Perception and attitude towards online clinical modules: a cross-sectional study among medical students from two countries

COVID-19 has deeply affected the world in various aspects including the education system worldwide. In this study, we intended to explore the merits and demerits of online clinical learning and its effect on medical education from a student’s perspective. The study also assessed the perception and attitude of final-year medical students towards online clinical modules. This observational study was carried out in the Department of Community Medicine, Kasturba Medical College, Manipal (KMC) in collaboration with King’s College London, UK (KCL). In our study, a total of 42 students were enrolled, with 37 students from KMC and 5 students from KCL. 81% of students reported that they were not willing to continue the online mode of learning. The abrupt switch to e-learning without prior preparedness has exposed some pitfalls that must be attended to. Contrary to other fields, the medical field places high importance on offline clinical teaching which has recently been impacted by online teaching. The survey responses were analyzed for improvisation of online clinical modules as well as to come up with better ideas and outcomes since this mode of learning may have to continue till the spread of the disease is under control.


Introduction
The coronavirus disease (COVID-19) pandemic has significantly affected the world, including the education system, in various ways.The COVID-19 pandemic forced many schools and colleges to remain closed temporarily.In several parts of the world, many students missed at least one semester, with some students missing as much as a year of offline teaching.Teaching in medical school has traditionally been didactic, with clinical postings in the hospital.The WHO (World Health Organization) labeled the coronavirus outbreak a pandemic on March 11, 2020. 1,2To battle this, several novel methods were employed like social distancing, masking, hand hygiene, and vaccination.The education sector has undergone substantial changes so that it can cope with the current situation. 3Universities and colleges have employed a transition from traditional face-to-face teaching to online teaching or a hybrid of face-to-face teaching with online modules. 4As the time spent on online education increases, a study in the United States showed that many educators are transforming their face-to-face teaching into an online format. 5Therefore, to build a robust teaching tool to continue medical teaching during the pandemic, it is necessary to involve the students' ideas and feedback to improve the online teaching modules.Online modules have restricted students from learning through bedside clinical teaching.However, this was necessary as there was a significant risk of medical students contracting the virus and spreading it within the community. 6,7In this study we explored the merits and demerits of online clinical learning, its effect on medical education from the perspective of a student and assessed the perception and attitude of final year medical students towards online clinical modules.
When compared to more traditional, in-person learning environments, there is some evidence of student anxiety regarding online learning.There is also data regarding how the media portrays emergency circumstances.In the event of a disease outbreak, learning may be both facilitated and impeded by public agencies, political bodies, and research institutes). 8Furthermore, crisis management is an ongoing process in which public institutions and entities may find it challenging to apply "lessons learned" or prior knowledge from disaster scenarios in a developing emergency scenario. 9lthough there is a lot of room for student participation using online learning tools, this may not be the same as in-person or on-campus learning. 10According to survey results, fewer than half of adults questioned said that an online course was equivalent to one completed in a classroom, and there seemed to be a higher risk of plagiarism when learning online. 11hen compared to traditional in-person instruction, distance learning that is exclusively provided by videoconferencing can also result in inferior academic grades and lower course satisfaction. 12Furthermore, there are real obstacles to overcome in the context of online learning, such as the "learning curve" towards active learning and computer confidence that affects both students and teachers. 13Nevertheless, other research has discovered that student performance (as determined by exam results) might be comparable when the same professor teaches both in-person and online classes. 14

Study design -Observational study.
Study setting -Department of Community Medicine, Kasturba Medical College (KMC), Manipal, and King's College London (KCL), UK.
Study participants -Total of 42 students were enrolled from KCL (5 students) and KMC (37 students).The recruitment of participants was through Google forms, data from which were directly populated to the primary student researcher from KMC. Final year MBBS students from KCL and KMC college were RANDOMLY picked up or the survey.

REVISED Amendments from Version 1
As compared to the previous version, in the current version the background section was added with further paragraphs and references.In new version, the method section was itemized and modified as per the STROBE checklist for observational studies which was lacking in older version.In older version, the results section was too lengthy and analysis was also mostly descriptive and hence in new version all the tables were deleted and results are depicted in figures and the technical difficulties faced by the students during the study was added.The Performance in final clinical evaluation is measured on clinical case scenario evaluation individually and it was added in new version.In the current version a set/validated teaching procedure was used for students to familiarize with hospital procedures like sending investigations and preparing discharge letters.Information regarding online training modules were added in new version.In the new version Majority of the medical students strongly disagreed online mode of learning in the future since hands on skills will not be adequate.Hence it was added in result to highlight its importance among medical students.In our current version the discussion section was edited and restructured providing the relevant evidence first which was lacking in previous version.
Any further responses from the reviewers can be found at the end of the article

Inclusion criteria
Final year MBBS students from KCL (who participated in the Virtual Global Health Elective between the two institutions) and students from KMC Manipal who were in Final year MBBS, as of June 30th, 2020, and underwent clinical teaching on an online platform during their academic year.

