A Day at the Farmers Market (oil) by Ralph C. Williams Jr.
Sir William Osler, a pioneer of modern medical education, taught “medicine is learned by the bedside and not in the classroom.”1 How, then, do we learn medicine in a world dominated by virtual interactions? This question was forced upon us in the era of the COVID-19 pandemic. From telemedicine to remote meetings, the rheumatology community adapted to paradigm shifts impacting both patients’ care and practitioners’ training.
As rheumatology education increasingly incorporates learning conducted via electronic media—eLearning, for short—integrating technology with evidence-based adult learning theory and best practices is paramount for effective virtual learning activities. The ARP eLearning Subcommittee offers these considerations to enhance your virtual learning experiences as both an educator and student.
Advantages of eLearning
Flexibility for the individual learner is one of the greatest benefits of eLearning. If leveraged properly, electronic media makes education both convenient and adaptable.2,3 eLearning programs are typically accessible online, creating lower cost and time barriers than traveling for in-person learning.
Asynchronous experiences, in which activities are available on demand, allow participants to schedule their education around preferences or other time commitments. Thus, the same virtual program can seamlessly accommodate both a learner dedicating a day off to complete coursework before a certification exam as well as one who has just a few minutes of break time during shifts on the wards. Moreover, on-demand functionality accommodates personal proclivities and attention spans. Students can pace or rewind virtual learning activities to adjust to their particular needs for each presented concept.
Despite its virtual nature, eLearning can improve practical clinical skills in a low-risk environment. Integrating case-based learning and other simulations into an eLearning curriculum allows learners to practice advanced critical thinking while receiving near-instantaneous feedback, all without consequences to patients. Imagine scenarios where you can make choices about diagnosis or treatment plans in safe, non-threatening circumstances and know immediately if you made the best decisions for a patient. It’s no surprise that virtual care exercises positively enhance the development of problem-solving abilities and pragmatic decision-making skills.2,4
Adult learners typically view eLearning positively. Published experiences report that most students rate virtual learning favorably and that even students initially apprehensive about eLearning often ultimately regard it positively.4
Drawbacks with eLearning
Do you remember taking a class with a professor who made 50 minutes seem like 15 or leading a session in which you were so engaged with your audience that no one noticed you forgot to stop for a break? These types of learner-teacher interactions are often undermined during virtual learning.
On an unconscious level, we process nonverbal communication as unspoken feedback, a task hampered by a computer screen.5 This interpersonal disconnect reaches beyond the classroom. A shy student who mustered the courage to engage a lecturer one on one after class may have trouble building a comparable relationship in a virtual environment.5 Organic professional interactions and minutes spent socializing after in-person didactics often fall to the wayside in cyberspace.
eLearning forces both learners and educators to make conscious efforts to recapture some of the interpersonal connection lost in a virtual forum.
Ironically, eLearning may be hindered by some of the same aspects that make it so valuable. Allowing on-demand access or adapting to the near-infinite audience capacity of a virtual seminar forces changes in teaching plans and materials. Educators may not yet feel comfortable leveraging technology effectively or modifying their existing teaching skills to the nuances of virtual learning. Developing these proficiencies takes preparation time, a resource often scarce when meeting the accelerating deadlines forced by the pandemic.5 Although eLearning can clearly build certain clinical competencies, it complicates the evaluation of other parts of that skill set.6
Moreover, eLearning also requires investments in equipment, bandwidth and accessibility.5
Pertinent Trends
Rheumatology professionals quickly embraced many important behaviors to enhance virtual learning in response to COVID-induced restrictions.
Effective collaboration plays a key role in current rheumatology eLearning. When many programs were forced to put in-person educational activities on pause, several joined together to create online options. For example, rheumatologists at Brigham and Women’s Hospital, Boston organized a multiprogram online journal club that included both local and out-of-state participants.6 In similar fashion, The George Washington University School of Medicine cooperated with institutions in Washington, D.C., to hold monthly online clinical-pathologic (CPC) style conferences.7
The ACR/ARP also sponsored multiple online offerings, including the Virtual Rheumatology Learning (ViRL) Collaborative, which created a nationwide on-demand core lecture series for fellowship programs.8
Such collaborations alleviate individual burdens and quickly generate useful eLearning content. Moreover, the online format enhances access: Developers report rheumatology learners from numerous locations are easily able to participate and attendance has been several times higher than pre-pandemic levels.6,7
Educators have also combined real-time and asynchronous virtual learning opportunities. This amalgamation offers flexibility by making information available at the click of a mouse, while still allowing interpersonal and social interactions, albeit through a screen.7,8
When assessing learners’ clinical skills, many rheumatology programs leverage the nature of telehealth to their advantage. This format affords the chance to unobtrusively view trainees without distracting from the patient-clinician interaction. Telehealth allows preceptors to gain a view of the learner’s skill set as they navigate the many facets of a clinical encounter, but still intervene at any moment if needed.7,8 If patients and regulations allow, appointments can also potentially be recorded so trainees can view themselves and perform self-assessments.
