Medical and Surgical Education Challenges and Innovations in the COVID-19 Era: A Systematic Review

Curriculum Innovations: A Podcast-Based Neurologic Emergency Flipped Classroom Curriculum for Neurology Residents

Introduction

Education on the management of neurologic emergencies is vital for neurology residents, and effective educational methods are needed. This study aims to implement and evaluate the impact of a podcast-based flipped classroom curriculum in neurologic emergencies. "Flipped classroom" instructional methods have been used in GME and informed by experiential learning theory.

Curriculum Objectives

The objectives of this curriculum were to (1) compare the clinical phenomena discussed in the neurologic emergencies podcast(s) with your own clinical experience; (2) discuss the pitfalls in the management of the neurologic emergencies discussed in the podcast(s); and (3) develop a management plan for the neurologic emergencies discussed in the podcast(s).

Methods

At 10 neurology residency programs, we implemented a 3-session flipped classroom curriculum covering topics in acute stroke, movement disorder emergencies, and status epilepticus. Each session consisted of a Neurology® podcast followed by content discussion with a clinical expert. Assessment of the curriculum included presession and postsession surveys focused on learners' confidence and attitudes toward podcast-based education.

Results

Our data sample consisted of survey responses from residents, with response volumes ranging from 29-111 across all surveys. Podcasts are already highly used by neurology residents in their self-directed education. Confidence increased among learners in the management of movement disorder emergencies (18% confident before vs 79% confident after, p < 0.001) and status epilepticus (72% confident before vs 91% confident after, p = 0.014) among those who completed the curriculum. A change in confidence in acute stroke management was not found (p = 0.15). Podcasts were consistently preferred over lectures and reading-based instructional methods while less preferred compared with simulation-based learning and case-based discussion with faculty. The podcast-based curriculum studied here showed high levels of enjoyment and perceived utility.

Conclusions

We present a 3-part curriculum to help build learners' familiarity and confidence in 3 neurologic emergency categories. The educational impact is established in Level 1 of the Kirkpatrick paradigm. Future studies can explore a higher-level impact of this curriculum. Evolution in neurology education is shifting increasingly toward immediately accessible information via digital media. This curriculum can be useful to neurology educators who need to be increasingly agile and facile with multiple educational techniques to meet learners' needs.

Impact of COVID-19 Pandemic on Dermatology Teaching Program in India: A Survey on the Faculty and Residents' Perspective

Background

Impact of COVID-19 pandemic has been immense. An innocent casualty of this disaster is medical education and training. Dermatology, which primarily deals with out-patient services, medical and surgical interventions, and in-patient services, was one of the worst hit. The National Medical Commission of India has implemented competency-based medical education (CBME) in Dermatology, Venereology, and Leprosy since 2019. The new curriculum relies on acquiring practical and procedural skills, training skills in research methodology, professionalism, attitude, and communication.

Objectives

The study was undertaken to understand the implications of the COVID-19 pandemic on postgraduate dermatology CBME training in India.

Materials and Methods

A questionnaire-based survey was carried out on postgraduate dermatology teachers and residents in India after obtaining ethics committee approval. An online semi-structured English questionnaire was administered by Google Forms. The calculated sample size was 366 dermatology faculty and 341 postgraduate students. Validity (Content validity ratio (CVR) ≥0.56) and reliability (Cronbach's alpha coefficient 0.7249) of the questionnaire were determined.

Results

Among the 764 responses received, 51.4% reported that their institutes were converted to exclusive COVID hospitals. Domains of dermatology education affected were procedural training (n = 655), bedside clinical teaching (n = 613), outpatient department-based clinical teaching (n = 487), bedside laboratory procedures (n = 463), research activities (n = 453), histopathology (n = 412), and theory classes (n = 302). To keep up with the teaching-learning process, online platforms were mostly utilized: Zoom Meeting (n = 379), Google Meet (n = 287), and WhatsApp Interaction (n = 224). Teaching during ward rounds was significantly more affected in exclusively COVID institutes than non-exclusive COVID institutes (P < 0.001). Psychomotor skill development suffered a major jolt with 26.7% of respondents reporting a standstill (P < 0.001). Communication skills among students suffered due to social distancing, mask, and poor attendance of patients. According to 23.84% of respondents, formative assessment was discontinued.

Conclusion

Online seminars, journal clubs, and assessments have been incorporated during the pandemic. Online modalities should be used as a supplementary method as psychomotor skills, communication skills, research work, and bedside clinics may not be replaced by the e-learning.

COVID-lateral Damage: Impact of the Post-COVID-19 Era on Procedural Training in Emergency Medicine Residency

Introduction: Hospitalizations during the coronavirus 2019 (COVID-19) pandemic peaked in New York in March-April 2020. In the months following, emergency department (ED) volumes declined. Our objective in this study was to examine the effect of this decline on the procedural experience of emergency medicine (EM) residents compared to the pre-pandemic period. Methods: We conducted this multicenter, retrospective cohort study of patients seen and key procedures performed by EM residents at hospitals spanning three Accreditation Committee for Graduate Medical Education-approved EM residencies in New York City and Nassau County, NY. We obtained numbers of procedures performed during May-July 2020 and compared them to the same time period for 2019 and 2018. We a priori classified critical care procedures-cardioversion, central lines, chest tubes, procedural sedation, and endotracheal intubation. We also studied "fast-track" procedures-fracture/joint reduction, incision and drainage (I&D), laceration repairs, and splints. Results: Total number of critical care procedures in the months following the COVID-19 peak decreased from 694 to 606 (-12.7%, 95% confidence interval [CI] 10.3-15.4%), compared to an increase from 642 to 694 (+8.1%, 95% CI 6.1-10.5%) the previous year (difference -9.3%). Total number of fast-track procedures decreased from 5,253 to 3,369 (-35.9%, 95% CI 34.6-37.2%), compared to a decrease from 5,333 to 5,253 (-1.5%, 95% CI 1.2-1.9%) the year before (difference -36.3%). Specific critical care procedures performed in 2020 compared to the mean of 2019 and 2018 as follows: cardioversion -33.3%; central lines +19.0%; chest tubes -27.9%; procedural sedation -30.8%; endotracheal intubation -13.8%. Specific fast-track procedures: reductions +33.3%; I&D -48.6%; laceration repair -17.3%; and splint application -49.8%. Conclusion: Emergency medicine residents' critical and fast-track procedural experience at five hospitals was reduced during the months following the COVID-19 peak in comparison to a similar period in the two years prior. Training programs may consider increasing simulation-lab and cadaver-lab experiences, as well as ED and critical care rotations for their residents to offset this trend.

A national survey of surgical training in gynaecology: 2014-2021

OBJECTIVES

Over the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time.

STUDY DESIGN

We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology. A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021.

RESULTS

During the study period trainees' confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees' ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training.

CONCLUSION

Our findings show an overall decrease in trainees' and trainers' confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.

Influence of online collaborative learning on social network and academic performance of medical students: lessons learned from the COVID-19 pandemic

Introduction

The social distancing restrictions due to the COVID-19 pandemic have changed students' learning environment and limited their social interactions. Therefore, the objective of this study was to investigate the influence of the social distancing restrictions on students' social networks, wellbeing, and academic performance.

Methods

We performed a questionnaire study in which 102 students participated before and 167 students during the pandemic. They completed an online questionnaire about how they formed their five peer social networks (study-related support, collaboration, friendship, share information, and learn-from) out-of-class. We performed social network analysis to compare the sizes, structures, and compositions of students' five social networks before and during the pandemic, between first- and second-year students, and between international and domestic students. Additionally, we performed Kruskal-Wallis H test to compare students' academic performance before and during the pandemic. We performed thematic analysis to answers for two open-end questions in the online questionnaire to explore what difficulties students encountered during the COVID-19 pandemic and what support they needed.

Results

The results showed that the size of students' social networks during the pandemic was significantly smaller than before the pandemic. Besides, the formation of social networks differed between first- and second-year students, and between domestic and international students. However, academic performance did not decline during the COVID-19 pandemic. Furthermore, we identified three key areas in which students experienced difficulties and needed support by thematic analysis: social connections and interactions, learning and studying, and physical and mental wellbeing.

Conclusion

When institutions implement learning with social distancing, such as online learning, they need to consider changes in students' social networks and provide appropriate support.

'Hold the course(s)!' - a qualitative interview study of the impact of pandemic-triggered contact restrictions on online instruction in community-based family medicine teaching

The COVID-19 pandemic has been identified as a catalyst for the digitalization of medical education. Less is known about the specific impact of the pandemic on decentralized, community-based education, such as in General Practitioner practices. The aim of this study is to understand the impact of the digital transformation process, triggered by the COVID-19 pandemic. As, family medicine courses involve both university-based and community-based teaching, this study focuses the mode and quality of instruction and instructors in family medicine teaching. A qualitative interview study was conducted. The participants (N = 12) of a multi-perspective Quality Circle in family medicine teaching were interviewed twice: first, in 2019, about digitalization in family medicine teaching in Tübingen, Germany, not yet aware of the global changes and local transformation that would take place shortly thereafter. Second, in a follow-up interview in 2020 about the transition process and digitalization following the impact of contact restrictions during the pandemic. Grounded Theory was used as a qualitative research approach to analyze the complex processes surrounding this transformation. By analyzing the interviews with various stakeholders of community and university-based teaching, a model for the digital transformation process of family medicine teaching at the University of Tübingen in response to an external stimulus (the pandemic) was developed. It involves six chronological steps: "The calm before the storm," "The storm hits," "All hands on deck," "Adrift," "Reset course," and "The silver lining." This model seeks to understand the process of digital transformation and its impact on the teaching institution (medical faculty of the University of Tübingen, Institute for General Practice and Interprofessional Health Care) and instructors from an integrated perspective and thereby critically revisits prior concepts and opinions on the digitalization of medical teaching. Insights gained are presented as key messages.

