Virtual educational meetings and activities during the COVID-19 pandemic and beyond: Egyptian oncologists’ experience

The COVID-19 pandemic has had ramifications for most healthcare activities, including medical education and communication aspects. Virtual educational meetings and activities (VEMAs) have been utilised tremendously in the pandemic era, reflecting a transition to new horizons of cyberspace. This creates the need to explore possible challenges for the implementation of such services in the rapidly evolving field of oncology. The aim of our study is to explore the impact of the COVID-19 pandemic on VEMAs in the oncology community in Egypt. It focused on the evaluation of current attitudes, satisfaction and expectations of Egyptian oncologists during and beyond the COVID-19 era. The study is a cross-sectional study using a survey that was distributed through social media. It targeted Egyptian oncologists during the months of May and June 2020. A total of 118 participants completed the survey and most of them were younger than 35 years (71%). Most participants (93.2%) agreed that COVID-19 affected the stream of live medical educational meetings. About three-quarters of them attended VEMAs during the COVID-19 period compared to 50% prior to the pandemic. The majority reported that evening hours after 8 PM was the best time to attend VEMAs and 1 hour is the optimal duration for a virtual meeting. Although the COVID-19 pandemic appeared as an unprecedented challenge for medical education, it can be a catalyst for VEMAs, especially in a rapidly evolving field such as oncology. Further research is needed to assess whether learners are ready and willing to make greater use of online educational platforms and investigate the possible barriers and strategies to enhance their use.


Introduction
Coronavirus disease 2019 (COVID- 19) was first recognised in December 2019 in the city of Wuhan, China, and has spread to more than 200 countries in the world to date [1,2]. The COVID-19 infection is mostly asymptomatic, but it can be fatal in 2%-3% of the cases from complications such as severe pneumonia, acute respiratory distress

Results
A total of 118 oncologists had completed the survey. Table 1 depicts the socio-demographic characteristics of the participants. More than half (54.2%) of the participants were male. The mean (SD) age of participants was 34 years (+5.99); most of them (71.19%) were younger in age (≤35 years). Most of the participants (67.79%) resided and worked (72.04%) in Great Cairo governate, and about half of them (48.3%) worked in university hospitals. About 56% were clinical oncologists. The remaining were distributed equally between medical and surgical oncology (18.6%) for each specialty, and radiation oncology (6.8%). Less than half of the participants (45.8%) had a master's degree, and more than half (55.9%) were specialists. Table 2 illustrates the oncologists' experience in participation in the educational activities before the COVID-19 pandemic in the year 2019, where conferences were the most frequent activity, being attended by about 90% of them. This was followed by workshops (61%), webinars (36.4%) and journal clubs (36.4%). Most of them (68.6%) presented 0-3 lectures/abstracts/posters in these activities, which were mostly inside Egypt, while about 12% of the participants had presented >10 lectures/abstracts/posters. Almost two-thirds of the participants had received funding to attend these activities. Before the COVID-19 period, half of them had experience with VEMAs and almost all of them (96%) had attended <5 educational activities outside Egypt.
Most of the participants (93.2%) agreed that COVID-19 affected the stream of live face-to-face medical educational meetings. About threequarters of them attended VEMAs during the COVID-19 pandemic with a maximum of once or twice a week (80.7%). Smartphones and laptops (72.8% and 51.7%, respectively) were the most used devices to attend VEMAs and Zoom was the most preferred platform (85.6%) ( Table 3).
The evening after 8 PM was the best time to attend VEMAs in the opinion of the majority (83.9%). The optimum frequency and duration of VEMAs were once weekly (83.05%), and for 1 hour (64.41%), respectively. Among the advantages of VEMAs, saving more time for family and social activities ranked number one (66.9%), followed by saving travel expenses (65.3%) and the availability of free educational content (62.7%). Sixty-seven percent believed that VEMAs fulfilled their educational goals and expected learning outcomes. On the other hand, problems with Internet connections ranked number one as a barrier for participation in VEMAs (66.9%), followed by the absence of travelling experience and the absence of interaction with other participants (56.8% and 44.1%, respectively).
While more than three-quarters of the participants believed that the information gained from VEMAs can be implemented in their practice, around half of them thought that VEMAs are generally useful for their work and development.
During the COVID-19 era, attendance of VEMAs was significantly associated with clinical and medical oncology specialty (p < 0.001), especially consultants (p = 0.01) with more experience (p = 0.05). There was no significant impact of age, sex, qualification degree or job facility sectors on the VEMAs attendance. The correlation between socio-demographic characteristics of the participants and attendance of VEMAs during the COVID-19 pandemic is illustrated in Supplementary Table 1.
When asked about their perceptions and expectations for virtual education after the COVID-19 era, about half of the participants thought that VEMAs will grow at the expense of traditional educational activities, 73.7% hoped that international conferences will allow virtual attendance as an option for registration in the future and 61% hoped that the VEMAs will continue after the COVID-19 pandemic (Supplementary  Table 2).  The correlation between socio-demographic characteristics of the participants and degree of perception about VEMAs in the post-COVID-19 world (Supplementary Table 3

