Vascular education through e-Learning
German results of the EL-COVID survey
Abstract
Summary:Background: The COVID-19 pandemic has changed everyday life and work in many ways. As travelling to meetings and conferences was almost completely suppressed for most of healthcare professionals, e-Learning became increasingly prominent. The overall utility of e-Learning during the COVID-19 pandemic as well as its shortcomings in the international community of vascular surgery were assessed through the EL-COVID study. Regional variability was observed amongst participating nations, which is currently being addressed through several ongoing subgroup analyses. Our study completes the aforementioned efforts and aims to investigate the adherence and adoption of vascular e-Learning in Germany. Methods and participants: Using an online survey, EL-COVID gathered answers from 856 vascular surgeons, of whom 70 were located in Germany. We analyzed the answers of 62 German responders that attended at least one e-Learning activity and compared them with the remaining worldwide data. Results: Out of all European countries, Germany was best represented and ranked second worldwide after Mainland China (n=109). 30.6 percent of the German responders were female (vs. 20% worldwide; p=0.048) and 56.4% were vascular surgeons with >5 years of practice (vs. 56.3; p=0.975). The international cohort generally engaged in more e-Learning. Most German participants attended less than 4 online activities, while only 24.2% took part in more than 4 such events (vs. 56.3; p<0.0001). While the overall impression of e-Learning activities during the COVID-19 pandemic was positive, German employers were less supportive of participation during working hours (30.6% vs. 44%; p=0.042). The main reason for not attending was lack of time due to increased workload (56.5% vs. 50%; p=0.328). National and international societies played a lesser role in promoting such activities in Germany (22.6% vs. 39.2%; p=0.010), the same accounts for social media (16.1 vs. 30.3; p=0.017). Conclusions: E-Learning complements the classical training methods and has been embraced as a relevant alternative in the time of the COVID-19 pandemic. The results of this survey appeal to German employers and national societies to improve support and dissemination of e-Learning activities in the vascular medicine community.
Introduction
As SARS-CoV-2 rampantly spread across the world, every nation had to adapt to its deleterious effects. Health systems crippled under the burden of new cases and surging fatalities. Redistributing personal and increasing workload are just a few of the unprecedented measures that had to be implemented. Medical education was subsequently dwarfed by the newly imposed state of emergency. As the classical narrative grounded to a halt, e-Learning counteracted its logistical shortcomings and allowed physicians to network, share and enhance their knowledge through various platforms.
As an actively expanding and dynamic community, vascular surgery has been especially vulnerable to the imposed restrictions. E-Learning in surgical training had been controversial and evidence of its pertinence is sparse [1, 2]. The EL-COVID Survey set to investigate the acceptance, effectiveness and limitations of this auxiliary training method in vascular surgery worldwide [3, 4].
Preexisting educational platforms, medical infrastructure and distinct socio-economic profiles accounted for great international variability in facilitating access to e-Learning during the COVID-19 pandemic. Gaining insight into each country’s adaptive process is a particularly compelling concept that may contribute to collective enhancement. Apart from the international reports, the EL-COVID panel is currently working on regional and national manuscripts that explore these inconsistencies. We investigated the way e-Learning complemented vascular surgery training in Germany by accessing the EL-COVID registry and subtracting the relevant data. National features were compared to the general findings, thus highlighting macro-trends that may be used as reference in managing similar future challenges.
Materials and methods
The EL-COVID survey was conducted online from June 15, 2020 to October 15, 2020 and addressed vascular surgeons and trainees.
An international expert panel was formed under the lead of former members and leaders of the European Society for Vascular Surgery′s (ESVS) e-Learning team that recruited national and regional representatives with experience in education and training. Only vascular surgeons were included in the panel. The survey was mainly promoted on social media. The national and regional representatives further disseminated the information on social media, by email or direct contact with colleagues. Eighteen questions addressed various topics, such as demographics as well as participants experience and opinion on e-Learning opportunities dedicated to vascular surgery. Data validation was conducted before analysis and publication of the original data. Duplicate entries and malicious content were deleted. Exhaustive informations on the methodology of the initial survey have been published previously [3].
We accessed the EL-COVID registry and performed a subgroup analysis of the 70 German responders. Data on participants that did not attend any e-Learning activities during the pandemic are reported, but were omitted from further analysis. The data was compared with the rest of the participating nations. The seven continent model was used to quantify participant’s demographic variability.
The results of the German participants were compared to the international cohort using the N−1 Chi-squared test for comparison of proportions. All calculations were performed using MedCalc® free online statistical calculator (MedCalc Software Ltd., Ostend, Belgium, https://www.medcalc.org/). The significance level was set to alpha=0.05.