Impact of virtual education on urology education during the COVID-19 pandemic

INTRODUCTION

The coronavirus pandemic changed the way urology education was delivered. At Dalhousie University, third-year medical students (clinical clerks) undergoing a two-week urology elective had the historic in-person seminars changed to virtual seminars with pre-recorded lectures by staff. The academic abilities of the clerks were measured via a standardized written exam and clinical score assigned by a staff preceptor. This study aimed to measure the impact of virtual education on student performance.

METHODS

Clerk clinical and exam scores have been recorded since 2014. The in-person seminar (pre-COVID) cohort included students from January 2014 to March 2020 (n=109), while the virtual seminar (post-COVID) cohort was recorded from April 2020 to August 2022 (n=60). Independent t-test was used to compare clinical, exam, and total scores between the pre-COVID student groups after ensuring normality.

RESULTS

Students in the virtual seminar group (mean ± standard deviation 88.69±6.50%) performed better than the in-person seminar student groups (86.32±6.33%) in terms of clinical performance gradings (p=0.02). There was no statistically significant difference in written exam scores between the in-person seminar and virtual seminar cohorts (77.34±10.94% vs. 78.75±11.37%, p=0.43). Cumulative scores were higher for virtual seminar student groups vs. in-person seminar cohort (86.70±5.40% vs. 84.52±5.44%, p=0.01).

CONCLUSIONS

Clinical clerks undergoing virtual education during a two-week urology elective had improved clinical and cumulative score performances when compared to the in-personal seminar cohort; virtual seminars did not statistically negatively impact exam scores.

Students' Perceptions on Online Clinical Learning amid the COVID-19 Pandemic in an Institution of Higher Learning: A Qualitative Inquiry

Institutions of learning have been disrupted globally with serious implications for clinical teaching for students of health professions. The purpose of our study was to explore the perceptions of students towards online clinical teaching during the COVID-19 pandemic at Fatima College of Health Sciences. This was a descriptive qualitative study conducted on a purposive sample of 25 students from 24 June to 30 August 2020. The sample size was determined by data saturation. These were mainly nursing students in their 2nd to the 4th years of study. Students are required to have experiences, of stipulated nature and duration, in various specialty clinical settings throughout the clinical years of their programs. Approval for the study was granted by the Fatima College Research Ethics Committee (approval number: INTSTF010BSN20). The research was conducted according to the requirements of the Declaration of Helsinki. Data were collected through online semistructured questionnaires. Prospective participants were sent a soft copy of the informed consent document, and consent was indicated by clicking an "agree" link on the page that took them to the questionnaire. All participants were informed of their freedom to either participate in the study or not, without any penalty and were assured of their confidentiality. The questionnaires were kept in a password-protected file to which the researchers had sole access. Manual thematic analysis was done following the stages of organisation, familiarisation, transcription, coding, developing a thematic framework, indexing, displaying, and reporting. The major themes identified were the unfamiliar experience, challenges of online clinical learning, and possible solutions. Challenges of online clinical learning are multifaceted and require concerted multidisciplinary efforts to resolve. Nursing institutions, ours included, must develop flexible education systems that will be able to thrive in crisis and other unforeseeable circumstances.

Analysis of female pre-clinical students' readiness, academic performance and satisfaction in online learning: an assessment of quality for curriculum revision and future implementation

BACKGROUND

The acceptance of online courses by medical and dental students, especially during the coronavirus disease 2019 crisis, is substantial, as reported in various studies. However, the unfavourable online learning experiences of the students during the pandemic were also highlighted. As the teaching-learning process is returning to the "new normal," it is necessary to identify online learning domains implemented during the pandemic crisis that may be applied in pre-clinical courses in the future.

METHODS

A validated Student Online Learning Readiness questionnaire assessed pre-clinical students' online learning competence. Students' academic performance in face-to-face post-pandemic was compared with their performance in online settings during the pandemic crisis. Students' satisfaction with online learning was evaluated using a self-made survey questionnaire. Descriptive statistics, the t-test, and multiple regression analysis were used to analyze the data gathered with a p-value ≤ 0.05 considered statistically significant.

RESULTS

Except for social skills with classmates and groupmates, in which 47.5% of respondents indicated unreadiness, most students were prepared for online learning. Theory-wise, online learners outperformed traditional learners, but the difference was insignificant. In contrast, students' practical skills in face-to-face modality are significantly higher (p = 0.029). Students rated their satisfaction with online learning higher for interactions with instructors and staff and lower for interactions with classmates and group mates and skill acquisition.

CONCLUSION

Providing high-quality pre-clinical online teaching was achieved for theoretical components but not practical skills acquisition. Students' social engagement with peers is one of the key elements crucial to online learning success. Academic leaders and curriculum developers must recognize potential gaps as they transition to online learning.

Evaluation of WebRTC in the Cloud for Surgical Simulations: A case study on Virtual Rotator Cuff Arthroscopic Skill Trainer (ViRCAST)

Web Real-Time Communication (WebRTC) is an open-source technology which enables remote peer-to-peer video and audio connection. It has quickly become the new standard for real-time communications over the web and is commonly used as a video conferencing platform. In this study, we present a different application domain which may greatly benefit from WebRTC technology, that is virtual reality (VR) based surgical simulations. Virtual Rotator Cuff Arthroscopic Skill Trainer (ViRCAST) is our testing platform that we completed preliminary feasibility studies for WebRTC. Since the elasticity of cloud computing provides the ability to meet possible future hardware/software requirements and demand growth, ViRCAST is deployed in a cloud environment. Additionally, in order to have plausible simulations and interactions, any VR-based surgery simulator must have haptic feedback. Therefore, we implemented an interface to WebRTC for integrating haptic devices. We tested ViRCAST on Google cloud through haptic-integrated WebRTC at various client configurations. Our experiments showed that WebRTC with cloud and haptic integrations is a feasible solution for VR-based surgery simulators. From our experiments, the WebRTC integrated simulation produced an average frame rate of 33 fps, and the hardware integration produced an average lag of 0.7 milliseconds in real-time.

Exploring the pharmacy students' perspectives on off-campus online learning experiences amid COVID-19 crises: A cross-sectional survey

Background

The pandemic of COVID-19 has placed many challenges for pharmacy students' learning experiences via the online e- system. There is paucity of studies that addresses this in colleges of pharmacies in United Arab Emirates (UAE).

Objective

We have explored the preparedness, attitudes, experiences, and barriers/facilitators, and delineated factors that may affect the pharmacy students' e-learning process amid the COVID-19 crises.

Methods

The current study was cross-sectional, and survey-based (anonymously self-administered) that utilized theoretical domains framework. The survey (multiple statements) was comprised of four domains (based on theoretical domain framework) that has elaborated on the preparedness, attitudes, experiences and barriers for the pharmacy students' e-learning (all years and interns). The validated (Cronbach Alfa 0.821) and piloted survey posted to the Google form and a link distributed to the pharmacy students. The survey was comprised of four domains (34 statements), distributed as five in preparedness, eleven in attitude, eleven in the experiences, and seven in the barriers/facilitators (theoretical domains framework).

Outcome measure

The primary outcome was the total sum of scores of individual statements and each individual four domain of the questionnaire (preparedness, attitude, experiences, and barriers/facilitators).

Results

Two hundred thirty respondents participated in the survey (230/400, response rate 57.5%), of which 193 were females (83.9%) versus 37 males (16.1%). The mean age (years) was 19.9 ± 1.9 (males 19.8 ± 1.6 and females 20.0 ± 1.9). The mean total score for preparedness Q1 to Q5 (domain maximum score 25); and for the attitude Q6 to Q16 (domain maximum score of 60) were 14.9 ± 3.8 (95% CI 14.4 - 15.4; P < 0.05), 29.5 ± 7.4 (95% CI 28.6 - 30.5; P < 0.05) respectively. While for the experiences Q17 to Q27 (domain maximum score 55); and for the barriers/facilitators Q28 to Q34 (domain maximum score 30) 40.1 ± 8.0 (95% CI 39.1 - 41.1; P < 0.0001), and 20.9 ± 4.9 (95% CI 20.3-21.5;P < 0.05) respectively.

Conclusion

Our pharmacy students support the use of e-learning in pharmacy education, and seems prepared for the future technology moves in education. The colleges of pharmacies need to conduct further research on versatile innovative models such as virtual learning/artificial intelligence that fits with their students' perspectives.

