RESEARCH ARTICLE Open Access

The sudden transition to synchronizedonline learning during the COVID-19pandemic in Saudi Arabia: a qualitativestudy exploring medical students’perspectivesRehana Khalil1, Ali E. Mansour1, Walaa A. Fadda2, Khaled Almisnid2, Mohammed Aldamegh3,Abdullah Al-Nafeesah4, Azzam Alkhalifah5 and Osama Al-Wutayd1*

Abstract

Background: The closure of educational activities in the Kingdom of Saudi Arabia due to the ongoing COVID-19pandemic resulted in an unplanned shift from traditional learning to a setup that exclusively involves digitalteaching and learning. Within this context, the present study aimed to explore undergraduate medical students’perceptions regarding the effectiveness of synchronized online learning at Unaizah College of Medicine andMedical Sciences, Qassim University, Saudi Arabia.

Methods: A qualitative study was conducted using virtual focus group discussions synchronously with the help ofa discussion guide consisting of seven open-ended questions. Overall, 60 medical students were recruited using amaximum variation sampling technique; these students then participated in eight focus group discussions. Allinterviews were recorded, transcribed verbatim, and analyzed for thematic contents using the standard (Mayring,Kiger. M. E. and Braun.V) content analysis framework.

Results: A thematic content analysis yielded four core themes: (1) educational impact, (2) time management, (3)challenges encountered, and (4) preferences for the future. The online modality was well-received, and allparticipants agreed that online sessions were time saving and that their performance was improved due toenhanced utility of time; however, they indicated that they encountered some challenges, includingmethodological, content perception, technical, and behavioral challenges during sessions and online exams. Mostof the preclinical students preferred online learning for the upcoming academic years.

Conclusion: Synchronized online classes were well-accepted by the medical students. This represents significantand promising potential for the future of medical education. The principles of the online learning model andlearning outcomes should be rigorously and regularly evaluated to monitor its effectiveness.

Keywords: Sudden transition, Online learning, COVID-19 pandemic, Saudi Arabia, Qualitative study, Medicalstudents, Perspective

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] of Family and Community Medicine, Unaizah College ofMedicine and Medical Sciences, Qassim University, Unaizah, Saudi ArabiaFull list of author information is available at the end of the article

Khalil et al. BMC Medical Education (2020) 20:285 https://doi.org/10.1186/s12909-020-02208-z

BackgroundThe Covid-19 pandemic started in December 2019 inWuhan, China and spread around the world rapidlywithin months. The pandemic affected all areas of life,including education. As the situation worsened, the glo-bal lockdown culminated in a lockdown of educationalinstitutions. This closing of schools, colleges, and univer-sities resulted in a stressful event for educational admin-istration with highly limited options. The Saudi Ministryof Education announced online classes to continue thelearning process in a safe and secure manner. All univer-sities including medical universities were shifted to on-line learning within days [1]. This massive unplannedtransition from traditional learning to an exclusively on-line learning setup has changed the methods of medicalinstitutions in delivering the courses for their students.Medical graduates of the twenty-first century are ex-posed to online textbooks and modules with video lec-tures and computer-based exams. With this evolution inteaching modalities, a “flipped classroom” model forlearning has been adopted by many medical schoolsaround the world [2, 3]. Although these experiences ofmedical institutions are not similar, this can at least helpthem in accepting synchronized online models in thiscritical period.Online learning is classified as synchronous or asyn-

chronous. Synchronous technology allows for “live”interaction between the instructor and the students (e.g.,audioconferencing, videoconferencing, web chats etc.)while asynchronous technology involves significant de-lays in time between instruction and its receipt (e.g., E-mail, earlier video recording, discussion forums etc.) [4].It has long been acknowledged that online instruc-

tional methods are an efficient tool for learning [5];however, online learning can be challenging for studentsbecause of the limited non-verbal communication. Otheraspects, such as students’ and professors’ interactions,accessibility of materials, and time management, can alsoaffect the opinions of online education participants [6].To assess students’ performance in an online course, arepresentative set of face-to-face courses should be com-pared to a similar set of online courses. This strategywas adopted in a study that involved utilizing a datasetof hundreds of courses being taught at 23 colleges ofVirginia’s community college system; the authors foundthat students’ performance was worse in online courseswith respect to both course persistence and end-of-course grades [7].Online learning in medical education can lead to more

