, and medical school. For the presenters, the survey was sent to the 112 lecturers, and we received 76 total responses. Of these, 2 responses were discounted due to lack of giving virtual lectures before of after the outbreak. Therefore, we had a total response rate of 66.1% for the presenters. Of the 74 respondents, the majority of the presenters are from North America, followed by South America, Europe, Asia, and Australia ( Figure 2 ). The majority of presenters are in microsurgery (87.8%), general reconstruction (47.3%), hand (25.7%), aesthetic (23%), craniofacial (6.8%), and orthopedics (1.4%). Prior to the COVID-19 outbreak, 39.1% of attendees did not use virtual lectures at all and 38.3% of them used virtual lectures monthly ( Figure 3 ). Only 6.1% of the attendees used online lectures daily. The majority of attendees reported that lack of virtual lecture opportunities (64.8%) was the cause of non-use ( Figure 4 ). In addition, 30.3% didn't see the need for virtual lectures, and 18% felt that they have enough education materials from their institutions. When compared across the continents, South America attendees used virtual lectures most frequently prior to the outbreak. 86.4% of them used virtual lectures to some degree when about 54-67.9% of each continent's users did. The range of daily users was 0 to 9.1% of each continent's users, and usage patterns were similar across the continents (p = 0.183). Similarly, virtual lectures were not frequently given prior to the outbreak; 45.9% of presenters did not give any virtual lectures ( Figure 5 ). The presenters reported that limited opportunities, lack of appropriate platforms, sufficient teaching opportunities in national conferences, and lack of need were the reasons of non-use ( Figure 6 ). After the outbreak, 35.4% of the attendees use virtual lectures daily and 52.2% use them weekly. The percentages of those who do not use virtual lectures at all have decreased from 39.1% to 2.9% after the outbreak. Interestingly, practicing plastic surgeons were using virtual lectures more frequently than trainees (p<0.05). Since the outbreak, presenters now give lectures weekly (51.4%) and monthly or less (35.1%). So far, 45.9% of the lecturers have given at least 5-10 virtual lectures, 31.1% have given less than 5, and 9.5% have given over 20. 91.9% reported that they did not have any difficulty with giving virtual lectures. Overwhelming number of the attendees had a positive experience with virtual lectures: 42.9% (excellent) and 49.6% (good). The majority of these attendees reported that they liked virtual lectures due to easy access to lectures given by international experts, convenience of watching lectures from home, ability to take notes/screen shots, and interaction with lecturers ( Figure 5 ). Overall views on virtual session were similar across different levels of training (p = 0.541). Equivalently, over 90% of presenters had at least good experience with virtual lectures: 40.5% (excellent) and 50% (good). They reported that no need to travel, convenience of giving lectures from home, wider audience, interaction with attendees, and easy use of software were the major benefits of virtual lectures ( Figure 6 ). A minority of attendees had a negative experience: 4.9% (fair), 2.3% (poor), and 2.3% (very poor). Only few attendees did not like virtual lectures (9 attendees), and they attributed causes to lack of interaction with lecturers (55.6%). For the presenters, only 9.5% had a fair experience with virtual sessions. None reported poor or very poor experience so far. They reported that difficulty in interacting with attendees (55.4%), concerns for patient privacy (41.9%), and issues with scheduling (20.3%) were the aspects of virtual lectures that they did not like ( Figure 6 ). As many inventions have sprouted in times of difficulty, the COVID-19 has completely changed the way medicine is practiced now. Drive-through screening tests, 3D printed medical devices, and hands-free door openers are just a few to name 16, 17 . Similarly, the way students are learning has changed completely. Across the globe, schools, from elementary school to colleges, have closed and moved to virtual classrooms in efforts to limit the spread of the COVID-19 [18] [19] [20] . Similarly, plastic surgeons have also joined this movement, and begun to institute virtual lectures such as ASPS Grand Round series, ASJ webinars, and multi-institutional grand rounds. As virtual lectures are being widely used, understanding current usage, general consensus, and its risks is paramount. In our study, we sent an electronic survey to the attendees of virtual lectures at 12 international institutions and International Microsurgery Journal Club webinar. Our study shows that a large number of plastic surgeons did not use virtual learning sessions prior to the COVID-19 (39.1%) or give virtual lectures (45.9%). This finding is not surprising as the majority of educational curriculum consists of didactics in classrooms, operating in the operating room, specialty-specific conferences, and hands-on labs. However, the number of plastic surgeons using the webinars exponentially increased after the outbreak. The majority of attendees became a daily user (35.4%), and 52.2% use weekly. Interestingly, practicing plastic surgeons were using virtual lectures more frequently than trainees (p<0.05) prior to the outbreak. However, about 50% of residents did not use virtual lectures prior to the outbreak but over 40% of residents now use lectures daily. Similarly, the majority of presenters now give virtual lectures weekly (51.4%) or daily (10.8%). Both attendees and presenters reported that the lack of live lecture opportunities as the most common cause of not using virtual lectures prior to the outbreak. This finding can be secondary to the number of courses and specialty-specific conferences that are available. Currently, there are numerous conferences available for different fields of plastic surgery: aesthetic, craniofacial, hand, and reconstructive surgery. Residents typically attend 1-2 conferences per year as a part of their educational conference. They frequently use this opportunity to network, discuss, and learn from experts of the field 7,21 . Given that numerous opportunities are available to learn in person, virtual lectures, although available, were not offered or used frequently. This phenomenon is also reflected on how 30.2% of attendees and 36.2% of presenters didn't see the need for virtual lectures. In addition, over 50% of residents did not use virtual lectures at all prior to the outbreak. Despite the lack of use prior to the outbreak, the future of virtual lecture is promising. Over 90% of both attendees and presenters had at least good experience, and 75% believe that virtual lectures can possibly replace the traditional classroom in the future. Currently, there are different platforms available to set up virtual classrooms: GoToMeeting, Skype, WebEx, and Zoom (Table 2 ). All three platforms work similarly. Typically, the number of