Socially distanced, virtually connected: Faculty and resident perceptions of virtual didactics

Abstract

Background

During the COVID‐19 pandemic, emergency medicine (EM) residency programs have transitioned from traditional in‐person to virtual synchronous didactics to comply with social distancing guidelines. This study explores the perceptions of EM residents and faculty regarding this new virtual format.

Methods

This was a multicenter, cross‐sectional study at five EM residencies using a mixed‐methods approach to investigate resident and faculty perceptions of virtual didactics. Institutions selected reflect different program lengths and geographic locations. Quantitative data measured on a Likert scale were summarized as percentages. Differences were calculated using Welch's t‐test and chi‐square, where p < 0.05 was significant. Open‐ended responses were analyzed qualitatively.

Results

Our response rate was 64% (n = 141) for residents and 48% (n = 108) for faculty. Fifty‐one percent of faculty and 54% of residents felt that they were more likely to attend virtually than in person. Among residents, 77% felt that they were more likely to attend virtual conferences during vacation or elective rotations. Perceived retention of information from virtual sessions was perceived to be the same or better for 69% of residents and 58% of faculty. Residents felt that they paid more attention in the virtual format (29% vs. 26%, p = 0.037). Both groups missed the social interactions of in‐person conference (86% of faculty, 75% of residents). Respondents from both groups felt that < 20% of total didactic time should remain virtual once social distancing recommendations are lifted. Qualitative analysis revealed recommendations from residents and faculty to optimize lecture style and interactivity. Decreased commute time and ability to multitask at home increased wellness for both groups.

Conclusions

While benefits of virtual didactics were acknowledged, residents and faculty missed the social interaction of in‐person conference and preferred < 20% of future didactics to be virtual. Further research should assess the difference in knowledge acquisition and retention between conference models.

INTRODUCTION

During the 2019 to 2020 and 2020 to 2021 academic years, graduate medical education faced unprecedented challenges due to the coronavirus pandemic (COVID‐19). Social distancing recommendations ¹ impacted medical education in a number of ways, including the need to transition all in‐person didactic activities to a virtual format. ² This transition occurred similarly throughout emergency medicine (EM) residency education, with the majority of didactics converted to video communication platforms with participants logging in remotely. ³ , ⁴

There are conflicting opinions on the impact of a virtual teaching format on the adult learner. Those opposing virtual learning platforms raise concerns regarding active engagement and losing a sense of community that is an important component of knowledge acquisition. ⁵ Proponents of online learning platforms report that it is possible to emulate the sense of community seen in a traditional classroom, which may foster similar feelings of connectedness and increased knowledge retention. ⁶

Given the widespread use of virtual didactics during the pandemic and their potential continued use in the future, it is important to understand the perceived impact of this format on resident and faculty physicians. The goal of this study was to explore the perceptions of EM residents and faculty regarding online synchronous didactics.

METHODS

This was a cross‐sectional, multicenter, survey‐based study using a mixed‐methods approach to investigate the perceptions of EM faculty and residents regarding virtual synchronous didactics. It was reviewed by the institutional review board at Yale University School of Medicine and deemed exempt.

Study subjects

The study was performed at five EM residencies intentionally selected to represent the major geographic regions of the United States with a mix of 3‐ and 4‐year residency programs. Emails were sent to all EM faculty and residents at the participating institutions, inviting them to participate in the study. Reminder emails were sent on a weekly basis for three total emails. Surveys were anonymous with each respondent creating their own unique identifier code to avoid duplicate data entries. Participants received no incentive for participation. Study investigators at each institution were excluded from participation.

Survey design

Utilizing best practice recommendations, we began the survey design process by performing a literature search followed by internal discussion of conference experiences. ⁷ The survey was iteratively revised by the study team through discussion until consensus was reached and was additionally reviewed by a statistician with expertise in survey design at the primary investigation site. It was then piloted with EM resident and faculty members to assess response process validity. The members of the pilot group and study team were not included in the survey responses. The final surveys consisted of 20 questions for faculty and 24 questions for residents (Data Supplement S1, Appendix S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10617/full). Surveys were distributed simultaneously at all sites to both subject groups on a weekly basis from November 17, 2020, to December 17, 2020.