Practical Considerations
What should you anticipate when implementing eLearning into your teaching program?
The social disengagement of virtual learning exacerbates participants’ boredom and contributes to virtual learning fatigue. Combating this boredom is key to maintaining learner motivation—and mastery of the material.9
Just as children are drawn to educational play, “gamification” can incentivize adult learners through interactions with point-
scoring systems, time-trial competition and other interactive elements.7
Strategically pausing eLearning activities to employ active engagement techniques, such as guessing at study outcomes, predicting diagnoses or reciting key learning points, can enhance virtual learning.
Similarly, virtual seminars can easily incorporate interactive elements and audience participation via real-time polling or other question-and-answer methods. Virtual breakout rooms can facilitate role-playing, smaller discussion groups or even standardized patient encounters to maintain social connections and mimic in-person learning exercises.7
eLearning audiences may be large or multi-institutional, so consider combining virtual learning with local follow-up activities or even in-person sessions. These pursuits should be tailored to the needs of the particular learner group to enhance understanding and further exploration.
Large groups can make getting through a presentation confusing if the speaker is also being bombarded with questions or sifting through a chat box. Appointing a moderator to sort through and consolidate questions can avoid unnecessary interruptions.
Transitioning to virtual learning takes a large investment, but eLearning can also help save time and effort. For example, instructors can reuse successful sessions as a reference for future trainees by keeping a database of their video presentations. Such a resource can also be targeted as a framework or preview for future learning.7
Technical Considerations
The computer froze. The formatting changed. The sound isn’t working. Common technological glitches interfere with learning by creating frustration.2 Several basic considerations can help keep these obstructions to a minimum.
First, strongly consider using the same software platform for multiple experiences: If telehealth is conducted over RingCentral, don’t try to use Microsoft Teams for journal club and Zoom for didactics. Sticking with familiar interfaces will help avoid the distraction of adjusting to each different platform.
Optimize media, especially videos and graphics, to the smallest size needed to retain the necessary details. At the same time, advise participants about appropriate computer and internet bandwidth requirements, particularly if using heavy applications, such as video or interactive exercises.
For online presentations, ensure presenters are appropriately front-lit and framed in the camera. Presenters’ backdrops should be professional and free from distracting elements. Whenever possible, have presenters connect well ahead of the session to make sure video and audio equipment is functioning properly—and have a backup plan if it isn’t.
Important Takeaways
No matter how basic or advanced your virtual learning experience is currently, plenty of options exist for improvement when incorporating eLearning into your education portfolio. First, keep your audience in mind. Adult learners lead busy lives full of distractions. Creating a virtual experience that is flexible yet engaging is key to success. Second, be prepared for the unexpected. Think prospectively and have a backup plan for common road bumps. Third, build on what you have and what you can find. An eLearning experience does not always need to be generated completely from scratch. Last, maintain the human connection. Use asynchronous learning where appropriate, but don’t forget about real-time experiences and in-person learning.
The pandemic has propelled us into the virtual world, but by strategically engaging the strengths and shortcomings of eLearning, we can bring the computer closer to the bedside than Sir William Osler could have imagined.
Colin Cox, BSc, is a third-year medical student at Kansas City University, Joplin, Mo.
Prateek C. Gandiga, MD, FACP, is an assistant professor in the Division of Rheumatology at Emory University, Atlanta.
References
- 10 Osler-isms to remember in your daily practice. Stanford Medicine 25 website. 2014 Nov 25.
- Magnussen L. Applying the principles of significant learning in the e-learning environment. J Nurs Educ. 2008 Feb;47(2):82–86.
- Blake H. Staff perceptions of e‐learning for teaching delivery in healthcare. Learning in Health and Social Care. 2009 Sep;8(3):223–234.
- Bolan CM. Incorporating the experiential learning theory into the instructional design of online courses. Nurse Educ. Jan–Feb 2003;28(1):10–14.
- Ahmed S, Zimba O, Gasparyan AY. Moving towards online rheumatology education in the era of COVID-19. Clin Rheumatol. 2020 Nov;39(11):3215–3222.
- Koumpouras F, Helfgott S. Stand together and deliver: Challenges and opportunities for rheumatology education during the COVID-19 pandemic. Arthritis Rheumatol. 2020 Jul;72(7):1064–1066.
- Bilal S, Shanmugam VK. Enhancing rheumatology education during the COVID-19 pandemic. Rheumatol Int. 2021 Mar;41(3):503–508.
- Dua AB, Kilian A, Grainger R, et al. Challenges, collaboration, and innovation in rheumatology education during the COVID-19 pandemic: Leveraging new ways to teach. Clin Rheumatol. 2020 Dec;39(12):3535–3541.
- Russell SS. An overview of adult-learning processes. Urol Nurs. 2006 Oct;26(5):349–370.
- Hall AK, Nousiainen MT, Campisi P, et al. Training disrupted: Practical tips for supporting competency-based medical education during the COVID-19 pandemic. Med Teach. 2020 Jul;42(7):756–761.