The impact of the COVID-19 pandemic on internal medicine clerkship by comparing exam results and feedback

COVID-19 pandemic affected the world in many ways. Internal medicine education needed to be shaped according to the requirements of this pandemic. The aim of this study is to understand the effect of COVID-19 pandemic on internal medicine education and evaluate the newly introduced methods for education. Fourth-year medical students of 2019-2020 and 2020-2021 academic terms are evaluated in this study. Exam results and feedback scores of students are obtained. Assessment methods in pre-pandemic group are face-to-face written exam and OSCE exam, whereas in post-pandemic group, online written exam and OSCE exam are used. Feedback forms are the same in both groups. The median written exam score was higher in the post-pandemic group than in the pre-pandemic group (84 vs 80, respectively, p = 0.003). There is no statistical significance among OSCE exam grades of the two groups. Feedback scores for bedsides were slightly higher in the post-pandemic group, and there is no statistical significance. Written and OSCE exam results in the post-pandemic group were as good as in the pre-pandemic group. We realized that the learning objectives in classical lecture can also be achieved from video recordings. Although not statistically proven, we claim that increasing the time spent in clinical practice will yield more experience to the students.

Medical education during the COVID-19 pandemic: lessons for the orthopedic departments

BACKGROUND

After the Coronavirus pandemic, many educational routines were stopped for the safety of medical staff. To achieve educational goals, we have implemented new policies in our hospitals. In this study, we aimed to evaluate the effect of such strategies.

METHOD

This survey-based study uses questionnaires to assess newly implemented educational strategies. We surveyed 107 medical staff of the orthopedic department of Tehran University of Medical Sciences, including faculty members, residents, and students. The survey contained three series of questionnaires for these groups.

RESULTS

The maximum satisfaction for all three groups was observed in the platform and facilities for using e-classes, and the cost- and time-saving capabilities (Respectively, faculty members (FM): 81.8%, residents (R): 95.2%, students/interns (S/I): 87.0%; FM: 90.9%, R: 88.1%, S/I: 81.5%). The new policies have been shown to reduce the stress level of most trainees, increase the quality of knowledge-based education, increase the opportunity for reexamining educational content, expand discussion and research opportunities, and improve work conditions. There was a broad acceptance of the virtual journal clubs and morning reports. However, there were discrepancies between residents and faculty members on issues such as the evaluation of trainees, the new educational curriculum, and flexible shift schedules. Our strategies failed to improve skill-based education and patient treatment status. Most participants indicated that e-learning should be used with face-to-face training post-pandemic (FM: 81.8%, R: 83.3%, S/I: 75.9%).

CONCLUSION

Our efforts to optimize the educational system during this crisis have generally improved trainees' work conditions and educational experience. Most participants believed that e-learning and virtual methods should be used alongside traditional training as a complementary component after the pandemic.

Designing for digital transformation of residency education - a post-pandemic pedagogical response

BACKGROUND

The forced transition to emergency remote teaching (ERT) during the COVID-19 pandemic has significantly impacted health professions education worldwide. In Sweden, the need for alternative solutions for the training of junior doctors became urgent, as many of the mandatory onsite courses required for residents to qualify as specialists were canceled. The purpose of this study was to understand course leaders' perceptions and experiences of using digital technologies, such as video conferencing, to teach medical residents (ST) during the pandemic and beyond.

METHODS

A qualitative study using semi-structured interviews was conducted with seven course leaders responsible for residency courses during the first year of the pandemic to capture their perceptions and experiences. The interviews were transcribed verbatim and analyzed using thematic analysis, drawing on the technology affordances and constraints theory (TACT) as a framework to explore pedagogical strategies and new teaching practices emerging from the forced use of digital technologies for remote teaching.

RESULTS

The data analysis revealed affordances of, as well as constraints to, teaching specialist medical training during the pandemic. The findings show that the use of digital conference technologies for ERT can both enable and inhibit social interactions, the interactive learning environment and the utilization of technological features, depending on the individual course leaders' goals of using the technology and the situated context of the teaching.

CONCLUSIONS

The study reflects the course leaders' pedagogical response to the pandemic, as remote teaching became the only way to provide residency education. Initially, the sudden shift was perceived as constraining, but over time they found new affordances through the enforced use of digital technology that helped them not only to cope with the transition but also to innovate their pedagogical methods. After a rapid, forced shift from on-site to digital courses, it is crucial to utilize experiences to create better preconditions for digital technology to facilitate learning in the future.

Twine virtual patient games as an online resource for undergraduate diabetes acute care education

BACKGROUND

Virtual patients provide a safe way to simulate authentic clinical practice. Twine is an open-source software that can be used to create intricate virtual patient games, including elements like non-linear free text history taking and time-related changes to the game's narrative. We evaluated the incorporation of Twine virtual patient games into a diabetes acute care online learning package for undergraduate medical students at the University of Glassgow, Scotland.

METHODS

Three games were developed using Twine, Wacom Intuous Pro, Autodesk SketchBook, Camtasia Studio, and simulated patients. Online material included three VP games, eight microlectures, and a single best answer multiple choice question quiz. The games were evaluated at Kirkpatrick Level 1 with an acceptability and usability questionnaire. The entire online package was evaluated at Kirkpatrick Level 2 with pre- and post-course multiple choice and confidence questions, with statistical analysis performed using paired t-tests.

RESULTS

122 of approximately 270 eligible students provided information on resource utilisation, with 96% of these students using at least one online resource. 68% of students who returned surveys used at least one VP game. 73 students provided feedback on the VP games they had played, with the majority of median responses being "agree" on positive usability and acceptability statements. The online resources were associated with a mean multiple choice score increase from 4.37 out of 10 to 7.96 out of 10 (p < 0.0001, 95% CI + 2.99 to + 4.20, n = 52) and a mean total confidence score increase from 4.86 out of 10 to 6.70 out of 10 (p < 0.0001, 95% CI + 1.37 to + 2.30, n = 48).

CONCLUSIONS

Our VP games were well-received by students and promoted engagement with online material. The package of online material led to statistically significant increases in confidence and knowledge in diabetes acute care outcomes. A blueprint with supporting instructions has now been created to facilitate rapid creation of further games using Twine software.

Medical education during the Covid-19 pandemic long-term experiences of German clinical medical students

INTRODUCTION

Due to the Covid-19 pandemic and the accompanying hygiene regulations, medical students in Germany faced multiple educational and personal challenges. The challenges included the cancellation and digitalisation of courses, the closing of university institutions such as libraries, a decrease in social contacts, and the risk of a Covid-19 infection. The aim of this study was to understand medical students' pandemic experiences as well as the consequences of these experiences for the students' future work as physicians.

MATERIALS AND METHODS

We performed 15 guided, one-on-one interviews with clinical medical students (third to fifth year) at the Otto-von-Guericke-University Magdeburg. Interviews were recorded, transcribed, and anonymised. We performed a qualitative content analysis in accordance with Mayring and thereby formed an inductive category system. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were applied.

RESULTS

Five categories were inductively formed: "Changes in the teaching experience", "negative effects on the learning experience", "decrease in personal social contacts", "contact with covid-19", and "pandemic-associated stress increase". The participating students reported higher levels of stress due to isolation and uncertainty regarding their educational future. Furthermore, students welcomed the digitalisation of lectures, developed individual coping strategies, and voluntarily took part in the care of Covid-19 patients. Limitations to social interactions were perceived as the major restrictive factor to their educational structure, their perceived learning success and personal development.

CONCLUSION

This study identified social restrictions as well as didactic and academic structural challenges as relevant factors contributing to perceived stress and fear for medical students during the Covid-19 pandemic, especially as regards their learning experience. Students' acceptance of digitalised learning may enable regular interaction with university peers and may facilitate a structured educational life. However, the implementation of digital resources could not provide a sufficient substitute for in-person courses.

New Media Platforms for Teaching and Networking: Emerging Global Opportunities for Breast Surgeons

Background

The framework of breast care is changing rapidly due to the increasing success of systemic therapies for breast cancer, and consequently, surgeons need to adapt themselves to the changing role of surgery in its management. Real-world evidence indicates that breast cancer patient-related outcomes are better if they are managed by specialized physicians and surgeons. On the other hand, the curriculum for the training of breast surgeons is expanding and includes skills that involve newer surgical techniques and nonsurgical technologies. De-escalation of surgery and also the fact that quality of life is becoming one of the priorities in breast cancer management require breast surgeons to be competent in all aspects of multidisciplinary management. Classical teaching including master-apprentice relation-based training is no more sufficient to satisfy the expectations of the trainees. However, on the other hand, the sources for contemporary postgraduate education are relatively scarce when considering these fast changes in the field. Therefore, there is a continuing quest among breast surgeons for finding ways to maintain their professional development.

