|Year : 2020 | Volume
| Issue : 6 | Page : 608-614
A comparative study of telemedicine-assisted traditional teaching classes and flipped classroom-assisted self-directed learning sessions during COVID-19 pandemic among first MBBS students in Burdwan Medical College: A pilot study
Arunima Chaudhuri1, Suhrita Paul2, Tanushree Mondal3, Ayan Goswami4
1 Department of Physiology, Burdwan Medical College, Burdwan, West Bengal, India
2 Department of Pharmacology, Burdwan Medical College, Burdwan, West Bengal, India
3 Department of Community Medicine, Calcutta Medical College, West Bengal, India
4 Department of Physiology, Lady Hardinge Medical College, Delhi, India
|Date of Submission||18-Jul-2020|
|Date of Decision||24-Sep-2020|
|Date of Acceptance||05-Oct-2020|
|Date of Web Publication||6-Nov-2020|
Krishnasayar South, Borehat, Burdwan, Purba Bardhaman - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Burdwan Medical College is one of the 212 medical colleges included under National Knowledge Network (NKN), and we use telemedicine platform for imparting medical education. COVID-19 pandemic has brought a sudden change in education across the globe. Medical colleges in India also started online medical teaching since nationwide lockdown from March 24, 2020. Aim: The aim of the study was to compare the impact telemedicine-assisted traditional teaching classes and flipped classroom (FC)-assisted self-directed learning (SDL) sessions among first MBBS students in Burdwan Medical College. Materials and Methods: This pilot study was conducted in a time span of 4 months after obtaining institutional ethical clearance. Two hundred medical students enrolled in the first year participated in this study. The study was conducted in the Department of Physiology. Traditional interactive classes were conducted and these were also shared with other institutions under NKN. Students of Burdwan Medical College were present physically in these classes. Multiple choice questions (MCQ) examinations were conducted to assess knowledge of the students of Burdwan Medical College prior to and after attaining the classes. After the nationwide lockdown, our students had to leave the institution and continue studies online. We were also unable to assess telemedicine-assisted sessions from March 24, 2020 onward. Hence, we started flipped classroom-assisted self-directed learning as the mode of teaching during this period. For these sessions also, MCQ examinations were conducted to assess knowledge of students before and after the teaching learning sessions. Two surveys were conducted to get feedback from students. Results: The students were more satisfied with telemedicine-assisted traditional classes. Academic activities carried by majority of students was 5 h or more. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in pretest sessions (45.83 ± 20.45 vs. 44.74 ± 17.1; P = 0.67). Students performed significantly better in posttest sessions (61.04 ± 12.75 vs. 45.83 ± 20.45; P < 0.0001**) as compared to pretest sessions in telemedicine-assisted traditional interactive lecture classes. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in posttest sessions (61.04 ± 12.75 vs. 61.51 ± 13.57; P = 0.74). Students performed significantly better in posttest sessions (61.51 ± 13.57 vs. 44.74 ± 17.1; P < 0.0001**) as compared to pretest sessions in FC-assisted SDL sessions. Conclusions: FC-assisted SDL is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in teaching physiology to undergraduate medical students and may be taken into consideration in future teaching–learning program. Flipped classroom-assisted SDL may be used as an alternative in teaching–learning methodology as it is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in physiology.
Keywords: Online medical education, telemedicine, undergraduate teaching in physiology
|How to cite this article:|
Chaudhuri A, Paul S, Mondal T, Goswami A. A comparative study of telemedicine-assisted traditional teaching classes and flipped classroom-assisted self-directed learning sessions during COVID-19 pandemic among first MBBS students in Burdwan Medical College: A pilot study. Med J DY Patil Vidyapeeth 2020;13:608-14
|How to cite this URL:|
Chaudhuri A, Paul S, Mondal T, Goswami A. A comparative study of telemedicine-assisted traditional teaching classes and flipped classroom-assisted self-directed learning sessions during COVID-19 pandemic among first MBBS students in Burdwan Medical College: A pilot study. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2021 Jun 13];13:608-14. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/608/300145
| Introduction|| |
Nearly over a decade, medical education has been on the lookout for transformation. The current health-care environment requires competent physicians to coordinate with an interprofessional team to deliver safer, quality, and more cost-effective patient care. These factors are responsible for the growing trend in medical education reforms.,,,
The Medical Council of India (MCI) in 2019 has implemented learner-centered models as well as competency-based curriculum. The MCI has laid the basic framework for the revised undergraduate medical curriculum. For teaching physiology, in the curriculum, the following schedule has been provided: 160 lecture h, small group teaching/integrated teaching/practical/tutorial 310 h, and self-directed learning (SDL) 25 h: a total 495 h.
