Abstract
Background
The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial impacts on all aspects of medical education. Modern health systems must prepare for a wide variety of catastrophic scenarios, including emerging infectious disease outbreaks and human and natural disasters. During the COVID-19 pandemic, while the use of traditional teaching methods has decreased, the use of online-based teaching methods has increased. COVID-19 itself and the accompanying infection control measures have restricted full-scale practice. Therefore, we developed an adapted hybrid model that retained adequate hands-on practice and educational equality, and we applied it with a group of undergraduate medical students participating in a mandatory disaster education course in a military medical school.
Methods
The course covered the acquisition of skills used in emergency and trauma scenarios through designated interdisciplinary modules on disaster responses. Several asynchronous and synchronous online webinars were used in this one-credit mandatory disaster and military medicine education course. To allow opportunities for hands-on practice and ensure education equality, the students were divided into 15 groups, with 12 students in each group. The hands-on practice exercises were also recorded and disseminated to the students in the designated area for online learning.
Results
A total of 164 3rd-year medical students participated in this mandatory disaster and military medicine course during the COVID-19 pandemic. The satisfaction survey response rate was 96.5%. The students were satisfied with the whole curriculum (3.8/5). Most of the free-text comments regarding the course represented a high level of appreciation. The students felt more confident in the knowledge and skills they gained in hands-on exercises than they did in the knowledge and skills they gained in online exercises. The students showed significant improvements in knowledge after the course.
Conclusions
We demonstrated that this adapted hybrid arrangement provided an enhanced learning experience, but we also found that medical students were more confident in their knowledge and skills when they had real hands-on practice.
Keywords: Keywords: disaster medicine , medical education , COVID-19 , hands-on practice , experiential learning
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial impacts on the health care system, including all aspects of medical education. 1 The pandemic was declared by the World Health Organization in March 2020. Infection control measures, such as the avoidance of gatherings and social distancing, have certainly changed routines and teaching environments. The necessity for physical distancing disrupts classic resident teaching forums. While some physicians in non-clinical specialties, the least experienced clinicians and medical students have been drafted to combat COVID-19 pandemic, and still some medical students have even been temporarily removed from direct patient care. 2 , 3 Those impacts highlight the urgent need of the incorporation of multidisciplinary disaster medicine education into current medical curricula. Traditional training methods have been gradually replaced by live or asynchronous online modalities. 4 Students on hospital rotations might only be required to complete virtual clerkships and clinical skill assessments and participate in newly created online activities. 2 Recently emerged flipped classroom models and other hybrid modalities can be easily transitioned to an online format, and in-class exercises can be transitioned to video conferences. The preclinical curriculum has also migrated to online learning with evidence of similar or improved learning compared to that in prior years. 5 , 6 Previous studies demonstrated that hybrid models combining distance learning via video technology with small on-site group lessons could be converted to a more integrated education system. 7 , 8
Modern health systems need to have a surge capacity to cope with a wide variety of catastrophic scenarios covering the breadth of disaster medicine, including emerging infectious disease outbreaks and human and natural disasters. 9 During mass casualty incidents (MCIs) or pandemics, an understanding of disaster medicine and the health care system is crucial to successful crisis management and has been recommended as an integral part of the medical curriculum. 10 , 11 We previously conducted a longitudinal, integrated disaster and military medicine education course for undergraduate medical students in a military medical school and found that medical students were highly motivated and actively participated in the course. 12 During the COVID-19 pandemic, while the use of traditional teaching methods has decreased, the use of online-based teaching methods has increased. 13 To overcome the lack of hands-on experience for medical students in this context, online video libraries have been proposed and shown to be useful. 14 - 16 Nonetheless, the level of satisfaction with online-based teaching methods has been found to be significantly lower than that with traditional face-to-face teaching methods. 8 , 13 Experiential learning activities promote learners’ perception of value and improve their ability to manage patients in a disaster situation. 17 - 19 It is reasonable to expect that most disaster medicine education should be immersed in hands-on practice to enhance students’ learning experience. We believe that hands-on practice in disaster medicine would provide an incomparable learning experience for undergraduate medical students. However, the pandemic itself and infection control measures have restricted full-scale practice.
We aim to redesign and evaluate whether a hybrid model that combines asynchronous and synchronous online webinars with small on-site group lessons and hands-on practice for a disaster medicine course could preserve hands-on experience and provide educational equality. We applied it with a group of undergraduate medical students attending a disaster education course and further evaluated the self-evaluation of students’ confidence regarding knowledge and skills between hands-on practice and online teaching.