Discussion
Our study revealed a significant increase in participation in VEMAs, which is a reflection of the impact of the COVID-19 pandemic on the educational activities shifted to the virtual domain.
Most participants in this survey were young oncologists ≤35 years old. About half of them were in the middle of their career, being specialists and had their master's degrees, which is the first step for specialisation in Egypt. At this point in their career, medical doctors seek knowledge to advance their skills and to establish their career in the field, while striving to get acceptable financial revenue. However, they do not have great scientific contributions, and they are not very well known to the scientific community. This is evident from the number of lectures/abstracts/posters presented by these participants in traditional educational activities, where about two-thirds of them presented only between 0 and 3 presentations last year. Also, data reflect the fact that conference attendance increases with career stages [13], and this may explain the age group of oncologists who showed interest in this study. In two other surveys about the experience of radiation oncologists [14] and ophthalmologists [15] with virtual learning during the COVID-19 pandemic, most respondents were young physicians less than 40 years, as in our study.
Approximately 70% of the participants strongly agree that the COVID-19 pandemic affected the traditional live medical educational meetings. As a result of this, there was an increase in their participation and experience with the VEMAs in comparison to the pre-COVID-19 era (74.58% versus 50%), which means that about a quarter of the participants had this educational experience for the first time due to the current circumstances. These results are in accordance with the findings of Chatziralli et al [15] in their survey about the use of e-learning in ophthalmology during the COVID-19 pandemic where 48% of participating ophthalmologists from both academic and non-academic institutions worldwide did not use any e-learning before the COVID-19 but during the pandemic there was a statistically significant increase in the use of all e-learning alternatives during the pandemic.  Table 3. Participants were allowed to choose more than one answer.

