E-learning benefits for medical students: the longitudinal use of an online learning experience at an international medical school

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Caballero, Steffi Verbeeck-Mendez, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4915453/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2025 Read the published version in BMC Medical Education → Version 1 posted 12 You are reading this latest preprint version Abstract The COVID-19 pandemic forced schools worldwide to change the delivery of the medical curriculum to an exclusively online format. Some important findings after this experience highlight the possibility of continuing with the online form of curriculum delivery, at least partially, to reinforce the learning experience of medical students. Our research goal was to analyze the benefits that medical students can gain after exposure to high-quality e-learning. Our primary aim was to analyze the gain of knowledge, as well as self-rated benefits and understanding, after exposure to high-quality e-learning. We conducted a retrospective study to report on the outcomes achieved after 3 years of experience with the online delivery of basic biomedical science courses. We included results from 1,546 students and 2,613 course enrollments in two different medical programs. Here, we report on students’ benefits after online courses in terms of knowledge gain and satisfaction. The information presented here could be used to make decisions about the incorporation of e-learning into the medical curriculum. e-learning medical school medical curriculum test performance gain of knowledge self-perceived benefits Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Online learning or electronic learning (e-learning) is defined as the use of electronic technology to deliver, support, or enhance both learning and teaching [ 1 ]. In medical education, over several decades, and more importantly during the COVID-19 pandemic, the necessities for medical education delivery changed, and e-learning was the only way to continue medical education for a while. However, not all delivery was consistent with e-learning because of time constraints and a lack of effective learning. Currently, e-learning is becoming more common, but we still need to constantly evaluate the quality of the online material since the use of an electronic device is not sufficient. Wasfy and colleagues published a guide for the evaluation of online learning, and such tools should be used in an attempt to standardize e-learning exposures [ 2 ]. Several reasons are behind the incorporation of e-learning into medical education, such as the need for more well-trained health professionals worldwide, their use in so-called “flipped classrooms”, the need to increase student satisfaction, the need to add forms to improve the retention of many concepts, and the need to unify concepts among students with different backgrounds [ 3 ]. With respect to student satisfaction, the DigiMed study included 3,286 medical students from 12 countries, and the results indicated that up to 40% agreed with continuing with e-learning for the partial delivery of the medical curriculum [ 4 ]. Additional studies have presented interesting findings with respect to adaptability and acceptance of online classes, with a majority of subtends and professors supporting online teaching and, in general, experiencing satisfaction with online education [ 5 ]. There is no question that e-learning is becoming more common in medical education, and we can begin to consider a blended form of curriculum delivery. Medical graduates are facing a more competent field, and additional competencies are needed, such as the ability to interact with digital platforms and the ability to find and filter the increased amount of daily new medical information [ 6 ] Examples of digital platforms include those that contain academic journals and guidelines as well as technology-driven tools for healthcare systems. For this purpose, the use of e-learning as a complement to the medical curriculum can provide easier and more effective access to a wider variety of information [ 1 , 7 ]. Even though gains have been described, the incorporation of e-learning to enrich medical education will not be fully achieved without challenges that we need to overcome as educators [ 8 ]. The effects of e-learning on health sciences students have been debated over the last decade. The incorporation of e-learning is usually left aside from health sciences curriculum education, mainly because of the lack of scientific evidence that sustains its effectiveness for learning compared with traditional methods, in addition to a lack of information to decide when and how e-learning enhances medical education and the factors that can be associated with it. A recent review revealed that most of the published evidence in this regard had one or several of the following three limitations: studies were mostly descriptive, failed to present measurements of outcomes, and usually had inappropriate or weak study designs [ 9 ]. An additional limitation is related to the high costs related to the generation of high-quality content since it often involves the acquisition of technology, software, specialized personnel for editing, and sometimes the need for special installations. Therefore, it might be extremely expensive for universities that have not acquired this equipment or technical ability. Several international initiatives have emerged with the purpose of creating a digital repository of electronic resources for public or institutional use, given the recognition of the need to share high-quality e-learning tools in medical education [ 10 ]. As medical educators, we should consider how students are now exposed to increasing time constraints and demands, as well as the need for an up-to-date use of technology to ensure flexibility in a dynamic field. On the other hand, professors are required to provide a more personalized, self-directed learning experience, since clinicians are now required to continuously update their skills and achieve digital literacy to effectively use technology communication tools to locate, evaluate, use, and create digital information [ 11 ]. Furthermore, the incorporation of technology into the medical curriculum provides an opportunity to create a personalized learning experience, allowing academic faculty to achieve better interaction with students. Finally, we should consider the additional benefits that students might acquire with the incorporation of high-quality e-learning. Benefits can be divided into short-term or long-term benefits; short-term benefits include gains in knowledge, increased student satisfaction, digital literacy, and the reinforcement of concepts in a self-paced manner. The long-term benefits described in the past in association with e-learning include resilience and metacognition. Our research question was as follows: what are the short-term benefits that medical students can gain after exposure to a high-quality e-learning course? Our primary aim was to analyze the gain of knowledge as well as self-rated benefits and understanding in medical students after exposure to high-quality e-learning. Methods Data Sources: We included information from 2,613 course enrollments in five basic courses related to biochemistry, genetics, immunology, pharmacology, and physiology from July 2019 to July 2022. The analyzed cohort comprised medical students from years 1–2 of an international medical program and years 1–4 of a Latino medical program who were actively enrolled at our university during the time of the analysis. The size of classes for the Latino program varied from 200–400 students, whereas for the international program, class sizes ranged from 110–236 students during the period of the study. Programs for medical training differ in curriculum design as well as in students’ demographic characteristics; the Latino program has a traditional curriculum organized by subjects and is 6 years long, and demographic differences are related to younger age and fewer years of academic experience. The international program enrolls students from the United States and complies with the regulations established by the USA Education Department. Students from this program follow an organ system-based curriculum with a duration of 4 years. The basic science curriculum for both programs is taught separately, as the Latino program has classes in Spanish and the international program has classes in