INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic was a complex situation that extremely rapidly influenced the way of life of most of the planet's population [1]. The sudden interruption in many aspects of our lives affected social, cultural, and professional components. One of the most affected disciplines was medicine. In addition to the health challenges that health professionals faced, medical education—both formal and continuing—was completely suspended due to quarantines and isolation measures [1-3]. The negative impact that this phenomenon would generate in the short and medium period, in terms of doctors' performance, confidence, and skills, was quickly noticed [3]. For this reason, and as a response to the impossibility of developing face-to-face content, educational processes had to be implemented taking advantage of technologies, and thus, the adoption of a pedagogical methodology that until then had been explored in a limited way or just as a complement to teaching processes: virtual medical education (VME). [3,4]. During confinement, synchronous and asynchronous tele-education (on demand) allowed many educational centers, such as Universities and University Hospitals, to continue implementing the educational process with adequate "social distancing" [1,3,5-9].
This novel experience allowed us to evaluate this type of tool more critically [1]. Wilcha [3], in a systematic review, listed the opportunities given by the VME implemented during the pandemic, among which the following stand out: "immediate access to knowledge taught by experts regardless of their geographical location, the possibility of immediate updating of the latest advances in science, strengthening of networks between student and tutor, growth of interinstitutional collaborations, ease of asynchronous access, complete content, improvements in motivation, capacity for teamwork, problem-solving, simple and easy access through highly available devices such as cell phones and tablets.” Although many researchers documented the benefits of VME during the pandemic [4-7], none of the studies conducted subsequent follow-ups to determine the impact of implementing the learned techniques and whether this theoretical content was valuable when doctors resumed their clinical activities, which needed to be verified [4].
Considering the above, a synchronous virtual course in endoscopic spine surgery (ESS) was developed for spine surgeons, complemented by a series of surveys that would allow measuring the impact that VME may have had on the clinical practice of the participating specialists. This study aims to report the experience with a new virtual learning model in ESS and measure the impact and perceptions of surgeons from more than 27 countries participating in the course.
MATERIALS AND METHODS
1. Participants
A descriptive cross-sectional study was carried out through 3 surveys implemented at 3 different times. Health personnel related to and interested in ESS were asked about their experience, perceptions, and impact of a synchronous VME program. During August and December 2020, a virtual ESS course was implemented. To obtain the certificate, participants had to attend (connect live) at least 80% of the activity, and at the end, they had to complete a general survey that included, besides aspects related to satisfaction, their perception of the proposed model and its usefulness in their future clinical practice.
2. Participant Consent and Ethical Considerations
No institutional review board approval was needed for this study. Participation in the ESS-VME and its survey was voluntary, and participants were informed prior to starting the survey that all data collected would be used for research purposes.
3. Structure of the Virtual Education Process
The learning model was developed using the Zoom platform (Zoom Video Communications, Inc., USA). The activity was divided into 17 modules (Table 1). Each module corresponded to a webinar or synchronous virtual conference-type activity with a specific topic related to managing spine pain and its treatment alternatives, with the topic of ESS techniques as its central focus. The frequency of the activity was a weekly module (webinar). Each module lasted 2 hours: 1 hour with the academic content developed by the faculty (keynote lecture) and a second hour exclusively for interaction, comments, and questions from the participants (question session). Topics related to spine pain management techniques were developed by international experts from 6 specialties (orthopedists, neurosurgeons, anesthesiologists, radiologists, physiatrists, physiotherapists).
4. Survey Structure
Three surveys were carried out: the first survey was before starting the activity; the second one was after 20 days of finishing the activity; and, finally, the third one was a year after answering the second survey. The surveys were developed by a group of surgeons, experts in minimally invasive spine surgery and ESS, and an expert in medical education, utilizing the Delphi consensus method.
1) Initial survey
The initial survey was part of the course registration process and was conducted to analyze the origin, specialty, and previous experience with the ESS.