Summary

Classrooms and operating theaters without walls that came with the internet boom brought substantial opportunities for breast surgeons. Platforms such as BreastGlobal, Breastics24 h, Global Breast Hub, Oncoplastic Academy-Brazil, ibreastbook, Virtual Breast Oncoplastic Surgical Simulator, and CluBreast helped surgeons who needed to get contemporary training and interaction for their professional continuous development. Networking sites such as YouTube, Facebook, and Twitter are also among the social media platforms for professional groups to interact. National and global breast surgery societies also provide periodical online meetings and congresses for their members in order to satisfy the ongoing demand for training, interaction, and networking. Therefore, web-based platforms helped many surgeons from different parts of the world who could not afford to travel or did not have time to attend the necessary meetings due to their limited time and resources. Moreover, these online programs may have also encouraged surgeons to pursue specialized training in breast surgery which in turn should be expected to increase the quality of breast care in their countries.

Key Messages

The platforms have downsides such as practical training and role modeling are limited and the opportunity of receiving real-time feedback on skills requirements lacks and networking would not be productive as expected. Nevertheless, web-based platforms require certain technology and infrastructure which still could not be provided everywhere.

Investigating mental rehearsal's applicability in guiding independent E-learning (IMAGINE) of eye examination skills during the pandemic

BACKGROUND

COVID-19's infection control policies have hindered the Deliberate Practice of clinical examinations. Guided Mental Rehearsal (GMR) may overcome this obstacle by facilitating independent, repetitive practice. Underpinned by the 'Motor Simulation Theory,' GMR reinforces similar neuro-circuit activations during physical practice and was proven effective in surgical training.

METHODS

This prospective, randomized controlled study evaluated the efficacy of GMR versus 'peer-learning' of Confrontational Visual Field Examination (CVFE). Third-year medical-students without clinical Ophthalmology experience were recruited. Controls (n = 40) watched an e-learning instructional video (8-min CVFE tutorial) followed by 6-min of 'peer-learning.' GMR-students (n = 40) had 'peer-learning' replaced by a 6-min GMR audio-recording (CVFE running commentary). Pre-test and post-test MCQs were administered to determine baseline knowledge and knowledge acquisition, respectively. 28 controls and 26 GMR-students performed CVFE on simulated patients with right homonymous hemianopia. Four Ophthalmologists graded their performances using a checklist-based marking scheme.

RESULTS

Both groups did not exhibit a significant difference in pre-test scores (8.550 vs. 7.947, p = 0.266); outcome of sub-group analysis of CVFE-performing candidates was similar (8.214 vs. 7.833, p = 0.561). Post-test scores were significantly higher than pre-test in both groups (all p < .001), without inter-group difference (14.000 vs. 15.000, p = 0.715). GMR-group had significantly higher scores on CVFE performance than controls (85.354 vs. 73.679%, p = .001).

CONCLUSIONS

GMR improved psychomotor but not cognitive aspect of learning CVFE. This may be attributable to GMR's theoretical resemblance with physical practice, with additional expert guidance. By enabling independent learning, GMR may also reduce the demand for teaching manpower and thus education cost in the future.

Online medical education: A student survey

BACKGROUND

During COVID-19, medical schools transitioned to online learning as an emergency response to deliver their education programmes. This multi-country study compared the methods by which medical schools worldwide restructured the delivery of medical education during the pandemic.

METHODS

This multi-country, cross-sectional study was performed using an internet-based survey distributed to medical students in multiple languages in November 2020.

RESULTS

A total of 1,746 responses were received from 79 countries. Most respondents reported that their institution stopped in-person lectures, ranging from 74% in low-income countries (LICs) to 93% in upper-middle-income countries. While only 36% of respondents reported that their medical school used online learning before the pandemic, 93% reported using online learning after the pandemic started. Of students enrolled in clinical rotations, 89% reported that their rotations were paused during the pandemic. Online learning replaced in-person clinical rotations for 32% of respondents from LICs versus 55% from high-income countries (HICs). Forty-three per cent of students from LICs reported that their internet connection was insufficient for online learning, compared to 11% in HICs.

CONCLUSIONS

The transition to online learning due to COVID-19 impacted medical education worldwide. However, this impact varied among countries of different income levels, with students from LICs and lower middle income countries facing greater challenges in accessing online medical education opportunities while in-person learning was halted. Specific policies and resources are needed to ensure equitable access to online learning for medical students in all countries, regardless of socioeconomic status.

The lasting impact of COVID-19 on surgical training from the perspective of surgical residents and consultants in Saudi Arabia: a nationwide cross-sectional study

BACKGROUND

Since the start of the COVID-19 pandemic, many precautionary measures have been set to curb the transmission of the virus. That has led to changes, most notably in surgical education, like lack of surgical exposure and clinical activities. However, the question aiming at the impact of changes made by the COVID-19 pandemic on surgical education and its extent remains unanswered.

MATERIALS & METHODS

An electronic survey was distributed among surgical residents and consultants from all over Saudi Arabia, starting from the 6th till the 21st of July, 2021. Descriptive statistics were presented using counts and proportions (%). Study subjects were compared with the different perspectives during the COVID-19 pandemic by using Chi-square test. A p-value cut-off point of 0.05 at 95% CI was used to determine statistical significance.

RESULTS

A total of 243 out of 500 surgical residents and consultants responded to the survey, giving a response rate of 48.6%. The majority were general surgeons (50.5%) and cardiothoracic surgeons (21.8%). Nearly 66% of surgeons, both residents and consultants, strongly agreed on the importance of training for infectious disease outbreaks. 44.7% of the consultants and 48% of the residents showed their willingness to respond to the pandemic regardless of its severity. Over 70% of surgeons agreed that developing clinical skills was compromised by the COVID-19 pandemic, and 40% expected a negative impact of the COVID-19 on their operative skills. Simulation was ranked best for disaster medicine training by over 77% of the respondents. The most common concern among surgeons during the COVID-19 pandemic was their family's health and safety. Regarding virtual curriculum components, online practice questions and surgical videos were preferred by the surgical consultant and resident, respectively.

CONCLUSIONS

Although the COVID-19 pandemic has impacted surgical education, it has highlighted the alarming need for adopting new components. For surgical training programs, we recommend improving the virtual curriculum, incorporating disaster medicine training, providing psychological services, and prioritizing immunization and treatment access for surgeons' families.

Effectiveness of a blended learning intervention in cardiac physiotherapy. A randomized controlled trial

Background

Blended learning (BL) combines both face-to-face learning (FL) and online learning. This study aims to compare the effectiveness of a BL intervention vs. a FL intervention in relation to the knowledge, competencies, satisfaction, perceptions, usability, and BL acceptance of physiotherapy students.

Methods

An assessor-blinded randomized trial was performed. A total of 100 students were randomly allocated to either the BL group (BLG, n = 48) or FL group (FLG, n = 52). The BLG received face-to-face classes plus access to online resources (online syllabus, Moodle, scientific-based videos and websites, activities, glossary, and apps). The FLG received face-to-face classes and hardcopy resources (hardcopy syllabus, scientific-based information, activities, and a glossary). Knowledge, ethical and gender competencies, satisfaction, perceptions, usability, and BL acceptance were assessed.

Results

The BLG showed higher scores than the FLG for knowledge (p = 0.011), three ethical/gender competencies (p < 0.05), increased motivation to prepare themselves before class (p = 0.005), increased motivation and ability of thinking (p = 0.005), improved understanding of important topics (p = 0.015), course organization (p = 0.017), educational material (p = 0.001), easiness of understanding (p = 0.007), comprehensive coverage of the subject (p = 0.001), and clarity of instructions (p = 0.004), while usability was acceptable.

Conclusion

The BL intervention can be used for improving the knowledge, competencies, perceptions, and satisfaction of the students. In addition, BL acceptance was positive, and usability was found to be acceptable. This study supports the use of BL as a pedagogical approach to foster innovative learning.

Experiences with telemedicine among family medicine residents at king saud university medical city during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

The healthcare system experienced various challenges during the coronavirus disease 2019 (COVID-19) pandemic, and a wide range of safety measures were implemented, including limiting the number of patients allowed to visit primary care clinics and follow-up through telemedicine clinics. These changes have accelerated the growth of telemedicine in medical education and affected the training of family medicine residents throughout Saudi Arabia. Therefore, this study aimed to evaluate the experiences of family medicine residents with telemedicine clinics as a part of their clinical training during the COVID-19 pandemic.

METHODS

A cross-sectional study was conducted with 60 family medicine residents at King Saud University Medical City, Riyadh, Saudi Arabia. An anonymous 20-item survey was administered between March and April 2022.

RESULTS

The participants included 30 junior and 30 senior residents, with a 100% response rate. The results revealed that most (71.7%) participants preferred in-person visits during residency training, and only 10% preferred telemedicine. In addition, 76.7% of the residents accepted the inclusion of telemedicine clinics in training if such clinics constituted not more than 25% of the training program. Moreover, most participants reported receiving less clinical experience, less supervision, and less discussion time with the attending supervisor when training in telemedicine clinics compared with in-person visits. However, most (68.3%) participants gained communication skills through telemedicine.

CONCLUSIONS

Implementing telemedicine in residency training can create various challenges in education and influence clinical training through less experience and less clinical interaction with patients if it is not structured well. With the growth of digital healthcare, further structuring and testing of a paradigm that involves using telemedicine in residents' training programs prior to implementation should be considered for better training and patient care.

