|Year : 2021 | Volume
| Issue : 4 | Page : 337-342
Pregraduation online curriculum delivery of internal medicine course during the COVID-19 pandemic: Experience of a medical college in Saudi Arabia
Salman Aljarallah1, Mohammed Bedaiwi1, Rashed Alrashed1, Mohammed A Omair1, Mona Soliman2, Assim A Alfadda1
1 Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medical Education, College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||20-Jan-2021|
|Date of Acceptance||16-Apr-2021|
|Date of Web Publication||06-Oct-2021|
Department of Medical Education, College of Medicine, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic has challenged medical education and resulted in a rapid and unexpected global shift toward online education. The study presents the experience of the College of Medicine of King Saud University in delivering a comprehensive internal medicine course for final-year medical students, which includes the implementation of novel methods of assessment. Methods: A 2-week revision of the internal medicine course was conducted for 70 pregraduation medical students. Lectures and focused case-based tutorials were conducted online. Novel assessment methods included brief written essays summarizing the tutorials, open-book short-answer question (SAQ) examination, and a virtual standardized oral examination (vSOE). A questionnaire was sent to the students (n = 70) on the contents of the course, clarity of objectives, duration, and online platform. Results: The response rate was 99.3%. Students scored higher in the SAQs compared with traditional multiple-choice tests (mean score: 92.3% vs. 69.8%). The vSOE was efficient, and grades were comparable to traditional objective structured clinical examination. The majority of students (93%) reported the scientific content as good or excellent, whereas approximately 30% found the course goals lacked a clear description. The majority (76%) found the course length appropriate, and 94% reported the online platform installation and operation easy or very easy. Conclusions: The comprehensive online internal medicine course was successfully delivered to pregraduation students. Innovative online examination methods can be a reasonable alternative in the case of lockdown. This modality of teaching and assessment was considered useful and met the expectations of students.
Keywords: COVID-19, objective structured clinical examination, online education, undergraduate medical education, virtual
|How to cite this article:|
Aljarallah S, Bedaiwi M, Alrashed R, Omair MA, Soliman M, Alfadda AA. Pregraduation online curriculum delivery of internal medicine course during the COVID-19 pandemic: Experience of a medical college in Saudi Arabia. J Nat Sci Med 2021;4:337-42
|How to cite this URL:|
Aljarallah S, Bedaiwi M, Alrashed R, Omair MA, Soliman M, Alfadda AA. Pregraduation online curriculum delivery of internal medicine course during the COVID-19 pandemic: Experience of a medical college in Saudi Arabia. J Nat Sci Med [serial online] 2021 [cited 2022 Jan 19];4:337-42. Available from: https://www.jnsmonline.org/text.asp?2021/4/4/337/327592
| Introduction|| |
The COVID-19 pandemic and its associated confinement measures, such as social distancing, isolation, and quarantine, have impacted all aspects of life. To limit the spread of the infection, governments have implemented strict lockdown measures and curfews, thus limiting the movement of people, including students and teachers.,, Medical education has been challenged, in particular as the majority of learning objectives and competencies require workplace- and campus-based education. In essence, the COVID-19 pandemic has forced leaders in medical education to rapidly shift to online education. Educators worldwide have been required to invent quick solutions and adopt teaching strategies that ensure obtaining learning outcomes and graduating competent physicians without jeopardizing patient, faculty, or patient safety. Online education using Internet-based platforms has become the major method of conducting teaching courses for medical students. Although this approach could be a reasonable substitution for traditional theoretical lectures, identifying alternative models of teaching and learning, which require patient contact or bedside skills, has been challenging, especially with the abrupt, unplanned shift. In the early stages of the pandemic, uncertainty about its potential course and fate rendered long-term planning a difficult task.
The assessment of medical students during the COVID-19 pandemic has been challenging. Although several traditional assessment methods can be used during the pandemic, the change in teaching methods has mandated the adoption of new assessment methods to test the achieved clinical competencies and ensure the safety of the students and faculty.
Early in March 2020, the Saudi government mandated that education should be delivered entirely online. Hospitals implemented stringent policies, which limited the presence of health-care workers to only very essential workers to deliver healthcare. However, final-year medical students were expected to graduate, thus, delays interfered with their career planning.