2) Perception and satisfaction survey
The second survey was sent only to participants who attended at least 80% of the modules (13 virtual education sessions). Questions were structured on a scale of 1 to 10, where 10 indicated the most important and 1 indicated the least important. The Google Form survey format was (Google Inc., USA) used, and once the course was completed, a survey was sent as a virtual link to participants who had completed sufficient modules. The questions were divided into 3 general aspects: (1) degree of satisfaction concerning different factors of the learning model: curricula, teachers, duration; (2) contribution and potential impact on their medical practice; (3) possibility of implementing ESS techniques shortly.
3) VME impact survey
The third survey was sent 12 months after the second survey was conducted. As with the perception and satisfaction survey, it was only sent to participants who had completed the course. The Google Form survey format was used. The questions pertained to the implementation of the technique after 1 year, participation in other educational events, and the impact of the VME experience after one year.
5. Statistical Analysis
Univariate and bivariate analyses of the responses were performed. Data analysis was conducted using Jamovi 2.3.13, a statistical program for Windows. Demographic parameters and frequencies of the variables were established. Pearson's Chi-square and Fisher's Exact tests were performed to establish group independence. Statistical significance was established with an α of 0.05.
RESULTS
1. Interest and Current State of the ESS in Ibero-Latin America
More than 996 spine surgery specialists attended the ESS-VME learning model. The majority of the enrolled individuals were men, comprising 799 (83.7%), compared to 156 women (16.3%). The participants were from 27 countries from 4 continents (America, Europe, Asia, and Africa) (Figure 1). Ninety-one percent (n=873) of those enrolled were from Spanish-speaking countries. Mexico, Colombia, and Argentina were the countries with the highest number of interested parties, together accounting for 50.7% of the participants. There were 5.9% of participants from the Iberian Peninsula, most from Spain (n=48) (Table 2).
Regarding the health profession, among the preliminary enrollees, there were 42.8% orthopedists, 29.4% neurosurgeons, and 3% anesthesiologists. Only 7.6% of those enrolled were training specialists (residents), and many were health professionals related to the commercial area (11.7%). Of these, 37.8% indicated they had experience in ESS, while 62.2% said they had never performed a procedure of this type. Regarding gender and experience, it was found that 40% of the men in the sample had some experience, compared to 27% of the women (p=0.002). Likewise, orthopedists were the specialists with the highest percentage of experience, at 46.7%, compared to neurosurgeons (31.3%) and anesthesiologists (41.4%) (p=0.001).
2. Adherence, Satisfaction, and Initial Perception of the VME Experience in ESS
At the end of the learning model, it was established that 371 enrollees fulfilled 80% participation in the activity, and 99.4% (369) of these completed the second survey. The adherence rate (participants who completed the learning model requirements and obtained certification) was 37% of participants. In this certified group, participants were from 23 countries across 3 continents (North America, Europe, and Asia), with a significant number from Spanish-speaking Latin American countries, comprising 82% (n=19). The country with the most significant participation in the VME experience was Colombia, with 76 participants (21%), followed by Mexico and Argentina, with 66 (18%) and 53 participants (14%), respectively. From regions other than Latin America, the following stand out: the United States (n=6), Spain (n=4), Portugal (n=2), and Saudi Arabia (n=1). In the distribution by sex, there was a notable difference, with only 47 women (12.7%) participating and completing it, compared to 322 men, corresponding to 87% of those surveyed. The adherence rate among women was lower (30%) compared to that of men (40%), indicating a statistically significant difference (p=0.01).
Among certified course participants, general satisfaction had values between 8 and 10 out of 10 in 97.8% (10: 64.5%; 9:26.3%; 8:7%), and only 0.6% of participants had a degree of satisfaction with the virtual training below 5 points (n=2). Satisfaction with the course content was 98.4%. This aspect had a value of at most 5 points out of 10. The duration of the course was another aspect evaluated. Although the satisfaction values between 8 and 10 were similar at 94%, the value of 8/10 was higher (12.2%), and there were values below 5 (0.8%). The highest satisfaction was with the teaching staff, with 99% of participants rating them between 8 and 10 points out of 10 (Figure 2).
