Discussion

Emergency medicine residency programs in India are only over a decade old, with the first residency program, Doctor of Medicine (MD) EM in medical colleges, approved by the erstwhile Medical Council of India (MCI) initiated in 2009. The National Board of Examination (NBE) accredited residency program in EM, conferring the Diplomate of National Board (DNB) degree was initiated later in 2013. To avoid heterogeneity in the study population based on the scope of practice and the resources/infrastructure, which are highly variable in the private health care sector in India, we have targeted residency programs in medical colleges only. E-learning, when compared to conventional learning strategies, has shown only a small positive effect in the past. ^{Reference Vaona, Banzi and Kwag2} Literature is scarce on the e-learning revolution in India. The potential for e-learning and its impact on the advancement of health training and education is not entirely known. ^{Reference Jorge, Lüders, Malunga and Neuhann5} It has been concluded in studies that e-learning contributes to learner-centric, active learning by promoting self-directed learning. ^{Reference Ozuah6} A significant change in learning in current times is the strategy of focusing on the learner rather than the educator. Adopting a virtual learning environment may facilitate collaborative learning, effectively distribute learning materials, facilitate discussion, and maintain log activity and assessment without constraints. The student satisfaction on using such e-learning tools studied earlier showed a positive impact. ^{Reference Seluakumaran, Jusof, Ismail and Husain7} The incorporation of an interactive e-learning module has already been attempted earlier in a rural medical college in India and was moderately effective but well received by students. The study finally suggested a blended approach integrating e-learning with the traditional learning modalities. Gaikwad et al. did a pilot study more than half a decade back, and the significant advances in technology need to be considered prior to generalizing the results to the present day. ^{Reference Gaikwad and Tankhiwale8} The growth of technology and the widespread use of smartphones and tablets have facilitated better interaction and online learning for medical and nursing domains. However, there is a need for organizational guidance for optimal utilization according to Lall et al. ^{Reference Lall, Rees and Law9} There was a significant rise in the number of regular online classes attended by the residents during the COVID-19 pandemic period compared to pre-COVID-19 pandemic period (see Table 1). Most of these online classes attended by the residents during the COVID-19 pandemic period were part of the university curriculum and were recorded and used asynchronously (see Table 1). The past 5 decades have seen rapid technology assimilation in health professional education. The various forms of digital education vary from simulation to Internet-based interactive discussions. ^{Reference Triola, Huwendiek, Levinson and Cook10} Web-based learning is not a homogeneous domain, and the comprehensive definition keeps increasing with the advancement of technology. ^{Reference Cook and West11} E-learning in medical education not only improves student engagement but also increases efficiency and effectiveness of faculty according to a review that focused on resource-limited settings from multiple countries. ^{Reference Frehywot, Vovides and Talib12} Appropriate development of the institutional protocol for e-learning in health sciences education is one of the most pivotal steps for optimal output. ^{Reference Young, Bailey and Guptill13}

There are multiple studies on the utilization of online strategies for medical education in emergency medicine residency programs. ^{Reference Young, Bailey and Guptill13,Reference Ashton and Bhati14} Toohey et al. succinctly described 10 tips for educating a millennial in EM residency programs and reiterated optimal use of technology. ^{Reference Toohey, Wray and Wiechmann15} With its vast and diverse population, a lower-middle-income country like India is a giant in information and communication technology development and has been integrating technology seamlessly into the education sector. It is also important to note that the conventional classes and bedside are not a landmark for social development but rather a more important learning strategy that supplements e-learning. However, with the rapid development in technology and quality Internet access, the utilization of online resources such as videos, podcasts, blogs, and online courses has been an integral part of EM residents’ learning strategy. The idea of asynchronous Free Open-Access Medical (FOAM) education in EM residency programs in India is on the rise along with simulation-based learning. The survey revealed that the Indian EM residents utilized a variety of online resources before and during the COVID-19 pandemic, the most common being videos (86.6%), podcasts (54.5%), and blogs/websites (44.5%). Social media platforms like Twitter were also used. There was an increasing use of webinars as e-learning resources for learning during the COVID-19 pandemic. Simple online platforms, such as websites and blogs, assist in providing basic information and offer opportunities to host videos for demonstrating essential skills, such as clinical procedures and communication. In addition to user-friendly social media tools like Twitter and YouTube, numerous platforms and learning management systems (LMS) are available for online learning, ^{Reference Pilli16–Reference McLaughlin and Brame19} most of which have proven to be effective educational tools in medical education. ^{Reference Sutherland and Jalali20}

As noted by faculty and residents, the major facilitators were the flexible timings for teaching/learning offered by the virtual platforms, especially during the pandemic period. Better engagement and small group discussions were facilitated in e-learning environments. The residents noted that asynchronous learning was augmented by integrating Ee-learning strategies in the curriculum. The pandemic has forced the stakeholders to explore different avenues and converge in the e-learning realm.