Educators were presented with the challenge to conduct course activities online and in a very short time. The modified course should aim to review clinical approaches to common and urgent medical problems, polish clinical skills, and optimize student engagement. Developing fair and reliable evaluation methods and providing meaningful feedback to students were also important aspects.
In this regard, the study presents the experience of the College of Medicine at King Saud University (KSU) in delivering an undergraduate course of internal medicine to final-year medical students during the peak of a strict hospital and nationwide lockdown. In addition, a new assessment plan is adopted for the internal medicine course during the COVID-19 pandemic. The study refers to the adopted course as a modified course (MC). The methodology, results in comparison with the prepandemic course, and student perception are reported.
| Methods|| |
The population consisted of 70 final (5th)-year medical students. The course is the last step before graduation and initiation to internship (clerkship). In the same year and before the pandemic, they completed rotations in pediatrics, surgery, and emergency medicine. In addition, as part of the curriculum of the KSU medical college, the students completed an introductory course in internal medicine in 3rd year where the technical aspects of clinical examination were learned and mastered. In addition, the medical college curriculum provided early clinical exposure during the 1st year, as students are introduced to the basics of history taking and clinical examination in a skills and simulation center every week in a system-oriented fashion. The study was approved by the Institutional Review Board Committee in King Saud University College of Medicine Board Research on research project on 18/08/2021, with Ref. No. 21/0680/IRB.
The curriculum of the College of Medicine of KSU is a 5-year system-oriented, problem-based, spiral, and hybrid curriculum. The internal medicine discipline is taught in a spiral approach during the 3rd and 5th years. Before the pandemic, the course entitled practice of internal medicine consisted of a series of traditional didactic lectures, bedside teaching (BST) sessions, and daily clinical activities where students join medical teams in wards, clinics, or emergency rooms. The lectures consisted of 21 lectures with a focus on critical and common problems in medicine delivered in a large group session. BST sessions are conducted weekly where a smaller group of students take history and examine a patient in the presence of a tutor. These activities typically occur over a period of 10–12 weeks. Students are evaluated by undergoing a multiple-choice question (MCQ) test, an objective structured clinical examination (OSCE), and a mini-clinical evaluation exercise (mini-CEX).
To accommodate the changing environment, didactic lectures were delivered virtually through a popular online video conferencing platform. As an alternative to BST, small student groups underwent a series of six 2-h tutorials that focused on major systems in medicine delivered virtually. A specialist on a topic of interest prepared the tutorial content, which was reviewed by a committee composed of members of different faculties. For example, a pulmonary tutorial focused on approaching a patient with dyspnea, chest X-ray interpretation, management of pulmonary embolism and pneumonia, and understanding the respiratory compensation of acidosis. These tutorials were delivered in a case-based fashion where the students were strongly encouraged to participate and lead the discussion in front of their video cameras. Following the tutorial, the students submitted a brief written essay summarizing what they learned, which increased the degree of engagement and participation in such a virtual platform.
The students have prior exposure to hands-on examination. They were also provided with access to a library of online videos on history taking and examination skills. An independent committee composed of internists and medical educators reviewed and preapproved the videos.
Assessment and evaluation
Multiple methods were adopted for assessment [Table 1]. First, the above-mentioned essays were considered and graded based on correctness and completeness in addition to the degree of interaction during the tutorials.
An open-book short-answer question (SAQ) examination was introduced as an alternative to the MCQ examination to assess theoretical knowledge. The examination was conducted through an online learning management system (LMS) (Blackboard®) where all students should access the examination at the same time using personal computers. As this was their first time to use the LMS for examination, two mock trials were conducted to familiarize the students with the process. The examination consisted of multiple open-ended questions on multiple-case scenarios, which mainly focused on managing the disease, listing investigations, or noting differential diagnoses. The students have direct access to immediate support via phone or text messaging for any unexpected events throughout the examination. An examination committee provided corrections and remarks to the responses of the students.