3. Impact of VME on ESS on Their Clinical Practice
Preliminary data on the percentage of participants who had training before the activity was measured and showed that one in 3 participants (30.6%) did not do any training before this course. To the question, on a scale of 1 to 10: How much did the ESS-VME contribute to your medical practice? Two hundred thirty-six respondents (64%) answered with 10 points, 74 (20.1%) with 9 points, and 34 (4.1%) with 8 points out of 10, and 6 participants considered that they had no contribution.
Likewise, on a scale of 1 to 10, what possibility do you have of implementing the techniques seen in the ESS-VME? More than 81% of the participants responded with a score above 7 points (Figure 3).
4. Impact After 1 Year of the Educational Experience
With the aim of establishing more concretely the impact of the course on the specialists, an analysis of the impact was carried out 1 year after the synchronous virtual course was carried out. In the survey, 3 fundamental aspects were asked: the impact on their activity, the continuity of the training process, and the implementation of the technique a year after the course was completed. Eighty-eight specialists completed this last survey. Of these health professionals, 68 were specialists (39 [52.7%] orthopedists; 27 [36.5%] neurosurgeons; 2 [2.7%] anesthesiologists), while 2 (2.7%) were residents and 4 were sales representatives (5.4%).
The time between the second and third surveys was 1.11± 0.08 years (Figure 4).
After 1 year, 63.6% of those surveyed indicated having completed some other training process between face-to-face conferences, cadaver courses, surgical stays, and formal programs (Figure 5). Likewise, 59% (n=52) start to perform the endoscopic technique at least once a month after the course (Table 3). Finally, according to the subjective impact of the training activity, the first survey showed that 97% of the participants considered that this ESS-VME could potentially impact their medical practice. After a year, the participants who rated the importance of the course above 7 out of 10 was 88% (Figure 6). One year later, the differences between the potential and actual impacts were not statistically significant (p=0.509).
5. Paired Comparative Analysis
Finally, a paired analysis of the responses from the 3 surveys was carried out. Complete responses to all 3 questionnaires were obtained from 74 participants.
1) Implementation of the technique after 1 year
The number of specialists who did not perform the ESS before the course was compared with those who, after a year of carrying out the activity, were already implementing it. Of the 74 respondents before the course, 39.2% indicated that they had experience in ESS, while 60.8% indicated that they did not have experience. After 1 year, the percentages changed significantly, showing that 60.8% of the participants performed at least one endoscopic surgery per month (p=0.017). Even 4.1% of these doctors performed more than 10 per month. Two key points should be highlighted: first, that 5 specialists who previously performed the technique stopped doing so, and second, that 21 inexperienced specialists, after a year of completing the course, now perform the technique (Table 4).
When comparing the scale of expectations for the technique's implementation with its practical implementation after 1 year, it was evident that 97% of specialists who indicated that they began to implement the technique after 1 year had answered values above 5 a year before to the question, "What possibility do you have of implementing the techniques seen in the future?"
It is also important to highlight that many doctors implemented the technique after a year of completing the course. However, other doctors who had already been doing it increased their monthly frequency of implementation, and this variation was statistically significant (p=0.01). The most significant change was the number of surgeons who reported performing the technique more than 4 times a month, which increased from 3% to 11% of the total number of respondents (Table 5).
2) Perception of Impact of the course after 1 year
The potential impact of the VME experience was compared to the impact 1 year later. This variable indicates that although many participants initially assigned lower values to the impact indicator (69 vs. 50 specialists with a value above 8/10), the differences were not statistically significant (p=0.509) (Table 6).