English. Neither of the programs experienced major changes related to the curriculum content during this period, except for the pandemic, which forced both programs to be delivered online from March 2020 to January 2022. Course Delivery: The addition of these e-learning resources to the medical curriculum aimed to strengthen the basic science formation of our programs. The courses were offered to all students as a no cost, optional resource for students who wish to advance their knowledge of basic sciences. An invitation was sent to all the active students from both of our programs. To enroll in one of five courses, the students had to complete an online registry form, and the students could take only one course at a time, with a maximum of two courses each semester. was sent once each semester, and there were no costs for students to take the courses. The completion of courses did not add credit to their academic track, and there were no penalties related to the lack of completion, apart from prevention in enrolling in another e-learning course in the same semester. Each course had a 10-week duration, and they occurred in parallel with mandatory courses, with the exception that e-learning was optional and was completed in a self-pace manner. Lessons from these courses consist of diverse types of videos, including teaching videos with writing and/or animations, clinical scenarios, text, assessments, and interactive visualizations. The duration of the videos is short (< 7 min average) with the purpose of increasing students’ virtual engagement. Lessons were released sequentially over the course period, with frequent formative assessments across the course and a single final exam at the end. All five courses were evaluated by the guidelines proposed by Wasfy et al . [ 2 ], all of which achieve the standard of quality resources. Evaluations: The knowledge gain was evaluated by a standardized pre course quiz released with the first lesson at the beginning of the course, whereas the post course quiz was released with the final lesson as a review for the final exam. Answers and explanations for these quizzes were not available to the students. Students were able to self-rate their benefit and understanding of topics before and after each lesson. In the same form, students had to undergo short quizzes throughout each lesson and one major exam at the end of the course. At the end of the course, students could achieve a certificate of achievement if they were able to obtain at least 80% overall in the course and at least 65% on the final exam. Or a completion certificate if they were able to watch all videos from all 10 lessons, complete all assessments, and work through all other course materials. The students were allowed two attempts on most questions in the body of the course and one attempt on each problem for the final exam. Ethical considerations. The study was conducted using anonymized data after the completion of the courses and the awarding of any relevant certificates. The protocol was submitted and approved by the institutional review board (IRB). Results We invited 4,874 students to be enrolled in e-learning courses. A total of 1,546 respondents were enrolled in at least one course, with a total of 2,613 course enrollments. During the study period, 30 courses were completed. The numbers of students enrolled in each course were as follows: Biochemistry, 486; Genetics, 515; Immunology, 535; Pharmacology, 549; and Physiology, 528. Table 1 contains information about the number of invited students and the number of students enrolled in multiple courses. Table 1 Number of students invited and enrolled in e-learning courses. Groups Number of students Latino Program (Class of 2019–2022) 3,574 International Program (Class of 2019–2022) 1,300 Total users of e-learning (both programs) 1,546 Total enrollments in e-learning 2,613 Students enrolled in one course 930 Students enrolled in two courses 332 Students enrolled in three courses 166 Students enrolled in four courses 73 Students enrolled in five courses 45 There was a self-rated benefit to e-learning from students across different courses. Figure 1 depicts the frequencies and percentages of self-rated benefits and self-rated understanding from students to all five courses. There was knowledge gained in all courses when scores in the standardized test were compared from the pre course quiz to the post course quiz (Fig. 2 ), which was noticeable in all courses. When knowledge gain was analyzed with respect to quartiles depending on the mean score from the pre course quiz, independent of the quartile, there was a significant gain in knowledge even for students who were in the 1st quartile. The median overall scores per course ranged from 75% in the genetics course to 84% in the pharmacology course (Fig. 4 ). Although all the courses had a median score above 70%, not all the students obtained certificates of completion or achievement. The course that had the highest percentage of students who obtained an achievement certificate was immunology (up to 45%), and the course with the highest percentage of students who obtained a completion certificate was genetics (40%). This information is depicted in Fig. 5. Discussion Our study confirmed the possibility of successfully integrating high-quality e-learning into the medical curriculum without the necessity of making changes to an ongoing curriculum. E-learning can be a useful complementary tool for students on many complicated or difficult topics during medical knowledge and training development. We found several advantages related to students’ e-learning experience. One advantage was the ability of students to be exposed to different cultural aspects related to medical practices that may exist between the country where e-learning is generated and the recipient, including the language or communication style, disease management and differences in healthcare systems, which has been addressed previously by others [ 12 ]. This was achieved through the incorporation of locally based case presentations with local treatment guidelines. Additionally, by incorporating the cultural aspects of patients, we can increase awareness of sociocultural differences in patients and how to address them. Students’ self-rated benefits and understanding. Students’ satisfaction is an important outcome previously associated with higher academic success [ 13 , 14 ]. During the COVID-19 pandemic, a positive significant correlation was found between satisfaction with e-learning and students’ academic achievement in different health sciences careers [ 15 , 16 ]. Satisfaction increases students’ motivation, effort, and perseverance, all of which are essential drivers of academic performance improvement [ 17 ]. However, this is considered a challenging task, especially for medical students compared to other fields of study, due to more complex educational curricula, challenging internships, frequent and complicated exams, and the constant fear of failure [ 18 ]. Here, the students reported both a self-rated benefit and self-rated improvement in their understanding of the material reviewed in each course. Both of these factors could be related to satisfaction with the exposure to e-learning. Several studies have reported on student satisfaction related to e-learning in comparison with traditional classrooms; nevertheless, most of these studies focused on the COVID-19 pandemic; therefore, the results cannot be limited to e-learning exclusively but rather to a complicated scenario in which students need to address additional concerns, such as social distancing from family and friends, economic insecurity, and even sickness or death of a family member. Despite this, the results tend to favor a combination of online and in-person forms of curricular delivery [ 19 ]. The most common positive outcome related to satisfaction in e-learning is the convenience and flexibility offered, which includes not traveling, saving time and being in the comfort of one’s own home. Additional benefits include an increase in the study resources and materials available for review, especially with asynchronous activities, and even a few students reported a positive impact on self-directed learning and productivity [ 19 , 20 ]. In our study, the participants had the ability to complete the course asynchronously, which was favorable because students can advance at their own pace and there are no limitations related to their ability to attend to certain lectures at specific times; however, this