effective and easier access to a greater quantity of infor-mation, especially in uncertain global situations such aspandemics [8]. There is no doubt that the currentCOVID-19 pandemic has augmented the focus on onlinelearning in education, but we anticipate that in the

future, this shift will prove to be a permanent trend inmedical education. The methods used by Unaizah Collegeof Medicine and Medical Sciences included lectures, casediscussions, 4-box case analysis, clinical case discussions,online seminars, and dry labs (online laboratory demon-strations). The largest proportion was covered throughlectures, which was about 60%, while case discussions (in-cluding 4-box case analysis and clinical case discussions)consisted of 20%, Online seminars consisted of 10% anddry laboratories made about 10% of courses. We con-ducted this qualitative study to assess the effectiveness ofthese techniques and [9, 10] the barriers to medical stu-dents’ engagement in online learning [9]. The foremostgoal of our exploratory study is to determine medicalstudents’ perceptions and satisfaction level regardingsynchronous online learning methods implemented incourses during their second semester as an emergencyintervention during the ongoing Covid-19 pandemic inthe Kingdom of Saudi Arabia.

MethodsStudy designWe employed an online focus group qualitative designfor our study for numerous reasons. Firstly, this designenables an interactive and in-depth exploration of re-spondents’ experiences [11, 12]. Secondly, the groupprocess can help individuals to clarify views that mightnot emerge from a one-on-one interview. In addition, itcan uncover extensive opinions that individuals holdabout an issue, as well as perceptive differences amongindividuals and groups [12]. Therefore, to effectively ad-dress the objectives of our study, focus group discussionswere the most suitable choice. The discussions wereconducted online because of the ongoing Covid-19 pan-demic and social distancing in the Kingdom of SaudiArabia and because this approach was cost-effective[13]. It also ensured a detailed probing of the percep-tions, expectations, and difficulties and was timed so asto generate recommendations for improvements and hy-potheses that can be tested in future research.

Study participantsParticipants were purposely sampled. To ensure suffi-cient diversity of opinion among groups, medical stu-dents in their first year through final year (attendingonline courses during their second semester) studying atUnaizah College of Medicine and Medical Sciences,Saudi Arabia, were recruited using a maximum variationsampling technique [14]. Roll-call lists of medical stu-dents were used as a sampling frame to select the partic-ipants. The class leaders of the first-year class throughthe final-year class were contacted. The reason forselecting class leaders first was that they had direct con-tact with the instructors and their classmates. As a

Khalil et al. BMC Medical Education (2020) 20:285 Page 2 of 10

result, they acted as connectors, and other participantswere selected with the help of those class leaders. Uponcontact, each student had been introduced to the back-ground of our study and was invited to participate.Overall, 60 students participated in eight focus groupdiscussions, and each group had seven to eight partici-pants. A satisfactory (40/60) male-to-female participantratio was maintained in discussions. Focus group discus-sions were continued unless the saturation of new infor-mation was encountered.

ProcedureThe students who opted to participate in our study re-ceived an e-mail with information about the use of theonline focus groups’ forum along with a discussion guideto generate discussion. Each of them was given a per-sonal log-in name and password to access the onlineforum. For data collection, only the moderators had ac-cess to the forum. The anonymity of statements in thetranscripts and in the final report was ensured, as well asthe confidentiality and security of the data. Because datacollection was done through the Internet, participantsprovided informed consent by clicking a button afterhaving read all relevant information.

Study setting and data collectionThe electronic focus group synchronous discussionswere based on a discussion guide which was developedby two authors (OW and AM), in consultation with ex-perts for this study. The guide was revised and approvedby all authors, and piloted with four students. It con-sisted of seven open-ended questions, allowing partici-pants to discuss as many elements as possible. The focusgroup discussions were conducted during the months ofApril and May 2020 by dual moderators.The forum for each group started with an introduction

and proceeded with questions for participants abouttheir experiences with online learning, the differencesbetween online learning and on-campus-learning, diffi-culties encountered, challenges, level of satisfaction withonline evaluation, and preferences regarding learningmodalities for their next academic year. All students ineach focus group simultaneously took part in a live syn-chronous session for discussion by logging into the web-site. The students used an online conferencing website,and their discussions were audio-recorded. Two modera-tors were present; one ensured the smooth progressionof the focus group sessions, and the other made surethat the topics in questions were all covered. Dual-moderator focus groups resulted in highly productivesessions. Each group discussion took between 90 and120 min. During the final two focus groups discussions,moderators agreed that saturation had been reached and

that the inclusion of more respondents would thus beunnecessary.

