International Journal of Community Medicine and Public Health

Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20203931
Original Research Article

Perspectives of Indian medical students on e-learning as a tool for

medical education in the country: a quantitative study
Neel N. Lawande1, Trusha D. Kenkre1, Nuala A. Mendes1, Lydia M. Dias2, Amit S. Dias3*

1
MBBS student, Goa Medical College, Bambolim, Goa, India
2
Department of Microbiology, Goa Medical College, Bambolim, Goa, India
3
Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa, India

Received: 05 July 2020

Accepted: 07 August 2020

*Correspondence:
Dr. Amit S. Dias,
E-mail: dr_amit_dias@yahoo.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: In view of the COVID-19 pandemic, medical colleges resorted to e-learning to continue teaching;
giving us a unique opportunity to explore the potential of this tool, understand the student perspective, help improve
its structure and assess its scope for future use.
Methods: A quantitative cross-sectional study was conducted across Indian medical colleges using Google forms.
The questionnaire consisted of sections on e-learning experience, technological readiness, effects of COVID-19 on
education and attitude towards e-learning.
Results: From 32 medical colleges in India, 556 undergraduate medical students participated in the study. The results
showed that 93.3% students were exposed to e-learning, from which 99% were introduced to it following the COVID-
19 pandemic-imposed lockdown. The study reported the pros and cons of e-learning for medical education. E-
learning methods were deemed fit for theory lectures, but wasn’t preferred for clinics and demonstrations. Students
believed that e-learning- preferably short live online classes, together with efficient portals, provision of offline
videos and discussion of clinical cases- had great scope to support the traditional methods of teaching.
Conclusions: According to the students, e-learning has immense potential and is an irreplaceable ally to the
traditional method of medical education, even beyond the COVID-19 pandemic.

Keywords: COVID-19, E-learning, India, MBBS, Medical colleges, Online education

INTRODUCTION curriculum. The medical colleges too, are pushed to rely

on technology-based learning in order to cater to students
The World Health Organisation has termed the COVID- during the pandemic and enhance their knowledge and
19 pandemic as an unprecedented Global Crisis that has performance.3-6
been met with an unprecedented global response.1 At the
time of writing this paper, the SARS CoV-2 virus had Negash and Wilcox classified e-learning into six
affected 8.06 million people in the world, 3,67,000 in categories (1) e-learning with physical presence and
India, leading to 12,237 deaths.2 Different countries over without e-communication (by use of power points, digital
the world have imposed lockdowns to restrict the versatile discs, etc. in the classroom); (2) e-learning
transmission of this virus and flatten the epidemic curve. without physical presence and without e-communication
In India, the lockdown that was enforced on March 22nd (self- learning); (3) e-learning without physical presence
2020, has led to schools, colleges and universities to and with e-communication (asynchronous learning); (4)
suspend the traditional teaching methods and instead start e-learning with virtual presence and with e-
using e-learning tools to continue teaching the communication (synchronous learning); (5) e-learning

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 Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

with occasional presence and with e-communication For this study, we define e-learning as a technology-based
(hybrid-asynchronous learning); and (6) e-learning with learning in which a computer network is used to deliver
physical presence and with e-communication (hybrid- learning material (via audio, video and text medium)
synchronous learning).7 electronically to remote learners. This can be done
through e-mail, live chat sessions, online discussions,
The COVID-19 pandemic has led to the introduction of forums, quizzes and assignments.8,9
various e-learning tools in medical colleges, and has also
provided us with a unique opportunity to study the A separate questionnaire was given to students whose
challenges and sustainability of this method and evaluate colleges hadn't started online classes, to identify the
its role in medical education much beyond the pandemic. challenges they felt their colleges were facing, amidst the
Medical education is constantly growing at a rapid speed COVID-19 crisis.
and knowing the scope of technology-based learning,
beyond the pandemic, will be essential to keep the Indian The data obtained from Google forms, was quantitatively
medical graduates at par with the competitive world.4-6 analysed.