Results
With 31 of the total 84 nations, Europe was the most represented continent in the EL-COVID Survey (Figure 1). 336 (39.3%) of the overall 856 participants derived from Europe. Within Europe, Germany’s contribution was the largest (n=70 participants; Figure 1) and the second largest altogether (7.2% of all participants), being surpassed only by People’s Republic of China (Mainland; 109) [3].
Of the 70 German responders, 8 were excluded from statistical analysis as they did not attend any e-Learning activity. This group consisted of 6 males and 2 females and split in 4 trainees and 4 vascular surgeons with more than 5 years of experience. The main reason not to participate in any activities (7 of 8) was lack of time due to increased workload. One of the excluded participants reported, that e-Learning would have been supported by the employers. The trainees denounced lack of activities for their training level.
Looking at the 62 responders who attended at least one activity, female participation was significantly higher in Germany in comparison to other nations (30.64% vs. 20%; p=0.048) (Table I).
Participant’s experience level in vascular surgery did not differ significantly in Germany, compared to the international community (Table I). Most German participants were experienced vascular surgeons with more than 5 years of practice, consistent with the general findings.
Overall, the participation in e-Learning activities was significantly less in Germany. While the majority of international responders (56.17%) did attend >4 e-Learning activities during the COVID pandemic, 46.77% of Germans attended merely 2–4 (Figure 2A).
German participation at national e-Learning activities was 7% lower compared to the rest of the cohort (61% vs. 68%; not significant) (Figure 2B). This activity was however more often officially accredited (67.56% in Germany vs. 48.15% other nations; p=0.003) (Figure 2C).
Participation in international activities did not vary (69% vs. 70%) (Figure 2D). However, official accreditation of this e-Learning activity was received only by 38.09% of German responders vs. 53.85% of the rest of the cohort (p=0.017; Figure 2E).
The selection criteria of the e-Learning activity were also debated, with no significant differences being identified between Germany and the other participating nations. The most important factor to attend an e-Learning activity was personal interest (Table II).
Divergent regional patterns could be observed when analyzing the methods of promoting e-Learning activities. German participants gained significantly more information by word of mouth (17.74% vs. 6.54%; p=0.001) and through online educational platforms (27.41% vs. 6.54%; p=0.007). However they were less likely to be notified about e-Learning opportunities though national and international societies (22.58% vs. 39.16%; p=0.010) or social media (16.12% vs. 30.35%; p=0.017) (Table II).
Compared to the rest of the cohort, German employers were less supportive of attending an e-Learning activity through protected time/allocated time during working hours (30.64% vs. 43.95%; Difference 13.26%; 95% CI [0.47–23.91%]; p=0.042).
The reasons for not attending an e-Learning activity are laid out in Table II. Lack of time due to increased workload prevailed in Germany, as well as in other nations (56.45% vs. 50%), followed by inability to isolate (16.12%). Unlike for other participants, time zone difference was to a lesser degree relevant in Germany (4.83 vs. 19.39%; p=0.004). Lack of official accreditation (6.45% vs. 2.01%; p=0.024) and lack of interaction (8.06% vs. 2.39%; p=0.009) were more often invoked by German responders.
The overall impression on e-Learning activities during the COVID-19 pandemic is exemplified in Figure 3A. Most of the participants evaluated the activities as positive or very positive. No significant differences were found between the feedback given by the German participants and the rest of the cohort.
The majority of German participants (56.45%) found it easy to retrieve or re-watch a previously attended interesting activity while the majority of the rest of the participating nations (55%) found it very easy (Figure 3B).
Citing e-Learning presentations in a manuscript or a presentation was equally unpopular in Germany as in the international community (40.32% vs. 39.79; p=0.935). 32.25% of German responders would definitely not list the attended e-Learning activities in their CV/Resume as CME activities (vs. 27.83%; p=0.456), while the majority of them (46.77%) would however list some of them, for example those with CME points or certification (vs. 53.4%; p=0.314).
Discussion
The opportunity for online education has long been debated and recognized. As migrational patterns changed dramatically during the SARS-CoV-2 pandemic, the need for borderless education became obvious. The trend of digital globalization prevailed amongst various medical professions.
The intense interdisciplinary approach and the emergence of novel endovascular options render the field of vascular surgery highly dependent on its international community. Although several online educational platforms have been designed, worldwide transition towards e-Learning varied tremendously, especially when considering the fact that digitalization cannot substitute for “hands on” training. Rigorous oversight and quality control programs further hampered the development of accredited e-Learning opportunities in the medical field.
The EL-COVID study is the largest international survey to date that inventorized the utility and overall adoption of e-Learning in the international vascular surgery community during the COVID-19 pandemic. Smaller and more limited studies have been published, but they cannot be directly compared to the EL-COVID results [5, 6, 7]. Although it would have provided critical insight, a comparison with pre-pandemic times is purely speculative as data that addressed this topic are lacking.