Data analysisDiscussions were recorded, transcribed verbatim, andanalyzed by summarizing content analysis developed byMayring [15], Kiger. M. E [16], and Braun. V [17]. Thishelped to condense the data into essential content in asystematic manner guided by sequential steps. The mainthemes of the data were based on the discussion ques-tions. An inductive process was used for analysis and toassign a code for each meaningful sentence and thengather similar codes in overarching sub-themes. Finally,similar sub-themes were grouped together under a maintheme reflecting its sub-themes. The data was analyzedand coded by all authors. Two authors performed a pre-liminary analysis, with the remaining authors acting assecond coders for the data. Subsequently, the initial cod-ing was reviewed and compared. It was then contem-plated and refined until a consensus was achievedamong all authors, which led to a more representativecoding scheme, sub-themes, and themes.

ResultsIn total, eight online synchronous focus group discus-sions were conducted. Each group included seven toeight participants. There were a total of 60 respondents,and more than half (60%; n = 36) of the participants werefemale. The approximate male/female students’ distribu-tion within Unaizah College of Medicine and MedicalSciences is 44/56. Half of the sample participants (50%;n = 30) were between 21 and 22 years old. Almost threefourth of the participants (72%, n = 43) resided withinthe city (Unaizah) where their medical college campuswas located, as indicated in Table 1.During the analysis, sub-themes were identified and

classified under four major themes, which are summa-rized below with relevant quotes from the participants.Four core themes included the following: (1) educa-

tional impact (2), time management (3), challenges en-countered (4), and preferences for future as indicated inTable 2.

Theme 1: educational impactThe educational impact of online courses identified bythe respondents of our study are discussed under twosub-themes, including (1) content understanding and (2)content perception challenges.The first sub-theme concerned the experience of con-

tent understanding. Although our study participantsheld different opinions about content understandingthrough online classes, two-thirds of them agreed that itworks better for some disciplines, which they elaboratedupon in the following statements:

Khalil et al. BMC Medical Education (2020) 20:285 Page 3 of 10

“In my opinion, online classes proved to be an ex-cellent opportunity for theoretical subjects like basicsciences but not suitable for clinical subjects likeclinical skills etc.”

Experiences of clinical students were different frompreclinical students. Some of the fourth-year and fifth-year students found online classes highly beneficial, andthey expressed their views as follows:

“Some online learning courses are very useful, suchas radiology and we were really benefited from on-line sessions like seminars and case discussions.”

“Online classes provided me with great opportun-ities to focus on applied courses like radiology, fo-rensic medicine.”

Almost all of the students regarded it as an opportun-ity to utilize recorded lectures to better understand andmaster the content. They revealed the following:

“Lectures recording option in online learning, bene-fited us a lot! I can listen to the lecture again andagain, at my convenience and can make notes veryeasily. I consider it, a wonderful experience at theend of this academic year.”

“Yes, there is no doubt that online classes are betterthan campus-based classes because recorded

Table 1 Characteristics of the study respondents (N = 60)

Characteristics Frequency (n) Percentage (%)

Age (years)

< 21 7 12

21–22 30 50

23–24 17 28

> 24 6 10

Gender

Male 24 40

Female 36 60

Educational Status

Pre-Clinical Years

Premed-2 (Year-1) 7 12

MD-1 (Year-2) 15 25

MD-2 (Year-3) 15 25

Clinical Years

MD-3 (Year-4) 8 13

MD-4 (Year-5) 15 25

Residence

Within City 43 72

Outside City 17 28

Table 2 Summary of themes and sub-themes

Themes Sub-themes Description Example

1 Educational impact Content understanding Educational improvement due to betterunderstanding of information

“Yes, there is no doubt that online classesare better than campus-based classes becauserecorded lectures are very helpful. It helpedme a lot in my academic progress this year.”