Online teaching and learning in medical education is new, it has the potential to become mainstream in future. Online teaching is flexible, learner centered, and can help students to develop SDL skills. The recently introduced competency-based curriculum has also advocated e-learning as an indispensable tool for SDL. For effective online learning, good online teaching practices need to be adopted. Good online teaching practices should have an inbuilt component of feedback. Online assessments, both formative and summative, should also ensure student involvement in the process. We have telemedicine facility for teaching in our college and are one of the 212 medical colleges included under National Knowledge Network Program. Hence, we have interactive lecture classes using this platform and in these classes, all colleges included in this network can participate.
The flipped classroom (FC) represents an essential component in curricular reform. Technological advances enabling asynchronous and distributed learning are facilitating the movement to a competency-based paradigm in health-care education. Flipping the classroom is a practice of assigning the students with didactic material before the class, which are traditionally covered in lectures. In the class, face-to-face time for more engaging and active learning strategies are further used. As medical educators are able to successfully flip a lecture, they can gain new teaching perspectives, and this is very essential to effectively engage in curricular reform.,,,
During active learning, students should have ownership of their learning for the meaningful outcome of learning experiences. The FC provides opportunity and time for face-to-face engagement. This aligns prior knowledge obtained with experiences and helps to prepare the learners for better practice. These experiences collectively help to build confidence of the learner and provide opportunities to support the development of self-efficacy. It also creates an environment of inquiry and open questioning. Various teaching tactics and strategies are in practice that support this approach. Tactics require less coordination than the strategies. They can also be used by individual faculty to engage learners in an FC.,,
The traditional lecture usually involves a single lecturer delivering to a large audience of students. There may be support from audiovisual aids such as blackboards, charts, models, or PowerPoint presentation. With the emphasis on students taking an active part in learning, new learning methods such as problem-based learning (PBL) and SDL have emerged. Furthermore, hybrid forms of lecture with self-directed methods are also in practice. SDL is as a process in which students usually take the initiative and responsibility for their own learning.,,,,
SDL as well as PBL are fundamental tools to achieve the goal of lifelong learning in medical curriculum. Furthermore, formative assessments can help to evaluate the development of multiple competencies. Identifying the learning gaps in the developmental stage of students is a pivotal process in the learning process. SDL has been popular in medical curricula and is advocated as an effective learning strategy for medical students. This helps to develop competence in knowledge acquisition.,,,,
From the above discussion, it is evident that flipped classroom teaching, SDL, and lecture classes combined may be more effective in implementing the new competency-based medical education (CBME). Overall, the above facts sound ideal for transforming the current curricula as envisaged by the MCI. The present study was conducted to compare the impact telemedicine-assisted traditional interactive teaching classes and FC-assisted SDL sessions among the first MBBS students in Burdwan Medical College in the Department of Physiology.
| Materials and Methods|| |
This pilot study was conducted in Burdwan Medical College after obtaining institutional clearance (Memo No: BMC/I. E. C/127: Dated March 12, 2020) in a time span of 4 months (February 2020–May 2020).
Two hundred undergraduate medical students of the first year were included in the study. Only theory classes were assessed included in this study. There were no exclusion criteria followed in this study, as all students participated during the whole study period.