Data analysis

Data were exported to R (R Studio, Version 1.0.136, 2016) for quantitative analysis. Descriptive statistics were presented as proportions and percentages. We evaluated differences using the Welch's t‐test and chi‐square test, where p < 0.05 was considered statistically significant.

Qualitative analyses were performed using the Framework Method: a systematic approach for research teams where not all members have previous experience conducting qualitative research. The Framework Method allows multiple researchers to work together to produce highly structured output of qualitative data. ⁸ Based on this model, three authors performed the initial coding and framework development (AT, KG, MG). One coder (MG), with formal training and experience in qualitative methodology, trained two additional coders (AT, KG). The two coders were associate program directors involved in conference planning while the third coder was not involved in conference planning. The two coders independently read through the entirety of qualitative data collected and developed a “code” (or label) for each statement. They then came together and, through an iterative process, ensured that each subject statement was coded consistently. Thematic “saturation” was reached when no additional codes needed to be added, although the total number of subjects was determined by the concomitant quantitative component. After the code was developed, all three coders engaged in exercises of reflexivity by considering their different perceptions and contextual factors. All three coders reviewed the coded responses collaboratively until preliminary conceptual categories were identified. The codes were then organized into themes and subthemes. All three coders reviewed and interpreted the results in their entirety, establishing the final language for their themes and subthemes. All disagreements were resolved by discussion until consensus was achieved. One investigator then charted the data in the framework by placing each subject statement into a subtheme. Each subject statement was placed into one or multiple subthemes. There were no statements that did not fit into at least one subtheme.

RESULTS

The survey was distributed to 220 residents and 223 faculty members (Table 1); 108 (48.4%) faculty and 141 (64%) residents completed the survey. One resident response was submitted twice, and the second response was excluded from analysis. A total of eight individual questions were left blank and were excluded from the denominator when calculating percentages (Appendix S2).

TABLE 1.

Program Information

Institution	U.S. region	Program length	Number of faculty	Number of residents
UCSF Fresno	West	4	41	44
University of Rochester	Northeast	3	70	42
Rush University	Midwest	3	43	36
University of Arkansas	South	3	24	30
Yale University	Northeast	4	57	69

Quantitative data

In evaluating likelihood of didactic attendance, 67% of faculty and 54% of residents felt that they were more or much more likely to attend virtual over in‐person conferences. Furthermore, 77% of residents felt that they were more or much more likely to attend virtual didactics when not required to (e.g., vacation or while on electives) than they would in person (Figure 1).

FIGURE 1.

Quantitative data: survey responses of residents and faculty to Likert‐scale questions

Both groups’ perception of ability to participate (e.g., ask questions and make comments verbally or via chat function) was not affected by the format, with one‐third of both groups stating that they were equally likely to participate (faculty 39.3%, residents 34.8%). Nearly half (45.7%) of residents felt equally comfortable participating during both formats. The majority of residents felt that faculty effectiveness in answering questions was the same or better (77%), faculty engagement was the same or better (82.5%), and faculty attendance was the same or better (92.6%). Both groups, however, felt that virtual format was either less or much less conducive to open discussion (faculty 61%, residents 51.4%) than in person. Approximately half of respondents from both groups felt that retention of information was the same (faculty 53.3%, residents 49.3%) in both formats (Figure 1).

Self‐reported ability to pay undivided attention differed among faculty and residents. While in both formats, both residents and faculty admit to being about to pay “undivided attention” for less than half the time; a significant percentage of residents reported that they were able to pay more undivided attention during virtual than in‐person didactics (virtual 29.0%, in person 25.9%, p = 0.037). Faculty felt that their ability to pay attention was similar in the two formats (virtual 19.8%, in person 18.2%, p = 0.22; Figure 2).

FIGURE 2.

Perceived ability (% of time paying undivided attention) to pay undivided attention by faculty and residents during virtual compared to in‐person didactics

Both groups of respondents missed or very much missed the social interaction afforded by in‐person didactics (faculty 86%, residents 75%; Figure 1). Looking forward, once social distancing needs are no longer a concern, both residents and faculty would like less than 20% of didactics to be in a virtual format, with faculty preferring significantly fewer virtual sessions than residents (faculty 11.84%, residents 15.74%, p = 0.0008; Figure 3).

FIGURE 3.