Content perceptionchallenges

Difficulties in understanding of the onlinedelivered information due to variationsin demand of content reception by learners

“I faced difficulty in understanding some ofthe lectures, especially those containing x-rays,were not clear in the online sessions.”

2 Time management _ Improved time organization and utilitydue to online learning

“Online sessions provided me with a greattime to study and I experienced better timemanagement.”

3 Challengesencountered

Methodologicalchallenges

Quality assurance issues in the contentdelivery and implementation issues ofthe online learning

“There were a lot of lectures scheduled inone day! Honestly speaking, I didn’t get timeto study them well…”

Technical challenges Difficulties experienced due totechnological hindrances of internetconnectivity and poor utility ofonline tools

“Slow internet connectivity and communicationsoftware failure were among frequent technicalissues ….”

Behavioral challenges Barriers in adoption of online learninginfluenced by the individual personalitycharacteristics

“It’s not suitable for me because I am a visual andkinesthetic learner. I must admit that even thoughonline classes helped me in raising my marks, …”

4 Preferences for future _ Students’ choices of learning modalitiesfor their next academic year

“I would like to continue online classes if system isfool-proof and well prepared before we start usingit again. I mean the technical part.”

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lectures are very helpful. It helped me a lot inmy academic progress this year.”

The second sub-theme which emerged concerned con-tent perception challenges, which encompass variationsin demand of content reception and learning by differenttypes of learners. Under this sub-theme, participants’expressed the following views:

“I faced difficulty in understanding some of thelectures, especially those containing x-rays, were notclear in the online sessions.”

“In my opinion, non-verbal communication like eyecontact with the instructor is essential to establishlearning process. Campus learning allows discussionamong students which is very helpful for clearing alot of concepts.”

“For me, online lectures are useful only for theoreticalexplanation of the content but I miss clinics! Absenceof the clinical practice and labs is problematic for meto master the practical concepts.”

Theme 2: time managementParticipants generally referred to the theme of timemanagement as a dominant perspective, and they allagreed that online sessions saved time for them and thattheir performance had improved as a result. This ismade evident in the following statements:

“Online sessions provided me with a great time tostudy and I experienced better time management.”

“I live away from the college campus and it usuallytakes two hours daily to reach college. So, theseonline classes saved my time by reducing my dailyexertion of going to campus and coming backhome.”

They experienced more contentment with onlinecourses because of their physical ease and because beingwithin their comfort zone reduced their anxiety. Theyexpressed their views in the following statements:

“Online classes had a positive effect on me in termsof saving time and effort, by reducing the campus-based distractions like compulsive participation inconversions, adjustment with unavoidable noise andwaste of time in finding a proper place to study alone.”

“I thoroughly enjoyed online courses. I used tochoose a comfortable place at my home for myonline classes and it also gave me a chance to relax

at my convenience. It really saved my time andeffort to study well.”

“Online learning has a positive impact on my sleeppattern and I felt more comfortable and balanced.”

Most of the participants were satisfied with onlinecourses because they were able to spend more time withtheir families. One stated the following:

“I experienced an entirely new method of timemanagement with online sessions. Online classesallowed me to save time for my studies and I foundmore time to sit with my family and enjoy qualityrefreshing time, whenever I wanted to take a breakbetween my studies.”

Theme 3: challenges encounteredThe participants encountered some challenges and iden-tified barriers to the acquisition of knowledge throughonline courses. These are discussed under the followingthree sub-themes here: (1) methodological challenges(2), technical challenges (4), and behavioral challenges.The first sub-theme, which can be regarded as a nega-

tive aspect from the perspective of participants, wasmethodological challenges, which included quality assur-ance issues in the content delivery of the lectures andimplementation issues. Adjustment and engagement inthe new system was perceived as a barrier to the devel-opment and implementation of online learning, andthere were multiple problems related to the durationand arrangement of learning sessions. Some participantsexpressed their ideas about these issues as follows:

“It felt like, some of the online lectures wereunnecessarily allotted long time! The sequence ofthe online lectures was also suboptimal and therewas a frequent change of lecture timing. I feltdifficulty in connecting the information out ofcontent heaps.”