Traditional interactive telemedicine-assisted lecture classes were arranged for first MBBS students from January 2020 by the Department of Physiology after approval from higher authorities of the Institution. The sessions were interactive. Students of Burdwan Medical College were physically present in the sessions while other colleges participated through telemedicine facilities available in different colleges. Each session lasted for 1 h and seven such sessions were conducted. Students of Burdwan Medical College had to participate in multiple-choice questions (MCQ) assessments before each session. This test was carried to assess their knowledge prior to the classes. After the sessions, students were allowed to read on their own and interact with their teachers to clear their doubts. Seven days after each session, a posttest MCQ was conducted to assess the knowledge of the students. In the pretest sessions, the questions were to assess preliminary concept of the students on the topics taught. In posttest sessions, problem-based questions were given to assess their knowledge. MCQ examinations were conducted using Google Forms.
We started our online teaching program on March 3, 20, as all our students had left their hostels and gone home due to the COVID-19 pandemic. One session was conducted with the help of telemedicine. From 24th March onward, we were not further allowed to use telemedicine platform for teaching purposes as per directive of the central authority. Hence, a departmental meeting was organized and it was decided in the meeting that the Department of Physiology of Burdwan Medical College will follow FC-assisted SDL as the teaching method in the present crisis. Many of our students are from remote villages having poor network connectivity. Hence, it is very difficult for them to access online classes through different Apps. Most of them do not have laptops or desktops. They depend mostly on mobile phones to continue their learning online. Many of them are from economically backward class and cannot avail data packages which cost more and their mobiles are also not costly. Hence, we decided to take up this method of teaching, i.e., FC-assisted SDL.
We created a WhatsApp group and included all undergraduate medical students of first MBBS batch. Faculties and residents of the Department of Physiology were also included in the group. Students were further divided into ten batches (twenty students in each batch), with each batch having a team leader. A Google classroom was created and named as BMC_MBBS_2019–20_Physiology. A Google group was created including ten class representatives of the student group (class representatives) and faculties for better communication with the students.
In all sessions, faculties of this college were facilitators. We have two professors, three associate professors, three assistant professors, five senior residents, and five postgraduate students in our department and they acted as facilitators. We had to take the same sessions multiple number of times as we interacted with the students in small groups of twenty. Hence, online education required much more involvement of faculties to make them effective.
The students were provided with PowerPoint presentations and video recordings for all topics they were taught. We have also uploaded some of our presentations in YouTube as per the request of the students. Many were not able to download the recorded videos due to network and financial issues. Their mobiles are of low cost, so storage of data was becoming a great problem for many. They were able to assess the recorded classes in YouTube from places where they could avail Wi-Fi connections.
Each topic was further divided into competencies and objectives. These were discussed in the WhatsApp group in voice messages along with relevant diagrams. The students were very interested in these voice messages and small presentations as they could easily download and assess them.
Flipped class is not for slow learners or those with poor visuospatial approach. They need personal contact with the teacher. Sessions were arranged in Google meet to clear doubts of the students and they were encouraged to contact their teachers whenever they had any problem. Each session had twenty students. In these sessions, students came in personal contact with the teachers. One teacher could easily monitor a group of twenty and interact with them. We also attended multiple webinars in this period to improve our teaching program.
We conducted MCQ assessments in this period and the students had to respond within a stipulated time. For all sessions, we had a pretest MCQ assessment and posttest MCQ assessment after 7 days after teaching each topic. The questions for the pretest session were basic questions related to the topic, while in posttest session, all questions were problem based.
Pre- and post-results could have been better as the students were staying at home and they could look into their books. To prevent this, the following measures were taken:
- All MCQ examinations had a time limit and the students could only attempt once
- The time got recorded in the sheets and the link was only open for a short interval of time
- For pretests, we did not give any intimation to the students that examinations will be conducted on that day
- For posttests, the questions were problem based and they were not able to answer at all until they studied and built up concepts.
Feedback surveys were conducted to assess the teaching module and impact of online education on the students.
Only cognitive domain could be tested and it goes against competency-based education. However, we had only assessed theory classes in the study. With the sudden onset of the pandemic and lockdown, all our students had to go home, so we had no other better option to carry our online education. Our institution and university could not provide us with any support and guideline during this period as there was severe patient load and everything was unplanned due to the sudden pandemic. Hence, the classes were conducted with the individual efforts of the teachers.