Preferred percentage of future (postpandemic) didactics to remain virtual

Qualitative data

Five themes and 15 subthemes were identified from the resident and faculty responses to the free‐text portion of the survey (Table 2).

TABLE 2.

Qualitative analysis themes and subthemes

Theme	Subthemes
Lecture format/style	Lecture style and small‐group learning
	Active participation and chat function utilization
	Shorter lectures and increased break frequency
	Access to external speakers
Virtual didactics as a medium	Camera use
	Chat function and online material access in real time
	Mute function
	Speaker–audience interaction
	Inadequacy of hands‐on learning
Convenience and wellness	Commute time elimination
	Improved wellness through increased sleep
	Ability to participate at otherwise inopportune times
	Recording capabilities
	Ability to multitask
	Loss of social interaction
Safety and decreased risk of infection
Looking to the future post–COVID‐19 social distancing recommendations

Theme 1: didactic lecture format/style

Both groups identified the need to revise lecture style to align with the virtual format instead of simply presenting the in‐person format virtually. They also recommended an increase in small group discussions to increase engagement.

Format is limited, less [PowerPoints] and more Creative use of technology. [resident]

Formats need to change, virtual presentations are less engaging and talks previously [derived] for in person need to be adapted for a more immersive format. [faculty]

The respondents discussed the need for increased interactivity and engagement, pointing to the chat function as a possible way to do so. However, the responses varied, with some feeling more comfortable interacting via this function than they would during in‐person lectures, while others found it less conducive to interaction.

… I love the chat function and the discussion that goes on there. I think it really augments the learning from lectures. [resident]

… Personally more comfortable participating virtually than in person. [resident]

… I feel uncomfortable asking/responding to questions as it feels more like a stage and less like a discussion …. [resident]

Virtual can be good when people know each other on the call and feel comfortable speaking up …. [faculty]

To adapt to the virtual format, many felt that the lecture time should be shortened and more breaks added in an attempt to reduce the detrimental effects of continuous screen time.

… It’s just hard to pay attention to a screen for a long time. [resident]

… more 15‐20 minute type sessions with breaks every half hour. [faculty]

The ease of recruiting guest lecturers was noted as a benefit of the virtual format.

Incorporating more outside lecturers [is easier]. Since the barrier to entry (travel) is much lower, we can get content experts. [resident]

Very helpful for recruiting and engaging outside speakers where travel and cost may be prohibitive. [faculty]

Theme 2: virtual didactics as a medium

There were varying opinions regarding the effect of camera use in both groups. Some stated that camera use increased accountability and engagement, whereas others felt it to be a distracting aspect of virtual didactics.

I like keeping my camera off. I feel like I pay more attention to what is said when I’m not worried about whether it looks like I’m paying attention …. [resident]

I think cameras on is helpful. [resident]

Make it mandatory that everyone has their camera on for improved participation and attention. [faculty]

The chat function and the ability to simultaneously access supplemental materials online was another positive feature of virtual didactics. Several participants also noted that viewing a lecture online allowed for more convenient note taking.

It is easier to quickly look things up during virtual didactics ….[resident]

Foster more conversation through use of the chat, this is the unique added value in the virtual format. [faculty]

Can take notes faster and screen shot slides. [resident]

… [virtual didactics allows] improved ability to read/research related material to close knowledge gaps. [faculty]

Respondents identified personal backgrounds as a source of distraction. The mute function was thought to decrease distraction but also to hinder interactivity of the lectures.

… I actually find it way more distracting. Half [of] our residents have babies who they show on their video feed and then the group chat turns into a discussion of how cute the babies are which is super distracting. [resident]

More use of forced muting of all participants. [faculty]

When possible, participants should stay unmuted so an actual conversation can occur. [faculty]

Both groups recognized that the virtual format can be difficult for the presenter due to reduced participant engagement and increased difficulty to gauge the audience.

I think a lot of presenters find it uncomfortable/less rewarding. [resident]

It's more fun to present a talk to a live group where you can “read” the room …. [faculty]

The virtual medium was found less effective for hands‐on teaching sessions such as procedure labs, ultrasound, and simulation education.

… have barely done any hands‐on/procedural/ultrasound/sim activities as part of conference this year relative to past years, couldn't do cadaver lab this year. [resident]

Theme 3: convenience and wellness

The elimination of commute time allowed for increased attendance and time for wellness.