[Instrument validation that measures disruptive education on clinical training]

Background

During the contingency derived from the COVID-19 pandemic, there were no instruments assessing the aspects of clinical training, which is why it is necessary to have a questionnaire that let us know the opinion of medical students about the disruptive education.

Objective

To validate a questionnaire designed to know the opinion of medical students about disruptive education in their clinical training.

Material and methods

Validation cross-sectional study which was developed in three phases: 1) Elaboration of the questionnaire aimed at undergraduate medical students who include clinical science subjects in their curricular program; 2) validation of content by Aiken's V test with 7 expert judges and reliability estimation with Cronbach's alpha coefficient in a pre-sample test with 48 students; 3) analysis of the information through descriptive statistics, where the following results were observed: Aiken's V index of V = 0.816; Cronbach's alpha coefficient = 0.966. A total of 54 items were incorporated in the questionnaire after the pre-sampling test.

Conclusions

We can rely on a valid and reliable instrument that objectively measures disruptive education in the clinical training of medical students.

"It's making me think outside the box at times": a qualitative study of dynamic capabilities in surgical training

Craft specialties such as surgery endured widespread disruption to postgraduate education and training during the pandemic. Despite the expansive literature on rapid adaptations and innovations, generalisability of these descriptions is limited by scarce use of theory-driven methods. In this research, we explored UK surgical trainees' (n = 46) and consultant surgeons' (trainers, n = 25) perceptions of how learning in clinical environments changed during a time of extreme uncertainty (2020/2021). Our ultimate goal was to identify new ideas that could shape post-pandemic surgical training. We conducted semi-structured virtual interviews with participants from a range of working/training environments across thirteen Health Boards in Scotland. Initial analysis of interview transcripts was inductive. Dynamic capabilities theory (how effectively an organisation uses its resources to respond to environmental changes) and its micro-foundations (sensing, seizing, reconfiguring) were used for subsequent theory-driven analysis. Findings demonstrate that surgical training responded dynamically and adapted to external and internal environmental uncertainty. Sensing threats and opportunities in the clinical environment prompted trainers' institutions to seize new ways of working. Learners gained from reconfigured training opportunities (e.g., splitting operative cases between trainees), pan-surgical working (e.g., broader surgical exposure), redeployment (e.g., to medical specialties), collaborative working (working with new colleagues and in new ways) and supervision (shifting to online supervision). Our data foreground the human resource and structural reconfigurations, and technological innovations that effectively maintained surgical training during the pandemic, albeit in different ways. These adaptations and innovations could provide the foundations for enhancing surgical education and training in the post-pandemic era.

Through the Webcam: Impact of Telehealth on Developmental and Behavioral Pediatric Fellowship Training

OBJECTIVE

The purpose of this study was to examine how fellowship program directors (PDs) and their fellows perceived the impact of telehealth on fellowship education in developmental behavioral pediatrics (DBP) during the COVID-19 pandemic.

METHODS

Two surveys were designed targeting DBP PDs and fellows and were distributed by e-mail from January to May 2021. Surveys consisted of closed-ended and open-ended questions about telehealth's impact on didactics, clinical teaching, and clinical experience. Analyses included descriptive statistics, Fisher's exact test, χ 2 test, and qualitative classical content analysis.

RESULTS

A total of 31 PDs (82%) and 62 fellows (51%) responded. Before the pandemic, 0% of programs had fellows do telehealth visits at least weekly vs during the pandemic, and 85% of the programs had fellows conduct telehealth video visits at least once/week ( p < 0.001). PDs and fellows agreed on many advantages of learning through telehealth particularly preceptors giving "real-time" feedback by private text messages and being able to observe fellow-run encounters unobtrusively. Ninety-four percent of fellows and 100% of fellowship directors believe that telehealth should be a formal part of DBP fellowship training even if in-clinic visits are available.

CONCLUSION

Prepandemic and pandemic learning experiences differed significantly. PDs and fellows shared similar perceptions on how telehealth affected fellow education, except how telehealth affected didactics. Institutions varied in how telehealth was used to teach fellows, but many reported they found benefit in giving real-time feedback using chat functions during telehealth appointments. DBP fellowship programs should consider providing specific guidance to effectively teach telehealth to fellows.

Are medical students happy despite unhappy conditions: a qualitative exploration of medical student cohorts during disruptive conditions

BACKGROUND

Shortly after the World Health Organization declared the SARS-CoV-2 outbreak a worldwide pandemic, medical school governing bodies issued guidance recommending pausing clinical rotations. Prior to the availability of COVD-19 vaccines, many schools implemented exclusively online curriculums in the didactic and clinical years. These unprecedented events and paradigm changes in medical education could contribute to trainee burnout, wellness, and mental health.

METHODS

This single-institution study interviewed first, second, and third-year medical students from a medical school in the southwestern United States. A semi-structured interview was conducted with paper-based Likert scale questions rating perceived happiness were administered both at the time of the interview and one year later in order to understand how their student experience and happiness were impacted. In addition, we asked participants to describe any major life events they experienced since the first interview.

RESULTS

Twenty-seven volunteers participated in the original interview. Twenty-four from the original cohort participated in the one-year follow-up. Happiness as a sense of self and who you "should be" was challenged during the pandemic and changes in happiness over time were not systematic across classes. Stress was caused not only by the pandemic which was experienced by all, but by a tripartite state of individual circumstances, academic workload requirements, and the world at large. Primary themes from the interviews were clustered around the individual, learner, and future professional levels and focused on the primacy of relationships, emotional wellness, stress management, professional identity, and impacts of educational disruptions. These themes created risk factors for developing imposter syndrome. Students demonstrated resiliency across cohorts and were able to utilize a variety of strategies to achieve and maintain both physical and mental health, but the primacy of relationships both personally and professionally was noted.

CONCLUSION

Medical students' identities as individual persons, a learner, and future medical professionals were all impacted by the pandemic. The results from this study suggest that the COVID-19 pandemic and changes in the learning format and environment may create a new risk factor in the development of imposter syndrome. There is also an opportunity to re-consider resources to achieve and maintain wellness during a disrupted academic environment.

Comparative effectiveness of telesimulation versus standard simulation for pediatric Minimally Invasive Surgery (MIS) essential skills training

BACKGROUND

Proctored on site simulation-based surgical education has been integrated in our residents curricula since 2012. Due to COVID-19 pandemic and social distance protocols, we developed a Tele-assisted Essential Skills Training Module (T-ESTM). The aim of this study is to evaluate comparative effectiveness between Telesimulation (T) versus Standard Simulation (S) for minimally invasive surgery (MIS) essential skills training.

METHODS

ESTM includes academic lectures, tutorials for ergonomics and 7 hands-on tasks scheduled into 2 sessions of 3 hours. Initial and final assessment scoring (adapted from GOALS) as well as timing for 3 of the tasks were registered. Telesimulation (T) group accessed the content online and completed their Hands-On practice through a digital communication platform. Standard Simulation (S) group attended conferences and Hands-On practice at the simulation center. Both groups were proctored by the same educators with summative and formative feedback and debriefing. Data was analyzed with the R-studio software program.

RESULTS

Each group had 20 participants with a mean age of 28 ± 5 years. 67.5% were surgeons in training, 47.5% had performed low complexity procedures and 40% had previous experience with simulation training. We observed a significant improvement in scoring and time reduction for all assessed tasks in S and T groups (p < 0.001), with no statistically significant differences when comparing both groups. Similar performance could be achieved with both strategies.

CONCLUSION

Telesimulation is a reproducible and effective educational tool for remote MIS essential skills training, and should be considered as an alternative to on-site simulation programs.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical Research.

Virtual Clinics: A Student-Led, Problem-Based Learning Approach to Supplement Veterinary Clinical Experiences

The COVID-19 pandemic created an abrupt need for effective remote clinical experiences for senior clinical veterinary students. Subsequently, the authors created virtual clinics. This activity was derived from a problem-based learning (PBL) model wherein students designed clinical cases and participated through virtual role play as clients and clinicians. The purpose of this article is to describe virtual clinics and to report data from focus groups of participating students and faculty facilitators from two institutions regarding the positive and negative aspects of the shift in practice. A few common emerging themes included that case rounds were fun and engaging, students could learn at their own pace, and peer-to-peer learning opportunities had perceived value. Themes are reflected against the pedagogical literature to draw out areas that resonated. Students felt this activity was more engaging than listening to a discussion of a case they had no ownership of, and facilitators agreed that the peer-to-peer interactions added to student engagement. Additionally, students developed deeper knowledge about the underlying disease process and clinical presentation of their case, which required independent and self-directed learning, enabling students to think about a case from a client's perspective. By participating in these activities, students developed skills of classroom-to-clinic transitional value. While virtual clinics should not replace in-person clinical experiences, this activity might be useful to facilitate students' transition from a structured classroom setting to a less-structured clinical experience.

Communication and cooperation challenges in the online classroom in the COVID-19 era: a qualitative study

BACKGROUND

The increasing prevalence of COVID-19 affected all aspects of life, including education. Communication and interaction are vital in any form of education. This study explained health profession educators' and students' experiences regarding the challenges of communication and cooperation in exclusively online classrooms during the COVID-19 era.

