The global COVID-19 pandemic has tremendously altered our everyday interactions. At the time of writing of this article, there have been over 7.5 million confirmed cases and over 400,000 deaths worldwide.1 Given the public health implications of this pandemic, most States have mandated shelter in place orders and enforced social distancing to reduce the spread of the virus. In addition, the Centers for Disease Control and Prevention has recommended the cancellation of any gathering of 10 or more individuals. These restrictions have led to over 36 States banning elective surgical procedures.2
In addition to its impact on the clinical care provided at major academic medical centers across the country, the COVID-19 pandemic has also had a dramatic effect on orthopaedic surgery education and training.3-5 As a result, several training programs across the country have implemented e-learning platforms to adhere to social distancing rules while continuing academic pursuits of grand rounds, journal clubs, case conferences, and research meetings.6 Although the use of videoconference technology for meetings is not new, the COVID-19 pandemic has hastened the utilization of this technology as part of residency and fellowship education. Videoconferencing has been used in resident education with great satisfaction in other fields.7-9 In the orthopaedic surgery literature, videoconferencing has been used to complement educational conferences and to perform fellowship interviews.10-12
The COVID-19 pandemic has increased the utilization of e-learning at our institution; however, to our knowledge, the efficacy of its use and satisfaction of participants has not been studied during the COVID-19 pandemic. The purpose of the current study was to evaluate resident, fellow, and attending perspectives on the use of e-learning. Our hypothesis was that both groups would be satisfied with e-learning as an educational tool during these complicated times in orthopaedic surgery education and training.
A 36-question survey was developed to evaluate residents'/fellows' (trainees') and attendings' perceptions regarding e-learning as part of orthopaedic surgery education. The survey consisted of four major sections focusing on (1) overall attitudes toward e-learning, (2) multi-institutional e-learning/e-conferences, (3) national/regional e-conferences, and (4) future directions with e-learning. Questions on e-learning alone were graded on a 0 to 100 Likert scale, and questions comparing e-learning and in-person learning were graded on a 5-point scale: most with in-person learning, somewhat more with in-person learning, neutral, somewhat more with e-learning, and most with e-learning. The survey was created on REDCap.
A list of 197 orthopaedic surgery residency training programs in the United States was obtained from the Association of American Medical Colleges, and the contact information for the program directors was obtained. The survey was distributed online via REDCap to all the included residency program directors, and they were asked to circulate the survey to their faculty and trainees. Responses were kept anonymous and confidential.
Qualitative statistical analysis was generated using SPSS version 26 (IBM Released 2019, IBM SPSS Statistics for Windows, Version 26.0: IBM Corp.). Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables were reported as weighted mean and estimated SD, whereas categorical variables were reported as frequencies with percentages. Fisher exact or chi-square test was used to analyze categorical variables. The independent or paired t-test for normally distributed variables or the nonparametric Mann-Whitney U test or Wilcoxon signed-rank test was performed to compare continuous variables. A value of P < 0.05 was considered statistically significant.
A total of 268 responses were collected, including 100 attendings and 168 trainees (15 fellows and 153 residents).
Overall Attitudes Toward E-Learning
Overall satisfaction with e-learning compared with in-person learning was higher among trainees than attendings, with 51.4% of trainees favoring e-learning, as opposed to 32.2% of attendings (P = 0.006). No difference was observed between attendings or trainees in how comfortable they felt participating in e-learning, or in asking questions, compared with the in-person learning (P = 0.07, P = 0.43, respectively). Trainees were more anxious overall presenting with either e-learning or in-person learning (P < 0.001 for both) but had a greater reduction in anxiety with e-learning (P < 0.01). Both groups felt e-learning was most beneficial to their daily travel time (P = 0.61). However, both groups felt they were more likely to pay attention with in-person learning and learn more about their colleagues with in-person learning (P = 0.89, P = 0.42, respectively). However, attendings were more likely to multi-task with e-learning than trainees (66.6 versus 59.4, P = 0.007). In addition, 85.7% of residents have used e-learning to join a conference in their specialty of interest while off-service during the COVID-19 pandemic. All survey responses are illustrated in Appendix 1, Supplemental Digital Content 1, https://links.lww.com/JAAOS/A520.
Attendings were more likely to have participated in multi-institutional in-person learning (69.4% versus 41.5%, P < 0.01); however, trainees were more likely to have participated in multi-institutional e-learning (82.2% versus 69.1%, P = 0.02). Both groups were more likely to favor multi-institutional learning than single institutional learning with no difference between the groups (P = 0.42). Trainees were more likely to find multi-institutional learning more thought provoking than single institutional learning, with attendings favoring in-person learning (P = 0.04). In addition, trainees felt multi-institutional conferences were more likely to help their overall growth in how they think about common problems (P = 0.002) and change the way they practice (P = 0.003). All survey responses are illustrated in Appendix 2, https://links.lww.com/JAAOS/A521.
