Heterogeneity in strategies to maintain the teaching activities during SARS-CoV-2 pandemic

During the SARS-CoV-2 pandemic, the training of medical students was severely disrupted. Government authorities imposed a second national lockdown, which lasted from December 2020 to May 2021, forcing medical schools to adapt their teaching strategies. Several surveys have assessed students’ perspectives, but there is limited data available to objectively assess and compare different strategies between medical faculties. The aim of this study was to evaluate the lecturer-based perspective to assess the impact on the theoretical and practical education of medical students before and during the second lockdown. We developed a questionnaire focusing on theoretical and practical training during pandemic before and during the second lockdown. The questionnaire was sent by personal invitation in January 2021 to all responsible lecturers of gastroenterology and hepatology departments at university hospitals in Germany. The complete response rate was obtained from 52.5% (21/40) teaching centres representative of all regions in Germany. While the majority of respondents (62%) reported a limited impact of the lockdown on theoretical training, 90.5% reported a significant impact on practical training during the SARS-CoV-2 pandemic response. Several centres adapted virtual or hybrid education early during the pandemic, bedside teaching was down to 38.1% (8/21), particularly for students in the early phase of education, suggesting a substantial long-term impact on students' skills. Our questionnaire-based data provide one of the first systematic evaluation of faculty-based assessments of the potential impact of the pandemic during lockdown on medical education. We observed considerable heterogeneity in strategies for maintaining teaching activities during the SARS-CoV-2 pandemic in Germany.


Introduction
The SARS-CoV-2 pandemic has been a challenge for almost all sectors, including education, over the past three years.During the first wave of the pandemic in 2020, when knowledge and resources were limited, many countries and authorities, including Germany, implemented nationwide lockdowns.In particular, teaching activities were massively affected by the measures.Universities were required to reorganise their curricula and teaching formats to meet the pandemic-related measures.These changes were continuously adapted to the regional severity of the pandemic.Despite the considerable knowledge gained, further research on the potential impact of these strategies on the long-term practical skills of medical students and on the comparison of different strategies by medical faculties is needed.
Medicine is probably one of the most challenging areas of education to implement new teaching methods, as it involves not only theoretical content, but also practical skills in dealing with a particularly vulnerable group, the patient, which could make changes in teaching methods especially challenging.In particular, practical training and bedside teaching require a strict approach to hygiene so that neither patients, staff nor students are put at risk.Nevertheless, patient contact is viewed as the most important part of education to be maintained during the SARS-CoV2 pandemic [1].The early part of 2020 was challenging due to global shortages of hygiene products, especially masks, and limited knowledge of virus transmission.By late 2020 and early 2021, considerable knowledge had been accumulated and new teaching approaches had been implemented.For example, in ophthalmology, an online examination course was introduced, with a high level of student satisfaction [2].Even before the pandemic, the concept of online teaching had already been successfully tested [3,4].
However, an overview of the strategies used to implement teaching formats in the 2020/21 winter semester and the strategies used by medical faculties has yet to be systematically investigated.Some studies indicate a rapid shift to virtual formats, especially in the case of lectures and seminars [5].Not only did the faculties face unexpected challenges, but so did the medical students, who may have suffered from a lack of interaction in the classroom as well as technical difficulties [6].In one study, teaching coordinators in Germany reported few or no technical problems [7].
The aim of this study was to assess the impact of the pandemic on the theoretical and practical education of medical students in the clinical phase of their training, as well as to compare the teaching strategies in the clinical teaching departments of medical faculties in Germany before and during the nationwide lockdown.With this rationale, we conducted a survey of teaching staff on their assessment and strategies.The questionnaires included information on teaching modalities for different courses, such as lectures, seminars and bedside teaching or block teaching, but also the conduct of exams and the possibility for students to use the cafeteria or libraries.

Methods
A digital survey was developed to analyse the view of lecturer on the teaching situation in the winter semester of 2020 during the SARS-CoV2 pandemic in Germany (Fig. 1A).The questionnaire was expanded to include comparison from before and during the second lockdown in order to adapt to the evolving situation during teaching.The invitation to participate in the survey was sent electronically to all teaching departments of gastroenterology and hepatology at state and private teaching universities in Germany, as representative clinical institutions responsible for all phases of training in Germany.The questionnaires were sent to the heads of the departments.
We received 22 responses with 21 completed questionnaires.One of these responses came from a private medical school.Of these 21 responses, 9 came from universities with model courses.The overall response rate in the period from 8 February 2021 to 15 March 2021 was 55.0% (22/40).Of these, 21 questionnaires contained a complete data set that could be used for analysis and were representative of the clinical departments of gastroenterology (and/or hepatology and/or infectious diseases) in the medical faculties of state universities.The distribution of participating universities across the Federal Republic of Germany was homogeneous (Fig. 1B).The full survey is available as Supplementary information.The first section, "Lectures and seminars", dealt specifically with the implementation of teaching formats before and during the lockdown.The questions were about the more specific strategy, i.e. whether lectures were delivered in person, as a hybrid version, recorded, annotated in Portable Document Format (PDF), or in a live online format such as Zoom.The second part of the survey, entitled 'Courses' , examined the implementation of block teaching and bedside teaching.This focused on the implementation of safeguards, such as the use of masks, rapid antigen tests and triage of students.
The internships and the practical year were examined in more detail in the third section.In addition to the safeguards mentioned in the previous section, universities' examination strategies and possible restrictions for students on placement were also reviewed.In the final section, 'Other issues' , academic supervisors were asked about the quality of teaching and the environment for medical students, including whether access to canteens, libraries and skills labs was possible before and during the second lockdown.