METHODS

The present descriptive explanatory qualitative study examined health profession educators' and students' experiences with exclusively online classrooms during the COVID-19 era. They were included in the study by purposive sampling. In-depth and semi-structured telephone interviews were conducted to collect data. The content analysis presented by Graneheim and Lundman was used to analyze the data. The present study employed four strength criteria: credibility, confirmability, transferability, and dependability.

RESULTS

The results of the present study included communication and cooperation challenges in exclusively online classrooms related to the COVID-19 pandemic. Two themes emerged from 400 open codes: lack of students' socialization and communication-related concerns, which each had subcategories.

CONCLUSIONS

Lack of students' socialization and communication problems were identified as the participants' main experiences. Defects in teacher training due to the sudden transition to virtual education, acquiring a professional identity that is possible in in-person education was also flawed. The participants experienced challenges in their class activities, leading to a decrease in trust, a lack of motivation to learn from students, and teachers' teaching. Policymakers and authorities should adopt new tools and techniques to improve exclusively virtual education outcomes.

Development and Optimization of a Remote Pediatric Cardiac Critical Care Bootcamp Using Telesimulation

We developed a novel cardiac critical care bootcamp consisting of didactic, small group, and simulation sessions. The bootcamp was remote due to the COVID-19 pandemic and included telesimulation. We aimed to assess learners' reactions to the bootcamp and their perception of telesimulation. Paired anonymous surveys were administered before and after participation. Surveys assessed participants' comfort in independently managing cardiac critical care scenarios, perceptions of telesimulation, barriers to its effectiveness, and specific feedback on course components. Forty-three fellows from 10 institutions joined the bootcamp over 2 years. Thirty-eight pre- and 28 postcourse surveys were completed. The course was rated good or excellent by all respondents, and 27/28 rated the material as appropriate to their level of training. Based on feedback from 2020, the electrophysiology sessions were converted to a small group format in 2021; positive assessment of these sessions improved from 65 to 90–100%. The telesimulations were highly rated, with 83–94% of participants in 2020 and 90–100% in 2021 rating them as good or excellent. Participants' views on telesimulation improved following the course, with 78% (14/18) post- versus 50% preparticipation agreeing that telesimulation is an effective educational tool (p = 0.06) and 56% (10/18) post- versus 67% (12/18) pre-rating telesimulation as less effective than in person simulation (p = 0.04). Identified limitations of telesimulation were limited active participation, lack of realism, impaired flow of conversation, and audiovisual and technical concerns. Telesimulation is feasible in cardiac critical care education and was an acceptable alternative to in person simulation for course participants.

Breast Imaging Fellowship Consortium: Developing a Comprehensive Virtual Educational Platform for Breast Imaging Fellows

Creating a comprehensive didactic curriculum for breast imaging fellows can be a demanding undertaking, especially considering that most breast practices are understaffed because of the COVID-19 pandemic and amid rising clinical volumes. This leaves little time for didactic education. In this article, we present our approach to creating a collaborative weekly multidisciplinary didactic lecture series involving multiple institutions, using the Society of Breast Imaging's suggested fellowship curriculum as the foundation. We discuss the advantages for both trainees and faculty, including fostering camaraderie, networking, and engagement among breast imaging fellows. Faculty have the opportunity for professional development by leveraging their clinical expertise through selecting didactic topics in their niche. This creates a pathway for speaking faculty to be recognized as regional and national experts.

Is Satisfaction with Online Learning Related to Depression, Anxiety, and Insomnia Symptoms? A Cross-Sectional Study on Medical Undergraduates in Romania

The objective of this study was to investigate online learning satisfaction in a sample of university students and its relationship with depression, anxiety, insomnia, and the average number of hours spent online. A total of 463 medical students were recruited for an online survey conducted from February to March 2022 with the main objective of estimating online learning satisfaction, while secondary outcomes involved assessing the relationship between online learning and depression, anxiety, insomnia, and the average number of hours spent online. A total of 285 participants were female (71.4%) and the mean age was 20.2 years. The results revealed that depression, anxiety, and insomnia are negatively correlated with overall satisfaction with e-learning. The more time students spent online, the greater the overall satisfaction. There are significant differences regarding student perceptions of interactivity in online learning satisfaction outcomes (p < 0.05, η2 partial Eta Squared-0.284). The opportunity to learn via chat-box presented differences in overall satisfaction while pleasant aspects of online learning, such as “no travel” and “economy”, were related to satisfaction. The students revealed that the higher the psychopathology scores, the less satisfied they were with online learning, while a higher number of hours spent online contributed positively to satisfaction.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure

BACKGROUND

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based.

METHODS

Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed.

RESULTS

A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling.

CONCLUSION

This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

Knowledge and confidence levels improvement among obstetrics residents regarding caesarean section training using video-mannequins combination

Background

Cesarean section rates are increasing worldwide. Obstetrics and gynecology residents are required to be experts in this surgery to provide safe procedures. Because of the COVID-19 pandemic situation, an alternative teaching strategy is needed to achieve adequate cesarean section skills. The purpose of this study was to identify the effect of video, mannequins, and the combination of video mannequins on residents' knowledge and confidence regarding cesarean section.

Method

A quasi-experimental study with pre-test and post-test designs was done. Based on stratified random sampling, 33 obstetrics and gynecology residents involved as study participant. Three groups were formed and received different interventions, learning using videos, mannequins, and a combination of video-mannequins. Two kinds of questionnaires were used to examine residents' knowledge and their confidence levels. The collected data were analyzed statistically.

Results

Video (0.42(CI95%-0.11-0.9)), mannequin simulation (0.60(CI95%-0.04-1.25)), and the combination of video-mannequin (1.3(CI95%0.73-1.93)) significantly increased resident's knowledge regarding caesarean section skill. Study participant showed increased scores regarding confidence in their caesarean section skills according to all learning subjects (p < 0.05) but a difference in confidence level occurred in level C- 7th semester residents (p < 0.05).

Conclusion

The combination of videos and mannequin simulations is the best method for increasing knowledge of cesarean sections, compared to single video and mannequin simulations. The confidence level has been shown to increase in all subject studies but the effectiveness at each level of resident needs to be investigated further.

"We're Not Going to Be as Prepared": A Qualitative Study of Healthcare Trainees' Experiences after One Year of the COVID-19 Pandemic

The COVID-19 pandemic had significant impacts on the mental health and academic experiences of healthcare trainees. Building on findings from earlier in the pandemic, we explore the impacts on healthcare trainees after a sustained pandemic period of 12-14 months, involving multiple lockdowns, changes in government COVID-19 regulations and the delivery of health education. A qualitative study was conducted between March-May 2021. Participants were 12 healthcare trainees (10 women, 2 men) of medicine, nursing, and midwifery, registered at one of three higher education institutions in the United Kingdom. Interviews were fully transcribed, and data were thematically analysed using a combination of deductive and inductive approaches. We identified three key themes with eight subthemes: (i) academic experiences (adjustment to online learning, loss of clinical experience, confidence in the university), (ii) impacts on wellbeing (psychosocial impacts, physical impacts, pandemic duration and multiple lockdowns), and (iii) support frameworks (university preparedness for increased student support needs, importance of relationship with academic tutors). Findings shed light on the long-lasting and emerging impacts of the pandemic over time. We identify support needs for trainees both during their academic studies, and as they move forwards into professional roles within the healthcare workforce. Recommendations are made for higher education institutions and healthcare employers.

Health worker education during the COVID-19 pandemic: global disruption, responses and lessons for the future-a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis identified early evidence quantifying the disruption to the education of health workers by the COVID-19 pandemic, ensuing policy responses and their outcomes.

METHODS

Following a pre-registered protocol and PRISMA/AMSTAR-2 guidelines, we systematically screened MEDLINE, EMBASE, Web of Science, CENTRAL, clinicaltrials.gov and Google Scholar from January 2020 to July 2022. We pooled proportion estimates via random-effects meta-analyses and explored subgroup differences by gender, occupational group, training stage, WHO regions/continents, and study end-year. We assessed risk of bias (Newcastle-Ottawa scale for observational studies, RοB2 for randomized controlled trials [RCT]) and rated evidence certainty using GRADE.

RESULTS

Of the 171 489 publications screened, 2 249 were eligible, incorporating 2 212 observational studies and 37 RCTs, representing feedback from 1 109 818 learners and 22 204 faculty. The sample mostly consisted of undergraduates, medical doctors, and studies from institutions in Asia. Perceived training disruption was estimated at 71.1% (95% confidence interval 67.9-74.2) and learner redeployment at 29.2% (25.3-33.2). About one in three learners screened positive for anxiety (32.3%, 28.5-36.2), depression (32.0%, 27.9-36.2), burnout (38.8%, 33.4-44.3) or insomnia (30.9%, 20.8-41.9). Policy responses included shifting to online learning, innovations in assessment, COVID-19-specific courses, volunteerism, and measures for learner safety. For outcomes of policy responses, most of the literature related to perceptions and preferences. More than two-thirds of learners (75.9%, 74.2-77.7) were satisfied with online learning (postgraduates more than undergraduates), while faculty satisfaction rate was slightly lower (71.8%, 66.7-76.7). Learners preferred an in-person component: blended learning 56.0% (51.2-60.7), face-to-face 48.8% (45.4-52.1), and online-only 32.0% (29.3-34.8). They supported continuation of the virtual format as part of a blended system (68.1%, 64.6-71.5). Subgroup differences provided valuable insights despite not resolving the considerable heterogeneity. All outcomes were assessed as very-low-certainty evidence.