DISCUSSION
Continuing medical education methods have substantially evolved from the Halstedian method, including high-tech tools using virtual reality and haptic simulators. However, the COVID-19 pandemic stimulated the use of a tool that had not yet gained sufficient acceptance and, for at least a few months, constituted the only available option: VME. This study shows how a VME activity can connect a significant number of spine surgery specialists around a topic as specific as ESS, achieving a highly favorable perception (>98%) and with significant adherence (close to 40%). Among the aspects to highlight is the continuity and interest generated by the participants in the learning process. Completing the activity with close to 40% of those registered initially shows that, despite being a new tool to which the specialists were little accustomed, the contents and dynamics created a stimulus, resulting in an average of 385 people connecting each week. Additionally, nearly every Ibero-American country was represented on the list of participants, underscoring the widespread participation in this type of virtual activity. Additionally, as the course was broadcast live, the time difference presented an extra challenge for the specialists. Always doing it on the same day of the week and at the same hour could have been positive. Within the perceptions, it is essential to highlight the finding of lower satisfaction with the duration of the activity. This may indicate that the tool, although valid, has limitations in generating long-term interest. It could be used in short courses on specific topics, but less frequently in long-term general content.
The authors consider that the most significant impact was the percentage of participants who, before the course, did not perform the ESS technique and who, 1 year after the training, had started to perform it. Although a causal association cannot be determined, it is undeniable that the course should contribute to the surgeon's decision cascade in implementing the technique. Additionally, our study found that nearly 70% of the specialists continued their training process in ESS.
To the best of the authors' knowledge, no similar study measures the perception of specialists in ESS-VME training, nor with a population of this size. Several authors evaluated the use of non-face-to-face learning tools during the pandemic. Swiatek et al. [3], showed in an extensive survey of nearly a thousand specialists that more than 80% of surgeons were interested in developing online education activities. Similarly, Nolte et al. [10], found that 82.5% reported interest in continuing with online education. Finally, Al-Ahmari et al. [7], reported a survey conducted within a Saudi Association of Neurological Surgery webinar in which 156 doctors participated. They found that 80% of them found this type of tool satisfactory. A similar study involving neurosurgery residents aimed to assess the impact on confidence in the residents' knowledge and found that a VME process had a positive effect [9]. A recent study showed that several European clinical autonomic education and research centers recommend the integration of online courses and on-demand webinars in medical school curricula to improve residency program quality [11]. Likewise, an interesting study [12] compared the impacts of the pandemic during isolation and a year later showed that some surgeons were still interested in virtual education. Although the proportion of spine surgeons who were "very interested" and "interested" decreased from 82% during the pandemic to almost 60% one year later, this still represented a significant number of surgeons who remained interested in the virtual process. This could be influenced by, as Rasouli et al. [13] mentioned, VME would help offset travel costs, decrease time away from work, and provide more flexible learning options.
The results presented in this research enable us to consider virtual courses as attractive and valuable tools in the learning process of ESS, indicating a perception of impact and high satisfaction, and, most importantly, generating stimuli for specialists to continue their learning curve or, in some cases, implement the technique. The demographic distribution in the study also confirms what was reported by Al-Ahmari et al. [7], who highlighted among the advantages of VME that being an "instruction in a learning environment where the educator and the student are separated in time or space" allows digital platforms to capture more people in different regions of the planet in real-time. This study brought together nearly 400 people from 27 countries around a learning process, and after a year of implementation, it had a tangible impact on almost 70% of them. Recent studies indicate that the integration of virtual technologies in medical education should become the new standard [14], and could enhance clinical education in low-income countries [15,16].
This follow-up study has several limitations. Although there is an important sample, the results could be significantly affected by selection bias because the source was a survey distributed to participants. Additionally, the high dropout rate in the last survey could limit the results and conclusions. Moreover, because the course was free, the participants could respond positively about their satisfaction. Also, women were underrepresented in this course. Despite this limitation, the study provides valuable insights into the perception and impact of a VME. Nevertheless, it is essential to develop a more solid understanding of the impact of the virtual learning process and its potential contribution to the ESS learning curve.
CONCLUSION
Based on the findings of this study, it can be concluded that VME can be a helpful tool in teaching surgical techniques, expanding the audience, making it multicultural, and facilitating discussion spaces. It cannot be considered the only way to train skills and abilities, but it maximizes the time of this other type of training. More research is necessary to determine the contribution to the learning curve. Technological and simulation tools clearly must be complemented with practical activities. However, the findings reported in this study show excellent potential for the expansion of ESS techniques in Ibero-Latin America, ultimately benefiting patients with spine conditions.
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