Methods
Protocols for Teaching Format and Infection Control
This one-credit disaster and military medicine education course is mandatory for this military medical school, along with emergency medical technician (EMT) training and MCI exercise in the summer as the third semester. The learning objective set for this disaster and military medicine education course is to provide undergraduate medical students with knowledge, skills, and confidence in the face of a variety of catastrophic scenarios. The course covered the acquisition of skills used in emergency/trauma/wilderness/environmental/chemical, biological, radiological, and nuclear (CBRN) scenarios through designated interdisciplinary modules on disaster and military responses. 12 In this study, we only retrieved and analyzed the data from the undergraduate medical students who attended the redesigned disaster and military medicine education course. This redesigned hybrid model aimed to provide feasible and real practice and immersive learning experience for the disaster and military medicine course upon restricted teaching resources during a pandemic, i.e., the regulation of traveling, gathering and physical distancing, availability of teachers and instructors and limited teaching space, materials and equipment. Emergency medicine physicians, military EMTs, intensivists, anesthesiologists, surgeons, and tactical combat casualty care instructors, Institute of Preventive Medicine, National Defense Medical Center (NDMC), flight surgeons and nurses, officers and sergeants from Health Service Training Center (HSTC), NDMC and sergeants from 4th Tactical Fighter Wing of Republic of China Air Force formed an interprofessional faculty group to conduct this course. The curriculum schedule is shown in Table 1 .
Table 1 . Schedule of the disaster and military medicine education course .
CRBN: chemical biological, radiological, and nuclear; PPE: personal protective equipment; ROCAF: Republic of China Air Force.
|
Day 1 Trauma care and resuscitation | ||||
|
Time |
Course |
Location |
||
|
10:00–10:50 |
Evaluation of trauma patients |
Online (dormitory) |
||
|
11:00–11:50 |
Wound care and burn injury |
Online (dormitory) |
||
|
Recess | ||||
|
Location |
Trauma sonography |
Orthopedic emergency |
Trauma airway management |
Trauma overview and evaluation |
|
Combat and Disaster Casualty Care Training Center |
1F square |
Room 01 (1F) |
Room 02 (1F) |
|
|
13:30–14:20 |
A |
B |
C |
D |
|
14:20–15:10 |
B |
A |
D |
C |
|
Recess | ||||
|
15:20–16:10 |
E |
F |
G |
H |
|
16:10–17:00 |
F |
E |
H |
G |
|
There are 6 instructors and 16 teaching assistants from emergency medicine physicians, trauma team members, anesthesiologist, and plastic surgeons. | ||||
|
Location |
High-altitude illness |
Heat illness |
Helicopter evacuation |
Evaluation and preparedness for aeromedical evacuation |
|
Room 01 (1F) |
Radiation Emergency Management Center and emergency room, Tri-Service General Hospital |
Combat and Disaster Casualty Care Training Center (1F) |
Room 20 (2F) |
|
We rearranged the disaster and military medicine course that combined asynchronous or synchronous online webinars for lectures, hybrid real practice or online learning for those originally hands-on practice topics and a final small group scenario test. For the lectures in the morning, either asynchronous or synchronous online webinars (depended on the preference of the instructors and other considerations, such as restriction in traveling and the use of mobile devices in some sensitive military camps) were delivered to the students in the dormitory. For the hands-on topics in the afternoon, we first determined the maximum number of students and teachers and the number of available classrooms and teaching equipment during the course period. Universal masking and social distancing are applied as the requirement of Central Epidemic Command Center (CECC) for all the students and teachers during the course. The topics of the hands-on exercises included trauma (sonography, orthopedic emergency, airway management, overview, and evaluation); environmental illness (high-altitude illness and acute heat injury); aeromedical evacuation (preparedness for aeromedical evacuation and helicopter evacuation); and CBRN incidents (decontamination, use of personal protective equipment [PPE], chemical warfare, sampling, and rapid testing for pathogens). The maximum student and teaching staff volume in each classroom to enable the maintenance of adequate physical distance (1.5 meters indoors and 1.0 meter outdoors) was calculated. The students and teachers were all required to wear masks, maintain adequate physical distance, and use the provided disinfection solution. For the techniques, drills and exercises to provide opportunities for hands-on practice and ensure education equality, the students were divided into 15 groups, with 12 students in each group. The hands-on practice exercises were also recorded and disseminated to the students in the designated area (dormitory) to have online learning. Therefore, students engaged in either hands-on practice or online webinar for the same topics. Eventually students would have 2 topics for real-practice and another 10 topics for online learning. Instructors and teaching assistants were at the class to facilitate hands-on practice. A schema of the topics and grouping is shown in Fig. 1 . At the end of the course, students would have their assigned scenario to practice together and have their feed-back. In addition, lectures, group discussions, hands-on practice, and field exercises focused on MCIs were conducted by the HSTC instructors after the course under the regulation of CECC. The study protocol was part of the routine surveys of all curricula. Therefore, the need for consent from the participants was deemed unnecessary according to the regulations issued by the Ministry of Health and Welfare, Taiwan (1010265075C, ).
Fig. 1 . A schema of grouping methods used for increasing the education equality.