Statistical analysis
The SoSci survey software (Leiner, 2019) was used to collect the data.The completed questionnaire was sent to the participants via email as a hyperlink to the server "http:// www.sosci survey.de/".The evaluation was done using the tabular form provided by SoSci Survey.It was calculated using Microsoft Excel 2019 (Washington, USA).GraphPad Prism 9.0.0 (California, USA) was used to create the graphs.

Results
The overall response rate from all teaching institutions was 55.0% (22/40).A complete dataset was available for 21 centres, only 52.5% of the questions were included in the final analysis.For the sake of clarity, the following parts are divided into the thematic sections of the survey.The second lockdown in Germany, having been extended several times, lasted from 15 December 2020 until the beginning of May 2021.The questionnaire distributed in February 2021 was designed to compare the implementation of teaching in the winter term 2020 before the lockdown, i.e. the period from the beginning of October 2020 to 15 December 2020, and during the lockdown until the end of the winter term in March 2021.

Lectures and seminars
According to the data obtained, only some of the lectures had been transferred to virtual mode or digitised at the beginning of the winter semester.42.9% (9/21) of respondents stated that lectures were still being held in person until the start of the second lockdown.During the lockdown period, face-to-face lectures were completely discontinued and transferred to digital formats, mostly in the form of live online lectures (71.4%, 15/21).The so-called hybrid variant, in which a small number of alternating students could attend the lecture on site and the majority online, was hardly ever used.
Overall, respondents were asked to give their assessment of the quality of theoretical education during the pandemic.38.1% (8/21) of respondents partially or strongly agreed that theoretical education is affected during a pandemic, while 61.9% (13/21) of respondents disagreed (Fig. 2).

Block internship and bedside teaching
Bedside teaching, which involves direct patient contact, is the key element of medical student education and is therefore likely to have been severely affected by the restrictions, particularly by the lockdown, during the pandemic.Before the second national lockdown, 76.2% (16/21) of respondents offered face-to-face bedside teaching, including hybrid teaching, which was offered by 28.6% (6/21) of departments.During the second lockdown, face-to-face teaching was reduced, with 38.1% (8/21) of institutions still active.Live online teaching was offered by 52.4% (11/21), digital recordings by 19.1% (4/21), and 28.6% (6/21) offered the hybrid solution (Fig. 3A).Interestingly, there was considerable heterogeneity in the different strategies used to provide face-to-face teaching (Fig. 3B).For example, 41.7% (5/12) of departments offering face-to-face or hybrid teaching reported that students also had patient contact, including a physical examination of the patient.25.0% (3/12) were able to provide bedside teaching using the 1.5 m distance restriction and the remaining 33.3% (4/12) provided block internship without patient contact (Fig. 3B).
One of the ways to provide bedside teaching was to implement different safety measures.For bedside teaching, 47.6% (10/21) of respondents reported that at least one SARS-CoV2 screening test had to be performed.Symptom triage was implemented in 61.9% (13/21), while all teaching activities were performed with mouth and nose protection (surgical or FFP2 masks) (Fig. 3C).
In addition, different strategies were used to cover the missed/cancelled bedside teaching blocks.In 50.0%(3/6) of these cases it was unclear if and when the courses would be rescheduled, 33.3% (2/6) of the faculties postponed them to the lecture-free period and 16.7% (1/6) offered the opportunity to repeat the course.None of the respondents stated that block internships were cancelled without replacement.
In contrast to the theoretical education, where the majority of respondents reported no concerns about the quality of education, 90.5% (19/21) of respondents agreed that the practical education of medical students was affected during the SARS-CoV-2 pandemic, while only 9.5% (2/21) disagreed with this statement (Fig. 2).
Interestingly, while the teaching activities were substantially affected by the pandemic measures, the most respondents noted that the exams were performed as usual, adapting the hygiene standards [61.9%, (13/21)].In 28.6% (6/21) of the departments the exams took place in home office and 9.5% (2/21) applied exam replacement tools/services.