As an alternative to the standard OSCE, which requires physical presence, a virtual standardized oral examination (vSOE) was conducted via the online platform. Each student underwent four examination stations for 10 min each. A web link is provided for each station. However, instead of providing each student with individual links, which can be confusing especially during the examination, a simple online portal was created [Figure 1]. The order of the stations was given in advance. Two additional emergency stations were added in the case of connectivity issues or delays from the student's side to avoid disrupting the schedule. Stations were designed to evaluate the student's approach to clinical scenarios and interpretation of data. Multiple dry runs were conducted to troubleshoot potential problems. The students were instructed to turn on their cameras and maintain eye contact throughout the examination, even while waiting between stations.
|Figure 1: Screenshot of the online portal to access standardized oral examination stations|
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The study was approved by the College of Medicine Institutional Review Board. After the course, an online questionnaire was sent to the students (n = 70). Online informed consent was obtained before the study. The questionnaire consisted of ten questions (six closed ended and four open ended). Course organizers prepared the questionnaire and evaluated the contents, clarity, duration, teaching strategy, platform used, and clarity of voice and image. The open-ended questions addressed the negative and positive points encountered in the course, compared between online and face-to-face teaching of internal medicine, and collected suggestions for further improvement.
Responses to the first six questions were reported as percentages and represented by bars or pie charts. Microsoft® Excel® 365 was used for the statistical analysis.
| Results|| |
Scheduled lectures were conducted on time without significant difficulties. The attendance rate reached 99.3%. Tutorials occurred on time, except for two. The first was delayed by 1 day due to the tutor's commitments and the second was delayed by 20 min due to technical difficulties from the tutors' side. Students completed the tutorial essays successfully. A limitation of the grading system was interrater variability between examiners.
Short-answer question examination
Apart from one student who experienced a transit power outage during the examination, no technical difficulties were experienced during the SAQ examination. The present scores were compared to those prepandemic. Students scored higher in the SAQ compared to the traditional MCQ (mean score: 92.3% vs. 69.8%, respectively) [Figure 2].
|Figure 2: Students' scores in the short-answer question and virtual standardized oral examination compared to traditional multiple-choice question and objective structured clinical examination (mean score)|
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Virtual standardized oral examination
The vSOE also went smoothly without major problems. One student reported an unexpected difficulty in accessing the platform, which was rapidly examined via a backup phone-based video call. The presence of the examiners within the college during the examination enabled the early identification of technical problems and rapid intervention. In terms of scores, the overall grades were slightly lower in the vSOE (mean: 77.2%; SE: 1.5%) but very close to the traditional OSCE (mean: 83.9%: SE: 0.7%) [Figure 2].
All students responded to the questionnaire. When asked about scientific content, 92.8% reported good or excellent content, although five students indicated dissatisfaction [Figure 3]. Approximately 21 students (30%) perceived that the goals lacked description. On a scale of 1 = poor to 5 = excellent, 76% of the students rated the teachers as 4 or 5. Approximately 76% stated that the length of the course is appropriate, whereas 21% felt that it was extremely short. The majority (94%) found that installing and running the online platform is easy or very easy. Meanwhile, the majority of students rated video and audio quality as four or five out of five. In terms of positives, the students favored the focus of the course on high-yield topics, increased cooperation among them, ease of access to lectures from home, and quality of lectures. Among the negatives, students perceived the announcements and details arrived with a short notice, whereas many students did not feel the vibe of being on a college campus. At times, the connection disruption affected the interaction during small group discussions. Notably, none of the students, faculty, or administrative staff contracted COVID-19 during the course.
|Figure 3: Students' perception of selected aspects of the course. (a) Students' perception of the contents of the course. (b) Students' perception of the clarity of the objectives of the course. (c) Students' satisfaction with the tutors of the course|
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| Discussion|| |
Students welcomed the interactive small group discussions, and many of them considered such discussions the highlight of the course. The course was conducted relatively early in the pandemic. Thus, many faculty members reported difficulties with the online platform. Thus, training the teachers on using the platform is important, and providing close and immediate technical support is essential.
Medical education has been severely affected during the COVID-19 pandemic due to the disruption of clinical training and complete shift to online education. The challenge is ensuring a balance between graduating competent graduates with essential clinical skills and maintaining effective curriculum delivery. Education leaders are required to make decisions and choices to ensure the achievement of learning outcomes by ensuring student, faculty, and patient safety. To manage curriculum delivery during COVID-19, clinical sessions were shifted online., However, this immature shift to online medical education in teaching clinical skills is novel and may not be the ideal method for learning clinical competencies.