Evaluations and Knowledge Tests
The medical students were encouraged to fill out a survey after their completion of the course. The survey questions focused on assessing the students’ subjective evaluations, satisfaction, and experiences of the course training. Students were also asked to indicate their confidence in the abovementioned hands-on practice. Students provided ratings on a 5-point Likert scale (5 = strongly agree, 1 = strongly disagree). The questions are listed in Table 2 . For the knowledge tests, before and after the course, the students were required to respond to 25 multiple-choice questions assessing students’ basic knowledge and their responses related to a given scenario. The evaluation of the students’ self-perceived knowledge and skills in disaster and military medicine before and after the course was based on the topics students who had real practice and those who had only online learning.
Table 2 . Questions assessing the medical students’ subjective evaluations of and satisfaction with the adjusted course during the COVID-19 pandemic .
|
Were you satisfied with the training sites? |
|
Were you satisfied with the content? |
|
Were you satisfied with the interactions? |
|
Were you satisfied with the online learning? |
|
Were you satisfied with the hands-on practice? |
|
Overall, were you satisfied with the whole curriculum? |
|
Were you familiar with the skills and concepts of disaster medicine before? |
|
Did you consider the course to be helpful for developing knowledge in disaster medicine? Did you consider the course to be helpful for developing skills in disaster medicine? Did you consider the online teaching helpful for developing knowledge in disaster medicine? Did you consider the online teaching helpful for developing skills in disaster medicine? |
Statistical Analysis
Continuous data are expressed as the means ± standard deviations and were analyzed using a two-tailed student’s t -test. The results of categorical data are expressed as frequencies (%) and were evaluated using the chi-square test or Fisher’s exact test. The data were analyzed using IBM SPSS Statistics 22.0 (released 2013, IBM SPSS Statistics for Windows, version 22.0; IBM Corp., Armonk, NY, USA).
Results
Evaluations
A total of 173 3rd-year medical students participated in this mandatory disaster and military medicine course during the COVID-19 pandemic. The satisfaction survey response rates were high (164/173, 94.8%). The students’ ratings of their overall satisfaction with the course, the course literature, and their subjective knowledge gains are shown in Fig. 2 . The students perceived that the course significantly increased their knowledge and skills related to disaster medicine ( Table 3 ). They were satisfied with the hands-on practice (3.8/5), online teaching (3.8/5), instructors (3.9/5), interactions (3.9/5), course content (3.8/5), and training site (3.7/5). Most of the students were satisfied with the whole curriculum (3.8/5). Most of the free-text comments about the course expressed a high level of appreciation. Sixty-one percent of the students believed the teaching hours for the whole course to be adequate. The students felt more confident in the knowledge and skills they gained from hands-on exercises than they did in the knowledge and skills they gained through online exercises ( Table 4 and Table 5 ). However, we also observed no significant differences in students’ confidence in the knowledge of high-altitude illness and chemical warfare they gained from hands-on versus online exercises and no differences in their confidence in the skills in the use of PPE and chemical warfare they developed from hands-on versus online exercises. All students completed the pretest and posttest. The results of the pre- and posttests for the disaster medicine course are shown in Figs. 3 and 4. In general, the students showed significant improvements in knowledge and judgment after the course (median score 52 vs. 60, p < 0.05).
Fig. 2 . Summarized results of the voluntary evaluation after the disaster medicine program asking about the medical students’ satisfaction with the program.
Table 3 . Evaluation of the medical students’ self-perceived knowledge and skills in disaster medicine before and after the course (N = 164) .
* p < 0.05.