Better work–life balance with some pretty big savings on travel time … better attendance. [resident]

Increased sleep was also discussed as a major benefit of virtual didactics over in‐person lectures.

… the sleep time saved in commuting alone is more than worth it …. [resident]

Not having to be present in person allowed for increased overall attendance. Those who were out of town, postovernight, between meetings, on vacation, or on electives could attend when they wouldn't have been able to in person.

… more willing to attend when off service or [on] vacation …. [resident]

Better attendance, especially faculty. [resident]

So much easier to schedule other meetings and make it for partial sessions if you can't make the whole time … much more flexible. [faculty]

Virtual lectures’ ease of recordings increased convenience for those who could not attend synchronously and allowed the presenter to prerecord some session segments in case of technological issues.

Access to session recordings [would be an improvement]. [resident]

… can prerecord some material and display easily. [faculty]

Virtual didactics also allowed participants to perform concurrent household responsibilities (e.g., childcare, cleaning, cooking). While some saw this as a benefit, and even reported that it increased their ability to pay attention, others felt that this contributed to increased distractions.

Sometimes doing things with my hands ‐ folding laundry, cleaning dishes, helps me keep my mind clear in a weird way. Often [this is] how I already study at home. [resident]

Being able to exercise, which actually makes me pay attention more. It's like listening to a podcast when I run, and there are no other distractions. [resident]

Distractions at home (childcare for me at home, but if not I wouldn’t attend at all some days) …. [faculty]

Easier to be distracted with other work. [faculty]

A significant drawback of virtual didactics was the loss of social interactions that accompanies in‐person didactics.

Less interaction with co‐residents (haven't gotten to know the interns as well this year because of this). [resident]

Less social bonding, less attending/resident interaction. [faculty]

Theme 4: safety and decreased risk of infection

Respondents identified the benefit of decreased infection risk due to virtual didactics.

Don't have to worry about coming into the hospital on days off, less likely to spread COVID‐19. [resident]

No infection [risk] with a potentially deadly disease. [resident]

Theme 5: post–COVID‐19 social distancing recommendations

When asked how to proceed once social distancing recommendations are lifted, respondents pointed to the possibility of a hybrid model: preserving some virtual didactics while transitioning back to an in‐person format.

I highly support virtual conference as a way to combat exhaustion and burnout among EM residents … the impact [on exhaustion] is MUCH less with virtual conference. This is a great step for EM. [resident]

I think for passive conferences, it's better done virtually. (also saves an hour of time getting ready and traveling). For hands‐ on seminars, sim, workshops, procedural conference, it is better done in person. [resident]

Splitting it up throughout the year is a great idea. [faculty]

DISCUSSION

This study is the first, large, multicenter assessment of the perceptions of virtual conference among EM residents and faculty. One prior study of EM and internal medicine residents at a single program, conducted during the first few months of transition to virtual format, demonstrated a preference for in person over synchronous online didactics. ⁹ Our study evaluates a much larger sample of EM residents, from a cross‐section of diverse programs including 3‐ and 4‐year residencies representing multiple regions of the United States, making the outcomes more generalizable. Our study was conducted 8 months after the transition, allowing further time to adjust and more experience with the virtual format. In addition, it is the first to examine the attitudes of both EM residents and faculty, as both are key end‐users of this format.

Overall, we found the likelihood of attendance was greater for virtual conferences for both faculty and residents, due to ease of access, convenience, and diminished barriers such as commuting. Residents felt that faculty were actively involved in their virtual didactic experience, with most perceiving faculty engagement, attendance, and ability to effectively answer questions to be the same or improved compared to in‐person format. While residents and faculty alike critiqued the limitations of the virtual format, particularly the opportunity for open discussion, most felt that they were just as or more likely to participate in didactics and retain the material as in person. Additionally, residents felt that it was easier to access supplemental resources. These findings align with previously published work citing increased convenience and flexibility of virtual didactics in EM education as well as its drawbacks of lack of social interactions, significant reduction of hands‐on learning opportunities, and decreased engagement. ¹⁰