“There were a lot of lectures scheduled in one day!Honestly speaking, I didn’t get time to study themwell. Most of the lectures’ content was huge andwas covered within limited time and some of theinstructors were not committed to the time of thelecture. It felt like we are taking lectures whole day.”

“The duration of some lectures was very long!Instructors were not committed to the allottedtime of the lectures. Some instructors were latefor the lectures and did not start it on time.The lectures were frequent during the day andat night.”

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“I noticed a serious communication gap betweenstudents and instructor. At time I needed moreclarification for some lecture content but thosepoints were left unexplained by the instructorsbecause of miscommunication. I missed direct dis-cussions with my instructors and my classmatesduring campus-classes.”

Technical challenges faced by the participants are dis-cussed under the second sub-theme. This includes all es-sential technical elements, such as internet connectivityand the use of online tools. Participants listed manytechnical issues which they faced during online sessions,as mentioned in the following statements:

“Slow internet connectivity and communicationsoftware failure were among frequent technical issueswhich I faced during whole course. Second big issuewas, most of our instructors have no experience indelivering online lecture. There was a wastage of timeevery day because of technical problems.”

“I used to face very frequent internet disconnectionduring online lectures daily and it was very hard forme to follow lectures with instructors.”

“My participation was greatly affected by issues likedelayed download the lectures and internet lagging!The technical problems like troubled sound due topressure on the internet software was very commonduring online sessions.”

“Some instructors were not in a habit of checkingtheir microphones before starting their lectures, sothere was interrupted voice which led to unnecessaryinconvenience and botheration.”

“Sometimes instructor’s voice was not clear andthey didn’t use appropriate explanatory tools givenin the online software. It led to wastage of timewhich could be otherwise avoided.”

Behavioral and acceptability challenges are discussedunder our third sub-theme, which encompasses negativeattitudes towards the adoption of new modes of learning.Participants’ perspectives about their acceptability ofonline learning is quite discernible from the followingstatements:

“It’s not suitable for me because I am a visualand kinesthetic learner. I must admit that eventhough online classes helped me in raising mymarks, but it did not help me in upgradation ofmy knowledge.”

“Even though, I managed to cope up with onlineteaching but I desperately missed body language likeeye to eye contact with instructors and writing onthe board. I missed active interactive sessions liketeam-based learning sessions, peer instruction skillsand discussion among students. I prefer to studywithin campus ambit.”

“Most of the times, I did not find a suitable place athome for taking my online classes and I felt likeenvironment is not suitable at home for attendingonline lectures.”

“My family did not realize that I am seriously busyin learning through online system and that put a lotof pressure on me.”

“If online lectures are continued then, I am afraidthat it will lead to laziness and its negatively affectingmy performance, as it takes me longer to study thecontent.”

“The best thing about online lectures was “recordedlectures”, but at the same time the drawback was, Icould not link the theoretical concepts togetherthrough recorded lectures. It simply doesn’t workfor me.”

“Online learning kept me away from my family, andit feels like I am always busy in my lectures andstudies.”

“While learning through online sessions, I had notime to enjoy my social life. I feel like I am busy allthe time with my lectures and I lost interaction withmy classmates.”

Theme 4: preferences for the futureThe students were asked about their preferences regard-ing their next academic year. Mixed responses were con-veyed. The majority of them preferred online learning,while others, especially clinical students, expressed inter-est in the continuation of campus-bound classes and liveclinical participation. The statements in favor ofcampus-based classes included the following:

“It is time saving to study together to master some dif-ficult concepts. Some lectures that need active discus-sion and eye to eye contact with instructors whileothers need joint study like team-based learning skills.”

“Courses that require practical application, such aswomen and children health, cannot be taughtthough online sessions.”

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“It was an unpleasant experience. Please do notrepeat it in any course of next academic year. In myopinion, college campus and clinics are mostsuitable for learning because it provides us with aspecial learning environment.”

“Well, it did not help me much in my academicprogress. Clinical practice and direct learning atcampus though live lectures is better, as eyes toeye contact with the instructors helps in betterunderstanding of content.”