National and Regional E-Conferences
Attendings and trainees both felt national and regional conferences would have better networking opportunities in-person (80.9% versus 77.7%, P = 0.57). No difference was observed in how attendings or trainees felt e-conferences would affect learning opportunities (P = 0.16) or how much they felt they would be able to contribute (P = 0.78), compared with in-person learning. Trainees felt more anxious when presenting in-person (61.4% versus 41.3%, P < 0.001) and felt they would be more likely to be less anxious with e-learning (P = 0.01). With a transition to e-learning, attendings felt they were more likely to attend fewer conferences in-person compared with trainees (49.5% versus 34%, P = 0.009). In addition, there was a mixed response on how beneficial e-learning versus in-person conferences was although there were no differences noted between the groups (P = 0.77). All survey responses are illustrated in Appendix 3, Supplemental Digital Content 3, https://links.lww.com/JAAOS/A522.
Future Directions With E-Learning
Most attendings and trainees felt e-learning should play a supplemental role in standard residency/fellowship education, with a minimum number of respondents feeling it should not play a role (86.6% versus 84%, and 2.1% versus 0.6%, respectively, P = 0.28). There were mixed responses among both attendings and trainees in how they felt e-learning could prepare them for the Orthopaedic in Training Examination/American Board of Orthopaedic Surgery, with most respondents being neutral (55.1% versus 42.5%) and no overall differences between the groups (P = 0.09). Trainees favored a transition toward e-learning as they could ask questions in a less intimidating environment (50.7 versus 38.9, P = 0.002), and attendings favored it due to time off from practice (72.5 versus 61.1 P = 0.002). No difference was observed between the attendings and trainees in favoring a transition to e-learning for time constraints, ability to multi-task, or have improved content. No difference was observed between attendings and trainees in how they felt a transition toward e-learning would affect burnout (40.4 versus 36.5, P = 0.06). All survey responses are illustrated in Appendix 4, Supplemental Digital Content 4, https://links.lww.com/JAAOS/A523.
This study sought to evaluate attending and trainee perception of e-learning during the COVID-19 pandemic and what role it should play in future residency/fellowship education. One of the most important findings from this study was that most attendings and trainees felt that e-learning should play a complementary role to standard residency and fellowship education moving forward. It is unknown if or when social distancing recommendations will be lifted. Regardless, it appears that e-learning will be the primary method of holding grand rounds, journal clubs, case conferences, and research meetings in the interim and likely will remain a part of orthopaedic surgery education once normal life resumes post-COVID-19.
Several commentaries have advocated for the further use and improvement of videoconferencing technologies as we continue to strive to educate residents and fellows in the midst of a pandemic.13-15 Recently, Kogan et al3 reported on the impact of COVID-19 on resident education. The review article discussed the common online videoconferencing applications used during the COVID-19 pandemic to adhere to social distancing mandates. Jones et al14 discussed the perspectives of residents, fellows, and attendings regarding orthopaedic education in the midst of the COVID-19 pandemic. They highlighted that e-learning has been an important aspect of maintaining their academic pursuits because clinical volume has decreased.
One of the most advantageous aspects of e-learning is the convenience of participating in meetings from your personal electronic device, and the ability to participate remotely, which most participants felt was beneficial to their daily travel time. The ability to join in a conference remotely has allowed most trainees to participate in a conference in their specialty of interest while off-service. In addition, the remote participation reduced the anxiety in trainees presenting and participating in e-learning sessions.
Our study showed that both trainees and attendings favored multi-institutional e-learning conferences compared with single institution in-person learning. Trainees found multi-institutional e-learning conferences particularly more thought provoking and practice changing when compared with single-institution in-person meetings. Similarly, trainees felt multi-institutional conferences were more likely to help their overall growth in how they think about common problems and change the way they practice compared with the attending faculty. These sessions have allowed trainees to engage with surgeons from other institutions, who may have different perspectives that trainees have not been exposed to, as geographical influence has been shown to affect how surgeons approach common problems. Multi-institutional didactic sessions have emerged in several programs during the COVID-19 pandemic. These collaborations have stemmed from attendings wanting to provide more engaging content to trainees and as a result of national and regional conferences being canceled. The more prominent usage of e-learning likely will result in less in-person attendance at conferences. Our study showed that approximately half of the trainees and attendings would attend fewer conferences in-person, despite the associated detrimental impact on networking opportunities.
Our study also highlighted some of the disadvantages of e-learning. Both trainees and attendings stated they were more likely to pay attention and learn from their colleagues during in-person meetings. Although e-learning may be convenient, it cannot replace in-person learning. There are dynamic aspects that take place during in-person interactions that cannot be replicated virtually. Some of these aspects include learning to publicly speak, picking up nonverbal cues, and assessing audience interest and engagement. In addition, the ability to network and development of meaningful relationships are more likely to occur during in-person encounters. The attendings and trainees both felt that the lack of in-person engagement meant that they learned less about their peers. The missing aspects of in-person interactions likely lead to the relatively low satisfaction results found in our study. Healy et al11 surveyed candidates and faculty that participated in videoconference interviews for arthroplasty fellowship and found that 30% of the candidates did not believe it was a good format for interviews with the most common comment being that in-person interviews provide a “feel” of the program that could not be conveyed in videoconference interviews.