strategy is risky for students who tend to procrastinate, as we observed that not all students were able to obtain a certificate of completion, and the factor associated with this was a late start in the course, which restricted their ability to complete the entire course. A study performed before the pandemic (2013) provided no benefit for self-rated gain of knowledge after exposure to e-learning for a physiology course [ 21 ]; however, this was an additional mandatory course for students, and their lack of satisfaction could be due to the implementation of more activities rather than the activity itself. Other variables associated with the design of e-learning could also explain the lack of satisfaction in this study, but this was not analyzed. Some of the previously reported drawbacks in terms of student satisfaction when students are exposed to e-learning include technology-related issues, including structural barriers such as limited bandwidth, poor audio, lack of equipment, and software problems [ 20 ]. However, this was not the case for our intervention, since during the pandemic, each student had to secure internet access, and most of them updated their computational devices. Moreover, the school had to improve its structure to allow more students to access online content. During the study, no software problems were reported, and the platform for course allocation was run by Harvard Medical School External Education and had no problems during this 3-year experience. However, it is understandable that a substantial proportion of medical schools can be in low- and lower-middle-income countries, which may be associated with a lack of funding and unaffordable costs for internet connectivity [ 22 ]. These previously reported advantages related to student satisfaction when exposed to e-learning still hold an area of debate related to virtual engagement, which can be challenging and needs to be accounted for when designing e-learning materials. The active participation of professors might be an important characteristic of this virtual engagement; we had a group of professors interacting through an active chat where students can raise questions related to different lessons. Another form of professor interaction involves commenting on classes and examples set out during online courses, which allows for more personalized interaction between professors and students, which has been identified as another important limitation for the regular use of e-learning [ 23 ]. Another way to assure students’ engagement was related to the diversity and duration of the videos for each course, since short videos and variety have been previously related to an increase in virtual engagement [ 24 ]. Students’ gain of knowledge. In our study, a gain of knowledge was evident when comparing the results of the pre- and postcourse final evaluations of each course (see Fig. 2 ). This gain of knowledge was confirmed for students in different quartiles after the initial evaluation. This gain of knowledge analyzed by written tests before and after e-learning has been addressed before by others either by delimiting the exposure with the use of laboratory-like settings [ 25 ] with a randomized design [ 26 ] or by using both a randomized controlled design in a laboratory-like environment [ 27 ]. Importantly, in these two studies, the e-learning resource was an addition to the traditional curriculum, not a substitution for already planned lectures. We believe that in this sense, e-learning has the potential to promote the gain of knowledge by reinforcing or repeating information that is provided in the ongoing curriculum and therefore should be considered a complement rather than a substitution. A recent study compared the acquisition of knowledge in two generations of students who learned in a traditional form (before the pandemic) to a generation that received their entire education in the ongoing semester through e-learning (during the pandemic). They reported that the knowledge gained was similar for both groups and stable after one year of pandemic-related implementation of digital teaching [ 28 ]. A very recent cross-sectional study aimed at comparing the effectiveness of blended learning in an evidence-based medicine course by comparing examination scores across 3 groups with different forms of curriculum delivery: 1) blended learning, 2) online learning, and 3) traditional offline learning. They reported that blended group exam scores and pass rates were significantly higher than those of offline and online groups; moreover, 71.6% of students preferred the blended form of delivery, with students highly rating the flexibility in time and space of the online part [ 29 ]. A recent study that compared final scores on a microbiology examination reported an increase of 5.57% in students who were exposed to e-learning compared with nonexposed medical students from Ireland [ 30 ]. However, this study failed to address other outcomes related to study habits, metacognition, and resilience, all of which could be associated with e-learning exposure. The question about gain of knowledge that could pertain to the summative evaluations of the medical curriculum could not be addressed in our study, owing to certain limitations: first, the students were exposed to courses at different times with respect to curricular content, some of them completed the subject and used the courses as a review, others took them in preparation before the subject and only a few were taking the course simultaneously to the subject, decreasing the sample size and the power to run such analysis; second, the duration of the courses was different from the longer duration of the subjects in either curriculum (for the international program, the subjects can be taught in two different semesters), so it was difficult to correlate times when students complete courses related to each subject; and third, now that we know there are benefits related to the exposure and since they are offered as an optional form to everyone, it would not be ethical to restrain students from this opportunity. Evaluations for each lesson in e-learning courses are designed as open-book examinations; some considerations for this adaptation of evaluations include time restrictions, the need for a complicated cognitive process that often involves more than two concepts, and the application of previously learned material in a different context. Disadvantages of e-learning. One important disadvantage is the cost related to the generation of high-quality content since it often involves the acquisition of high-cost technology and software; furthermore, editing and special installations might be necessary. Therefore, it might be extremely expensive for universities that have not acquired this equipment or technical ability. All the content related to the e-learning courses was assembled by another institution, which holds an important investment in the acquisition of equipment and experience to design and implement the courses. Furthermore, technological barriers still exist in several countries; in Mexico, there are considerable numbers of rural areas with restricted access to broadband services. Thus, to overcome such technological barriers in low/lower income countries and rural regions of high-income countries, a world-based approach to reduce the social gap between and within countries is still needed. Moreover, adding programs/courses on how to overcome and complete distance educational programs could also be important for decreasing such technological barriers, allowing for broader utility of online learning [ 31 ]. Study limitations. A limitation of our study might be related to the fact that e-learning courses were not embedded in the curriculum; therefore, we were not able to test the gain of knowledge in curriculum summative evaluations. However, this would take off the flexibility and optionality in which the courses were offered. Furthermore, the implementation of these resources as part of the curriculum would require time for adaptation and the need to wait for a reaccreditation. Furthermore, the cost associated with the delivery of these resources to every student could be significant. Another limitation is the presence of selection bias, since students self-select themselves to enroll in e-learning, and we do not know how different these students can be from those who decide not to enroll in these e-learning resources. Future studies with different designs can help us address whether study habits, abilities or other characteristics are important for the benefits associated with e-learning exposure. Concluding remarks. This study suggests that the use of e-learning to reinforce basic science concepts in an ongoing curriculum is possible and desirable since several advantages can be added to formative forms of learning for medical students. Some important advantages include satisfaction and knowledge gain. The role of e-learning in voluntary and formative evaluation is valuable for medical students in their preclinical years and should be further explored in additional learning environments. The debate over optional versus mandatory e-learning activities and their effectiveness is another aspect that should be clarified and explored in future studies. Declarations Ethics approval and consent to participate : The protocol was approved by UAGs’ IRB “ Comité de ética en investigación del Hospital Dr. Ángel Leaño ” bwith number CEI/2024/003. Students provide electronic consent to participate in the study. Consent for publication : Not applicable. Clinical trial number : Not applicable. Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests . The authors declare that they have no competing interests with the present study. Funding . This research received no external funding. Authors’ contributions . Conceptualization: MGZC, AEC, and MJP. Data curation: MGZC, SVM, and MJP. Formal Analysis: MJP. Investigation: MGZC, AEC, SVM, and MJP. Methodology: MGZC, AEC, and MJP. Writing - Original Draft Preparation: MGZC, AEC, SVM, and MJP. Writing – Review & Editing: MGZC, AEC, SVM, and MJP. Acknowledgments . None References Pettersson F, Olofsson AD: Implementing distance teaching at a large scale in medical education: A struggle between dominant and non-dominant teaching activities . Education and Information Technologies 2015, 20 (2):359-380. Wasfy NF, Abouzeid E, Nasser AA, Ahmed SA, Youssry I, Hegazy NN, Shehata MHK, Kamal D, Atwa H: A guide for evaluation of online learning in medical education: a qualitative reflective analysis . BMC Medical Education 2021, 21 (1):339. Tang B, Coret A, Qureshi A, Barron H, Ayala AP, Law M: Online Lectures in Undergraduate Medical Education: Scoping Review . 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Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 18 Sep, 2024 Reviews received at journal 17 Sep, 2024 Reviews received at journal 16 Sep, 2024 Reviews received at journal 12 Sep, 2024 Reviewers agreed at journal 08 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers invited by journal 25 Aug, 2024 Editor invited by journal 23 Aug, 2024 Editor assigned by journal 22 Aug, 2024 Submission checks completed at journal 22 Aug, 2024 First submitted to journal 14 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4915453","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":355490502,"identity":"2acbb0f9-8a86-43c1-9fee-0c61fc946548","order_by":0,"name":"Maria G Zavala-Cerna","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYJCCA1Ca8QEDG4lamA2I1gIDbBJEadFtP/vwwA8GOznz2c3PKj6UHWYwOH78AtPNNtxazM6kGxzsYUg2lrlzzOzmjHNALWdyCphzzuDRciCN4QAPw4HEGRIJZrd524BaDuQkMOdU4NFy/hnDwT8MB+pnSKR/K/4L0nL+DVCLAR4tN9IYDgNtSZCQyDFjZgRpuZF+AL8tN54xHJYxSDacIZFTLNlzLp1H8sYbhsN4/XI+jfnjmwo7eQmJ9I0ffpRZy/GdT3/4OBdPiEEAkst5gMjgACEN6ID9Aak6RsEoGAWjYHgDAMWUUzqBaHzNAAAAAElFTkSuQmCC","orcid":"","institution":"Universidad Autónoma de Guadalajara","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"G","lastName":"Zavala-Cerna","suffix":""},{"id":355490503,"identity":"518ed037-1cc3-4ab0-a199-1ce8c2f28d7d","order_by":1,"name":"Augusto E. Caballero","email":"","orcid":"","institution":"Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Augusto","middleName":"E.","lastName":"Caballero","suffix":""},{"id":355490507,"identity":"9e8721a7-d0d6-4175-bb47-a4d2953fd491","order_by":2,"name":"Steffi Verbeeck-Mendez","email":"","orcid":"","institution":"Universidad Autónoma de Guadalajara","correspondingAuthor":false,"prefix":"","firstName":"Steffi","middleName":"","lastName":"Verbeeck-Mendez","suffix":""},{"id":355490511,"identity":"18260fca-11ae-44ec-9e5c-c2854c2cabfa","order_by":3,"name":"Michael J. Parker","email":"","orcid":"","institution":"Harvard Medical School","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"J.","lastName":"Parker","suffix":""}],"badges":[],"createdAt":"2024-08-14 18:05:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4915453/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4915453/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-06794-8","type":"published","date":"2025-02-11T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64894671,"identity":"70b8fe13-a0ca-4b59-af2b-b99ddcfaf286","added_by":"auto","created_at":"2024-09-20 06:49:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1613044,"visible":true,"origin":"","legend":"\u003cp\u003eSelf-rated benefits and understanding of 5 basic science online courses. The students’ self-rated benefit and understanding were evaluated before (blue dots) and after (green dots) each lesson on a 5-point Likert scale that included poor, fair, good, very good and excellent. Larger dots represent a greater number of students. The blue lines represent the means, and the crossed lines indicate the differences observed between the before- and after-lesson means.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4915453/v1/be10d09377d98786c45810b7.png"},{"id":64894672,"identity":"3890db47-aadd-4f4f-8345-26bc49cba31c","added_by":"auto","created_at":"2024-09-20 06:49:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":659429,"visible":true,"origin":"","legend":"\u003cp\u003eGain of knowledge in each course by quartile of performance after the mean scores on a standardized test performed before and after the course were evaluated. Quartiles were obtained by analyzing precourse quiz scores such that blue bars indicate the postcourse quiz outcomes for that group of students.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4915453/v1/a5d9f7240b6e07604b6ed84e.png"},{"id":64894670,"identity":"2f476614-36d8-48d7-98e3-1202049bbc18","added_by":"auto","created_at":"2024-09-20 06:49:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":112584,"visible":true,"origin":"","legend":"\u003cp\u003eDistributions of overall scores per course, with each box indicating the median and interquartile range (25--75%) for the overall scores in each course.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4915453/v1/4f3bcc3035736c43eba3d4f4.png"},{"id":64894674,"identity":"b99ef871-fedd-40d9-aeeb-39c859d3f5ba","added_by":"auto","created_at":"2024-09-20 06:49:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":122099,"visible":true,"origin":"","legend":"\u003cp\u003ePercentages of certificates achieved by students enrolled in basic electronic science courses.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4915453/v1/f60f041cb8417ca9789a7352.png"},{"id":76487547,"identity":"149d1ef4-93ab-4170-8f35-b8a89e8f19bb","added_by":"auto","created_at":"2025-02-17 16:08:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4332922,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4915453/v1/fae902da-d1b1-4f8b-8896-4933f732e98d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"E-learning benefits for medical students: the longitudinal use of an online learning experience at an international medical school","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOnline learning or electronic learning (e-learning) is defined as the use of electronic technology to deliver, support, or enhance both learning and teaching [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In medical education, over several decades, and more importantly during the COVID-19 pandemic, the necessities for medical education delivery changed, and e-learning was the only way to continue medical education for a while. However, not all delivery was consistent with e-learning because of time constraints and a lack of effective learning. Currently, e-learning is becoming more common, but we still need to constantly evaluate the quality of the online material since the use of an electronic device is not sufficient. Wasfy and colleagues published a guide for the evaluation of online learning, and such tools should be used in an attempt to standardize e-learning exposures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral reasons are behind the incorporation of e-learning into medical education, such as the need for more well-trained health professionals worldwide, their use in so-called \u0026ldquo;flipped classrooms\u0026rdquo;, the need to increase student satisfaction, the need to add forms to improve the retention of many concepts, and the need to unify concepts among students with different backgrounds [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith respect to student satisfaction, the DigiMed study included 3,286 medical students from 12 countries, and the results indicated that up to 40% agreed with continuing with e-learning for the partial delivery of the medical curriculum [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additional studies have presented interesting findings with respect to adaptability and acceptance of online classes, with a majority of subtends and professors supporting online teaching and, in general, experiencing satisfaction with online education [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There is no question that e-learning is becoming more common in medical education, and we can begin to consider a blended form of curriculum delivery.