Research article
Open Access

European medical students’ attitudes on distance learning during COVID-19 pandemic

Suleyman Yildiz[1], İhsan Selçuk Yurttaş[2], Ayfer Gözü Pirinççioğlu[1], İrem Aktar[2], Emine Senkal[3], Abdullah Yıldız[4], İlker Kelle[1], İsmail Yıldız[1]

Institution: 1. Dicle University, Diyarbakır, Turkey, 2. European Medical Students' Association, Brussels, Belgium, 3. Chelsea and Westminster Hospital NHS Trust, Chelsea, United Kingdom, 4. University of Health Sciences Istanbul Umraniye Training And Research Hospital, Istanbul, Turkey
Corresponding Author: Dr Suleyman Yildiz ([email protected])
Categories: Education Management and Leadership, Educational Strategies, Students/Trainees, Teaching and Learning, Technology
Published Date: 14/06/2021


There are over 60 million cases and over 1,000,000 deaths worldwide. Many countries have undertaken radical decisions to prevent the spread of the disease, including lockdowns and limited allowances for mobility. As a consequence of lockdown policies, many educational activities have since been suspended by universities globally. This situation impacted even medical faculties and prevented the entry of new professionals to the health workforce. Many medical faculties have moved onto distance learning while many are preparing to do so. It is important to understand how medical students and faculties are being impacted and what adaptations must be considered. Thus, we have conducted a survey study on “Attitudes of Medical Students to Distance Learning during COVID-19 Pandemic” through European Medical Students’ Association’s member faculties. We aimed to evaluate the satisfaction rate of medical students across Europe and record their suggestions for the present and future.

Keywords: Distance learning; e-learning; European medical students; COVID-19; coronavirus; medical faculty; distance education; motivation


Distance learning is not a new paradigm; first applications go back to the 18th century where face-to-face education was not possible (Hills and Keegan, 2020). Initially, the approach was to send materials to students in hard-copy format. Later on, the concept continued in a correspondence style by using CD-ROM based materials (Lim, Morris and Kupritz, 2019). Students used to receive materials and respond via postal services. In this concept, the distance between students, teachers and peers caused a significant barrier, and fast communication was not possible (Moore, 1989). Nevertheless, distance learning evolved rapidly with the advances in technology and gradually transformed into an entirely online, more interactive learning experience that zeroed the distance between student and teacher. Nowadays, online distance education enables students to access education wherever and whenever they want (Beldarrain, 2012).

According to Grant (2008), "distance learning" is the individual study of specially prepared learning materials, usually print and sometimes e-learning, supplemented by integrated learning resources, other learning experiences, including face-to-face teaching and practical experience, feedback on learning and student support (Taylor et al., 2020). Distance learning, nowadays often equated with online education, is a highly utilized sector; according to certain estimates the number of e-students will be 160 million by 2025 (Roach, 2001). Many online learning tools, such as the ones listed by UNESCO in their distance learning solutions, are already extensively used in universities to facilitate or augment regular educational courses around the globe (UNESCO, 2020).

To focus on distance education, we must also talk about “e-learning”, a fundamental component of distance learning.



Online distance learning is defined as “the process of creating and providing the learning online by grounding on the resource of knowledge, learners or, both.” (Miller, 1993). A significant development in recent years has been the application of new learning technologies including simulation and e-learning. In the healthcare education, e-learning has been adapted in curricula very quickly. In many aspects, it differs from the traditional format of teaching (mainly based on face-to-face classes) from self-learning programs (in which students engage themselves in independent private studies) as well as from the other use of technology for education. Under normal circumstances, traditional education and e-learning have been used in a “blended” format, since both methods have their advantages and disadvantages (Ellaway and Masters, 2008).