Statistical analysis of data
The computer software “Statistical Package for the Social Sciences” (SPSS) version 16 (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. SPSS Inc., Chicago, IL, USA) was used to analyze the data. The difference between the groups was considered significant and highly significant if the analyzed probability values (P value) were P < 0.05* and P < 0.01**, respectively. T-test was used to compare the MCQ test scores.
| Results|| |
The students were more satisfied with telemedicine-assisted traditional classes as compared to FC-assisted SDL online sessions. Academic activities carried by majority of students was 5 h or more. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in pretest sessions (45.83 ± 20.45 vs. 44.74 ± 17.1; P = 0.67) [Table 1] and [Figure 1]. Students performed significantly better in posttest sessions (61.04 ± 12.75 vs. 45.83 ± 20.45; P < 0.0001**) as compared to pretest sessions in telemedicine-assisted traditional interactive lecture classes [Table 2] and [Figure 2]. Students performed significantly better in posttest sessions (61.51 ± 13.57 vs. 44.74 ± 17.1; P < 0.0001**) as compared to pretest sessions in FC-assisted SDL sessions [Table 3] and [Figure 3]. There was no statistically significant difference in performance between telemedicine-assisted traditional lecture classes and FC-assisted SDL in posttest sessions (61.04 ± 12.75 vs. 61.51 ± 13.57; P = 0.74) [Table 4] and [Figure 4].
|Table 1: Results of multiple-choice question assessments of students in presessions in telemedicine-assisted traditional classes and flipped classroom-assisted self- directed learning sessions|
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|Figure 1:Results of multiple-choice questions assessments of students in presessions in telemedicine-assisted traditional classes and flipped classroom assisted self-directed learning sessions|
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|Table 2: Results of multiple-choice question assessments of students in pre- and posttest session in telemedicineassisted lecture sessions|
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|Figure 2:Results of multiple-choice questions assessments of students in pre- and posttest session in telemedicine-assisted lecture sessions|
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|Table 3: Results of multiple-choice question assessments of students in pre- and posttest session in flipped classroom-assisted self-directed learning sessions|
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|Figure 3:Results of multiple-choice questions assessments of students in pre- and posttest session in flipped classroom-assisted self-directed learning sessions|
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|Table 4: Results of multiple-choice question assessments of students in post sessions in telemedicine-assisted traditional classes and flipped classroom-assisted selfdirected learning sessions|
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|Figure 4:Results of multiple-choice questions assessments of students in postsessions in telemedicine-assisted traditional classes and flipped classroom-assisted self-directed learning sessions|
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| Discussion|| |
In the present study conducted in Burdwan Medical College among two hundred undergraduate medical students, we observed that FC-assisted SDL as an online mode of teaching to be equally effective as telemedicine-assisted traditional interactive lecture sessions. However, student satisfaction was significantly more in traditional lecture classes as compared to online sessions. For online sessions, the network connectivity was a huge problem, but it was much easier to monitor and follow up the students in online mode as compared to traditional classes.
A study by Sabale et al. was carried in the Community Medicine Department to train the second MBBS using FC methodology. Forty eight second-year MBBS students participated in the study. The present study was conducted among first-year students in the Department of Physiology. Selected topics (nutrition in under-five children) were taught through the “FC” model in the study conducted by Sabale et al. A pretest assessment was done. After 3 months, a posttest was conducted in the classroom to assess retention in knowledge and significant improvement was observed. The results of the study were similar to the present one.
The aim of a study conducted by Pai et al. in 2014 was to find out if there was any benefit of supplementing SDL activity with a traditional lecture on two different topics in physiology among first-year medical students. No additional benefit was gained by supplementing SDL with a lecture in the above study. We did not use SDL sessions as supplement classes.
A study was conducted by Zia et al. in 2016 on 100 students of first-year MBBS. They were randomly divided into two groups, each having 50 students. In the exposure, both the batches were provided with 1-h lecture on the following topic: “Physiological Causes of Different Types of Shocks.” Following this, an SDL session was conducted on the same topic for “Batch A.” Both the groups were evaluated by ten MCQ. During the second exposure, both the batches were given 1-h lecture on “Physiology of Platelets and Coagulation.” Following the lecture session, SDL session was conducted on “Batch B.” Assessment was done with MCQs for both the batches. The students who had attended additional SDL sessions scored higher marks as compared to students who attended the lecture classes only. In our study, we observed that both the methods of teaching were equally effective. Our SDL sessions were online and it had to be arranged very suddenly due to the pandemic and infrastructure was not well developed for online teaching.