Exclusion criteria
Students attempting the final year exam for the second (or more) time were excluded from the study.

Data collection procedure
Informed consent was obtained from the participants before the study initiation.Questionnaire was used to conduct the survey.It was structured on an electronic database using Google forms and it was open for one month.The questionnaire was divided into four sections.The first section contained the disclaimer and the informed consent.This was followed by the participant information sheet in the second section.The third section addressed the general information on the participants like gender, which college they belong to, the year of medical school they are in, and the duration of online teaching exposure they have received.The final section of the questionnaire asks the students various questions about online clinical modules (prepared as per NMC Competency Based Undergraduate Curriculum), their perception and attitude toward e-learning, and the applicability of online clinical teaching as a modus operandi of teaching in the future.The questionnaire provided to the participants was in English.

Statistical method
The characteristics and replies of respondents were analyzed using descriptive statistics such as frequencies and percentages.Data obtained through this survey will not be transferred to the foreign collaborator.Collaboration with KCL was only in place until the collection of data through a Google form created by the primary student researcher.This data will be directly accessible only to the primary student researcher and will not be shared with the foreign collaborator.

Results
In our study, a total of 42 students were enrolled, 24 were male and 18 were female (Figure 1). 2026 out of 42 students received in-person clinical exposure for more than 6 months (Figure 2).Around 16 students were not able to grasp clinical concepts well through online sessions (Figure 3).In total, 39 students felt that their attention had been affected in online mode in comparison with attending clinics in person (Figure 4).In the absence of peers, the motivation level was altered in 36 of our students (Figure 5).Because of online clinical modules a lot of atmosphere distractions were present as per our study (Figure 6).More than half the students disagreed to the fact that they were trained by online class to take clinical cases independently (Figure 7).28 of 42 students felt that their interpersonal skills were affected due to the pandemic Total no. of participants (n=42) No. of participants  (Figure 8).Giving online presentation to the class was a difficult task to 17 out of 42 students (Figure 9).At the same time most of the students were able to get their doubts solved during online lectures (Figure 10).Due to online teaching, students also felt that demonstrating a clinical sign on a patient in future would be challenging (Figure 11).14 out of 42 students were not satisfied with their performance in final clinical evaluation is measured on clinical case scenario evaluation individually (Figure 12).More than half the students were familiar with hospital procedures like sending investigations and preparing discharge letters (Figure 13).In addition, 22 students were overwhelmed about the responsibilities that they will have to undertake as a junior doctor (Figure 14).More than half the students in the study agreed on the fact that online mode of learning has given them more time to explore extracurricular interests (Figure 15).The online mode of learning was not interesting for students, and they did not wish to continue with this (Figures 16, 17).The technical difficulties faced by the students during the study were poor internet connectivity, Compatibility issues and Limited interaction.

Total no. of participants (n=42)
No of participants

Yes No
Total no. of participants (n=42) No of participants

I feel prepared and confident
I feel overwhelmed about the responsibiliƟes that I will have to undertake I haven't given it much thought Total no. of participants (n=42) No of participants