Clerkship and practical year
Practical training during the final year was less restricted.Only 23.8% (5/21) of respondents considered that there might be restrictions on practical training during the placement year, while the majority, 77.2% (16/21), reported no restrictions on students.A much more worrying situation was the compulsory clerkship, where 14.3% (3/21) of institutions had no restrictions, and 38.1% (8/21) had more restrictions than for the practical year.A mixed picture was reported regarding the SARS-CoV-2 testing strategy.At this point in time, most trainees would receive a SARS-CoV-2 test if they had symptoms [61.9% (13/21)].38.1% (8/21) of respondents that they tested regularly, e.g.once a week.Prior to the start of the placement year or rotation within a department, 19.0% (4/21) reported additional testing and 57.1% (12/21) reported pre-trial testing.We also asked whether there were any other educational restrictions for students in their practical year.In the majority of cases (61.9% 13/21) the seminars were offered as usual.Rotation to functional diagnostics remained possible in 76.2% (16/21) of the departments.Transfer and assistance of students to the Corona virus units was reported by 19.0% (4/21).

Daily student life on campus
In general, there were restrictions on teaching facilities during the second lockdown for all.According to the respondents, 33.3% (7/21) of the libraries were already closed before the lockdown.During the second lockdown, the percentage of closed libraries increased to 81.0% (17/21).In addition, 28.6% (6/21) of cafeterias remained closed to students before the lockdown and 81.0%(17/21) during the lockdown.Teaching in the skills labs was also affected.Only 28.6% (6/21) were able to continue their face-to-face teaching as usual and 42.9% (9/21) used an alternative digital meeting and other digital learning programmes.The remaining skills labs have remained closed since the second lockdown, meaning that it was not possible to provide students with hands-on skills lab instructions.
Several regional restrictions in Germany were driven by the 7-day incidence value.Therefore, we asked whether the restriction on face-to-face training was modified based on the regional 7-day incidence, but 90.5% (19/21) replied that this was not the case and that other individual parameters were used for the decision.

Comparison of the different study models
Medical education in Germany is currently undergoing a restructuring process, which is why there are currently different study models.Standard degree programmes in medicine are characterised by a clear separation between pre-clinical and clinical learning content.In contrast, model degree programmes aim to combine preclinical and clinical learning with an increased practical component at an early stage.Based on our results, we examined possible differences between both curricula in the implementation of teaching during the second lockdown in the winter semester 20/21.For lectures, we found that both standard and model curricula switched to digital lectures at the beginning of the second lockdown.The same was true for seminars.Both curricula show the same evolution from face-to-face teaching to digital teaching.Before the lockdown, 91.67% (11/12) of the students in the standard curricula took part in placements, whereas only 55.56% (5/9) of the students in the model courses did so.During the lockdown, the proportion of placement attendance in the standard programme fell to 33.33%, while the proportion in the model programme cohort fell only minimally, remaining at 44.44% (4/9).The two curricula showed a similar trend towards digitised lectures, but the standard curriculum showed a clearer decrease in face-to-face teaching.Unsurprisingly before the lockdown there was a higher proportion of face-to-face teaching in standard courses.