\u003c/p\u003e \u003cp\u003eMedical graduates are facing a more competent field, and additional competencies are needed, such as the ability to interact with digital platforms and the ability to find and filter the increased amount of daily new medical information [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Examples of digital platforms include those that contain academic journals and guidelines as well as technology-driven tools for healthcare systems. For this purpose, the use of e-learning as a complement to the medical curriculum can provide easier and more effective access to a wider variety of information [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEven though gains have been described, the incorporation of e-learning to enrich medical education will not be fully achieved without challenges that we need to overcome as educators [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The effects of e-learning on health sciences students have been debated over the last decade. The incorporation of e-learning is usually left aside from health sciences curriculum education, mainly because of the lack of scientific evidence that sustains its effectiveness for learning compared with traditional methods, in addition to a lack of information to decide when and how e-learning enhances medical education and the factors that can be associated with it. A recent review revealed that most of the published evidence in this regard had one or several of the following three limitations: studies were mostly descriptive, failed to present measurements of outcomes, and usually had inappropriate or weak study designs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn additional limitation is related to the high costs related to the generation of high-quality content since it often involves the acquisition of technology, software, specialized personnel for editing, and sometimes the need for special installations. Therefore, it might be extremely expensive for universities that have not acquired this equipment or technical ability. Several international initiatives have emerged with the purpose of creating a digital repository of electronic resources for public or institutional use, given the recognition of the need to share high-quality e-learning tools in medical education [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs medical educators, we should consider how students are now exposed to increasing time constraints and demands, as well as the need for an up-to-date use of technology to ensure flexibility in a dynamic field. On the other hand, professors are required to provide a more personalized, self-directed learning experience, since clinicians are now required to continuously update their skills and achieve digital literacy to effectively use technology communication tools to locate, evaluate, use, and create digital information [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, the incorporation of technology into the medical curriculum provides an opportunity to create a personalized learning experience, allowing academic faculty to achieve better interaction with students.\u003c/p\u003e \u003cp\u003eFinally, we should consider the additional benefits that students might acquire with the incorporation of high-quality e-learning. Benefits can be divided into short-term or long-term benefits; short-term benefits include gains in knowledge, increased student satisfaction, digital literacy, and the reinforcement of concepts in a self-paced manner. The long-term benefits described in the past in association with e-learning include resilience and metacognition.\u003c/p\u003e \u003cp\u003eOur research question was as follows: what are the short-term benefits that medical students can gain after exposure to a high-quality e-learning course? Our primary aim was to analyze the gain of knowledge as well as self-rated benefits and understanding in medical students after exposure to high-quality e-learning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Sources:\u003c/h2\u003e \u003cp\u003eWe included information from 2,613 course enrollments in five basic courses related to biochemistry, genetics, immunology, pharmacology, and physiology from July 2019 to July 2022. The analyzed cohort comprised medical students from years 1\u0026ndash;2 of an international medical program and years 1\u0026ndash;4 of a Latino medical program who were actively enrolled at our university during the time of the analysis. The size of classes for the Latino program varied from 200\u0026ndash;400 students, whereas for the international program, class sizes ranged from 110\u0026ndash;236 students during the period of the study.\u003c/p\u003e \u003cp\u003ePrograms for medical training differ in curriculum design as well as in students\u0026rsquo; demographic characteristics; the Latino program has a traditional curriculum organized by subjects and is 6 years long, and demographic differences are related to younger age and fewer years of academic experience. The international program enrolls students from the United States and complies with the regulations established by the USA Education Department. Students from this program follow an organ system-based curriculum with a duration of 4 years. The basic science curriculum for both programs is taught separately, as the Latino program has classes in Spanish and the international program has classes in English. Neither of the programs experienced major changes related to the curriculum content during this period, except for the pandemic, which forced both programs to be delivered online from March 2020 to January 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCourse Delivery:\u003c/h2\u003e \u003cp\u003eThe addition of these e-learning resources to the medical curriculum aimed to strengthen the basic science formation of our programs. The courses were offered to all students as a no cost, optional resource for students who wish to advance their knowledge of basic sciences. An invitation was sent to all the active students from both of our programs. To enroll in one of five courses, the students had to complete an online registry form, and the students could take only one course at a time, with a maximum of two courses each semester. was sent once each semester, and there were no costs for students to take the courses. The completion of courses did not add credit to their academic track, and there were no penalties related to the lack of completion, apart from prevention in enrolling in another e-learning course in the same semester. Each course had a 10-week duration, and they occurred in parallel with mandatory courses, with the exception that e-learning was optional and was completed in a self-pace manner.\u003c/p\u003e \u003cp\u003eLessons from these courses consist of diverse types of videos, including teaching videos with writing and/or animations, clinical scenarios, text, assessments, and interactive visualizations. The duration of the videos is short (\u0026lt;\u0026thinsp;7 min average) with the purpose of increasing students\u0026rsquo; virtual engagement.\u003c/p\u003e \u003cp\u003eLessons were released sequentially over the course period, with frequent formative assessments across the course and a single final exam at the end.\u003c/p\u003e \u003cp\u003eAll five courses were evaluated by the guidelines proposed by Wasfy \u003cem\u003eet al\u003c/em\u003e. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], all of which achieve the standard of quality resources.