Discussion
We looked into many aspects of e-learning that students at KMC Manipal and KCL encountered during the COVID-19 epidemic, including technical readiness, the teaching and learning process, engagement and communication, and assessment techniques.Online instruction might not be the best option for senior colleagues during the epidemic, even though it might be more suitable for preclinical students.While students from KMC Manipal had online rotations in medicine, surgery, OBGyn, orthopedics, and pediatrics, KCL students experienced rotations in short-and long-term conditions, acute care, general practice, and women's health.Significantly, these rotations are essential for teaching medical students clinical expertise.Additionally, in order for final-year students to develop effective communication skills, they must have enough bedside exposure and patient interaction and clinical skills.
Similarly, students at Imperial College London were exposed to tele-teaching via computers in hospital settings as an alternative to clinical rotations.It was discovered that there was still a paucity of student-patient engagement. 15There were 24 male students and 18 female students involved in our study.Of the students who took online classes, only four thought they had received enough training to be able to handle clinical cases on their own, while 37 said they had not received enough training.Additionally, 19 students stated that the pandemic had an impact on their interpersonal skills, and 22 students felt that there were distractions in the studying environment.Every e-learning system starts with a base of  computers, networks, communications, and technical facilities, and information technology specialists keep these systems updated and maintained on a constant basis to upgrade the system, train users, and provide technical support. 16[19] E-learning approaches encounter various obstacles and difficulties.Poor motivation and the expectation that one can achieve one's own needs and ambitions, both personally and professionally, are two of these. 20Thirteen The process of learning and motivation is hampered by internal variables include low engagement, low motivation and perception, excessive levels of stress and anxiety, and bad relationships between facilitators and learners. 21,22The vast majority of pupils expressed a lack of interest in learning online.
Due to the lack of regular social connection, exhaustion from online learning, and difficulties imposing self-discipline, the students' attendance and involvement during the virtual sessions decreased.E-learning has been linked to stress more frequently than traditional learning. 23,24ly 19% of students in our study said they would like to continue learning in an online format, whilst 81% said they would not be willing to continue in an online style.When comparing student satisfaction in in-person versus online courses, varying outcomes have been documented in the literature; a greater percentage of students seem to favor inperson instruction. 25cording to a recently published study from King Abdulaziz University in Jeddah, Saudi Arabia, medical students accepted online learning during the pandemic lockdowns to a reasonable extent.Approximately half of the study's respondents said online learning was superior to or comparable to in-person instruction. 26r study yielded a variety of responses about students' experiences with the technological aspects of online learning.
According to some, these classes allowed them to pursue their extracurricular interests, and they were appropriate and manageable given the current circumstances.Nonetheless, the majority of students expressed dissatisfaction, difficulty focusing, and belief that technology should never replace the in-person, hands-on learning experience.A few of the technical problems were with the application, the network and connectivity, and the audio and video quality.It was challenging because of these problems, particularly when the kids were anticipating a topic of interest.Furthermore, even while some facilitators were more skilled at using online resources than others, the time it took to set up the online lecture frequently detracted from the overall learning environment.The same instructors who had previously involved the students and the classroom in in-person lectures had suddenly turned to dry online lectures.As a result, the majority of the study's participants said that, given the choice, they would not prefer to enroll in any further online courses.Everyone agreed that after taking lengthy and taxing online classes, the students now had more energy and enthusiasm to attend inperson classes whenever possible.

Conclusion
The sudden shift to e-learning without prior preparedness has revealed some pitfalls that need to be addressed.The central hypothesis is that COVID-19 has impacted the academic performance and clinical skills of medical students.The responses were analyzed for improvisation of online clinical modules as well as to come up with better ideas and outcomes since this mode of learning may have to continue till the spread of the disease is under control.In the near future, with the re-emergence of the pandemic and the advent of modernization and the digital world, e-learning and e-teaching should be incorporated in the medical curriculum along with clinical teaching.

Recommendations
Medical education places an emphasis on offline clinical teaching with the most ideal learning known to happen at the bedside.As a result, given the current pandemic scenario, medical educators must develop new approaches to imparting knowledge to medical students; they can no longer rely on markers and whiteboards, or chalks and blackboards.
Since the online mode of learning may have to continue for the foreseeable future, one of the effective methods that can be adopted to create the most effective multimedia learning experiences are Mayer's 12 principles of multimedia learning. 27hese principles can be used as guidelines to develop productive digital learning experiences.Thank you for the opportunity to review this manuscript.