An interventional study was conducted among 96 students studying in the third semester, in the academic year 2014 by Devi et al. Lectures and SDL sessions were conducted for the students simultaneously. Feedback from students revealed that SDL classes were more interesting and helped in better understanding of the topics. Our SDL sessions were online which may be the cause of the difference in the feedback given by our students.
In a study, Fatima et al. implemented the “FC” model. The study was conducted to enhance active learning among medical students with neurosciences module at Aga Khan University in Karachi. The study materials were provided to students in the form of video lecture and reading material. This was for the nonface-to-face sitting, while face-to-face time was spent on activities such as case solving, group discussions, and quizzes to consolidate learning. Pre- and post-class quizzes, worksheets, and blog posts were used to ensure better learning for each session. Students reported that their queries and misconceptions were cleared in a much better way in the face-to-face session following FC as compared to the traditional setting. The present study also observed similar results, but we had to conduct our whole session online due to the pandemic.
The CBME curriculum is designed to identify the desired outcomes, define the level of performance for each competency, and develop a framework for assessing competencies. CBME is learner centric and focuses on competencies (outcomes) as endpoints and the internal assessment is embedded in curriculum providing a continuous evaluation of student's performance. Hence, multiple assessments were conducted in the present study.
Coaching classes nowadays have become the unorganized sector of education in India. They greatly attract students aspiring for professional courses. However, the limited number of higher institutions in our country makes this rat race an act of desperation. By the time they enter medical school, the students are tired and bored lot having undergone the extreme stress of coaching and competition. Recommendations in the new curriculum pose a challenge for implementation given the limited resources and large number of mostly indifferent students. The present online teaching sessions were somewhat similar to coaching classes, this may be a reason why our students participated so well in our online sessions. Students were very easily able to contact their teachers in online mode. They could also study different topics according to their own time and pace. They felt more comfortable to express their opinions, thoughts, and queries online.
Technology in the wake of COVID-19 has already forced us to examine and explore more fundamentally the purpose and process of teaching, what constitutes valid knowledge, and how best medical students can acquire it. In such an hour of crisis, with geographical and time barriers to education, technology can be used in an innovative way of maintaining learning. This crisis may have given us the opportunity to divulge into unexplored areas of technology-based medical education. When COVID 19 resolves, transformative changes will possibly occur in medical education with the use of emergent technology.
The COVID-19 pandemic and nationwide lockdown has brought a sudden change in medical education across the globe. Many medical colleges and health universities have taken the initiative to start teaching and learning using various online platforms on their own as there were no definitive directives from either MCI or any other statutory bodies. Undergraduate teaching is being conducted by various methods using various online platforms by many medical colleges without any uniformity. Multiple studies need to be conducted across the country to know the effectiveness of these teaching and learning tools.
The introduction of CBME in the undergraduate curriculum requires regular assessments of students' achievement. Medical schools have a great challenge to observe student performance or to hold large-scale examinations during this period of lockdown. Some of the factors which may affect medical education are economic constraints; availability of infrastructure; and continuation of providing treatment to COVID patients by the same clinical workforce who are engaged with teaching the students. These factors are likely to have a significant impact on the future approach in medical education across India. The observation of the present study shows some promising aspects of online medical education.
| Conclusions|| |
FC-assisted SDL is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in teaching physiology to undergraduate medical students and may be taken into consideration in future teaching–learning program. Flipped classroom-assisted SDL may be used as an alternative in teaching–learning methodology as it is equally an effective tool as telemedicine-assisted traditional interactive lecture classes in physiology.
Limitations and future scope
Due to the sudden onset of the pandemic, medical education had to be continued online without proper planning programming and preparation, this adds a limitation to the present study, but when COVID 19 resolves, transformative changes will possibly occur in medical education with the use of emergent technology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]