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEvaluations:\u003c/h2\u003e \u003cp\u003eThe knowledge gain was evaluated by a standardized pre course quiz released with the first lesson at the beginning of the course, whereas the post course quiz was released with the final lesson as a review for the final exam. Answers and explanations for these quizzes were not available to the students.\u003c/p\u003e \u003cp\u003eStudents were able to self-rate their benefit and understanding of topics before and after each lesson. In the same form, students had to undergo short quizzes throughout each lesson and one major exam at the end of the course.\u003c/p\u003e \u003cp\u003eAt the end of the course, students could achieve a certificate of achievement if they were able to obtain at least 80% overall in the course and at least 65% on the final exam. Or a completion certificate if they were able to watch all videos from all 10 lessons, complete all assessments, and work through all other course materials. The students were allowed two attempts on most questions in the body of the course and one attempt on each problem for the final exam.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEthical considerations.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe study was conducted using anonymized data after the completion of the courses and the awarding of any relevant certificates. The protocol was submitted and approved by the institutional review board (IRB).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe invited 4,874 students to be enrolled in e-learning courses. A total of 1,546 respondents were enrolled in at least one course, with a total of 2,613 course enrollments. During the study period, 30 courses were completed. The numbers of students enrolled in each course were as follows: Biochemistry, 486; Genetics, 515; Immunology, 535; Pharmacology, 549; and Physiology, 528. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e contains information about the number of invited students and the number of students enrolled in multiple courses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of students invited and enrolled in e-learning courses.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of students\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLatino Program (Class of 2019\u0026ndash;2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3,574\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternational Program (Class of 2019\u0026ndash;2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal users of e-learning (both programs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1,546\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal enrollments in e-learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,613\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents enrolled in one course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e930\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents enrolled in two courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents enrolled in three courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents enrolled in four courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents enrolled in five courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a self-rated benefit to e-learning from students across different courses. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the frequencies and percentages of self-rated benefits and self-rated understanding from students to all five courses.\u003c/p\u003e \u003cp\u003eThere was knowledge gained in all courses when scores in the standardized test were compared from the pre course quiz to the post course quiz (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), which was noticeable in all courses. When knowledge gain was analyzed with respect to quartiles depending on the mean score from the pre course quiz, independent of the quartile, there was a significant gain in knowledge even for students who were in the 1st quartile.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe median overall scores per course ranged from 75% in the genetics course to 84% in the pharmacology course (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAlthough all the courses had a median score above 70%, not all the students obtained certificates of completion or achievement. The course that had the highest percentage of students who obtained an achievement certificate was immunology (up to 45%), and the course with the highest percentage of students who obtained a completion certificate was genetics (40%). This information is depicted in Fig.\u0026nbsp;5.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study confirmed the possibility of successfully integrating high-quality e-learning into the medical curriculum without the necessity of making changes to an ongoing curriculum. E-learning can be a useful complementary tool for students on many complicated or difficult topics during medical knowledge and training development.\u003c/p\u003e \u003cp\u003eWe found several advantages related to students\u0026rsquo; e-learning experience. One advantage was the ability of students to be exposed to different cultural aspects related to medical practices that may exist between the country where e-learning is generated and the recipient, including the language or communication style, disease management and differences in healthcare systems, which has been addressed previously by others [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This was achieved through the incorporation of locally based case presentations with local treatment guidelines. Additionally, by incorporating the cultural aspects of patients, we can increase awareness of sociocultural differences in patients and how to address them.\u003c/p\u003e \u003cp\u003e \u003cem\u003eStudents\u0026rsquo; self-rated benefits and understanding.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStudents\u0026rsquo; satisfaction is an important outcome previously associated with higher academic success [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. During the COVID-19 pandemic, a positive significant correlation was found between satisfaction with e-learning and students\u0026rsquo; academic achievement in different health sciences careers [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Satisfaction increases students\u0026rsquo; motivation, effort, and perseverance, all of which are essential drivers of academic performance improvement [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, this is considered a challenging task, especially for medical students compared to other fields of study, due to more complex educational curricula, challenging internships, frequent and complicated exams, and the constant fear of failure [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Here, the students reported both a self-rated benefit and self-rated improvement in their understanding of the material reviewed in each course. Both of these factors could be related to satisfaction with the exposure to e-learning.\u003c/p\u003e \u003cp\u003eSeveral studies have reported on student satisfaction related to e-learning in comparison with traditional classrooms; nevertheless, most of these studies focused on the COVID-19 pandemic; therefore, the results cannot be limited to e-learning exclusively but rather to a complicated scenario in which students need to address additional concerns, such as social distancing from family and friends, economic insecurity, and even sickness or death of a family member. Despite this, the results tend to favor a combination of online and in-person forms of curricular delivery [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most common positive outcome related to satisfaction in e-learning is the convenience and flexibility offered, which includes not traveling, saving time and being in the comfort of one\u0026rsquo;s own home. Additional benefits include an increase in the study resources and materials available for review, especially with asynchronous activities, and even a few students reported a positive impact on self-directed learning and productivity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the participants had the ability to complete the course asynchronously, which was favorable because students can advance at their own pace and there are no limitations related to their ability to attend to certain lectures at specific times; however, this strategy is risky for students who tend to procrastinate, as we observed that not all students were able to obtain a certificate of completion, and the factor associated with this was a late start in the course, which restricted their ability to complete the entire course.