Distractions were perceived to be higher in the virtual format. More residents felt they paid less or much less attention during virtual than in‐person didactics, consistent with the increased use of electronic devices for nonprofessional purposes. When specifically asked about paying undivided attention, less than 30% of both faculty and residents reported doing so during either format of didactics. However, comparing the two formats, residents perceived paying more attention during virtual than in‐person didactics. However, it remains unclear whether undivided attention is essential, as one study of EM residents found that performing basic tasks, such as driving, while engaged in learning did not impact knowledge acquisition or retention compared with undivided attention. ¹¹ This was echoed by several resident comments in our study stating that doing tasks such as laundry or exercise increased their ability to focus. While this sentiment is reassuring, it is important to note that the medium of synchronous video lectures is not meant to be purely auditory and the comparison to an auditory medium (such as podcast) needs to be further evaluated. Specifically, the perceived ability to pay attention or retain information may be biased based on experience with purely auditory formats and differ from actual. While these endpoints have been studied for auditory media, ¹¹ further investigation is needed to draw conclusions regarding synchronous video lectures.

Qualitative comments on the format of virtual didactics are consistent with previous critiques of EM didactics. ¹² , ¹³ , ¹⁴ As has been previously shown, EM residents may benefit from shorter, more interactive lectures. ¹² This paradigm shift was already in motion prior to the pandemic. ¹³ Previously published best practice guidelines for didactics in EM include “real‐time video conferencing [as a way] to improve access and attendance.” ¹⁴ Virtual conference falls in line with this recommendation. Implementation of online didactics may have amplified the need for format changes that have been ongoing.

From a wellness perspective, most people missed the social interaction associated with in‐person conferences. This may reflect the importance of periconference interaction with colleagues, residents, and faculty alike, as an opportunity for peer connection, informal mentorship, and networking. ¹⁵

In general, we found a mixed response to virtual conferences with some distinct benefits (e.g., convenience, attendance, wellness), as well as some limitations (e.g., more distractions, reduced social interactions). Thus, it is not surprising that residents and faculty proposed a hybrid model with components of both in‐person and virtual conference once the pandemic is controlled. A hybrid format may allow a balance of the benefits and limitations of each approach. Future studies should evaluate the impact of virtual versus in‐person conferences on knowledge acquisition and retention, as well as best practices for increasing the effectiveness of virtual conferences. Given the impact of COVID‐19 on social interactions, it would be important to assess whether the concern over reduced social connections persists once social distancing outside of conferences is no longer in place.

LIMITATIONS

We conducted our survey 9 months into the COVID‐19 pandemic in the United States. Therefore, the data are a reasonable representation of resident and faculty sentiment over half a year into the experience of social distancing and virtual teaching. The diminished opportunity for social interaction and prolonged exposure to a relatively uniform format of weekly didactics may have affected the perceived experiences and, therefore, reported preferences for future learning formats. Conversely, with more time and opportunity to hone the format, perhaps improvements to the experience would alter the results. A repeat study is needed to assess this question.

While the resident response rate was substantial (64%), the faculty response rate was lower (48.4%). Data show a decreasing response rate to email surveys across the United States since the 1980s with a mean email survey response rate of 36%. ¹⁶ Our study exceeds this rate and utilized purposeful site selection by location and program length to increase representativeness. Nonetheless, our sample size is relatively small, including only five institutions at academic medical centers and so may not be reflective of experiences at all residencies.

Finally, the authors did not separate the resident responses by postgraduate year (PGY) level. There may have been differences in perception of the virtual didactics based on baseline knowledge (with lower PGY level having more knowledge gaps to fill) and established social relationships (with higher PGY level having preexisting social connections).

CONCLUSION

In light of both the quantitative and the qualitative responses of the study groups, virtual didactics are, in many ways, perceived to be at least as good as in‐person didactics, though with several key drawbacks. There is a desire from both residents and faculty to keep at least a portion of conference virtual moving forward. While hands‐on sessions such as simulation, procedure lab, and ultrasound training should remain in person, there is potentially a role for virtual didactics in the future of emergency medicine residency training.

Supporting information

Data Supplement S1. Supplemental material.

Tsyrulnik A, Gottlieb M, Coughlin RF, et al. Socially distanced, virtually connected: Faculty and resident perceptions of virtual didactics. AEM Educ Train. 2021;5:e10617. 10.1002/aet2.10617