With the implementation of social distancing measures during the COVID-19 pandemic, virtual educational formats became standard for many internal medicine (IM) residents.1 However, most IM residency programs were not using synchronous virtual teaching previously2 and little is known about residents’ perceptions of the live video conference format. We surveyed our IM residents for their perspectives on live, virtual case-based conferences as compared to the traditional, in-person format, and we used this feedback to make rapid, iterative improvements.
At our hospital, morning report (MR) occurs four times per week and an intern-only conference, or intern report (IR), once weekly—both are led by a chief resident. Early in our local COVID-19 experience, both conferences assembled using ZoomTM, with limited in-person attendance. Residents were encouraged to join the conference from their hospital team rooms, other University of Washington hospitals, or home. At the conferences, case information was written on an electronic whiteboard which was screen-shared with all attendees. Residents participated via microphone or a chat box, moderated by a chief resident or an attending. At least once per conference, trainees were placed into virtual breakout rooms for small group discussion of differential diagnoses, clinical reasoning, and/or management.
To determine residents’ perceptions of these virtual case-based conferences, we developed a brief survey based on prior studies of MR.3 Prior to survey distribution, we tested the surveys with and obtained feedback from three IM chief residents on question clarity and answerability. The survey included an optional free text response for qualitative feedback. We distributed the anonymous, voluntary, 5-item REDCApTM survey at the end of each conference via chat box and institutional email. Trainees were invited to complete the survey after each conference session to share their perceptions of each virtual session. The survey was deemed exempt by the University of Washington IRB.
Thirty-three responses were collected over a four-week period from April through May 2020—22 for MR and 11 for IR. When compared to traditional in-person conferences:
- 24/33 (73%) responses rated the overall virtual MR/IR as “about the same,” while 4/33 (12%) rated it as “better” or “much better,” and 5/33 (15%) rated it “worse” or “much worse”.
- 22/33 (67%) responses rated the learning environment as “about the same,” and 7/33 (21%) rated it “better” or “much better,” and 4/33 (12%) rated it “worse” or “much worse”.
- 18/33 (55%) responses rated personal engagement as “about the same,” 9/33 (27%) rated it “better” or “much better,” and 6/33 (18%) rated it “worse” or “much worse”.
Additionally, most responses (25/33, 76%) “agreed” or “strongly agreed” that that the use of virtual conference features (e.g., virtual breakout rooms, chat) improved the learning experience at MR/IR and 23/33 (70%) indicated a preference for at least some virtual conferences, even when in-person options may be safely resumed.
Twenty-nine of 33 respondents provided qualitative comments, each of which was coded into three different themes: (1) benefits of virtual learning, (2) challenges of virtual learning, and (3) feedback on virtual teaching tools. Forty-five percent of coded comments mentioned the benefit of increased accessibility of conferences and 21% of coded comments provided specific feedback on how to improve virtual technology use during conference. Key representative comments from the three themes included the following:
(1) Benefits of virtual learning:
- “I think that conferences should ALWAYS be offered virtually—mostly for us folks who are at home or in clinic with extra time to spare. Love it!”
- “It’s nice in the virtual mode when we can put stuff in the chat box when we think of it and not interrupt.”
(2) Challenges of virtual learning:
- “As a virtual participant, it can be difficult to know when to jump in with your audio without the in-person cues and view of the whole room.”
- “There’s nowhere to participate except from our team rooms, which makes it very challenging to engage in learning fully.”
(3) Feedback on virtual teaching tools:
- “Having a person running the chat box is really helpful for sorting through comments and allowing the person writing on the board to focus on other teaching things.”
Results of this small-scale survey suggest that our IM residents perceived the learning environment and overall educational quality of our virtual conferences to be similar to pre-COVID in-person conferences. Moreover, most responses noted a preference that conferences include a virtual option even after in-person teaching resumes. Because we desired to obtain residents’ assessment of each conference, they were able to complete the survey multiple times if desired and this may have biased the results. The survey collection period spanned two rotation blocks permitting sampling of different groups of residents. The qualitative comments suggest that this is due to increased accessibility. Residents also had valuable suggestions to improve technology use, allowing us to perform rapid quality improvement iterations of our conferences. For example, we have worked to improve the team rooms as virtual learning spaces and we also now begin each conference by asking residents to enable microphones and video, if they are comfortable doing so. This feedback has helped to hone our virtual classroom, and we continue to elicit resident suggestions as a rich source of future improvements.
The COVID-19 pandemic forced educators to quickly adapt to the virtual classroom. Our survey data provides insight into the benefits and challenges of virtual synchronous learning. The generally positive responses from our residents to the virtual case-based conferences during the COVID-19 pandemic, as well as suggestions for improvement, serve as a good starting point for future adaptations. We are aware that many hospitals, including our own, have now begun to shift to “hybrid” conferences (i.e., in-person plus synchronous virtual attendance). Since our learners desire it moving forward, it is essential that we continue to study the hybrid format and optimize our teaching practices for it.