The information you learnt from virtual educational meetings and activities can be implemented in your practice
Selection of the right time, frequency and duration of educational activities is important to ensure that the message is delivered effectively. For example, The European Molecular Biology Organisation organised a virtual conference (T6SympoZOOM) between 15 and 17 April, 2020, during the pandemic. In the post-conference survey, 131 out of 181 respondents found the conference schedule with 2-hour sessions, 3 consecutive days and 10-15 minute talks as the most appropriate for them [16]. As a result of the cancellation of all major spine educational conferences in the first half of 2020, the Virtual Global Spine Conference (VGSC) was created in April 2020 by multi-institutional board-certified and board-eligible, spine fellowship-trained neurosurgeons and a board-certified interventional neuroradiologist in the form of biweekly virtual meetings every Monday and Thursday at 1000 and 1700 Eastern Standard Time, respectively, for 60-90 minutes [17]. In our study and from the answers, we can say that most of the participants prefer attending a maximum of one or two VEMAs per week, and in their opinion the most appropriate time to hold them is after 8 PM. Perhaps, they prefer this time because the majority would have finished their work, returned to home and had some rest before attending any VEMAs. Also, learning before night-time sleep has been shown to foster the consolidation of new memories [18], which may represent another advantage of this timing. Regarding the duration of the VEMAs, most participants believe it should be an hour or less. This is consistent with the fact that typical learner attention span wanes after about 15-20 minutes [19]. After 20 minutes, lectures become less effective for two reasons: working memory and interference, which make longer lectures both less enjoyable and less effective [19,20]. Taken together, we think that scientific societies should take the perspectives of the audience into consideration while planning for their VEMAs. They should also be aware that delivering their content online at their homes does not mean the target audience will always be available to receive this content.
The affordable and easy access to smartphones in everyday social and work life of participants made them the preferred tool to be used in the VEMAs (72.9%). In one of the studies conducted on university students, it was found that 66% use mobile devices for e-learning, 45% used a mobile phone and 38% a laptop [21].
Zoom application was the preferred platform in our study to conduct VEMAs. Although not completely free, the application became very popular during social distancing time, recruiting millions of users and achieving great profits [22]. The application was the preferred platform for e-learning during the COVID-19 pandemic in many other studies [15][16][17][23][24][25].
Education comes with a cost. Although free educational courses are now available online on multiple platforms, international conferences and workshops are expensive especially for early and mid-career physicians in developing countries [26]. Salaries for physicians in Egypt are among the lowest in the region [27]. That is why it is important for these physicians to get financial support to attend these meetings to cover the registration and travel costs. This was clear in the answers of our participants, where the great majority of them depended on external fund sources to attend educational activities. However, we did not ask about the source of this fund (whether it comes from their work place or pharmaceutical companies). This cost is usually obviated during VEMAs, which explains why participants considered that the major advantage of virtual education is saving money through the availability of free content. A Norwegian study about the benefit of 88 learners from online education in dermatology found that the participants saved 455,198 Norwegian krone in travel expenses [28], which is equivalent to 81,189 US dollars according to the average exchange rate in 2011 [29]. In another study about the impact of a Small private online course (SPOC) in oncology education and after comparison of the overall cost of the SPOC and the theoretical costs of comparable face-to-face education, the SPOC was a more cost-effective educational method (€148,000, versus €154,000 for face-to-face education) [30]. Although the fact that virtual conferences are supposed to consume lesser budget than needed by live conferences, still some landmark oncology conferences amid the COVID-19 pandemic require registration fees that reach 300$/participant [31]. The results of our survey guided the oncology community to exert their efforts to try to provide the VEMAs with amenable charges that can fit the lower income countries.
Burnout is common among oncologists including Egyptians as they have a stressful career [32][33][34]. The relationship with family members and practicing activities and hobbies are effective in reducing stress and overcoming burnout [35]. Flexible time management and saving travel time were advantages for online education according to students attending electrocardiogram course at the University of Ulm [36]. In this survey, it seems that social distancing, limited travel and VEMAs enabled our participants to save more time for family/activities. We think that this represents the other side of the coin, where physicians who were forced to 'stay at home' could regain their social life partially.
However, VEMAs lack some advantages which are provided by live events. Conferences and live educational meetings represent good opportunities for attendees to interact with their peers in the field as reported in a survey of travel behaviour among scientists in Germany. This is particularly important for early career doctors and scientists, where they can also have a chance to know about different cultures [13,37]. A systematic review of the factors affecting e-learning in health sciences found that lack of interaction and collaboration between learners and facilitators is a barrier for this type of education [38]. This was evident in the responses of our participants, who reported the lack of interactions with other participants and experience with new cultures among the drawbacks of VEMAs.
Internet connection speed in Egypt improved in 2020 to rank number no. 2 in Africa, in comparison to 2017 [39], where Egypt's Internet speed ranked among the world's slowest [40]. However, a major problem with VM in this survey was the problem with Internet connection speed in Egypt, which indicates that major efforts should be carried out to overcome this problem and improve the speed. It seems that the problem with Internet connection and its speed is an obstacle to education in other countries as well. Healthcare worker in sub-Saharan Africa who completed the University of Washington School of Medicine online graduate course reported slow or limited Internet among the barriers to course completion [41]. However, in a survey about the online education for undergraduate health professional in Jordan during the COVID-19 pandemic, the lack of past experiences on using online tools was identified as the main barrier to e-learning among 75% of the participants in comparison to 13% in our study [42]. This difference may be due to the difference in age and experience between participants in the two studies.