CONCLUSION

The COVID-19 pandemic has severely disrupted health worker education, inflicting a substantial mental health burden on learners. Its impacts on career choices, volunteerism, pedagogical approaches and mental health of learners have implications for educational design, measures to protect and support learners, faculty and health workers, and workforce planning. Online learning may achieve learner satisfaction as part of a short-term solution or integrated into a blended model in the post-pandemic future.

The gaps in undergraduate medical education due to the ongoing pandemic: An experience from a private medical college in Kerala

The Covid-19 pandemic affected undergraduate medical education worldwide. By March 2020, colleges in India had to close following a national lockdown. Most of the colleges including ours started using e-platforms. Our earlier studies highlighted concern for lack of patient examination in clinical settings and successes of the online teaching programmes were limited to didactic teaching. The year 2020 also was the year in which the National Medical Commission (NMC) introduced a competency-based system, which was new to all stakeholders. We assessed the impact of Covid-19 on the ongoing teaching pattern in our institute. Actual coverage of theory classes and practical/clinical teaching sessions were gathered from departments across all years of undergraduate medical education and the gap percentage was calculated against the NMC/ Medical Council of India requirements. The gap percentage was calculated as missing classes divided by required classes multiplied by hundred. The heads of departments were consulted, and details of theory, practical and clinical classes taken for each batch before and after lockdown were gathered using a questionnaire. These were compared against the mandated teaching by the NMC guideline for theory, practical and clinics. The results showed a gap ranging from 2% to 83% for theory classes, the least being in anatomy and the highest being in medicine. As there were no practical or clinical sessions during the lockdown, the gap was zero. Various challenges were faced due to online medical education. There was a dilemma over choosing the type of training that would produce adequate numbers with low quality or a delayed training but of assured quality. Various solutions including suspending the ongoing course and converting it to short-term skill training sessions to deal with pandemic care and strategies to improve online teaching were considered.

Is Virtual Learning Here to Stay? A Multispecialty Survey of Residents, Fellows, and Faculty

The transition to virtual learning during the coronavirus disease 2019 pandemic marks a paradigm shift in graduate medical education (GME). From June to September 2021, we conducted a dual-center, multispecialty survey of residents, fellows, and faculty members to determine overall perceptions about virtual learning and assess its benefits, drawbacks, and future role in GME. We discovered a mainly positive view of virtual education among trainees (138/207, 0.67, 95% CI 0.59-0.73) and faculty (180/278, 0.65, 0.59-0.70). Large group sessions, such as didactic lectures, grand rounds, and national conferences, were ranked best-suited for the virtual environment, whereas small groups and procedural training were the lowest ranked. Major benefits and drawbacks to virtual learning was identified. A hybrid approach, combining in-person and virtual sessions, was the preferred format among trainees (167/207, 0.81, 0.75-0.86) and faculty (229/278, 0.82, 0.77-0.87). Virtual learning offers a valuable educational experience that should be retained in postpandemic GME curriculums.

In-service training policy during the COVID-19 pandemic: The case of the agents of the farmers, rural people, and nomads social insurance fund

Introduction

The COVID-19 pandemic has posed the in-service training of agents of the Farmers, Rural People, Nomads Social Insurance Fund (hereafter the Fund) to many problems. In-service training is one of the most effective development factors for organizational goals. This sort of training will increase employees' skills and subsequently improve their job performance. Accordingly, the present research mainly aimed to shed light on the effect of in-service training policy on employees' capabilities and job performance.

Methods

The research was conducted among the agents of the Fund in Fars province, Iran (N = 197) out of whom 127 agents were sampled by simple randomization. The research instrument was a standard questionnaire whose face and content validity was confirmed by a panel of experts and its reliability was determined by calculating Cronbach's alpha in a pilot study. The results showed that the indicators used to measure the research variables were acceptably consistent with the factor structure and the theoretical framework of the research.

Results and discussion

Based on the findings, in-service training in the Fund during the COVID-19 pandemic has had a positive and significant effect on the agents' capabilities (communication and team-working skills, creativity and problem-solving skills, commitment and responsibility, technical information and knowledge, and technical and practical skills) and job performance at the individual, technical, and general levels. Also, the agents' capabilities have had a positive and significant influence on their job performance. It can be concluded that in-service training can influence the agents' capabilities and job performance and improve organizational performance during the COVID-19 pandemic. Thus, the enhancement of in-service training courses' quantity and quality during the COVID-19 pandemic can influence the job performance of the agents at the individual, general, and technical performance levels.

Scholarship in anesthesiology: the role of critical appraisal, literature review, quality improvement, journal club, and presentation skills

If asked to describe the term "anesthesiologist scholar", one may receive a variety of definitions depending on the individual's area of practice, location in the world, and the generation in which they trained. In this article, we review the roles of five core elements that make an anesthesiologist a "scholar": skills in critical appraisal, literature review, quality improvement, journal club participation, and presentation delivery. Although this list of scholarly components is not comprehensive, review of each element's role in the everyday practice and training of physicians will offer insight into their evolution and may offer a glimpse into the future of anesthesiologist scholars. Overall, through the dissemination, recognition, and support of scholarship through these practices, we will continue to achieve meaningful outcomes for our patients and promote a culture of collaboration worldwide. We should ensure that these topic areas become a bedrock of medical education globally, and we must foster opportunities for those who have already completed training to develop and master these skills as a part of their clinical and academic practice.

Measuring the impact of simulation debriefing on the practices of interprofessional trauma teams using natural language processing

BACKGROUND

Natural language processing (NLP) may be a tool for automating trauma teamwork assessment in simulated scenarios.

METHODS

Using the Trauma Nontechnical Skills Assessment (T-NOTECHS), raters assessed video recordings of trauma teams in simulated pre-debrief (Sim1) and post-debrief (Sim2) trauma resuscitations. We developed codes through directed content analysis and created algorithms capturing teamwork-related discourse through NLP. Using a within subjects pre-post design (n = 150), we compared changes in teams' Sim1 versus Sim2 T-NOTECHS scores and automatically coded discourse to identify which NLP algorithms could identify skills assessed by the T-NOTECHS.

RESULTS

Automatically coded behaviors revealed significant post-debrief increases in teams' simulation discourse: Verbalizing Findings, Acknowledging Communication, Directed Communication, Directing Assessment and Role Assignment, and Leader as Hub for Information.

CONCLUSIONS

Our results suggest NLP can capture changes in trauma team discourse. These findings have implications for the expedition of team assessment and innovations in real-time feedback when paired with speech-to-text technology.

Impact of COVID-19 on the academic performance and mental health of HBCU pharmacy students

INTRODUCTION

The COVID-19 pandemic has increased the use of distance learning, which may hinder academic success. Moreover, students at Historically Black Colleges and Universities (HBCUs) have been adversely affected by COVID-19. The purpose of this study was to assess the impact of online/hybrid learning on the academic performance and mental health of HBCU pharmacy students during COVID-19.

METHODS

A survey was developed to assess how COVID-19 affected the mental health and academic performance of pharmacy students who attend a HBCU. The survey collected demographic information and student responses using a Likert-type, multiple-choice, and select all that apply questions.

RESULTS

Most participants were women, African American, unemployed, and between the ages of 18 to 25. Most students did not experience a confirmed case of COVID-19 while enrolled. The majority of participants self-identified as visual learners, and most students somewhat or strongly agreed that online learning created a feeling of isolation from teachers and classmates. Furthermore, most students somewhat or strongly agreed that online learning during COVID-19 negatively affected their stress levels and mental health. Many students also disagreed that the faculty displayed empathy towards students during the COVID-19 pandemic.

CONCLUSIONS

Though most students felt isolated and changed their study habits during COVID-19, they were allowed to freely manage their time and did not find it more challenging to learn and retain information. Unfortunately, mental health and stress levels were negatively impacte,d and there was a significant number of students that felt there was a lack of empathy from faculty members.

Dental student oral surgery training-Comparing the impact of COVID-19 and cohort sizes

INTRODUCTION

The response to the COVID-19 pandemic potentially reduced the clinical experience and academic education of dental trainees through reduced supervised clinical sessions. Graduating dental students, future employers and regulators may be concerned over the level of clinical experience of graduates trained within the COVID-19 pandemic. The purpose of this study was to try and document the evidence for, and significance of, this impact.

MATERIALS AND METHODS

From dental student data in the 2017, 2018, 2019 and 2020 cohorts attending the University of Sydney, Australia, the number of dental extractions and adjunct oral surgery procedures, as well as final end-of-year examination results, was recorded. Results were compared to determine whether differences in experience and final academic achievement existed between these cohorts.