attendees varies from 50 to 100 attendees for a free plan, and it can go up to 1,000 attendees with a monthly plan. Presenters can share their content, and attendees can participate via microphone, text their questions, record the lecture with presenter's permission, and take screen shots of the lectures. In addition, the majority of attendees reported that its advantages include easy access, convenience, usability, and increased interaction with lecturers. Similar trend was observed from the presenters. Many attendees agree that virtual lectures allow many advantages over traditional classrooms: 1) ability to freely join or leave lectures; 2) opportunity to listen from international experts whom they can only meet at international or national conferences; 3) ability to ask questions without feeling shy; 4) chance to listen to answers to all questions without interruptions; and 5) having the access of world-class experts from their smartphones. For the presenters, the benefits were as follows: 1) no traveling; 2) convenience of giving lectures from home; 3) wider audience; and 4) increased interaction with attendees. These features are not available in pre-recorded lectures 22 . In contrast, there are concerns for virtual lectures: lack of interaction with lecturers, limited Internet access, and difficulty with the software in those who did not have a positive experience. Due to the nature of virtual platforms, respondents reported that these platforms don't provide the same level of interaction and interpersonal relationship as the in-person lectures do. In addition, each presenter may use different types of platforms, and attendees need to be well versed at using all types of platforms if they want to maximize their experience. There are also concerns for online security and privacy. There has been multiple reports of "Zoombombing," in which intruders hijack Zoom sessions and show profanity 23 So what does this finding mean for the future of plastic surgery training? According to the survey, the majority feels that this method of education and training will be able to replace some aspects of direct, face-to-face training. There will be commoditized lectures and resources available to trainees all over the world. They could watch and study at their own pace and place, and have access to international experts leading in that field. These changes will allow trainees to better prepare themselves for the actual surgery or training. Most of all, with the current reduction in training time, this may perhaps allow an improved allocation of trainees' time and enable them to prepare accordingly. Additionally, it will also allow professors and teachers to dedicate more time for mentorship, research and other matters that can be more valuable than just basic teaching. The authors believe that this unexpected change in learning and teaching due to the COVID-19 pandemic perhaps can be an opportunity to change the delivery of education in a more efficient manner in future. Lastly, many presenters agree with Dr. Andrew Hart's sentiment: "It's an exciting opportunity to democratize education and bring the world closer together in what is already a more international specialty than most." Additionally, it has allowed "people from less fortunate countries have access to teaching by super academic teachers" as Dr. Hinne Rakhorst said. However, "[Virtual education] is here to stay but it needs refinement" as Dr. Rod Rohrich said. Many lecturers also agree with Dr. Justin Sacks' sentiment: "[online education] is nice but not the same. [We] want to walk the earth, meet the people, sample the cuisine of the cities, and cultures we interact with. However, online virtual education is here to stay and will become an important part of what we do and making the world even smaller than it already is for us." Dr. Scott Levin also agrees that "experiencing each other's cultures, customs, and family cannot be underestimated." There are few limitations in this study. First, survey responses regarding pre-COVID era can be biased by memory recall. In addition, the outbreak started at different time points for each country, which can further lead to increased variation among survey respondents. Second, survey questions were not open-ended, and this study may not have captured the scope of potential responses for the positives and negative of virtual lectures. Given the current situation of the COVID-19 global pandemic, plastic surgery trainees and faculty have changed the way plastic surgery education is performed. Overall, our study shows that virtual lectures provide numerous benefits at this time, and many respondents believe that this method of education can possibly substitute traditional classrooms beyond the COVID-19 pandemic. It has allowed those with years of experience to share their wisdom and pearls selflessly with those who are seeking to learn during this unprecedented time. While virtual education has been adapted to continue education during this unprecedented time, we believe the benefit of using this type of learning is paramount and may serve as an adjunct to traditional classroom lectures in the future. However, the study also shows that there are concerns for online security and patient privacy, and involvement of professional societies maybe warranted to ensure patient privacy. New Cases of COVID-19 Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. The New England journal of medicine Covid-19 -Navigating the Uncharted. The New England journal of medicine Wuhan novel coronavirus (COVID-19): why global control is challenging? Public health CMS issues guidance for elective surgery; PPE conservation strategies The Future of Plastic Surgery Resident Education. Plastic and reconstructive surgery E-learning in surgical education and training. 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The Lancet Infectious diseases The Impact of COVID-19 on Vascular Training The Rise of Technology in Plastic Surgery Education: Is the Textbook Dead on Arrival (DOA)? Aesthetic surgery journal Implementation of screen-capture video recordings of resident conferences in an academic radiology department: pilot experience A Must For Millions, Zoom Has A Dark Side -And An FBI Warning Live-case demonstrations in pediatric urology: Ethics, patient safety, and clinical outcomes from an 8-year institutional experience. Investigative and clinical urology Live case demonstrations: patient safety, ethics, consent, and conflicts Live broadcasting in cardiac surgery does not increase the operative risk. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery The authors would like to thank all survey participants for providing their valuable insights and experience of using virtual lectures during the COVID-19 Pandemic. M.J.C. conceptualized and designed the study, drafted the initial manuscript, and approved the final manuscript as submitted. J.P.H. conceptualized and designed the study, critically revised the manuscript, and approved the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.