The current study presents a new experience in teaching a comprehensive online revision course and a new modality of assessment of internal medicine for final-year medical students during the pandemic. Students' evaluation of the comprehensive online revision course indicated high levels of appreciation of the clear objectives and high levels of satisfaction with the duration and contents of the online course. The newly introduced online comprehensive course can serve as a replacement of the traditional in-hospital clinical encounter and patient BST given the strict rules of social distancing due to the COVID-19 pandemic. The COVID-19 situation challenged medical education worldwide to create urgent solutions for training and educating pregraduation medical students through online training.
The pandemic led to the urgent need to introduce new modalities of teaching and assessment by utilizing online resources for out-of-hospital clinical training and assessment of pregraduate students. The decision to introduce the new comprehensive course was an urgent decision made at the period of complete lockdown during the COVID-19 pandemic to meet the needs of final-year students and avoid a delay in graduation.
Evaluating and comparing the performance scores of students before and during COVID-19 are important to produce a reflection on teaching and training quality. Furthermore, leaders in medical education agreed that the students' grades were similar, whereas no statistically significant difference was observed as a result of the impact of the strict social distancing rules during the pandemic.
Assessment of students during the COVID-19 pandemic can be challenging. The strict rules demanded the introduction of new assessment tools. Although traditional assessment methods were used, the course introduced an online SAQ examination utilizing the LMS (Blackboard®). Although the university has adopted the LMS for a relatively long time, this type of SAQ was not used in the medical college. Several successful practices implemented during COVID-19 should be implemented and continued. In the SAQ format, students produced much higher scores than the MCQ format. This finding could be explained by the fact that the SAQ examination was an online, open-book examination on Blackboard®. However, the SAQs were based on clinical scenarios and required critical thinking, deep analysis, and problem-solving skills. A challenge, however, was the large number of students, which renders marking and feedback time-consuming for busy clinicians, especially during the pandemic. Other challenges observed for SAQs are reliability and potential subjectivity in grading.
OSCE is a well-known method for the summative assessment of medical students. Thus, the successful completion of the OSCE is a requirement for passing the internal medicine course in the final year and subsequently, graduating. The vSOE was introduced to ensure the safety of the students and maintain the required social distancing. This method enables direct face-to-face interaction with examinees, discussion of clinical scenarios, interpretation of tests, and presentation of clinical findings via pictures or videos. Virtual OSCE was delivered in other medical schools as an assessment method due to the COVID19 pandemic. Craig et al. reported positive feedback from participants during and post-OSCE. The participants perceived the online virtual alternative as representative of in-person OSCE. The main limitation was the lack of physical examination stations, which was reported in the present study. Comparing the scores between vSOE and traditional OSCE, the study found only a small difference, which indicates that the test is a viable alternative to OSCE in the absence of physical presence [Table 2].
|Table 2: Advantages and disadvantages of modified versus traditional methods|
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The study presented the use of online and virtual assessment tools to adapt rapidly to the current COVID-19 situation with flexibility. Introducing new methods of teaching and assessment that have not been experienced prior to the COVID-19 pandemic has been required.
Furthermore, the study presented the experience of the College of Medicine at KSU, Saudi Arabia, in delivering comprehensive revision online internal medicine course to pregraduation students prior to the final examinations. In addition, a novel online clinical examination method was presented, which was formulated and implemented during the lockdown. Furthermore, this modality of teaching and assessment was considered useful and met the expectations of the students.
The report provides a description of the course content and assessment methods and emphasizes that certain changes in the curriculum are feasible. However, conclusions should be avoided about the effectiveness of the methods as the MC cannot be directly compared to the traditional course given the many variables that have changed.
| Conclusions|| |
The comprehensive online internal medicine course was successfully delivered to pre-graduation students. Innovative online examination methods can be a reasonable alternative in the case of lockdown. This modality of teaching and assessment was considered useful and met the expectations of students.
The authors would like to extend their gratitude to the academic staff and secretaries of the department for their valuable work during the pandemic to ensure the successful delivery of curriculum to students. The authors thank the Deanship of Scientific Research and Researchers Support and Services Unit at KSU for their technical support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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|[Pubmed] | [DOI]|