The significant barrier noted according to this national survey was Internet connectivity issues. Devices used for e-learning also posed challenges. The overt dependence on smartphones and the challenges of using laptop applications on phones led to unnecessary troubleshooting. The lack of understanding of the potential of the device being used and applications without proper synchrony across multiple devices was specifically mentioned as challenging by residents and faculty. The faculty also felt the need to define good teaching practices using e-learning.

During the COVID-19 pandemic, discussions and interaction were the significant advantages of e-learning felt by the residents. E-learning methods are less favored if they are not interactive. ^{Reference Cook and Steinert21} Gamification in which “game design elements are used in non-game contexts” is one of the promising methods that can boost interaction during online sessions. Student response systems like polls, quizzes, and breakout rooms are the strategies used in gamification. ^{Reference Hamari, Koivisto and Sarsa22–Reference Muir, Tirlea, Elphinstone and Huynh24} E-learning leads to more content coverage than traditional classes with more faculty involvement, and the residents could express their views during these sessions. Residents are free to ask and clear their queries anonymously, encouraging further participation in a live lecture due to the less intimidating online environment. Even though online sessions lead to more assignments and a better understanding of the subject, residents do not grasp the subject better via this strategy. Another major disadvantage of E-learning is the lack of interaction with patients. During the pandemic, many countries had canceled clinical clerkships. Learning from actual patients in a clinical setting is essential for medical education and cannot be wholly replaced by e-learning. To some extent, virtual patients could be a solution that can simulate real-life clinical scenarios, allowing the resident to prepare for an actual patient encounter.

There are various comments about online teaching among faculty, primarily favoring online sessions where it could be a virtuous substitute for face-to-face classes, especially during the crisis of the COVID-19 pandemic. Online classes have come as a consecration for solving and reducing the academic gap during the pandemic. ^{Reference Chandwani, Singh and Singh25} These sessions would enable residents to gain knowledge without going anywhere, and incorporating this innovation into the curriculum may lead to an effective outcome, especially during the pandemic. However, technical glitches may lead to discontinuity in the topic discussed during the online session. Online education may get wider acceptance amongst academicians once the digital culture develops in all institutions. The development of dynamic online sessions will be challenging for most faculty and institutes, where proper training, infrastructure, and technical support may be required to make it a successful venture.

Evidence has proven that online learning is not like reading a newspaper, where one can begin and end whenever they choose; instead, it is a planned program to accomplish a specific goal. The aim is to use the right tool, learner, dose, time, and route. ^{Reference Cook26} A recent survey on pulmonology trainees found that even though they were involved in COVID-19 patient care, the overall training toward skill acquisition was deficient and that modifications in educational models will be required in current and future health care crises, both global and local. ^{Reference Kalchiem-Dekel, Schwalk and Patel27} At this point, one may explore the possibility of an overhaul in the educational delivery system wherein early clinical exposure and training are mandated. The bulk of the didactic training occurs online and particularly for programs such as EM, where departments work on a shift basis around the clock, 24 hours a day, 7 days a week, and 365 days a year. Southworth et al. reported during the first wave of the pandemic how experiences in changing educational practices would affect the response in educational and academic delivery during a second wave or any other disaster that prevents in-person training. ^{Reference Southworth and COVID28} Hall et al. shared 12 tips on supporting competency-based medical education during the COVID-19 pandemic, including innovation, repeated assessment, maximizing existing clinical teaching experiences, collaborative learning, and post-pandemic catch-up. ^{Reference Hall, Nousiainen and Campisi29} All these factors call for a revamp in the educational system with a focus on synchronous and asynchronous teaching/learning methods with predefined good teaching/learning practices. A blended approach with a curriculum incorporating traditional and e-learning strategies may lead to a better end-user experience for all stakeholders.