A comparative study about attitudes towards the efficiency, effectiveness, and atmosphere of offline and online learning among medical students

Introduction

In recent decades, the mode of learning and education has changed (1), and online learning has become more common (2). This learning method uses electronic technology and media to provide, support, and enhance learning and teaching, and to achieve information exchange between online learners and teachers (3).

A previous study (4) at Johns Hopkins University School of Medicine found that only 14% of medical undergraduates and 33% of medical postgraduates engaged in full-time online learning in 2019. Data from The National Center for Education Statistics (5) revealed that in 2019, only 20% of American public schools offered any online learning. However, since the start of the Coronavirus disease 2019 pandemic, online learning has rapidly gained ground worldwide. Various educational activities in major countries around the world switched to online learning during the pandemic (6). Many students have been learning from home, via the Internet (7), which has significantly changed education activities (8,9). Some scholars believe that a large number of students will continue to choose online learning even after the end of the pandemic. These changes in education and behavior patterns may ultimately affect human behavior patterns (10,11). They may even change energy consumption in the education system, reversing the previous structure and habits related to energy use (12,13).

Given the popularity of online learning in medical schools, more scholars have begun to consider the effectiveness of online learning, because it is an pivotal factor that affects whether students can obtain good learning results. Even before the pandemic, the global shortage of medical teachers aroused widespread concern. During the pandemic, many doctors had to cease teaching to concentrate on clinical work due to the pressure placed on resources. Work and research also exacerbate the shortage of medical teacher resources (14,15). The proportion of online learning in medical curricula is thus rising. However, scholars who have compared online learning to traditional offline learning have concluded that traditional offline learning is more effective (16-19), especially for medical majors.

The nature of medicine makes it difficult for medical students to learn some aspects of subjects effectively online. Al-Elq et al. (20) argues that mainstream online lectures and seminars cannot simulate face-to-face interactions between students and patients and that online education is thus not suitable for “bedside teaching” and training of practical skills (21). However, traditional learning also has a number of limitations, including that students and teachers must be in a specific place at a specific time (22), which limits learning flexibility. Conversely, online learning can transcend time and space and provide medical students with a personalized learning space and time, making learning ubiquitous (23-27). We have been unable to find any studies comparing offline and online learning between medical undergraduates and postgraduates. Thus, this study administered a questionnaire to investigate the views of medical undergraduates and postgraduates on the efficiency, effectiveness, and atmosphere of offline and online learning. We present the following article in accordance with the SURGE reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-22-5112/rc).

Methods

Research tools

The questionnaire used in this study was compiled with Questionnaire Stars. We used the “Guidelines for Educational Research Questionnaires” published by Harvard University Graduate School in 2014 (28) to compile a questionnaire for the “self-assessment of online and offline learning by medical undergraduates and postgraduates”. The questions covered the following 4 areas: basic information about students, learning effectiveness, learning efficiency, and learning atmosphere. There questionnaire comprised 33 items. All the items used a 7-point Likert-type scale (on which 1 indicated completely disagree and 7 indicated completely agree). A 7-point scale has a higher reliability and enables a more detailed trend analysis to be undertaken than a 5-point scale (29,30). It also provides more accurate results than a 9- or 11-point scale. Additionally, a 7-point scale does not affect the abstract thinking ability of the study participants and is more likely to reflect students’ views about the questions (31) than a 9- or 11-point scale.

Cronbach α The coefficient is 0.879, greater than 0.8, indicating that the reliability of the questionnaire is good; KMO value is 0.901, greater than 0.8, and the p value in Bartlett test is 0.000, <0.05, indicating that the validity is good.

After completing the first draft of the questionnaire, we conducted a small-scale experiment in which 8 medical students were asked to complete the questionnaire and provide comments on its contents. The questionnaire was then revised and adjusted. The specific composition of the questionnaire is shown in Table 1.

Research participants

The study participants were medical undergraduate and postgraduate students attending some universities in China. The basic information of subjects participating in the test is shown in Table 1. All the participants were randomly selected. All the participants were anonymous, and the questionnaire did not ask for any sensitive or identifiable personal information. We are of the view that the random nature of the selection of the participants did not have any adverse effects on the investigation or the participants. We obtained a total of 287 questionnaires, of which 7 were invalid; thus, 280 questionnaires were included in analysis, and the study had an effective response rate of 97.56%. Table 2 sets out some basic information about the study participants.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Before the investigation and test, we ensured that all respondents have provided informed consent. Ethical approval was waived by the ethics committee of the Affiliated Hospital of Qingdao University Ethics Committee, because this study did not involve ethical issues. Our questionnaires are all about medical college students and graduate students. All questions are composed of online and offline learning information, excluding any clinical trial and clinical observation, as well as any personal privacy issues.