Online experience of learning was preferred by somestudents, but they suggested some conditions in case ofits continuation. The following statements elaboratedupon this:

“I prefer online learning, provided the doctor shoulduse the online teaching tools like writing on screen,highlighting the text etc.”

“I prefer to continue with online learning in upcomingacademic year, only in the fields of scientific researchand forensic medicine.”

“I agree to continue online sessions for somecourses like radiology but it cannot be applied in allcourses, especially clinical courses. Excellent intheoretical courses but unsatisfactory experience inpractical courses.”

“Online learning is better than studying in collegecampus and is preferable for female students likeme who lives outside Unaizah.”

“I would like to continue online classes if system isfool-proof and well prepared before we start using itagain. I mean the technical part.”

“Online learning is excellent and saves time forstudying. I suggest that there should be one day perweek specified for online learning to cover sometheoretical courses but not for whole year’scourses.”

DiscussionOur research study examined undergraduate medicalstudents’ perspectives and preferences regarding onlinemodules of synchronized learning. The concept of onlineclasses is not new in the Kingdom of Saudi Arabia, inrelation to online synchronized learning in medical edu-cation at the undergraduate level, no research was previ-ously conducted in the Kingdom.

In our analysis, we have identified the factors influen-cing the medical students’ assent or dissent in relationto synchronized online learning. Assenting students inour study were motivated by the benefit of masteringthe content in less time compared to campus learning.They utilized updated educational technologies whichfulfilled the requirements of adult learners by promotingactive and student-centered learning. This instructionalmethod helped empower learners in controlling theireducational needs constructively and provides them withstructured guidance for self-directed learning [18]. Even-tually, this enables students to utilize their time product-ively to achieve their individual goals. Additionally, mostof the students in this study found more time to spendwith their families and to improve their sleep pattern.However, some students mentioned some negative factorsrelated to managing their time. The overall satisfactionlevel with online learning was found to be high in ourstudy, and students’ attitudes were quite positive towardsonline learning as a new teaching modality relative totraditional didactics. This finding is consistent with previ-ous research on online learning modalities [19–38].However, our study assessed the individual learning

experiences using online modules, and we found thatthe use of online learning is more productive within thecontext of particular medical disciplines, such as forbasic medical sciences or preclinical subjects; this madeit difficult to compare its relative effectiveness with clin-ical disciplines [19, 20]. That is why more preclinicalstudents preferred online learning for their future aca-demic years, as compared to clinical students whoparticipated in our study. Conversely, Cardall S. con-ducted a study in 2008 which concluded that preclin-ical students preferred to have live lectures whengiven an option; the authors agreed that online lec-tures are an efficient method for the acquisition ofknowledge [39].According to our study participants, the missing elem-

ent in the effectiveness of online learning was clinicalpractice. Nothing can replace seeing a patient becauseclinical experience and human interaction are extremelyimportant for the practice of medicine. However, onlinelearning may serve as an efficient resource for clinicalstudents if the method is upgraded through the integrationof modalities such as virtual simulation technologies andcomputer-based models of real-life processes. This can pro-duce multiple benefits for clinical learners by providingcontrolled opportunities to practice rare and critical eventsin safe environments excluding the risk to patients. An in-structional technology, such as a computer-based virtualpatient program designed to simulate real-life clinical sce-narios, can be useful for clinical learners to facilitatehistory-taking and physical examination and can encouragediagnostic and therapeutic decision-making [18].

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Although the themes that emerged from this studysupport the notion that “online learning works for med-ical students,” this does not imply that online learningcan completely replace in-person live sessions. Ourstudy participants encountered numerous challenges inadopting online learning. One of the most common bar-riers was technical insufficiency, including poor internetconnectivity and deficits in educators’ basic computerskills. The themes identified in our study complementnumerous previous studies [40–42]. The high-yieldingtechnological use in medical education depends on thefaculty’s readiness and expertise to employ the technol-ogy to facilitate learning. Training physicians with theseskills need a divergence from traditional teaching meth-odology. Hence, it appears that training in educationaltechnology mastery is a neglected competency in facul-ties which should be mandatory for the enhancement ofmedical universities [2].Aside from technical issues, our study participants’ ex-