RESULTS

The smallest student cohort, 2017, demonstrated greater clinical experience than the 2018, 2019 and 2020 cohorts. The 2020 COVID-19-affected cohort demonstrated no statistically significant reduction in clinical experience in all measured clinical procedures when compared to the 2018 and 2019 cohorts. The decrease in city teaching hospital clinical experience was compensated by an increase in rural placements. The 2020 cohort achieved the lowest academic results, and this was statistically significant.

CONCLUSION

The oral surgery clinical experience of the 2020 dental cohort at the University of Sydney was comparable to prior cohorts. Rural clinics were able to compensate for COVID-19 interruptions to clinical training. The number of students in a cohort, if all other variables remain constant, appeared to affect clinical exposure to a greater extent than COVID-19.

Fostering Authenticity in Surgical Education: Creating a Safe Space for Medical Students to Practice as Doctors

Over the past 10 years we have witnessed major changes to the medical education landscape in response to advances in digital technologies. Couple this with the disruptions imposed by the COVID-19 pandemic and we have what could be described as a 'perfect storm.' Rather than hunker down and wait for it to pass, we took it as an opportunity to re-evaluate how we practice surgical education in the fourth year of our 6 year medical programme. In this article, we describe the formation of 6 core principles that function as pivot points in developing a new perspective centered on the importance of engaging and empowering our students as emerging clinicians. From these 6 principles, we designed and developed 3 interventions. Each intervention is discussed in regard to its purpose, operation and overall integration into the program.

Transforming the "SEAD": Evaluation of a Virtual Surgical Exploration and Discovery Program and its Effects on Career Decision-Making

OBJECTIVE

The abrupt cessation of in-person education due to the COVID-19 pandemic has made it difficult for preclerkship students to explore a career in surgery. To supplement the lack of exposure, the Surgical Exploration and Discovery (SEAD) program was transitioned to an entirely virtual format. This study aims to describe the virtual SEAD program and evaluate its effectiveness as a career decision-making (CDM) intervention.

DESIGN

The week-long program was delivered on Microsoft Teams, featured 11 surgical specialties, and comprised four activities: live demonstrations, virtual operating room observerships, career talks, and technical skills workshops. The program was evaluated using the four levels of the Kirkpatrick model: (1) reactions, (2) knowledge, (3) CDM behaviors - assessed using the Career Decision-making Difficulties Questionnaire (CDDQ) - and (4) results. The latter was indirectly assessed using CDDQ scores from an in-person SEAD program, where lower CDDQ scores indicate less difficulty with CDM.

SETTING

Faculty of Medicine at the University of Ottawa in Ontario, Canada.

PARTICIPANTS

Forty pre-clerkship students (27 first and 13 second year students) at the University of Ottawa RESULTS: Level 1: 97.5% of participants rated the program as good or very good. Live demonstration and technical skills workshops were the highest rated activities. Level 2: participants' scores on knowledge-based questions about a surgical career significantly increased following the program (pre: 9/25 vs post: 15/25, p = 0.008). Level 3: overall mean CDDQ scores (±SD) decreased difficulties with significantly following the program (pre: 45.6 ± 10.5 vs post: 38.8 ± 10.9, p < 0.001), which indicates decreased CDM difficulties. Level 4: Except for one sub-category, the difference in mean CDDQ scores between the virtual and in-person programs were not significantly different.

CONCLUSION

The program received the positive reactions and significantly increased participants' knowledge. The change in CDDQ scores following the virtual program suggests it may reduce career decision-making difficulties in the short-term. In-person surgical exposure remains important; however, a hybrid model may be valuable in resource limited settings. WC: 300.

Twelve tips for conducting medical education research via videoconference

The demand for current practical advice in how to conduct research by videoconference is internationally recognised. Many researchers in medical education are transitioning to using online methods for the first time, through design or necessity. This paper aims to provide practical advice on utilising videoconference technology for research, from design to execution. The tips include how to manage important elements such as ethics approval, online etiquette, contingency planning, technology management, and data capture. Recommendations include how to promote participant engagement with online data collection methods, in some cases paralleling the literature around synchronous online learning. The tried and tested tips have been developed by the authors based on their research experience, a literature review and the results of a post-participation survey of medical students on their experiences engaging in research online via videoconference.

Exploring the challenges of virtual internships during the COVID-19 pandemic and their potential influence on the professional identity of health professions students: A view from Qatar University

Introduction

COVID-19 has imposed many shared limitations on medical and health education. Just like other health professions programs at most institutions, the Qatar University health cluster (QU Health) applied a containment approach and shifted all learning online, and onsite training was replaced by virtual internships (VIs) during the first wave of the pandemic. Our study aims to explore the challenges of virtual internships during the COVID-19 pandemic and their influence on the professional identity (PI) of the health cluster students from the College of Medicine, the College of Health Sciences, and the College of Pharmacy at Qatar University.

Methods

A qualitative approach was employed. In total, eight focus groups with students (N = 43) and 14 semi-structured interviews with clinical instructors from all the health cluster colleges were conducted. Transcripts were analyzed following the inductive approach.

Results

The major challenges reported by students were mainly related to the lack of the required skills for navigating the VI, professional and social stressors, the nature of VIs and the quality of learning, technical and environmental issues, and the development of students' professional identity in an alternative internship environment. The challenges relating to the development of professional identity included: limited clinical (practical) experience, a lack of experience in fighting a pandemic, a lack of communication and feedback, and a lack of confidence in meeting the internship's goals. A model was constructed to represent these findings.

Discussion

The findings are important in identifying the inevitable barriers to virtual learning for health professions students and provide a better understanding of how such challenges and different experiences would be affecting the development of their PI. Hence, students, instructors, and policymakers alike should strive to minimize these barriers. Since physical interactions and patient contact are indispensable components of clinical teaching, these extraordinary times demand innovations involving technology and simulation-based teaching. There is a need for more studies that are focused on determining and measuring the short- and long-term effects of the VI on students' PI development.

"Burnout felt inevitable": Experiences of university staff in educating the nursing and allied health workforce during the first COVID-19 waves

Introduction

Maintaining progress in the face of looming burnout during the first 2 years of the COVID-19 pandemic was crucial for the health workforce, including those educating the next generation of health professionals. The experiences of students and healthcare practitioners have been explored to a greater degree than the experiences of university-based health professional educators.

Methods

This qualitative study examined the experiences of nursing and allied health academics at an Australian University during COVID-19 disruptions in 2020 and 2021 and describes the strategies that academics and/or teams implemented to ensure course continuity. Academic staff from nursing, occupational therapy, physiotherapy, and dietetics courses at Swinburne University of Technology, Australia provided narratives regarding the key challenges and opportunities they faced.

Results

The narratives highlighted the strategies generated and tested by participants amidst rapidly changing health orders and five common themes were identified: disruption; stress; stepping up, strategy and unexpected positives, lessons, and legacy impacts. Participants noted challenges related to student engagement in online learning and ensuring the acquisition of discipline-specific practical skills during periods of lock-down. Staff across all disciplines reported increased workload associated with converting teaching to on-line delivery, sourcing alternative fieldwork arrangements, and dealing with high levels of student distress. Many reflected on their own expertise in using digital tools in teaching and their beliefs about the effectiveness of distance teaching for health professional training. Ensuring students were able to complete required fieldwork hours was particularly challenging due to constantly changing public health orders and conditions and staffing shortages at health services. This was in addition to illness and isolation requirements further impacting the availability of teaching associates for specialist skills classes.

Discussion

Solutions such as remote and blended learning telehealth, and simulated placements were rapidly implemented in some courses especially where fieldwork could not be rescheduled or amended at the health settings. The implications and recommendations for educating and ensuring competence development in the health workforce during times when usual teaching methods are disrupted are discussed.

Health Research and Education during and after the COVID-19 Pandemic: An Australian Clinician and Researcher Perspective

Introduction: The COVID-19 pandemic had an unprecedented global effect on teaching and education. This review discusses research, education and diagnostics from the perspectives of four academic clinicians and researchers across different facilities in Australia. Materials and methods: The study adopted a literature review and an Australian researcher's perspective on the impact of the COVID-19 pandemic on health education, research and diagnostics. Results: At the start of the pandemic, medical facilities had to adhere urgently to major work restrictions, including social distancing, mask-wearing rules and/or the closure of facilities to protect staff, students and patients from the risk of COVID-19 infection. Telemedicine and telehealth services were rapidly implemented and adapted to meet the needs of medical education, the teaching of students, trainee doctors, nursing and allied health staff and became a widely accepted norm. The impact on clinical research and education saw the closure of clinical trials and the implementation of new methods in the conducting of trials, including electronic consents, remote patient assessments and the ability to commence fully virtual clinical trials. Academic teaching adapted augmented reality and competency-based teaching to become important new modes of education delivery. Diagnostic services also required new policies and procedures to ensure the safety of personnel. Conclusions: As a by-product of the COVID-19 pandemic, traditional, face-to-face learning and clinical research were converted into online formats. An hybrid environment of traditional methods and novel technological tools has emerged in readiness for future pandemics that allows for virtual learning with concurrent recognition of the need to provide for interpersonal interactions.