Discussion
The SARS-CoV-2 pandemic has had a significant impact on health education.Medical schools were faced with unprecedented challenges.On the one hand, the safety of patients, staff and students should not be compromised due to limited resources, while on the other hand, the need for high quality education had to be maintained.However, there is limited knowledge of the strategies used to address educational challenges during lockdown.In this paper, we obtained primary data from clinical departments on the different strategies for implementing teaching formats before and during the second lockdown, as well as personal assessments of the impact of the pandemic on the quality of education.The data showed that heterogeneous strategies were used to maintain teaching activities.For a country such as Germany, these heterogeneous strategies were particularly problematic because these reveal such different levels of practical knowledge.The consequences will only become clear in the next years, when the students who were in the early clinical part of their education at the beginning of the pandemic become certified doctors.One may speculate that the quality of the theoretical knowledge was not affected, while practical skills potentially were.A consistent approach supported by policy might have led to less uncertainty among teaching coordinators and universities and might have enabled students to receive practical and patient-oriented training.With the knowledge of previous years and the availability of personal protective measures, one may speculate that the intensity of the lockdown would probably not have been fully justified.
With a significant trend towards virtual teaching, many departments were able to continue with face-to-face practical training, while others even shifted practical training to virtual or digital formats.The key point of this survey is the faculty-based assessment of the impact of the pandemic on the quality of theoretical and practical training of continuing doctors.According to these data, only a limited pandemic-related impact is expected on theoretical education, while significant concerns were raised about practical education, regardless of the novel educational formats implemented during the pandemic.
Clinical practical trainings are an essential and indispensable part of the training of future doctors.Our data show that most lecturers expect significant deficits in practical training, but not in theoretical training.In other countries, teachers also feared that clinical skills would be harder to teach [8].The same was true for students.Students shared the view that the training deficit could have had a significant negative impact on education [9,10], and that practical skills are best taught in the clinic [11].Both the Singapore and UK studies showed that most students also would have liked to return to face-to-face teaching [12,13].
It is not known whether the challenges of the pandemic may have a long-term impact on the skills of future doctors and, if so, this may only become apparent in the next few years.There were several ways to maintain high quality standards in training and one of the options could have been voluntary placements that could have been offered in an organised way; however, the establishment of such formats was challenging due to the ongoing pandemic at the time on the one hand and also due to implementation challenges at the regulatory level on the other.A Canadian study showed that medical students were often excluded from ward rounds [14].A solution to such a problem was presented in another study.The students were offered virtual rounds [15].This would have been a potential approach to enable continued contact with patients, but it did not necessarily replace the face-to-face personal training including practical skills such as examination of a patient.In a study from Libya, only 21.10% of students indicated that e-learning was a good substitute for clinical teaching [16].
The status of online teaching in the last three years since the outbreak of the SARS-CoV-2 pandemic has been increasingly studied.It has been shown that students not only want a high level of digital literacy from their lecturers, but also innovative teaching methods that were not widely used before the pandemic, such as podcasts or educational games [17].It was also shown that the lack of social interaction among students, in addition to the general pandemic situation, has been reflected in the mental health of students [18].This can be seen as an important issue, as the healthcare sector is at higher risk of mental illnesses such as depression and burnout [19,20].
In addition to the psychological consequences of online learning, there are also structural problems, such as unstable internet connection, which sometimes make e-learning impossible.Although this may have been less of an issue in developed countries such as Germany or the UK, it should also be taken into account if lockdowns and restrictions on face-to-face teaching occurred in less developed countries as part of a global pandemic.For example, in a study from India, only about 66% of students reported having easy access to the Internet [21].
In addition to the problems and drawbacks of e-learning, there are innovations and additions that have outlasted the pandemic.Examples of these are short videos summarising the teaching content for the students [22] or gamebased clinical education [23,24] that may have been easily adapted.In conclusion, we strongly believe that the SARS-CoV-2 pandemic has pushed the digitalisation of medical student education towards new and probably positive innovations, but there were additional challenges related to the practical curriculum.In addition, it is important to gain knowledge about the potential risk associated with face-to-face teaching during the pandemic and whether face-to-face teaching was indeed associated with a measurable risk of SARS-CoV-2 transmission and risk to patients, staff and students.
This survey-based study was conducted in a short-term response to the current situation during the pandemic, but there are several limitations that need to be acknowledged.In order to obtain the most comparable conditions, we contacted only the Departments of Gastroenterology and Hepatology, so there may be some differences in relation to other institutions in preclinical or clinical training.In addition, the pandemic was a dynamic process that posed challenges to certain regions with higher incidence rates.Although the response pattern, which is well distributed across Germany (Fig. 2), is informative, a more extensive return of responses could provide more detailed information.In addition, this study evaluates only one phase of the pandemic, and the impact along the duration of the pandemic may not be easy to assess.In addition, students entering medical school at the beginning of the pandemic are likely to have been at greater risk of impaired practical skills than those entering later in their education.Finally, further studies are needed to accurately and objectively reassess the need for pandemic preparedness measures and whether such measures are likely to be avoided in the future.The decision to lock down universities was taken under extreme conditions and on the basis of mathematical modelling with low evidence.Based on the post-pandemic experience of the past 2 years, it remains questionable whether the lockdown was of health-related benefit to students, staff or parents.Nevertheless, given the concerns raised by our study, we believe that practical bedside teaching is one of the key elements in the proper education of medical students and should not be replaced by virtual alternatives.
In summary, we observed considerable heterogeneity in the educational strategies used during the early phase of pandemic in Germany, which may have had a potential impact on the practical education of medical students.In general, there was a common trend to shift from face-to-face teaching to a virtual format.Although digitisation and the use of virtual formats would have become the standard soon, regardless of the SARS-CoV-2 pandemic, virtual learning may have been of limited value for practical skills training.This is strongly supported by the significant concerns expressed by faculty members in our survey.In order to maintain quality standards of education, it may have been necessary to prioritise the role of practical education as one of the key elements of the curriculum.

Fig. 1
Fig. 1 Time trend of pandemic in Germany and study design.A Time trend of the SARS-CoV-2 pandemic from the first case in Germany to the end of the questionnaire period.The time periods for the questionnaire are highlighted in colour.B An overview of the participating universities in Germany

Fig. 2 Fig. 3 A
Fig.2The survey on theoretical and practical training.Lecturers were asked to answer the question of whether the theoretical respectively practical training was suffering as a result of the pandemic (n = 21)