periences were influenced by the individual characteris-tics of students themselves, such as their learning styles,acceptance of new learning modalities, and levels of en-gagement in online classes [43–45]. Other barriers in-cluded quality assurance issues in the implementation ofonline learning by the institution. This finding is consist-ent with a study performed by Bediang et al. in 2013, inwhich the authors concluded that one of the most im-perative means for implementing online modules is en-couraging collaboration among all departments andstakeholders. An organized and clear institutional ap-proach is required to formulate a well-regulated and effi-cient system which can facilitate the adoption ofstructured methodologies by faculty members whileimplementing an online learning module [10].A lack of non-verbal communication by instructors

was also identified as a significant challenge for ourstudy participants. According to communication theo-rists, verbal messages are conveyed through words,whereas nonverbal messages are conveyed beyond theactual meaning of words, which typically complementsthe spoken words [46]. The psychological closenesswhich a student may feel with their instructor is primar-ily based upon the instructor’s nonverbal clues. Nonver-bal communication, such as eye contact, gestures, andposture, comprise a major part of all communications.

ConclusionOur study concludes that synchronized online learningwas well-received by the medical students. At the sametime, some challenges for our study participants in-cluded technical issues, individual behavioral charac-teristics, institutional methodology barriers, and theabsence of non-verbal clues. Moreover, preclinicalstudents were more likely to opt for online lectures

as their preference for the next academic year com-pared to clinical students.

LimitationsThere are some limitations to this study. The findings ofthis study cannot be generalized because it was con-ducted in only one medical school. Although four corethemes and a number of subthemes emerged from ourstudy, the authors are aware that there must be otherpotential strengths and weaknesses of this modality forundergraduate medical students. Secondly, to ensure theeffectiveness of online learning modules for undergradu-ate medical students, the principles of online learningmodel and learning outcomes should be rigorously andregularly evaluated.

RecommendationsThe findings of our research support the evidence re-garding the effectiveness of online learning for medicalstudents; however, it is important to realize that it is notthe only mode of transferring efficient knowledge. Ofcourse, there are other teaching modalities and clinicalteaching which are essential to implement as compul-sory parts of an ideal undergraduate medical educationmodel. Thus, the online module’s predominately syn-chronized learning represents a meaningful and promis-ing potential for the future of medical education and canbe integrated into the curriculum to enhance the effect-iveness for lifelong learning.There is a need for research to identify other effective

online and offline teaching modalities and to formulate ameticulous model through the integration of an optimalproportion of online learning in undergraduate medicaleducation.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s12909-020-02208-z.

Additional file 1.

AbbreviationsCOVID-19: Coronavirus disease 2019; MD: Doctor of Medicine

AcknowledgementsThe authors thank all medical students for their time and contribution to thestudy.

Authors’ contributionsOW, RK devised the project, the main conceptual ideas, and analysis. AM,WF, KM, MD data collection, AN and AK drafting of manuscript. All authorsparticipated in the interpretation of data, drafting and revision of the paper.All authors read and approved the final manuscript.

FundingNo funding was received for this research.

Khalil et al. BMC Medical Education (2020) 20:285 Page 8 of 10

Availability of data and materialsData sharing is not applicable to this article.

Ethics approval and consent to participateEthical approval has been granted by Qassim University (reference number191103) and verbal consent was obtained.

Consent for publicationParticipants gave a verbal consent for direct quotes to be published in thismanuscript.

Competing interestsThe authors declare that they have no competing interest.

Author details1Department of Family and Community Medicine, Unaizah College ofMedicine and Medical Sciences, Qassim University, Unaizah, Saudi Arabia.2Department of Basic Medical Sciences, Unaizah College of Medicine andMedical Sciences, Qassim University, Unaizah, Saudi Arabia. 3Department ofRadiology, Unaizah College of Medicine and Medical Sciences, QassimUniversity, Unaizah, Saudi Arabia. 4Department of Pediatrics, Unaizah Collegeof Medicine and Medical Sciences, Qassim University, Unaizah, Saudi Arabia.5Department of Medicine, Unaizah College of Medicine and MedicalSciences, Qassim University, Unaizah, Saudi Arabia.

Received: 23 June 2020 Accepted: 25 August 2020

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