Statistical analysis

We used the t-test method via SPSSAU software to process and analyze the collected data. First, we compared online learning and offline learning among all students to examine learning efficiency, effectiveness, and atmosphere. We also compared the views of the undergraduates and postgraduates. In the process of the comparison, we summarized the advantages of online and offline learning. Subsequently, we summarized and compared the similarities and differences between medical undergraduates and postgraduates on online and offline learning, including the sense of classroom participation, learning atmosphere, peer-to-peer learning, and teacher supervision.

Results

Table 3 shows that the learning efficiency (3.88), effectiveness (4.0), and atmosphere (3.78) were all lower for online learning than offline learning (4.93, 4.64 and 4.50), and the differences were significant (P<0.01). This suggests that medical students may not yet be skilled or mature enough for online self-learning and teaching.

Table 4 shows that the scores for learning effectiveness, enthusiasm, and concentration were all significantly higher for offline than online learning. Both undergraduates and postgraduates thought that offline learning was more effective, and the scores were significantly higher from undergraduates (5.11) than postgraduates (4.66) (P<0.05). Both undergraduates and postgraduates thought that online learning had less classroom participation than offline learning. Most students believed that they would be more distracted by other applications during online than offline learning. This also suggests that online learning is not highly focused. Most students thought that the absence of companionship during online learning would have a negative effect on their study. They also valued teacher supervision and real-time communication and believed that their absence would have a negative effect on learning. However, most students also thought that an online learning platform provided a broader learning horizon and easier retrieval of learning materials, and thus had a positive effect on their learning. Overall, most medical students valued offline learning over online learning, but recognized that online learning had obvious advantages in terms of obtaining learning materials and flexibility.

Discussion

Many studies have shown that before online learning, medical education resources were affected by the natural environment and human activities, resulting in an uneven distribution of resources (32-36). Online education models and tools can remove some of the restrictions of geography and environment. Thus, they may help to address the uneven distribution of medical offline education resources (2,37). For example, the University of Cleveland School of Medicine in the United States (38) developed 3-dimensional electronic anatomical software for the repositioning of bone models and uploaded a tutorial for medical students to study at home during the pandemic. The popularization and development of online education also enables students who cannot attend school to use the same educational resources (4,39).

Over the past decade, the effectiveness of online learning has greatly improved, but its limitations still restrict its use in medical teaching. We found that both postgraduates and undergraduates valued offline learning more than online learning; however, the difference was only significant among undergraduates (4.66 vs. 4.34, P>0.05 for postgraduates, and 5.11 vs. 4.04, P<0.005 for undergraduates). Thus, most medical students are of the view that offline learning is better than online learning, even if the differences were not significant among the postgraduates. We think that there may be 3 main reasons for this.

Class participation is insufficient online

Students obtain a sense of classroom participation when they “actively participate in the course activities and strive to obtain learning results in the course” (40). Hensley et al. pointed out that this participation directly affects the learning of medical students and plays a vital role in learning activities (40). When asked, “Do you think class participation is higher online than offline?”, 47% of students said “no”, and only 30% said “yes”; 23% were neutral.

Similarly, Thom et al. (38) concluded that most medical undergraduates thought that their participation was lower in online classes than offline classes. Some students even stated that this form of learning did not effectively help them to develop a comprehensive practical ability in which subject.

There may be several reasons for these results. The first relates to the weakening of humanistic care. In online education, the transmission of knowledge remains, but the humanistic care and emotional communication between teachers and students are weakened by removing the learning activities from reality. In a meta-analysis, Pei et al. (2) found that in online medical education, the humanistic care received by both undergraduates and postgraduates was gradually decreasing. The second reason relates to a lack of self-control. Almost all the students in our study agreed or strongly agreed with the following question: “When you use electronic devices to learn, do you find that you can’t help opening entertainment or non-learning software?”. This suggests that the self-control of both undergraduates and postgraduates is still not ideal. There is seldom supervision in online learning, which may have a negative effect on learning. The third reason relates to the learning atmosphere. Our data showed that most medical students thought that the learning atmosphere of online learning was worse than that of offline learning. We believe that there are 2 main reasons for this. The first reason relates to the reduction in communication with teachers. Our data showed that most students believe that the change in the teacher-student relationship as a result of online learning has had a negative effect on their learning activities. The second reason relates to the absence of mutual learning, as online learning represents a shift from “team” to “individual” learning. We believe that online learning weakens the interaction between medical students and has a negative effect on learning. This has adverse effects on the ability of students to accumulate knowledge at the undergraduate stage and on academic discussion and clinical practice at the postgraduate stage. This has led medical students to feel a low sense of participation of in online classrooms, which in turn has led to lower enthusiasm and concentration. These have had negative effect on learning efficiency and effectiveness. There is currently no formal consensus on students’ sense of participation in online learning (30), but most scholars appear to believe that it is lower for online learning than offline learning.