|
Before |
After |
p |
|
|
Trauma sonography |
|||
|
Knowledge |
2.46 ± 0.79 |
3.50 ± 0.73 |
< 0.001 * |
|
Skills |
1.94 ± 0.78 |
3.23 ± 0.79 |
|
|
Orthopedic emergency |
|||
|
Knowledge |
2.62 ± 0.78 |
3.51 ± 0.68 |
< 0.001 * |
|
Skills |
2.18 ± 0.76 |
3.27 ± 0.70 |
|
|
Trauma airway management |
|||
|
Knowledge |
2.71 ± 0.76 |
3.59 ± 0.66 |
< 0.001 * |
|
Skills |
2.18 ± 0.75 |
3.29 ± 0.73 |
|
|
Trauma evaluation |
|||
|
Knowledge |
2.48 ± 0.73 |
3.50 ± 0.69 |
< 0.001 * |
|
Skills |
2.07 ± 0.79 |
3.27 ± 0.69 |
|
|
High-altitude illness |
|||
|
Knowledge |
2.80 ± 0.69 |
3.51 ± 0.70 |
< 0.001 * |
|
Skills |
2.15 ± 0.77 |
3.24 ± 0.73 |
|
|
Acute heat injury |
|||
|
Knowledge |
3.00 ± 0.67 |
3.61 ± 0.66 |
< 0.001 * |
|
Skills |
2.40 ± 0.86 |
3.40 ± 0.69 |
|
|
Helicopter evacuation |
|||
|
Knowledge |
2.16 ± 0.78 |
3.42 ± 0.75 |
< 0.001 * |
|
Skills |
1.92 ± 0.83 |
3.13 ± 0.83 |
|
|
Preparedness for aero-evacuation |
|||
|
Knowledge |
2.23 ± 0.83 |
3.47 ± 0.75 |
< 0.001 * |
|
Skills |
1.89 ± 0.79 |
3.19 ± 0.76 |
|
|
Decontamination |
|||
|
Knowledge |
2.23 ± 0.75 |
3.40 ± 0.71 |
< 0.001 |
|
Skills |
1.89 ± 0.80 |
3.16 ± 0.72 |
|
|
Personal protective equipment |
|||
|
Knowledge |
2.21 ± 0.79 |
3.71 ± 0.79 |
< 0.001 * |
|
Skills |
1.88 ± 0.80 |
3.51 ± 0.77 |
|
|
Chemical warfare |
|||
|
Knowledge |
2.19 ± 0.81 |
3.38 ± 0.72 |
< 0.001 * |
|
Skills |
1.90 ± 0.83 |
3.15 ± 0.74 |
|
|
Sampling and rapid tests |
|||
|
Knowledge |
2.26 ± 0.84 |
3.36 ± 0.75 |
< 0.001 * |
|
Skills |
1.94 ± 0.83 |
3.15 ± 0.76 |
Table 4 . Medical students’ self-perceptions of knowledge gained during the disaster education course (N = 164) .
* p < 0.05.
|
1 |
2 |
3 |
4 |
5 |
p |
|
|
Trauma sonography, n (%) | ||||||
|
Hands-on |
0 (0) |
5 (14) |
23 (66) |
7 (20) |
0.0000 * |
|
|
Online |
9 (7) |
74 (56) |
42 (32) |
7 (5) |
||
|
Orthopedic emergency, n (%) | ||||||
|
Hands-on |
0 (0) |
8 (23) |
20 (59) |
6 (18) |
0.0010 * |
|
|
Online |
6 (4) |
72 (54) |
50 (38) |
5 (4) |
||
|
Trauma airway management, n (%) | ||||||
|
Hands-on |
0 (0) |
6 (27) |
8 (37) |
8 (36) |
0.0001 * |
|
|
Online |
1 (1) |
76 (52) |
61 (42) |
7 (5) |
||
|
Trauma evaluation, n (%) | ||||||
|
Hands-on |
0 (0) |
1 (4) |
3 (10) |
20 (69) |
5 (17) |
0.0003 * |
|
Online |
1 (1) |
3 (2) |
80 (58) |
48 (35) |
6 (4) |
|
|
High-altitude illness, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
9 (30) |
17 (57) |
4 (13) |
0.1022 |
|
Online |
1 (1) |
5 (4) |
72 (52) |
50 (36) |
9 (7) |
|
|
Acute heat injury, n (%) | ||||||
|
Hands-on |
1 (3) |
6 (18) |
20 (61) |
6 (18) |
0.0026 * |
|
|
Online |
1 (1) |
69 (51) |
56 (42) |
8 (6) |
||
|
Helicopter evacuation, n (%) | ||||||
|
Hands-on |
0 (0) |
1 (3) |
8 (24) |
16 (47) |
9 (26) |
0.0000 * |
|
Online |
2 (2) |
7 (5) |
77 (58) |
44 (33) |
3 (2) |
|
|
Preparedness for aero-evacuation, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
1 (6) |
7 (44) |
8 (50) |
0.0000 * |
|
Online |
1 (1) |
8 (5) |
82 (54) |
54 (36) |
6 (4) |
|
|
Decontamination, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
5 (22) |
15 (65) |
3 (13) |
0.0060 * |
|
Online |
2 (1) |
6 (4) |
88 (61) |
41 (29) |
7 (5) |
|
|
Personal protective equipment, n (%) | ||||||
|
Hands-on |
0 (0) |
8 (24) |
17 (50) |
9 (26) |
0.0263 * |
|
|
Online |
2 (1) |
57 (43) |
62 (47) |
12 (9) |
||
|
Chemical warfare, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
9 (37) |
12 (50) |
3 (13) |
0.1097 |
|
Online |
1 (1) |
8 (6) |
87 (61) |
38 (26) |
9 (6) |
|
|
Sampling and rapid tests, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
6 (30) |
10 (50) |
4 (20) |
0.0254 * |
|
Online |
2 (1) |
9 (6) |
88 (60) |
40 (27) |
8 (6) |
|
Table 5 . Medical students’ self-perceptions of skills gained during the disaster education course (N = 164) .