\u003c/p\u003e \u003cp\u003eA study performed before the pandemic (2013) provided no benefit for self-rated gain of knowledge after exposure to e-learning for a physiology course [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; however, this was an additional mandatory course for students, and their lack of satisfaction could be due to the implementation of more activities rather than the activity itself. Other variables associated with the design of e-learning could also explain the lack of satisfaction in this study, but this was not analyzed.\u003c/p\u003e \u003cp\u003eSome of the previously reported drawbacks in terms of student satisfaction when students are exposed to e-learning include technology-related issues, including structural barriers such as limited bandwidth, poor audio, lack of equipment, and software problems [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, this was not the case for our intervention, since during the pandemic, each student had to secure internet access, and most of them updated their computational devices. Moreover, the school had to improve its structure to allow more students to access online content. During the study, no software problems were reported, and the platform for course allocation was run by Harvard Medical School External Education and had no problems during this 3-year experience. However, it is understandable that a substantial proportion of medical schools can be in low- and lower-middle-income countries, which may be associated with a lack of funding and unaffordable costs for internet connectivity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese previously reported advantages related to student satisfaction when exposed to e-learning still hold an area of debate related to virtual engagement, which can be challenging and needs to be accounted for when designing e-learning materials. The active participation of professors might be an important characteristic of this virtual engagement; we had a group of professors interacting through an active chat where students can raise questions related to different lessons. Another form of professor interaction involves commenting on classes and examples set out during online courses, which allows for more personalized interaction between professors and students, which has been identified as another important limitation for the regular use of e-learning [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Another way to assure students\u0026rsquo; engagement was related to the diversity and duration of the videos for each course, since short videos and variety have been previously related to an increase in virtual engagement [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eStudents\u0026rsquo; gain of knowledge.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn our study, a gain of knowledge was evident when comparing the results of the pre- and postcourse final evaluations of each course (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This gain of knowledge was confirmed for students in different quartiles after the initial evaluation. This gain of knowledge analyzed by written tests before and after e-learning has been addressed before by others either by delimiting the exposure with the use of laboratory-like settings [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] with a randomized design [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] or by using both a randomized controlled design in a laboratory-like environment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, in these two studies, the e-learning resource was an addition to the traditional curriculum, not a substitution for already planned lectures. We believe that in this sense, e-learning has the potential to promote the gain of knowledge by reinforcing or repeating information that is provided in the ongoing curriculum and therefore should be considered a complement rather than a substitution.\u003c/p\u003e \u003cp\u003eA recent study compared the acquisition of knowledge in two generations of students who learned in a traditional form (before the pandemic) to a generation that received their entire education in the ongoing semester through e-learning (during the pandemic). They reported that the knowledge gained was similar for both groups and stable after one year of pandemic-related implementation of digital teaching [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA very recent cross-sectional study aimed at comparing the effectiveness of blended learning in an evidence-based medicine course by comparing examination scores across 3 groups with different forms of curriculum delivery: 1) blended learning, 2) online learning, and 3) traditional offline learning. They reported that blended group exam scores and pass rates were significantly higher than those of offline and online groups; moreover, 71.6% of students preferred the blended form of delivery, with students highly rating the flexibility in time and space of the online part [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent study that compared final scores on a microbiology examination reported an increase of 5.57% in students who were exposed to e-learning compared with nonexposed medical students from Ireland [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, this study failed to address other outcomes related to study habits, metacognition, and resilience, all of which could be associated with e-learning exposure.\u003c/p\u003e \u003cp\u003eThe question about gain of knowledge that could pertain to the summative evaluations of the medical curriculum could not be addressed in our study, owing to certain limitations: first, the students were exposed to courses at different times with respect to curricular content, some of them completed the subject and used the courses as a review, others took them in preparation before the subject and only a few were taking the course simultaneously to the subject, decreasing the sample size and the power to run such analysis; second, the duration of the courses was different from the longer duration of the subjects in either curriculum (for the international program, the subjects can be taught in two different semesters), so it was difficult to correlate times when students complete courses related to each subject; and third, now that we know there are benefits related to the exposure and since they are offered as an optional form to everyone, it would not be ethical to restrain students from this opportunity.\u003c/p\u003e \u003cp\u003eEvaluations for each lesson in e-learning courses are designed as open-book examinations; some considerations for this adaptation of evaluations include time restrictions, the need for a complicated cognitive process that often involves more than two concepts, and the application of previously learned material in a different context.\u003c/p\u003e \u003cp\u003e \u003cem\u003eDisadvantages of e-learning.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne important disadvantage is the cost related to the generation of high-quality content since it often involves the acquisition of high-cost technology and software; furthermore, editing and special installations might be necessary. Therefore, it might be extremely expensive for universities that have not acquired this equipment or technical ability. All the content related to the e-learning courses was assembled by another institution, which holds an important investment in the acquisition of equipment and experience to design and implement the courses.\u003c/p\u003e \u003cp\u003eFurthermore, technological barriers still exist in several countries; in Mexico, there are considerable numbers of rural areas with restricted access to broadband services. Thus, to overcome such technological barriers in low/lower income countries and rural regions of high-income countries, a world-based approach to reduce the social gap between and within countries is still needed. Moreover, adding programs/courses on how to overcome and complete distance educational programs could also be important for decreasing such technological barriers, allowing for broader utility of online learning [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eStudy limitations.