Online learning improves knowledge

This online module in ENT has shown significant improvements in undergraduate medical students’ subjective confidence and objective test performance. Both content and examination material were aligned to University of Sheffield Medical School curriculum requirements and additionally guided by the Student and Foundation Doctors in Otolaryngology UK handbook.

Confidence in knowledge-based subjects notably improved. Prior to the module in anatomy and ENT conditions, 5 per cent of students rated themselves as ‘fairly confident’ or ‘very confident’; these values improved to 76 per cent and 79 per cent, respectively, after module completion. By comparison, confidence in ENT examinations improved from 7 per cent to only 61 per cent. Other studies utilising online learning for ENT have also shown its efficacy in improving objective knowledge in anatomy and common conditions.^{Reference Pandya, Mistry and Owens7} However, there are no studies on the role of online learning specifically in teaching ENT examinations.

This lower confidence response was noted, and a follow-up face-to-face lecture was delivered on ENT examinations, with good feedback response. This may highlight a potential shortcoming in isolated online learning, and may be a reason to advocate for face-to-face or supplemental teaching in practical skills and clinical examination.

Need for online learning

Limited clinical exposure in ENT has been a long-standing issue for medical students.^{Reference Patel, Saeed and Smith3} A systematic review of ENT teaching in UK medical schools confirmed that low student confidence in ENT was well-documented, and specifically identified limited clinical placement duration as an important factor.^{Reference Ferguson, Bacila and Swamy8} Although an increase in clinical placements would address this, because of curriculum constraints this is not a realistic option, and studies advocate for the use of ‘integrated learning’, including using online learning as an educational tool.^{Reference Ferguson, Bacila and Swamy8}

The Covid-19 pandemic has accelerated the use of online learning across all clinical learning within the medical curriculum. Despite the loss of face-to-face teaching, evidence suggests that students have been broadly satisfied with the use of technology, particularly when used in combination with traditional teaching methods.^{Reference Walker and Stapleton5–Reference Plch6}

Given the importance of ENT in clinical practice, medical students’ lack of confidence and wider curriculum pressures, online learning represents a feasible solution to address this.

Although there is no standardised undergraduate curriculum, given the specialist nature of ENT, it is likely that the required learning objective across UK medical schools will be grossly similar. With the introduction of the UK Medical Licensing Assessment for all medical students from 2022, there is additional pressure to ensure that teaching prepares students for this, and it may homogenise UK medical school curricula.^{Reference Sharma, Murphy and Doody9} Consequently, there may be a role for a standardised UK-wide ENT online package.

Current ENT online learning in medical schools

Evidence from other studies into the strengths of online learning has been largely positive in a variety of topics, including anatomy, clinical skills and examination.

When directly compared with face-to-face teaching, online learning has been shown to be equally effective, although with slightly lower student satisfaction.^{Reference Alnabelsi, Al-Hussaini and Owens10} A systematic review on the use of technology in teaching ENT shows that it may even be more effective than face-to-face teaching.^{Reference Tarpada, Hsueh and Gibber11} There are acknowledged weaknesses when teaching more complex, spatial anatomy;^{Reference Pandya, Mistry and Owens7} however, when online learning is used in addition to traditional methods, it has superior effects in terms of both confidence and objectively measured test performance.^{Reference Chin, Tjahjono, Rutledge, Lambert and Deboever12}

This evidence supports the use of online learning as an effective method of delivering education, which can be used either as a direct replacement for face-to-face teaching or, more successfully, as part of an integrated teaching methodology.

Alternatives to online learning

Near-peer teaching models have also been shown to significantly improve both confidence and assessed knowledge in ENT anatomy.^{Reference Schuster-Bruce, Davies, Conchie, Penfold, Wilson and Waddell13} This can be an alternative, resource-friendly approach to address curricular constraints, whilst also offering face-to-face learning.

Despite concerns over Covid-19 transmission, patients seem happy to participate in face-to-face learning with medical students in ENT, reporting a 95 per cent comfortable rate despite Covid-19.^{Reference Patel, Gera, Lozidou, Hannan and Saeed14} Additionally, most patients report being happy to participate in remote learning by being recorded and included as part of a virtual clinic or ward round – a technological solution to reduce contact in light of the pandemic.

A US multi-centre project compiled a mixture of videos, case-based discussions, podcasts and online learning in response to reduced ENT exposure during Covid-19.^{Reference Ruthberg, Quereshy, Ahmadmehrabi, Trudeau, Chaudry and Hair15} This aimed to comprehensively cover all major aspects of clinical ENT, surgical procedures, clinic work, and the diagnosis and management of common conditions. This, again, is to be used in collaboration with practical exposure, but is a realistic option for medical schools with no formal ENT placements.

Simulation

Use of physical models within ENT has good evidence of efficacy, particularly for practical examination and procedural skills. This can include mannequins to practise otoscopy, flexible nasendoscopy and micro-suctioning,^{Reference Bhalla, Beegun, Awad and Tolley16} as well as models for practising surgical techniques.^{Reference Musbahi, Aydin, Al Omran, Skilbeck and Ahmed17} This is relatively resource-friendly and is a common mode of teaching introductory procedural skills such as otoscopy.

Simulation has expanded significantly with the introduction of virtual reality. This concept combines physical anatomical models, often three-dimensionally printed, with augmented reality headsets. This allows students to ‘operate’ in a virtual environment, emphasising the visual-motor skills required in a low-fidelity environment. This novel tool has been shown to be effective in teaching ENT skills in temporal bone, endoscopic sinus, and open head and neck surgical procedures.^{Reference Maniam, Schnell, Dan, Portelli, Erolin and Mountain18–Reference Al Janabi, Aydin, Palaneer, Macchione, Al-Jabir and Khan20} Wider use of augmented reality at undergraduate level has included bedside teaching and anatomy, with good results.^{Reference Stojanovska, Tingle, Tan, Ulrey, Simonson-Shick and Mlakar21–Reference Rafi, Stackhouse, Walls, Dani, Cowell and Hughes22} Such simulation is currently limited by cost and resource requirements; however, it could represent the future of ENT and generic medical teaching.

Limitations

This was a single-centre study with a relatively low number of participants. Our objective assessment tool would ideally have been taken from summative examination data rather than our own written test. Furthermore, we were only able to include data from participants who had completed the module; therefore, the more driven students may have skewed our data. Additionally, examination technique would be best assessed via the Objective, Structures, Clinical Examination format rather than multiple choice examination, and would corroborate the findings of our Likert scales.