In order to strengthen the medical education system, it is Ethical approval

important to learn about the perspectives of medical
students towards this e-learning experience. This study Approval granted by the Institutional Ethics Committee
was conducted with the aim to understand the of Goa Medical College, Bambolim, Goa, India. Data was
perspectives and effectiveness of e-learning among kept confidential. Informed Consent was taken
medical undergraduates, in order to help improve its electronically form all the participants as was permitted
format and to assess its scope for future use, even beyond by ICMR during the pandemic.10 To ensure that the
the pandemic. Moreover, the study would also give us a student was answering the questionnaire, their names
better insight about the larger effect of COVID-19 were checked with their information on the college
pandemic on the students, with and without access to e- website. Data was kept confidential and no identifiers
learning and the future prospects of technological tools in were used during the analysis.
the medical education system.
RESULTS
METHODS
Students from 32 medical colleges, from 8 States and 1
Participants and data collection Union Territory in India participated in this study. It was
conducted in the 2nd and 3rd months of the COVID-19
A cross sectional study was conducted in undergraduate lockdown in the months of May and June.
medical MBBS students open to all medical colleges in
the country. A total of 556 students from 32 medical Among the 556 medical students that took part in this
colleges in India, from 8 states and 1 union territory, study, 61.2% (340) were female and 38.8% (216) were
participated in the study. 1st year, 2nd year, 3rd year part-1 male. The age of the participants ranged from 18 years to
and 3rd year part-2 undergraduate MBBS students were 24 years, with a mean age being 20 years (SD 0.062).
included in the study, irrespective of whether their college There were 28.2% (157) from first year, 22.7% (126)
had begun e-learning facilities or not. Interns and post- from second year, 31.7% (176) from third year part one
graduate students were excluded from this study. Most of and 17.4% (97) from third year part two.
the postgraduate courses had not resorted to e-learning at
the time of the study. We conducted this study in the The e-learning experience
month of May and June 2020, over a period of one
month. Among the 556 students, 93.3% (519) informed that their
college had started using e-learning for medical
A structured questionnaire was developed and used to education. Of these, 14.1% (73) of the students had e-
collect data from the undergraduate medical students, learning without physical presence and without e-
which was made available electronically through Google communication (self-learning), e.g. lecture slides; 4.4%
forms. (23) had e-learning without physical presence and with e-
communication, e.g. pre-recorded classes; 89.8% (466)
Study questionnaire had e-learning with virtual presence and with e-
communication, e.g. online virtual classroom and 0.6%
A self-administered questionnaire we developed (3) followed other means of e-learning.
consisting of 5 main sections: 1) Socio-demographic
characteristics; 2) E- learning experience; 3) Out of the students, 94.8% (492) attended most of the
Technological readiness; 4) COVID-9 and its effect on e- online classes. Those who did not, stated reasons like lack
learning; 5) Attitude toward and future prospects of e- of concentration, network issues and lack of interest.
learning. With regards to the timing, 41.8% (217) had classes in the
morning, 17% (88) in the afternoon, while 41.2% (214)

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 Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

had classes both in the morning and afternoon. While Among the students, 42% (218) said that
73.2% (380) preferred classes in the morning, 17% (88) assignments/projects/homework were given. Out of these,
preferred afternoon classes and 18% (52) did not have 21.9% (80) preferred if homework/projects/assignments
any preference for the timing of the e-class. were given, 51.1% (187) did not, while 27% (99) were
indecisive.
Where 74.6% (388) students had classes for an average of
30 minutes-1 hour, 20.6% (107) had them for 1 hour-2 Clinical skills were considered as an important part of
hours, 3.8% (20) had them for more than 2 hours and 1% their study in the medical curriculum by 98.1% (509) of
(5) had them for less than 30 minutes. The preferred the students. Among the students, 94.4% (490) found it
duration was 30 minutes-1 hour for 77.1% (401) of the difficult to study the subject without direct patient
students, less than 30 minutes for 9.4% (49), 1hour- exposure. Of the participants, 52.4% (272) had a clinical
2hours for 8.5% (44) and 4.6% (24) did not have any case discussion for their lectures.
preference.

The online classes consisted of 98.5% (511) of theory

lectures, 11.8% (61) of demonstrations, 20.6% (107) of
practical classes, 18.9% (98) of clinical classes and 31.6%
(164) of case discussions.

Table 1 gives the format of the online lectures.

Table 1: Format of online lectures.

Format of online lectures

Online live classes: Pre-recorded classes:
97.3% (505) 2.7% (14)
Powerpoint
Teaching with presentations Figure 1: Reasons for inability to concentrate in e-
use of 96.8% with voice 57.1% classes
PowerPoint (488) recording of (8)
presentation teachers’ Concentrating in the e-classroom was reported as a major
explanations problem by most of the students. Only 15.8% (82)
Teaching Video format of reported that they could concentrate for the whole class.
without use of 12.5% lecture without 14.28% 60.1% (311) reported that they could pay attention only
PowerPoint (63) powerpoint (2) halfway through the class, 16.3% (85) could only for a
presentation presentation few minutes, and 7.9% (41) reported that they could not
Video format of concentrate at all. The reasons for difficulty in
Dictation of 5.6% lecture with 21.4% concentrating are provided in Figure 1, while the
lecture notes (28) powerpoint (3) solutions to address this is provided in Figure 2.
presentation
Discussions
21.8% Voice recording 7.14%
(Interactive
(110) of lecture (1)
learning)

Out of the participants, 77.8% (404) said that the live

classes were recorded and sent to them after class. Of
those who did not, 80.3% (339) of the students preferred
if these lectures were recorded and sent to them.