* p < 0.05.
|
1 |
2 |
3 |
4 |
5 |
p |
|
|
Trauma sonography, n (%) |
||||||
|
Hands-on |
0 (0) |
0 (0) |
11 (31) |
17 (49) |
7 (20) |
0.0000 * |
|
Online |
2 (1) |
18 (14) |
88 (67) |
19 (14) |
5 (4) |
|
|
Orthopedic emergency, n (%) |
||||||
|
Hands-on |
1 (3) |
12 (35) |
16 (47) |
5 (15) |
0.0003 * |
|
|
Online |
14 (11) |
88 (66) |
27 (20) |
4 (3) |
||
|
Trauma airway management, n (%) | ||||||
|
Hands-on |
1 (5) |
7 (32) |
10 (45) |
4 (18) |
0.0055 * |
|
|
Online |
14 (10) |
92 (63) |
32 (22) |
7 (5) |
||
|
Trauma evaluation, n (%) |
||||||
|
Hands-on |
0 (0) |
0 (0) |
10 (35) |
16 (55) |
3 (10) |
0.0006 * |
|
Online |
1 (1) |
12 (9) |
93 (67) |
27 (19) |
5 (4) |
|
|
High-altitude illness, n (%) |
||||||
|
Hands-on |
1 (3) |
11 (37) |
15 (50) |
3 (10) |
0.0002 * |
|
|
Online |
16 (12) |
93 (68) |
20 (14) |
8 (6) |
||
|
Acute heat injury, n (%) |
||||||
|
Hands-on |
0 (0) |
12 (36) |
16 (49) |
5 (15) |
0.0041 * |
|
|
Online |
8 (6) |
84 (63) |
36 (27) |
6 (4) |
||
|
Helicopter evacuation, n (%) |
||||||
|
Hands-on |
0 (0) |
1 (3) |
8 (23) |
18 (53) |
7 (21) |
0.0000 * |
|
Online |
6 (4) |
18 (14) |
90 (68) |
16 (12) |
3 (2) |
|
|
Preparedness for aero-evacuation, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
2 (13) |
9 (56) |
5 (31) |
0.0000 * |
|
Online |
3 (2) |
17 (11) |
99 (66) |
28 (18) |
4 (3) |
|
|
Decontamination, n (%) |
||||||
|
Hands-on |
0 (0) |
0 (0) |
10 (43) |
13 (57) |
0 (0) |
0.0018 * |
|
Online |
5 (4) |
10 (7) |
100 (69) |
23 (16) |
6 (4) |
|
|
Personal protective equipment, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
14 (41) |
13 (38) |
7 (21) |
0.1255 |
|
Online |
2 (1) |
5 (4) |
70 (53) |
46 (35) |
10 (7) |
|
|
Chemical warfare, n (%) |
||||||
|
Hands-on |
0 (0) |
0 (0) |
15 (63) |
7 (29) |
2 (8) |
0.2042 |
|
Online |
4 (3) |
13 (9) |
97 (68) |
23 (15) |
7 (5) |
|
|
Sampling and rapid tests, n (%) | ||||||
|
Hands-on |
0 (0) |
0 (0) |
9 (45) |
7 (35) |
4 (20) |
0.0102 * |
|
Online |
4 (3) |
15 (10) |
100 (68) |
22 (15) |
6 (4) |
|
Fig. 3 . Summarized results of the voluntary evaluation after the disaster medicine program asking about the medical students’ self-evaluation regarding the program.
Fig. 4 . Summarized results of the multiple-choice tests that were performed before (pre) and after (post) the adjusted longitudinal integrated disaster and military medicine program.
Discussion
Owing to the COVID-19 pandemic, a redesigned hybrid model that combined asynchronous and synchronous online webinars with small on-site group lessons and hands-on practice for a disaster medicine course could preserve hands-on experience and provide education equality with adequate satisfaction. Moreover, participating in hands-on practice clearly enhanced the students’ confidence in their knowledge and skills in disaster medicine.