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA limitation of our study might be related to the fact that e-learning courses were not embedded in the curriculum; therefore, we were not able to test the gain of knowledge in curriculum summative evaluations. However, this would take off the flexibility and optionality in which the courses were offered. Furthermore, the implementation of these resources as part of the curriculum would require time for adaptation and the need to wait for a reaccreditation. Furthermore, the cost associated with the delivery of these resources to every student could be significant. Another limitation is the presence of selection bias, since students self-select themselves to enroll in e-learning, and we do not know how different these students can be from those who decide not to enroll in these e-learning resources. Future studies with different designs can help us address whether study habits, abilities or other characteristics are important for the benefits associated with e-learning exposure.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConcluding remarks.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study suggests that the use of e-learning to reinforce basic science concepts in an ongoing curriculum is possible and desirable since several advantages can be added to formative forms of learning for medical students. Some important advantages include satisfaction and knowledge gain. The role of e-learning in voluntary and formative evaluation is valuable for medical students in their preclinical years and should be further explored in additional learning environments. The debate over optional versus mandatory e-learning activities and their effectiveness is another aspect that should be clarified and explored in future studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The protocol was approved by UAGs\u0026rsquo; IRB \u0026ldquo;\u003cem\u003eComit\u0026eacute; de \u0026eacute;tica en investigaci\u0026oacute;n del Hospital Dr. \u0026Aacute;ngel Lea\u0026ntilde;o\u003c/em\u003e\u0026rdquo; bwith number CEI/2024/003. Students provide electronic consent to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e. The authors declare that they have no competing interests with the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e. This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e. Conceptualization: MGZC, AEC, and MJP. Data curation: MGZC, SVM, and MJP. Formal Analysis: MJP. Investigation: MGZC, AEC, SVM, and MJP. Methodology: MGZC, AEC, and MJP. Writing - Original Draft Preparation: MGZC, AEC, SVM, and MJP. Writing \u0026ndash; Review \u0026amp; Editing: MGZC, AEC, SVM, and MJP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e. None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePettersson F, Olofsson AD: \u003cstrong\u003eImplementing distance teaching at a large scale in medical education: A struggle between dominant and non-dominant teaching activities\u003c/strong\u003e. \u003cem\u003eEducation and Information Technologies \u003c/em\u003e2015, \u003cstrong\u003e20\u003c/strong\u003e(2):359-380.\u003c/li\u003e\n\u003cli\u003eWasfy NF, Abouzeid E, Nasser AA, Ahmed SA, Youssry I, Hegazy NN, Shehata MHK, Kamal D, Atwa H: \u003cstrong\u003eA guide for evaluation of online learning in medical education: a qualitative reflective analysis\u003c/strong\u003e. \u003cem\u003eBMC Medical Education \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(1):339.\u003c/li\u003e\n\u003cli\u003eTang B, Coret A, Qureshi A, Barron H, Ayala AP, Law M: \u003cstrong\u003eOnline Lectures in Undergraduate Medical Education: Scoping Review\u003c/strong\u003e. \u003cem\u003eJMIR Med Educ \u003c/em\u003e2018, \u003cstrong\u003e4\u003c/strong\u003e(1):e11.\u003c/li\u003e\n\u003cli\u003eStoehr F, M\u0026uuml;ller L, Brady A, Trilla A, M\u0026auml;hringer-Kunz A, Hahn F, D\u0026uuml;ber C, Becker N, W\u0026ouml;rns MA, Chapiro J\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eHow COVID-19 kick-started online learning in medical education-The DigiMed study\u003c/strong\u003e. \u003cem\u003ePLoS One \u003c/em\u003e2021, \u003cstrong\u003e16\u003c/strong\u003e(9):e0257394.\u003c/li\u003e\n\u003cli\u003eSong Y, Wang S, Liu Y, Liu X, Peng A: \u003cstrong\u003eOnline education at the medical School of Tongji University during the COVID-19 pandemic: a cross-sectional study\u003c/strong\u003e. \u003cem\u003eBMC Med Educ \u003c/em\u003e2021, \u003cstrong\u003e21\u003c/strong\u003e(1):512.\u003c/li\u003e\n\u003cli\u003eNiebuhr V, Niebuhr B, Trumble J, Urbani MJ: \u003cstrong\u003eOnline faculty development for creating E-learning materials\u003c/strong\u003e. \u003cem\u003eEduc Health (Abingdon) \u003c/em\u003e2014, \u003cstrong\u003e27\u003c/strong\u003e(3):255-261.\u003c/li\u003e\n\u003cli\u003eHowlett D, Vincent T, Gainsborough N, Fairclough J, Taylor N, Cohen J, Vincent R: \u003cstrong\u003eIntegration of a Case-Based Online Module into an Undergraduate Curriculum: What is Involved and is it Effective?\u003c/strong\u003e \u003cem\u003eE-Learning and Digital Media \u003c/em\u003e2009, \u003cstrong\u003e6\u003c/strong\u003e(4):372-384.\u003c/li\u003e\n\u003cli\u003eBrueckner JK, Gould DJ: \u003cstrong\u003eHealth science faculty members\u0026rsquo; perceptions of curricular integration: insights and obstacles\u003c/strong\u003e. \u003cem\u003eJ Int Assoc Med Sci Educ \u003c/em\u003e2006, \u003cstrong\u003e16\u003c/strong\u003e(1):31-34.\u003c/li\u003e\n\u003cli\u003eRegmi K, Jones L: \u003cstrong\u003eA systematic review of the factors - 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Some important findings after this experience highlight the possibility of continuing with the online form of curriculum delivery, at least partially, to reinforce the learning experience of medical students. Our research goal was to analyze the benefits that medical students can gain after exposure to high-quality e-learning. Our primary aim was to analyze the gain of knowledge, as well as self-rated benefits and understanding, after exposure to high-quality e-learning. We conducted a retrospective study to report on the outcomes achieved after 3 years of experience with the online delivery of basic biomedical science courses. We included results from 1,546 students and 2,613 course enrollments in two different medical programs. Here, we report on students\u0026rsquo; benefits after online courses in terms of knowledge gain and satisfaction. The information presented here could be used to make decisions about the incorporation of e-learning into the medical curriculum.\u003c/p\u003e","manuscriptTitle":"E-learning benefits for medical students: the longitudinal use of an online learning experience at an international medical school","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-20 06:49:25","doi":"10.21203/rs.3.rs-4915453/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-18T04:22:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T21:00:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-16T11:41:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-13T00:57:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262232820126272099507333105825098717423","date":"2024-09-08T12:31:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120801360976442402011030995897241071556","date":"2024-09-06T17:37:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149268508847260144815474242039762321327","date":"2024-09-06T12:09:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-26T00:13:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-08-23T04:48:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-22T06:52:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-22T06:50:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-08-14T18:02:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"34194aa2-e695-43dd-87db-122f150a7e73","owner":[],"postedDate":"September 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:01:31+00:00","versionOfRecord":{"articleIdentity":"rs-4915453","link":"https://doi.org/10.1186/s12909-025-06794-8","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-02-11 15:57:30","publishedOnDateReadable":"February 11th, 2025"},"versionCreatedAt":"2024-09-20 06:49:25","video":"","vorDoi":"10.1186/s12909-025-06794-8","vorDoiUrl":"https://doi.org/10.1186/s12909-025-06794-8","workflowStages":[]},"version":"v1","identity":"rs-4915453","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4915453","identity":"rs-4915453","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}