A majority of students 64.2% (334) had their doubts

cleared during class itself, 12.7% (66) could do so by
contacting the teacher via email, 3.8% (20) did it through
a separate session, 7.9% (41) could not get their doubts
cleared and 11.3% (59) were unsure.
Figure 2: Factors that could increase concentration in
Out of the participants, 31.2% (162) of the students found e-classes.
these classes to be at a fast pace, 3.9% (20) found them
slow, while 64.9% (337) found it to be at an adequate While 71.5% (371) preferred traditional learning to
pace. improve their concentration, 28.5% (148) preferred online

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 Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

learning. Among the participants, 43.9% (228) faced Students felt that improvement in audio-visual software,
distractions during online classes, 18.5% (96) did not and inclusion of clinical discussions, adding more student-
37.6% (195) were not sure. While 48.3% (212) of the teacher interactive sessions, and solving existing network
distractions were avoidable, 17.3 % (76) were not and issues would better the quality of e-learning in the future.
34.4% (151) of the students were unsure. Among the The subjective preference of the students for the use of e-
students 47.5% (223) felt that scrolling through social learning methods for various types of medical classes is
media/ talking to people during online lectures was a given in Figure 3.
cause of their decreased concentration.

In this sample, 70.5% (366) of students had attendance

for online classes. Out of those who did not, 39.1% (128)
said that this reduced their motivation to attend online
lectures.

Technological readiness

Out of the students who participated in this study, 70.1%

(364) used mobile phones to attend online classes, 20.2%
(105) used laptops, 2.7% (14) computers and 6.9% (36)
used tabs and other devices. While 83.8% (435) of the
students did not face any difficulty while using these
devices, 9.2% (48) did and 6.9% (36) were indecisive.
Figure 3: The preference of e-learning for various
Where 49.9% (259) students used Cisco WebEx, 15.8% types of medical classes.
(82) used GoToMeeting, 12.9% (67) Zoom and 21.4%
(111) used other software like Microsoft teams, Adobe DISCUSSION
Connect, Medwhizz and MOOC Armed Forces Medical
portal. Technology always had the potential to boost medical
education, but it was not used to its full potential in
Out of the students, 22% (114) faced difficulty while medical education in the country. The unprecedented
using the software on their device. Difficulties in software measures and strict enforcement of lockdown and the
login, network disturbances and audio and visual closure of all colleges, forced the medical colleges to use
problems were some of the issues that the students faced e-learning as a tool for medical education. In this study,
while using their device. e-learning methods were reported to be introduced for the
first time by 99% of the participants in view of the
Wi-Fi was used by 40.1% (208) of the students and COVID-19 pandemic. The growing popularity of this
mobile network was used by 59.9% (311). Where 22.7% technology-based learning and its probable value in the
(118) of the students claimed that they faced network future of medical education was clearly reported in this
issues during most of the classes, 21% (109) did not and study.
56.3% (292) of the students faced network issues for less
than one out of three online classes. The students felt that the COVID-19 pandemic paved the
path for a new form of medical education and in turn
COVID-19 and its effect on medical education boosted the productivity of students across India during
this crisis, who were otherwise confined indoors due to
Out of all the students, 99% (514) reported that the the lockdown.
COVID-19 lockdown was the reason for initiation of e-
learning in their colleges. These methods were not used A lot of stress is put upon attendance in the India medical
earlier for medical undergraduate teaching. Of the education system. The Medical Council of India makes it
participants, 56.8% (295) felt that online classes boosted mandatory to achieve at least 75% attendance in each
their productivity during the lockdown. Among the subject to be allowed to answer the exams. Majority
students, 60.5% (314) felt that there was scope for e- (94.8%) of the students attended online classes and the
learning even after the lockdown. few (5.2%) who didn’t, cited reasons, such as difficulty in
understanding and lack of interest due to attendance not
Attitude towards e-learning being compulsory. Studies on class attendance have
shown that, on an average, students with high attendance
Out of all the students who had started online classes, achieve higher academic performance in both coursework
43.4% (225) were in favour of e-learning. Those who and examinations than students with poor attendance. To
were not, gave reasons such as lack of clinical exposure decrease absenteeism, a good attendance policy can have
and case discussions, and difficulty in covering practical a strong impact on student performance.11-14 At the same
classes.