During the pandemic, students’ perspectives about teaching practices have been negatively affected. 20 Herein, we demonstrated another mandatory course that specifically provided another hybrid model to enhance learning experience and education equality for disaster medicine education and highlighted the incorporation of disaster medicine into current medicine courses during the COVID-19 pandemic. Appropriate training for medical students could play an essential role in pandemic management and indicate an effective course and assessment structure for medical student training during the COVID-19 pandemic. 21 The cancellation of routine ambulatory care visits and elective surgeries has dramatically reduced overall clinical volume and, consequently, the number of learning opportunities for trainees in many specialties. 22 To overcome this lack of hands-on experience among medical students, online video libraries have been proposed and shown to be useful. 14 - 16 Before the pandemic, the majority of participants used traditional training modalities, including lectures, grand rounds, and journal clubs; 48% did not use any e-learning. The COVID-19 pandemic resulted in a significant increase in the use of all e-learning alternatives in residency training. 20 The education times for lectures and clinical case discussions decreased during the pandemic, the use of traditional teaching methods decreased, and the use of online-based teaching methods increased. 13 Notably, consistent with our observations, it has been shown that satisfaction levels with online-based teaching methods can be lower than those with traditional teaching methods. 13 Remote objective structured clinical examination has been used to perform summative assessments while saving travel time and costs in response to pandemic restrictions. 23 Previous studies have also indicated that medical students generally believe in the importance of teaching disaster medicine as part of the regular curriculum, that they would like to increase their knowledge in disaster medicine and that they are generally highly motivated to learn disaster medicine. 24 - 26 Consistent with previous studies, our study showed that despite a high willingness to participate in disaster management, the students might not have been well educated regarding such situations. 25 - 27 Consistent with previous study, we found that medical students were highly interested in and appreciated a disaster medicine course and actively participated in hands-on training. However, gaps existed between the students’ scores and the educators’ expectations. 12
This is consistent with some previous studies regarding lower satisfaction in students who received online teaching. 17 , 18 We also found that students were more confident in their knowledge and skills when engaged in real hands-on practice rather than online teaching during disaster medicine education. The integration of disaster medicine education into the medical curriculum has been recommended by the Association of American Medical Colleges and by the federal laws of Germany. 10 , 11 In a survey conducted in medical schools in the United States, only 17.2% of medical students believed that they were receiving adequate education and training for natural disasters. 28 While physicians of all specialties may respond in emergencies, disaster medicine training is still inadequate in most medical school curricula. 29 , 30 Although teaching theory has continued, the surgical training of residents/fellows has been dramatically reduced during the pandemic. 20 The provided “Describe-Demonstrate-Do” model during hands-on practice was highly appreciated by the students. 31 As technology and healthcare systems continue to grow, the use of hands-on surgical simulation could enhance the learning experience. Simulation training improves students’ knowledge and confidence in surgical skills. 32 Early exposure and the incorporation of such simulation programs into medical school curricula may increase interest in pursuing highly specialized surgical specialties, improve skills acquisition, and enable students to be better informed in the selection of future career choices. 33 , 34 Disaster medicine education has long been considered inadequate but also a necessary part of the medical curriculum by both undergraduate medical students and medical experts; in a pandemic situation, flexible and sustainable strategies are necessary to prepare for the future as well as the current situation. 13 , 35 , 36 A shift toward certification programs can alleviate the lack of knowledge and skills and better prepare medical students who will engage in disaster scenarios, e.g., medical students could have been recruited to combat COVID-19 pandemic. 37 Standardized competency-based educational and training programs can ensure that training is based on practices, and policies that meet both the standards of care, disaster preparedness, and surge capacity are needed. 38
However, the generalizability of the results to civilian medical students could be limited, i.e., the study was conducted at a military medical school, and the military medicine training course was scheduled at the time typically used for summer vacation in civilian schools. However, this adjusted hybrid model could be a blueprint for other medical schools. The comparison regarding long-term retention of the knowledge and skills in those who exposure online teaching and real hands-on practice should be further monitored.
In conclusion, we demonstrated that this adapted hybrid arrangement provided preserved hands-on practice and education equality in a disaster medicine education course. Nonetheless, medical students were more confident in their knowledge and skills when they engaged in real hands-on practice.
Conflicts of Interest Statement
The authors declare that they have no competing interests. This study was supported by a grant from the Tri-Service General Hospital, National Defense Medical Center, Taiwan (TSGH-E-111208), Ministry of National Defense-Medical Affairs Bureau (MND-MAB-110-121, MND-MAB-C-11111-111050X) and the Ministry of Science and Technology (MOST 108-2314-B-016-047-MY3).