Data availability
I commend the authors for exploiting COVID situation to assess the attitudes of students towards online learning.However, in my opinion, the reporting needs to be further expanded, including relevant literature sources, reporting guidelines and more straightforward statistical reporting.
My comments are the following: a) In the background section more references are needed, especially scoping reviews of the literature.Further expansion of background in several paragraphs would also be helpful (especially is those would answer the questions "What is this about and why it is important?",What have previous studies discovered, Which questions remained unanswered, What did we decide to do?).
b) Methods section should be more itemized.The recommendation is to use STROBE checklist for observational studies.Here I would emphasize on the importance of sample size calculation, since it seems that the sample of 42 students can be understood as relatively small.
c) The results section can be shortened, since the analysis is mostly descriptive, and I would recommend that all results are entered in a single table, rather than series of small tables.Moreover, Likert type scales can be entered as medians and interquartile ranges, rather than frequencies.Also, all percentages in the description of the sample should be removed and presented as simple frequencies, because there are less than 100 participants in the sample.d) Finally, the discussion should rely on the evidence granted from the Results, which it does.The recommendation is to restructure it, by putting the most important results first, and providing more precise explanations for findings, with literature sources.
recommend that all results are entered in a single table, rather than series of small tables.Moreover, Likert type scales can be entered as medians and interquartile ranges, rather than frequencies.Also, all percentages in the description of the sample should be removed and presented as simple frequencies, because there are less than 100 participants in the sample.
Response: The result section was shortened and corrected as per the suggestions.
4. Finally, the discussion should rely on the evidence granted from the Results, which it does.The recommendation is to restructure it, by putting the most important results first, and providing more precise explanations for findings, with literature sources.
Response: Discussion section was edited and restructured providing the relevant evidence first.
Competing Interests: No competing interests were disclosed.The present observational study focuses on differences between online and offline learning in the medical setting.The authors designed a questionnaire in which students expressed their views.
The study is valuable in highlighting some issues with the sudden adoption of an educational style, nevertheless some issues remain. Comments: -The authors expressed that participants were exposed to online clinical training, was online training similar to all students at the same institution?Was it different?Please provide more information about the online training received and any differences between them.Was the online lecture presented with slides?Are there any other features such as sound, etc.?
-What was the duration of a typical online session?
-While the authors emphasize several elements as contributing factors for a low of interest in online education, it is not clear which one of them was more influential.I strongly recommend a regression analysis to extract information about what factors were more influential in predicting a particular preference.
-Please provide data on students that suffered from technical difficulties.I think this factor should be considered in the regression model.
-I recommend the use of bar graphs instead of tables for each of the items described.Please omit tables.Response: Our study utilized a descriptive quantitative design to obtain the opinions of the respondents.

Is
The recommendation by the reviewer for regression analysis will be followed to extract information about the factors involved to predict particular preference in our future studies.Response: Though the question was hypothetical, since it was a pandemic and necessity of doctors were highly required at the time of study.Hence it was added to know their mind set.

Gehanath Baral
9. Table/Figure 17. Wish to continue online mode of learning in the future.Without looking at its impact, the data shown here will not be realistic.Because the level of knowledge and skill acquisition by a medical student is for real-time implementation, theoretical knowledge will not suffice for medical education.
Response: Majority of the medical students strongly disagreed online mode of learning in the future since hands on skills will not be adequate.Hence it was added in result to highlight its importance among medical students.
10. Discussion on technology is not supported by results.
Response: Discussion part is modified accordingly.
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Figure 3 .
Figure 3. Able to grasp clinical concepts well through online sessions online.

Figure 2 .
Figure 2. Duration of clinical exposure received in person and online.

Figure 5 .
Figure 5. Change in motivation level in the absence of peers.

Figure 7 .
Figure 7. Trained by online classes to take clinical cases independently.

Figure 14 .
Figure 14.Working as a junior doctor in the following year.

Figure 17 .Figure 16 .
Figure 17.Wish to continue online mode of learning in the future.

Reviewer
Report 04 October 2023 https://doi.org/10.5256/f1000research.143129.r198153© 2023 Trenado C.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Carlos Trenado 1 Heinrich Heine University, Duesseldorf, Germany 2 Heinrich Heine University, Duesseldorf, Germany

Comment 4 .
Please provide data on students that suffered from technical difficulties.I think this factor should be considered in the regression model.Response: The technical difficulties faced by the students during the study was added.Comment 5. I recommend the use of bar graphs instead of tables for each of the items described.Please omit tables.Response: Tables were deleted as per the recommendation Competing Interests: No competing interests were disclosed.Reviewer Report 04 October 2023 https://doi.org/10.5256/f1000research.143129.r198158© 2023 Baral G.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Version 1
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No Competing Interests:
No competing interests were disclosed.

confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Information regarding online training modules were added.The online lecture was presented with slides in Zoom and Google platforms which includes clinical contents, videos, images, diagrams and flow charts etc.
1Nepal Health Research Council, Kathmandu, Nepal whether it is on patient evaluation or clinical reports or case scenarios; and how the performance was measured or gauged.Response: The Performance in final clinical evaluation is measured on clinical case scenario evaluation individually and it was added now.7.Table/Figure13.Familiar with hospital procedures like sending investigations and preparing discharge letters needs objective verification.Such learning requires a set/validated teaching procedure -is it used or not?Response: Such learning requires a set/validated teaching procedure was used for students to familiarize with hospital procedures like sending investigations and preparing discharge letters 8. Table/Figure14information on "Working as a junior doctor in the following year" seems to be an assumption or hypothetical.For this research, design should be different like time series information on online and offline experiences.