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 Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

time students complained of missing out on attendance maintenance of even the most current and sophisticated
due to the poor network. software, the ability of teachers and students to access
and use technology is highly compromised.21 Organising
Classic lectures can be improved by increasing student- training workshops for students as well as teachers
teacher interaction.15,16 In an online set up, this could be regularly, to improve their technological skills and be at
done via polls, quizzes, tests and other interactive par with updates in software is a solution. Also, usage of
sessions. Use of e-learning modules (flash multimedia a single, safe and effective software by all medical
and digitized images), patient surrogates such as virtual institutions in India, would standardise the training
patients (to teach clinical examination, procedural, programs which need to be given to students and
diagnostic skills and communication skills) and virtual- teachers.
reality simulators (to teach palpation, surgical and
resuscitation skills) is needed.3 A common drawback identified by a majority of the
participants (79%) was loss of connection during classes
Live online classes were chosen over pre-recorded due to poor or unstable network availability and
classes, perhaps due to it being more engaging and disruption in the flow of the lecture. This obstacle can be
interactive.17 Many (80.1%) were in favour of classes overcome by recording the lectures and providing them to
being recorded and sent, post a live session. A good the students through various social platforms. Another
approach to see that the classes missed can be referred solution to this would be provision of alternate means of
back, and that important topics can be reviewed when attending these lectures, for example through a ‘call in’
required, would be to ensure that a system is in place for means for joining and attending classes in audio only
recorded live classes to be sent in a timely manner daily mode. An innovative and effective solution would be
or weekly. development of e-learning software that function
smoothly even at low bandwidths.22
The students had their doubts cleared by the teacher
during class, or in a separate doubt-resolving session, or A recent survey by Uma V stated that 40% of the
by direct contact with the teacher through email, which concerns about online education were related to
should be encouraged as it is a good way to assure better unreliable connectivity, 30% cited the cost of data and
understanding in class. Though many students did not 10% reported uncertainty in electrical supply.23 Only 28%
receive any homework assignments, a study conducted by of the students belonging to rural households had access
Ahsan et al stated that introducing a simple pre-lecture to the internet at home.24 Such issues need to be worked
assignment (PLA) before the lecture will help make on, to extend the reach of e-learning to rural population as
classes more student-centred and focused more toward well.
active learning.18 Preparing for a lecture beforehand, puts
a student in a better place to understand and gather The medical field calls for students to have a great deal of
information taught in class, which promotes in-depth social soft skills in order to win the trust of patients and
learning.19 ace the art of medicine. The lack of patient exposure and
clinical cases creates a great void in medical learning,
Although the pace of the lectures was found to be which seemed to be one major setback for e-learning,
adequate, only 15.8% reported that they could concentrate causing students to prefer the traditional method of
through the whole class, while 60% of the respondents in classes. While e-learning was considered unsuitable for
this study could not concentrate beyond 30 minutes and practical classes and demonstrations, it was considered a
felt it would be more effective if the duration of the great method to teach theory classes and case discussions.
classes was reduced. A study on concentration of medical
students by Stuart and Rutherford showed similar results This gap in the clinical sphere of e-learning can be met by
where student concentration rose sharply to reach a introducing innovative ideas like purely holding clinical
maximum in 10-15 minutes, and fell steadily thereafter.20 case discussions in a separate interactive class, or
The study also stated that the optimum length of a lecture integrating these discussions while teaching certain topics
may be 30 minutes instead of 60 minutes. Technical could help increase clinical interest and diagnostic skills.
issues and lack of interaction were an important hurdle in In addition, separate video clips demonstrating basic
the flow of the lecture, causing preference of offline clinical skills, such as clinical procedures and physical
classes with respect to better concentration. Decreasing examination skills could be streamed live or sent pre-
the length of the lecture or providing breaks between the recorded. This could be used as a supplementary learning
sessions; making offline videos of the live lecture resource to help students master clinical skills. 25 The
available to all students and trying to make the sessions online lecture sessions allowed students to attend classes
more interactive, as mentioned above, are solutions, in in their own comfort zones, make better notes with the
order to ensure better concentration of the students. audio-visual aids, address their queries more freely and
also avoid the travel hassles.
Difficulty in operating the software through which online
classes were held was a complaint reported by 22.1% of A study conducted by Rose S established that reduced
the students. In the absence of proper support and student-student discussions, dependence on emails and

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 Lawande NN et al. Int J Community Med Public Health. 2020 Sep;7(9):3610-3616

internet facilities and a difficulty in delineating Dean of Goa Medical College, Prof. Dr. S. M. Bandekar
boundaries between home and work were some of the for giving us the opportunity to conduct this study.
pitfalls of online education that needed to be worked on.26
We would also like to thank Dr. Aadishree Kenkre for
Though most of the institutes of the participants in the being our constant support during this project. Finally, we
study, had rapidly converted their entire preclinical would like to thank all the participants who gave us their
curriculum to online formats, some of them were still valuable time to be a part of this study.
unable to initiate this transition due to lack of
infrastructure and technological awareness, especially Funding: No funding sources
when a large part of the medical fraternity had been Conflict of interest: None declared
redirected to fight the COVID-19 pandemic.3 Ethical approval: Approval granted by the Institutional
Ethics Committee of Goa Medical College, Bambolim,
Most of these students looked forward to e-learning and Goa, India
believed it to be useful. There is a need for training the
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