References
- 1. Dedeilia A, Sotiropoulos MG, Hanrahan JG, Janga D, Dedeilias P, Sideris M. Medical and surgical education challenges and innovations in the COVID-19 era: a systematic review. In Vivo . 2020;34(3 Suppl):1603-1611. doi: 10.21873/invivo.11950 [DOI] [PMC free article] [PubMed]
- 2. Wayne DB, Green M, Neilson EG. Medical education in the time of COVID-19. Sci Adv . 2020;6:eabc7110. doi: 10.1126/sciadv.abc7110 [DOI] [PMC free article] [PubMed]
- 3. Marshall AL, Wolanskyj-Spinner A. COVID-19: challenges and opportunities for educators and generation Z learners. Mayo Clin Proc . 2020;95:1135-1137. doi: 10.1016/j.mayocp.2020.04.015 [DOI] [PMC free article] [PubMed]
- 4. Reinholz M, French LE. Medical education and care in dermatology during the SARS-CoV2 pandemia: challenges and chances. J Eur Acad Dermatol Venereol . 2020;34:e214-e216. doi: 10.1111/jdv.16391 [DOI] [PubMed]
- 5. Ramnanan CJ, Pound LD. Advances in medical education and practice: student perceptions of the flipped classroom. Adv Med Educ Pract . 2017;8:63-73. doi: 10.2147/amep.S109037 [DOI] [PMC free article] [PubMed]
- 6. Woolliscroft JO. Innovation in response to the COVID-19 pandemic crisis. Acad Med . 2020;95:1140-1142. doi: 10.1097/acm.0000000000003402 [DOI] [PMC free article] [PubMed]
- 7. Weissmann Y, Useini M, Goldhahn J. COVID-19 as a chance for hybrid teaching concepts. GMS J Med Educ . 2021;38:Doc12. doi: 10.3205/zma001408 [DOI] [PMC free article] [PubMed]
- 8. Sindiani AM, Obeidat N, Alshdaifat E, et al. Distance education during the COVID-19 outbreak: a cross-sectional study among medical students in North of Jordan. Ann Med Surg (Lond) . 2020;59:186-194. doi: 10.1016/j.amsu.2020.09.036 [DOI] [PMC free article] [PubMed]
- 9. Sarin RR, Hick JL, Livinski AA, et al. Disaster medicine: a comprehensive review of the literature from 2016. Disaster Med Public Health Prep . 2019;13:946-957. doi: 10.1017/dmp.2019.18 [DOI] [PubMed]
- 10. Smith J, Levy MJ, Hsu EB, Lee Levy J. Disaster curricula in medical education: pilot survey. Prehosp Disaster Med . 2012;27:492-494. doi: 10.1017/s1049023x12001215 [DOI] [PubMed]
- 11. Pfenninger EG, Domres BD, Stahl W, Bauer A, Houser CM, Himmelseher S. Medical student disaster medicine education: the development of an educational resource. Int J Emerg Med . 2010;3:9-20. doi: 10.1007/s12245-009-0140-9 [DOI] [PMC free article] [PubMed]
- 12. Tsai YD, Tsai SH, Chen SJ, et al. Pilot study of a longitudinal integrated disaster and military medicine education program for undergraduate medical students. Medicine (Baltimore) . 2020;99:e20230. doi: 10.1097/md.0000000000020230 [DOI] [PMC free article] [PubMed]
- 13. Chang DG, Park JB, Baek GH, et al. The impact of COVID-19 pandemic on orthopaedic resident education: a nationwide survey study in South Korea. Int Orthop . 2020;44:2203-2210. doi: 10.1007/s00264-020-04714-7 [DOI] [PMC free article] [PubMed]
- 14. Porpiglia F, Checcucci E, Amparore D, et al. Slowdown of urology residents’ learning curve during the COVID-19 emergency. BJU Int . 2020;125:E15-E17. doi: 10.1111/bju.15076 [DOI] [PMC free article] [PubMed]
- 15. Mian A, Khan S. Medical education during pandemics: a UK perspective. BMC Med . 2020;18:100. doi: 10.1186/s12916-020-01577-y [DOI] [PMC free article] [PubMed]
- 16. Bittner JG 4th, Logghe HJ, Kane ED, et al. A Society of Gastrointestinal and Endoscopic Surgeons (SAGES) statement on closed social media (Facebook ® ) groups for clinical education and consultation: issues of informed consent, patient privacy, and surgeon protection. Surg Endosc . 2019;33:1-7. doi: 10.1007/s00464-018-6569-2 [DOI] [PubMed]
- 17. Bank I, Khalil E. Are pediatric emergency physicians more knowledgeable and confident to respond to a pediatric disaster after an experiential learning experience? Prehosp Disaster Med . 2016;31:551-556. doi: 10.1017/s1049023x16000704 [DOI] [PubMed]
- 18. Moye PK, Pesik N, Terndrup T, et al. Bioterrorism training in U.S. emergency medicine residencies: has it changed since 9/11? Acad Emerg Med . 2007;14:221-227. doi: 10.1197/j.aem.2006.10.102 [DOI] [PubMed]
- 19. Chou WK, Lin CH, Cheng MT, Chen YC, Shih FY. The value of functional exercise in pediatric mass-casualty incident training. J Acute Med . 2019;9:118-127. doi: 10.6705/j.jacme.201909_9(3).0004 [DOI] [PMC free article] [PubMed]