Online learning leads to a lack of discussion and cooperative learning

Discussion is perhaps the most important element of teaching in higher education. As students develop and are more able to learn by themselves, rigid indoctrination learning is not the best learning method for undergraduates and postgraduates (41). Some scholars believe that experiential learning and cooperation are the most effective learning methods during the resident stage of medical postgraduate education (42). Wang et al. (43) pointed out that problem- and case-based learning, which are both based on the idea of discussion learning, are better for comprehensive learning among medical students than traditional teaching methods. These methods also help to cultivate independent thinking and clinical analysis (43,44). However, most online learning is relatively passive, and involves activities such as consulting materials and watching online courses. Further, online learning tends not to involve active learning methods, such as group cooperative discussion and laboratory practice (45). This undoubtedly has a negative effect on the effectiveness of online learning for medical undergraduates and postgraduates.

Teachers may have problems teaching online

Our research showed that real-time communication with teachers and supervision by teachers had a positive effect on the learning of medical students. This suggests that teachers are very important in the effective learning of medical students. However, medical teachers may find it difficult to adapt to online teaching quickly due to work and other reasons. Many medical teachers have insufficient online teaching experience, and the pandemic has left them with even less time and/or energy to learn new online teaching tools (1,45,46). This has led to a decline in teaching effectiveness.

We compared and analyzed the similarities and differences in attitudes of medical undergraduates and postgraduates to both online learning and offline learning. The 2 groups had similar attitudes toward most problems and issues. We thus believe that medical undergraduates and postgraduates have similar cognitive levels and learning ideas. There are subdivisions of research fields at the graduate stage, but most medical postgraduates and undergraduate share the same broad training objective (to become doctors), and thus often hold similar attitudes. However, there were differences across some individual issues. For example, when asked, “Do you think offline learning helps you to master knowledge better than online learning?”, both undergraduates (5.32) and postgraduates (4.91) agreed (P<0.05). Both undergraduates (5.11) and postgraduates (4.66) also thought that offline learning was more effective than offline learning (P<0.05). We believe that the main reason why medical undergraduates rated offline learning more highly than postgraduates was due to subtle differences in their learning modes and training objectives. Most medical undergraduates are still at a basic stage of learning, and their educational focus is the accumulation of basic knowledge. Conversely, medical postgraduates are more likely to focus on clinical experience and academic thinking and thus need to engage in more reflection and deeper thinking than undergraduates and need a relatively quiet environment. Online learning can meet these objectives. The independent learning atmosphere and the reduction of examination pressure (47) can help medical postgraduates to better acquire resources, think deeply, and reflect. However, as a result of the switch to online learning, medical postgraduates have lost the opportunity to accompany their teachers into workplaces, such as laboratories and wards, and engage in reduced communication with tutors. This has had a negative effect on their ability to develop the clinical skills required by doctors, including the ability to communicate with patients face-to-face (41,48-50).

Conclusions

In conclusion, there is no single form of learning that can meet all the needs of medical education. Both online and offline learning have their limitations, and no single mode can be maximally effective. We are of the view that the best form of medical education is mixed learning that combines traditional face-to-face teaching and online learning (51).

This would provide the original advantages of offline learning, but add the flexibility of online learning, creating a more efficient and convenient education and learning system. Several studies have shown that mixed learning has advantages over online or offline learning individually, and the mixed approach has great potential in medical education (52-57). Online and offline learning should clearly not be viewed as being in competition with one another; rather, they should be viewed as being in a cooperative relationship in which each method compensates for the other’s weaknesses and draws on its own strengths to increase the efficiency and convenience of the learning of all medical students.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-22-5112/rc

Data Sharing Statement: Available at https://atm.amegroups.com/article/view/10.21037/atm-22-5112/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-5112/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Before the investigation and test, the authors ensured that all respondents have provided informed consent. Ethical approval was waived by the ethics committee of the Affiliated Hospital of Qingdao University Ethics Committee, because this study did not involve ethical issues.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)