Abstract
Virtual meeting platforms, such as Zoom, have become essential to medical education during the SARS-CoV-2 pandemic. However, many medical educators do not have experience planning or leading these sessions. Despite the prevalence of Zoom learning, there has been little published on best practices. In this article we describe best practices for using Zoom for remote learning, acknowledging technical considerations, and recommending workflows for designing and implementing virtual sessions. Furthermore, we discuss the important role of cognitive learning theory and how to incorporate these key pedagogical insights into a successful virtual session. While eventually in-person classrooms will open, virtual teaching will remain a component of medical education. If we utilize these inventive tools creatively and functionally, then virtual learning can augment and elevate the practice of medical education.
Introduction
Virtual meeting platforms have become a critical component of medical education during the SARS-CoV-2 pandemic. Medical educators are using virtual meeting platforms to teach learners, often without experience in planning or implementing these sessions. Virtual platforms have been used for didactic, small group, problem-based learning, and simulation sessions. While there are many platforms available, Zoom has been particularly popular. 1 Despite the sudden ubiquity of remote teaching using virtual meeting platforms, there is a paucity of best practices for their use. Literature regarding Zoom specifically is limited; it has been described as a tool for qualitative research 2 or a supplemental teaching tool for healthcare professionals. 3 Therefore, in this article we describe best practices for using Zoom for remote learning, elucidating important technical considerations, and proposing workflows for creating and leading virtual sessions. In addition, we emphasize the importance of cognitive learning theory and discuss how Zoom can be used to address key points of this theoretical framework.
Technical Considerations
Online security
Cybersecurity is a requirement for all online interactions, especially when working remotely. All virtual interactions should take place over a password-enabled home router and WiFi system. More detailed discussion of passwords and other cybersecurity tools can be found elsewhere, 4 but all systems should be updated and maintained with strong password protection. Additionally, all remote learning sessions should be password-protected and invitation only. Zoom allows for sessions to require passwords for access and a host can require users to have permission prior to screen-sharing as a default setting. In order to change security settings on Zoom, one can navigate to the “settings” tab and click “meeting” to enable security options. 5
Video quality
To create an inviting learning environment, it is important to optimize video images. These platforms require significant bandwidth to function optimally with respect to picture quality and sound transmission. Bandwidth of 600 kilobits per second is cited as the minimum needed for video platforms, with a recommended bandwidth of 1.5 megabits per second. 6 One should use a hardwired system to get the highest bandwidth. If using WiFi, mesh networks such as Eero (www.eero.com), Synology (www.synology.com), or GoogleWiFi (store.google.com/us/product/nest_wifi) can increase bandwidth.
Video quality is also affected by lighting. To optimize lighting, use as much natural light as possible and avoid being backlit (ie, do not sit with a window behind you). The focal length of many device-based cameras is 24 to 36 inches, but modern cameras can adjust rapidly to movement to maintain image focus. An online survey demonstrated that sitting too close to the camera on a video call was off-putting to others. 7 It is important that your image is appropriately framed with both appropriate height, such that the camera is at your eye level, and distance, such that your face and shoulders are viewable.
Video background
Zoom supports a feature that provides a “virtual” background whereby users can be seen in front of a chosen image. This feature is helpful for teacher or learner privacy to obscure their home setting. The virtual background can be changed by choosing the “^” by the video icon in the control panel, selecting “choose virtual background,” and then selecting from either the standard or customized options. This feature requires setting ground rules with participants so that it is not used in a distracting or inappropriate manner.
Sound quality
As with lighting, the sound quality for instructors and participants is fundamental. Zoom sessions can be joined either via internet-based audio, landline, or mobile phone. Modern devices have highly optimized microphones that register sound extremely well, picking up background noise such as sirens or an air conditioner. Background noise can significantly disrupt audio quality. Therefore, choosing a broadcast space that is quiet and not echo-prone is important. Wired or wireless headphones are an effective means to limit background noise.
If there is a participant whose audio is distracting, the instructor should ask the participant to mute themselves either by asking directly or sending them a personal chat. However, if the loud participant does not respond, the instructor can mute the participant by going to the “participant list” and hovering over the participant name and selecting “mute.” The instructor can also mute all participants.
If the participant or the instructor find themselves with distorted audio, then one can mute themselves and test their audio by clicking “^” next to the mute button and selecting “audio options.” If someone is still having issues with their microphone, then they may need to open their operating system settings to ensure that Zoom has access to audio/video. 8
Keys to a Successful Session
Cognitive learning theory
The past year has required flexibility and adaptation to new learning environments and learner constraints. Despite those challenges, there have been a number of innovations and opportunities for enhancing medical education. When applying the lens of cognitive learning theory, there may be aspects of remote learning which can be better than in-person learning. The pillars of cognitive learning theory include: retrieval practice, spaced learning, interleaving, generation, elaboration, and reflection. 9 The fundamentals of adult learning theory additionally emphasize the need for setting expectations, building a safe learning environment, ensuring relevant material, facilitating active and autonomous learning, and providing feedback. 10 In the next sections, we discuss how virtual platforms can leverage these theoretical considerations.
Ground rules and expectations
Setting expectations and rules prior to a Zoom meeting is critical to ensure that all participants understand how the meeting will proceed and to build an educational contract. It is helpful to follow a checklist prior to a meeting to combat the technical challenges above, and to introduce participants to the meeting’s structure (Table 1). Some of the most important behaviors to discuss are whether video should be on or off (on is preferred, especially in small groups), staying muted while not talking, determining if participants consent to recording the session, and agreeing on how and if certain Zoom features (next section) will be used.