- 20. Chatziralli I, Ventura CV, Touhami S, et al. Transforming ophthalmic education into virtual learning during COVID-19 pandemic: a global perspective. Eye (Lond) . 2021;35:1459-1466. doi: 10.1038/s41433-020-1080-0 [DOI] [PMC free article] [PubMed]
- 21. Ashcroft J, Byrne MHV, Brennan PA, Davies RJ. Preparing medical students for a pandemic: a systematic review of student disaster training programmes. Postgrad Med J . 2021;97:368-379. doi: 10.1136/postgradmedj-2020-137906 [DOI] [PMC free article] [PubMed]
- 22. Goldhamer MEJ, Pusic MV, Co JPT, Weinstein DF. Can covid catalyze an educational transformation? Competency-based advancement in a crisis. N Engl J Med . 2020;383:1003-1005. doi: 10.1056/NEJMp2018570 [DOI] [PubMed]
- 23. Lara S, Foster CW, Hawks M, Montgomery M. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. Acad Pediatr . 2020;20:760-761. doi: 10.1016/j.acap.2020.05.029 [DOI] [PMC free article] [PubMed]
- 24. Ragazzoni L, Ingrassia PL, Gugliotta G, Tengattini M, Franc JM, Corte FD. Italian medical students and disaster medicine: awareness and formative needs. Am J Disaster Med . 2013;8:127-136. doi: 10.5055/ajdm.2013.0119 [DOI] [PubMed]
- 25. Mortelmans LJM, Dieltiens G, Anseeuw K, Sabbe MB. Belgian senior medical students and disaster medicine, a real disaster? Eur J Emerg Med . 2014;21:77-78. doi: 10.1097/MEJ.0b013e3283643874 [DOI] [PubMed]
- 26. Wunderlich R, Ragazzoni L, Ingrassia PL, et al. Self-perception of medical students’ knowledge and interest in disaster medicine: nine years after the approval of the curriculum in German universities. Prehosp Disaster Med . 2017;32:374-381. doi: 10.1017/s1049023x17000280 [DOI] [PubMed]
- 27. Mortelmans LJM, Bouman SJM, Gaakeer MI, Dieltiens G, Anseeuw K, Sabbe MB. Dutch senior medical students and disaster medicine: a national survey. Int J Emerg Med . 2015;8:77. doi: 10.1186/s12245-015-0077-0 [DOI] [PMC free article] [PubMed]
- 28. Kaiser HE, Barnett DJ, Hsu EB, Kirsch TD, James JJ, Subbarao I. Perspectives of future physicians on disaster medicine and public health preparedness: challenges of building a capable and sustainable auxiliary medical workforce. Disaster Med Public Health Prep . 2009;3:210-216. doi: 10.1097/DMP.0b013e3181aa242a [DOI] [PubMed]
- 29. Walsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep . 2012;6:44-52. doi: 10.1001/dmp.2012.4 [DOI] [PubMed]
- 30. Kommor MB, Hodge B, Ciottone G. Development and implementation of a Disaster Medicine Certificate Series (DMCS) for medical students. Prehosp Disaster Med . 2019;34:197-202. doi: 10.1017/s1049023x19000165 [DOI] [PubMed]
- 31. Chan CY, Lee FY, Chen CH. An effective format for a teaching skills workshop. J Med Educ . 2009;13:133-139. doi: 10.6145/jme.200906_13(2).0007 [DOI]
- 32. Lentz AC, Rodríguez D, Chandrapal JC, et al. Cadaveric laboratory simulation training of male stress urinary incontinence treatment improves trainee knowledge and confidence. Urology . 2020;143:48-54. doi: 10.1016/j.urology.2020.06.008 [DOI] [PubMed]
- 33. Hon NWL, Hussein N, Honjo O, Yoo SJ. Evaluating the impact of medical student inclusion into hands-on surgical simulation in congenital heart surgery. J Surg Educ . 2021;78:207-213. doi: 10.1016/j.jsurg.2020.06.023 [DOI] [PubMed]
- 34. Agyeman KD, Summers SH, Massel DH, Mouhanna J, Aiyer A, Dodds SD. Innovation in orthopaedic surgery education: novel tools for modern times. J Am Acad Orthop Surg . 2020;28:e782-e792. doi: 10.5435/jaaos-d-19-00411 [DOI] [PubMed]
- 35. Altintas KH, Boztas G, Duyuler S, Duzlu M, Energin H, Ergun A. Differences in opinions on disaster myths between first-year and sixth-year medical students. Eur J Emerg Med . 2009;16:80-83. doi: 10.1097/MEJ.0b013e32830a996c [DOI] [PubMed]
- 36. Barrimah I, Adam I, Al-Mohaimeed A. Disaster medicine education for medical students: is it a real need? Med Teach . 2016;38(Suppl 1):S60-S65. doi: 10.3109/0142159x.2016.1142515 [DOI] [PubMed]
- 37. Mincin J, Hansen R. Disaster mental health in higher education: a review. J Emerg Manag . 2019;17:217-224. doi: 10.5055/jem.2019.0421 [DOI] [PubMed]
- 38. Ingrassia PL, Foletti M, Djalali A, et al. Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs. Prehosp Disaster Med . 2014;29:115-126. doi: 10.1017/s1049023x14000235 [DOI] [PubMed]