E-learning has previously been shown to result in a high satisfaction rate among residents when integrated.7,8 Palan et al12 described their experience implementing virtual journal clubs and case-based discussions for orthopaedic trainees in Leicester, England. They found that the virtual learning was convenient for trainees in various sites. In addition, there was the advantage of having the material available online to review at the convenience of the resident. Moreover, there was the ability to access clinical material and highlighted articles pertinent to the topic being taught. The authors concluded that virtual environments will expand in its role in trainee education. Similarly, we envision the use of e-learning to play a complementary role to residency and fellowship education moving forward. It will be interesting how this affects the evolution of training once we return to the new normal. Future study endeavors could assess trainee and attending perceptions of e-learning based on the conference type. For example, another survey study could compare perceptions on journal clubs, subspecialty conferences, grand rounds, and national/regional conferences. The findings in our study support its increased use, and thus, we believe it will have a prevalent role moving forward, even after the social distancing restrictions are lifted.
There are several limitations to this survey study. The number of respondents is relatively low and may not be representative of the entire orthopaedic surgery community. We attempted to minimize this bias by sending the survey to all residency programs in the United States. In addition, because this survey was performed in the midst of the COVID-19 pandemic, the responses may have been influenced by circumstances that occurred during the pandemic such as increased nonorthopaedic clinical responsibility or, alternatively, from increased free time due to decreased patient care responsibilities. These perceptions may change if and when normal patient volumes resume.
E-learning has been an important modality to continue academic pursuits during the COVID-19 pandemic. Most trainees and attendings felt that e-learning should play a supplementary role in resident and fellow education moving forward. Although e-learning does provide an opportunity to hold multi-institutional conferences and makes participation in meetings logistically easier, it cannot fully replicate the dynamic interactions of in-person learning.
References printed in bold type are those published within the past 5 years.
1. COVID-19 Dashboard by the Center for Systems Science and engineering (CSSE) at Johns Hopkins University (JHU). 2020. Available at: https://coronavirus.jhu.edu/map.html
. Accessed June 13, 2020.
2. Abresch S: State Guidance on Elective Surgeries. Ambulatory Surgery Center Association. 2020. Available at: https://www.ascassociation.org/asca/resourcecenter/latestnewsresourcecenter/covid-19/covid-19-state
. Accessed May 1, 2020.
3. Kogan M, Klein SE, Hannon CP, Nolte MT: Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg 2020;28:e456-e464.
4. Schwarzkopf R, Maher NA, Slover JD, Strauss EJ, Bosco JA, Zuckerman JD: The response of an Orthopedic Department and Specialty Hospital at the Epicenter of a Pandemic: The NYU Langone Health Experience. J Arthroplasty 2020;35:S3-S5.
5. Konda SR, Dankert JF, Merkow D, et al.: COVID-19 response in the Global Epicenter: Converting a New York City Level 1 Orthopedic Trauma Service into a Hybrid Orthopedic and Medicine COVID-19 Management Team. J Orthop Trauma 2020; April 29 [Epub ahead of print].
6. An TW, Henry JK, Igboechi O, et al.: How are orthopaedic surgery residencies responding to the COVID-19 pandemic? An Assessment of resident experiences in cities of major virus outbreak. J Am Acad Orthop Surg 2020;28:e679-e685.
7. Kroeker KI, Vicas I, Johnson D, Holroyd B, Jennett PA, Johnston RV: Residency training via videoconference—Satisfaction survey. Telemed J E Health 2000;6:425-428.
8. Ahn HH, Kim JE, Ko NY, Seo SH, Kim SN, Kye YC: Videoconferencing journal club for dermatology residency training: An attitude study. Acta Derm Venereol 2007;87:397-400.
9. Boatin A, Ngonzi J, Bradford L, Wylie B, Hospital MG, Medical H: Education across two continents. Open J Obstet Gynecol 2015;5:754-761.
10. Baruffaldi F, Giangiacomo L, Paltrinieri A, Toni A: Videoconferencing for distance. J Telemed Telecare 2003;9:241-242.
11. Healy WL, Bedair H: Videoconference interviews for an adult reconstruction fellowship: Lessons learned. J Bone Joint Surg Am 2017;99:e114.
12. Palan J, Roberts V, Bloch B, Kulkarni A, Bhowal B, Dias J: The use of a virtual learning environment in promoting virtual journal clubs and case-based discussions in trauma and orthopaedic postgraduate medical education: The Leicester experience. J Bone Joint Surg Ser B 2012;94 B:1170-1175.
13. Plancher KD, Shanmugam JP, Petterson SC: The changing face of orthopedic education: Searching for the new reality after COVID-19. Arthrosc Sport Med Rehabil 2020; April 27 [Epub ahead of print].
14. Jones SD, Thon S, Frank RM: Shoulder & elbow education during COVID19—Perspectives from the resident, fellow, and attending Level. J Shoulder Elbow Surg 2020;29:1297-1299.
15. Stambough JB, Curtin BM, Gililland JM, et al.: The past, present, and future of orthopedic education: Lessons learned from the COVID-19 pandemic. J Arthroplasty 2020;35:S60-S64.