Checklist prior to Zoom session.
Furthermore, one should discuss how participants can ask questions. If the group is small enough, participants can simply unmute themselves and speak. Participants can also open the “participant list” and select “raise hand.” The chat function is another useful way for participants to send messages to everyone or to specific people. It is helpful to assign a moderator to monitor the chat, troubleshoot any technical issues, and reduce the need for multi-tasking by the primary facilitator.
Safe learning environment
As with in-person sessions, successful virtual learning requires a safe learning environment. Given the unique challenges of remote learning, educators must be intentional about establishing psychological safety and community. Allowing time to welcome learners and even asking them to briefly introduce themselves is helpful. Having members share their video is important and helps educators visualize learners’ non-verbal cues that communicate confusion, understanding, or interest in the material. Breakout rooms can create smaller groups that may be more psychologically safe for some learners, promoting interaction, and questions.
Platform tools
Zoom and other virtual platforms have a variety of tools that, when used effectively, can augment and innovate virtual teaching by varying participants’ interactions with the platform, with each other, and with the material (Table 2).
Summary of Zoom tools.
Breakout rooms can be used in versatile and creative ways to enrich sessions. In one study about effective strategies for online learning, one third of respondents mentioned breakout rooms, and one stated that students had “more intimate conversations with peers, similar to how we would do in-person.” 11 By dividing a large class into smaller groups, learners can directly engage with topics in a more comfortable setting. Four to six students per group is recommended. 11 Each group should complete a meaningful and clear task, such as (1) answering questions by applying topics learned in the session and/or searching the literature, (2) creating differential diagnoses from a clinical scenario, or (3) acting out simulated patient encounters (eg, giving bad news). Depending on the task, the duration of breakout should range from 5 minutes if simple or 10 to 30 minutes if complex. It is important to identify breakout group leaders to ensure that groups stay on time and to report out to the larger group when breakout groups end. While breakout rooms are occurring, educators have the opportunity to reflect on how sessions are going and possibly make changes going forward. The educator could also join each room briefly to confirm technical success, ensure task understanding, and to assess the group’s progress. If the educator chooses thoughtful topics for breakout rooms, participants own their learning experience by actively participating, teaching and learning with peers, and testing their understanding. These principles reflect the fundamentals of elaboration, interleaving, generation, and reflection.
Regular pauses
The flow of conversation on virtual meeting platforms is not the same as face-to-face interactions. In virtual sessions, body language may be challenging to gauge, tone, and inflection may be interpreted differently, and there may be a subtle delay in what is said and what is heard. These factors can contribute to misunderstanding, and can manifest in a cognitive psychological phenomenon referred to as “interference.” Interference occurs when one’s working memory is unable to efficiently or effectively process new information due to distraction or cognitive overload. 12
To optimize interactions and to decrease the risk of interference, pauses need to occur at regular intervals. Frequent check-ins with participants are valuable to ensure technical success (eg, audio or visual issues) and to ensure learner understanding and engagement with the topic. The optimal check-in frequency is unknown, but adult learning data has demonstrated that a typical learner’s attention span fades after 15 to 20 minutes for in-person teaching, and is as short as 6 to 8 minutes for online activities.13,14 This also emphasizes the importance of choosing relevant and interactive topics for online sessions.
As an alternate to verbally checking in, one may utilize Zoom features such as “reactions” and polls. Polls can be used to test understanding of a topic covered earlier, providing retrieval practice and spacing learning.
In addition to cognitive fatigue, physical fatigue and restlessness can occur due to having to stay in 1 position with constant eye contact with a blue-lit screen for a prolonged period of time. Pausing reminds participants to take moment and allow equilibration of mind and body.
Post-Session Best Practices
Durable resources
After the virtual session is over, educators must ensure retention of knowledge. One can utilize electronic resources to provide a source to refer to, thereby promoting spaced learning. Examples of durable electronic resources include PowerPoint slides from the session, any in-session “whiteboard” notes, and summary documents that highlight key take-home concepts. If recorded, the video of the session itself can also be disseminated to learners as an enduring resource as long as all participants have consented and all information is HIPAA compliant. 15
Session debrief
As with in-person teaching, there are always opportunities for improvement with virtual sessions. One must dedicate time and energy to constructively reflect on and debrief what went well during the session and what should be improved. While there are multiple strategies for debriefing, a 2-step process can be effective in ensuring that immediate observations are captured and reviewed.
Specifically, immediately after a virtual teaching session is over, the instructor should document short-term wins that should be carried forward in future sessions and identify areas for improvement. If other instructors were present, seeking out their impressions immediately after the session can be valuable. After capturing initial reactions, the instructor should set the list aside for 24 hours. Allowing some time for the cognitive fatigue attributable to virtual teaching to dissipate will allow the instructor to review the list more rationally and constructively to determine what observations are actionable and what changes may need to be instituted for future virtual sessions.
Conclusion
Familiarity with best practices for using Zoom is important, because while the SARS-CoV-2 pandemic will eventually resolve, virtual teaching will certainly remain a component of medical education. If we utilize these technical considerations and inventive tools while remaining cognizant of relevant educational theories, then virtual learning does not have to be “second best” but can truly elevate medical education in new, creative, and innovative ways.
Footnotes
Funding:
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration Of Conflicting Interests:
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