A great majority of our participants believed that the information learnt from VEMAs can be implemented in their practice. This is similar to the results proved by other healthcare professionals, where distance learning was found to be effective for oncology nurses and neurosurgeons training [43,44]. However, a fewer number of participants reported that VEMAs are useful for their work and development, which may reflect that the content should be more tailored to match their needs.
Certainly, the world will change after this pandemic in different aspects, including education with fears of a new recession and financial collapse [45]. VEMAs need less costs and arrangements. This may be why participants think and hope the VEMAs will continue and grow at the expense of traditional educational activities after the COVID-19 pandemic. These opinions and expectations are consistent with the opinions of other healthcare professionals, including neurosurgeons and orthopaedists, who intend to participate in e-learning activities after the end of this pandemic [43,46]. Our respondents also hope international conferences to put virtual attendance as an option for registration in the future.
In the present study, the attendance of VEMAs during the COVID-19 era was significantly associated with the clinical and medical specialty (p < 0.001), especially consultants (p = 0.01) with more experience (p = 0.05), mostly because most participants were clinical or medical oncologists. Having more senior physicians attending these activities may reflect a targeted marketing to attract this particular group, or the ability to manage their time better to attend the meeting or being more experience in identifying these events and connecting with them. Around 1,000 Libyan doctors participated in a survey about the interaction of pharmaceutical company representative with doctors. There was a statistically significant difference in visiting rates based on the age group and all doctors older than 45 years who communicated with pharmaceutical company representatives [47]. Likewise, continuous medical education participation was more common among older Chinese doctors with intermediate or senior job titles in a nationwide cross-sectional survey [48].
E-learning may be more favourable for women through its flexible and interactive learning approach [49]. Interestingly, female participants in our study thought optimistically and hoped that VEMAs will continue more than male participants. Young female physicians often experience difficulty in returning to a clinical setting once they start having children and a Japanese nationwide cohort revealed that the proportion of female physicians who take leave is higher than the proportion of those who return to work [50]. We think that VEMAs are convenient for female doctors and may help them to achieve a balance between updating their knowledge continuously and caring for their homes and families. On the other hand, MOH and private sectors doctors were less optimistic about this point. This may reflect their need for more networking with their peers in other universities and with international experts as well.
The proposed strategies that could encourage oncologists to engage in future VEMAs include using attractive platforms for conferences as for instance the 3D interactive virtual platform and organising the VEMAs schedules to avoid overlapping. Moreover, CME accreditation and offering the lectures in recorded forms to be retrieved in the convenient time will up skill the oncologists' carrier in real life. On the other hand, providing the chance for the junior oncologists to directly reach and get in touch with the oncology international experts and mentees in different fields virtually can greatly motivate them to attend these events and overcome financial obstacles for oversees collaborations and training. Finally, providing post-meeting satisfaction surveys for the speakers and attendees will help in evaluating and improving these services and upgrade its content.
To the best of our knowledge, there is no published data yet on the evaluation of the impact of the COVID-19 pandemic on virtual educational practices in the oncology field in Egypt or Arab countries. This research aims to explore the socio-demographic attributes of oncologists' willingness to achieve virtual education, identifying the possible barriers for participation in these activities and clarify their needs for future events. In an attempt to improve the implementation of the VEMAs in the post-COVID-19 era, this study will enhance the technical skills of oncologists to use the virtual platforms in order to maximise the benefits of attending such meetings.
This study illustrated several important results by taking a snapshot for the current perspective towards VEMAs amid the COVID-19 pandemic. However, some limitations should be considered. Firstly, this survey was conducted and administered through social networking sites, including Facebook and WhatsApp groups, and this may result in sampling bias, e.g., most participants were young as only those who were interested and familiar with social media answered the survey. Secondly, the cross-sectional design of this study. Thirdly, limited sample size was among the study limitations. Fourthly, we did not evaluate the speakers or moderators' experience as they may have different perspectives or needs. Fifth, we did not ask about hybrid meetings since they were not common options at the time of the distribution of the survey. Finally, and importantly, the participants' perspective regarding the curriculum or the content of VEMAs was not deeply explored. VEMAs may represent a golden opportunity to exchange knowledge and experience with experts in the fields and follow the latest updates, but it is difficult to learn manual skills through them or utilise them when direct interaction with patients is needed. So, it is not possible to generalise this type of educational activities to all specialties and fields, which mandates a separate evaluation for other disciplines.

Conclusion and recommendations
The COVID-19 pandemic has led to new opportunities for virtual education. Curricula for this type of education should be developed and tailored according to the needs of target groups. Virtual registration and free content should be added as an option in future international scientific events to help young physicians in developing countries improve their knowledge and skills, without the need to bear the costs for travel and accommodation.

Supplementary material
Supplementary