Germany is Europe’s biggest economy, has the largest number of inhabitants in the European Union and also the highest percentage of immigrants in its population. Although not lacking human capital nor financial support, in 2021, Germany ranked 11th in the digital economy and society index (DESI) out of the 28 EU countries and only narrowly made it into the top 50% [8]. The complex political milieu of the 16 federal states, highly regulated legal prerogatives, lack of financial incentives and various intercultural aspects have contributed to a slow adoption of online education in Germany. Several measures recently addressed the technological lag, when the “Data strategy of the federal German government” [9] and “Shaping digitalization – Executive Summary” [10] were released on 27.01.2021 and 09.06.2021 respectively.
Our subgroup analysis of the EL-COVID registry revealed that overall e-participation of German vascular surgeons was less than in the international community. Increased workload and the inability to isolate (e.g. crowded home environment during lock-down or busy office) prevailed as hindering factors. Chronic staff shortage and pandemic induced overexpansion of the healthcare system may account for the low regulatory support of protected time or allocating time during working hours for attending e-Learning activities.
Attendance at national e-Learning activities was significantly lower in Germany than in the rest of the nations, despite the fact that an official accreditation was awarded more often. International e-participation did not differ between German respondents and other nations. However 15% fewer German vascular surgeons received an official accreditation after attending this international e-Learning activity, despite the fact that lack of official accreditation was found to be up to three times more disincentivizing to them than to the international community. It is interesting to investigate to what extent these somewhat conflicting patterns are attributable to cross-participation. We hypothesize that some of the non-German participants may have attended the German accredited e-Learning activities. This may be supported by the fact that e-participation in the international community was significantly burdened by time zone difference, which was not the case amongst German vascular surgeons. A direct causality warrants however further investigations.
The promoting patterns of the e-Learning activities had great variability. While direct contact from national/international society and social media was prevalent in the rest of the participating nations, the German vascular surgery community demonstrated better access to/awareness of online educational platforms as well as enhanced networking via “word to mouth”. The German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG) is the largest vascular surgical society in Europe. The results of this study should initiate further active promotion and provision of e-Learning opportunities. However, the European Society for Vascular Surgery (ESVS) has been and continues to be very active in this field and has expanded its activity during the pandemic [11]. The fact that more German responders actively searched for activities from well-known institutions may also indicate a better penetrance/influence of the pharma industry.
Gender distribution in vascular surgery has been an intensely debated topic in recent years. The number of female medical graduates and women in academic medicine is steadily increasing. In the 2020/2021 winter semester, a total of 101,712 students were enrolled in human medicine in Germany, around two-thirds of whom were women [12]. Although the number of women in surgery and surgical subspecialties has been disproportionally low, an uprising trend has emerged. The percent of board-certified women physicians working in a surgical field (including orthopedics and trauma surgery) in Germany increased from 10.6% in 2011 to 14.6% in 2020, accounting to a 37.7% increase over the course of a decade [13]. Statistical information from the Federal Medical Register 2020 revealed that 17.6% women were practicing as board-certified vascular surgeons in Germany at the end of 2020, with a 2.3% increase compared to the previous year [14]. The increased interest amongst female participants in vascular e-Learning in Germany may directly correlate with the aforementioned real world data. Although it seems that the adopted inclusive measures may be effective in closing the gender gap in vascular surgery in Germany, no such conclusion can be drawn based merely on our promising data. Increased awareness and eradicating systemic barriers are still necessary to achieve equity and to addresses the impeding surgical workforce shortages.
Limtations
The findings of this study have to be seen in light of some limitations. The comparison between Germany and other countries is based on an observational study and is therefore subject to various biases. The dissemination strategy on social media and personal communications over email, direct message or telephone is somewhat debatable and may generate selection bias. Moreover, the fact that the study population was not randomly selected from the international vascular surgery community may also contribute to selection bias.
Author affiliations and locations may have contributed to an unbalanced rate of participating countries and regions. Although this may lead to confounding results, these variables are almost impossible to eliminate when conducting an investigator-driven survey. Other sources of confounding factors include gender and training status.
The inherent variability between participating nations – attributed partly to pre-COVID status of e-Learning as well as the familiarity of vascular surgeons and trainees with e-Learning – might have resulted in clustered data. Adjustment for all potential clusters and biases seemed impossible, thus a correlation between national and international results has to be viewed with caution.
The study was limited to the participation of vascular surgeons and trainees in vascular surgery. However, we believe that the results can be translated to other specialties, especially the ones addressing vascular medicine. These specialties share interest in vascular disease and their treatment, thus the opportunities for e-Learning are comparable, while their adoption might require additional investigation.
Conclusions
Despite broad adoption and positive feed-back amongst participating vascular surgeons and trainees, e-Learning in Germany is lacking employer acknowledgment and supporting legal framework. National societies can improve their support and dissemination of e-Learning activities in the vascular medicine community.
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