COVID-19 and Distance Learning

On December 27th, 2019, three patients were admitted to hospital with severe pneumonia in Wuhan, China. This event was followed by the detection of a new virus, which later, Chinese authorities identified it as a beta coronavirus related to SARS and MERS or as it was subsequently named by the World Health Organization (WHO), COVID-19. WHO announced that this new disease has leveled up into a pandemic list on 11 March 2020. Currently, there are over 60 million cases and over 1,000,000 deaths worldwide. Many countries have undertaken radical decisions to prevent the spread of the disease, including lockdowns and limited allowances for mobility (World Economic Forum, 2020; Kaplan et al., 2020). As a consequence of lockdown policies, many educational activities have since been suspended by universities globally. This situation impacted even medical schools and prevented the entry of new professionals to the health workforce (Arandjelovic et al., 2020). Many medical faculties have moved onto distance learning while many are preparing to do so (University of Oxford, 2020). It is important to understand how medical students and faculties are being impacted and what adaptations must be considered. Thus, we have conducted a survey study on “Attitudes of Medical Students to Distance Learning during COVID-19 Pandemic” through European Medical Students’ Association’s member faculties. We aimed to evaluate the satisfaction rate of medical students across Europe and record their suggestions for the present and future.


We have conducted a survey study on “Attitudes of Medical Students to Distance Learning” between 28 July-13 September 2020. We sent a 24-item online questionnaire to medical students in the European Medical Students’ Association-Faculty Member Organizations (EMSA FMOs). In the first part of the study, we asked questions related to communication between students-school administrations and the evolving situation (face-to-face/ online). In the second part of the study, we asked questions related to attitudes about ongoing distance learning. Attitude questions have been asked as 5 Likert Scale questions.

Data were analyzed with SPSS Statistics v26.0 (IBM Corp., Armonk, NY) and RStudio version 1.2.5033 (RStudio, Inc., Boston, MA). Kolmogorov-Smirnov tests were conducted for each items’ normality. Spearman rho was used for correlations.


We received answers from 76 medical faculty representatives of EMSA that come from 13 different European countries: Austria, Germany, Greece, Hungary, Italy, the Netherlands, Portugal, Romania, Russia, Serbia, Spain, Turkey, and Ukraine.

According to the answers we gathered usual physical medical education has stopped during pandemic, with the exception of 4 faculties. The first part of our questionnaire was on the level of satisfaction on the announcements made by the medical faculties. 72 faculty representatives responded that they have been receiving announcements on ongoing changes in their education regularly. Student involvement during decision-making processes has been voted on average 3 out of 5 most (See Figure 1).

Figure 1: Satisfaction rate on announcements


To the question “Are there any online courses in your faculty?”, 37 participants answered “Partially Yes” (48%), 22 answered “Totally Yes” (29%), 10 answered “Soon” (13%) and 7 answered “No” (10%). The participants that answered “Partially Yes” and “Totally Yes” to this question accounted for 59 participants out of a total of 76 (See Table 1).

Table 1: Are there any online cources in your faculty?




Partially Yes

Totally Yes















The second part of the questionnaire was asked to this group. Our survey inquired if the medical faculties provided mobile devices to students in need and 64.9% responded as “No” to this question (See Figure 2).

Figure 2: Mobile device providing be schools

We defined 10 parameters that determine the overall satisfaction rate of participants’ distance learning experiences. These were the following: Learning outcomes coverage in lectures (Q12), presenters’ clothing (Q13), teaching environment (Q14), technical knowledge/preparedness (Q15); educational content used in lectures (Q16), presentation (Q17), provided resources (reading recommendation, booklets, articles, audibles, etc.) (Q18), online course platforms’ accessibility (Q19), platform’s design (Q20) and user interface (Q21). The results were on a 1-5 Likert scale. Figure 3 shows the most common answers given for each parameter with their percentages (See Figure 3).

Figure 3: Parameters affecting overall satisfaction rate on distance learning

Based on the results of the study, provided resources (reading recommendation, booklets, articles, audibles, etc.) have the most influence on overall satisfaction (rs= 0.76, p < 0.01). Learning platform’s design also has a significant impact on overall satisfaction (rs= 0.68, p < 0.01).

40.7 % of the faculty representatives declared that feedback mechanisms exist to evaluate online courses although 23.7% percent of faculty representative declared that they do not know if there is one.The rest, 35.6% of the group mentioned ‘no’ for any kind of feedback system.

The relationship between parameters that affects satisfaction level and overall satisfaction level was investigated using the Spearman rho coefficient. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity, and homoscedasticity. There was a strong, positive correlation between provided resources (reading recommendation, booklets, articles, audibles, etc.) and overall satisfaction (rs= 0.76, p < 0.01), making provided resources the most impactful parameter that affects overall satisfaction level. Learning platform’s design also has a significant impact on overall satisfaction (rs= 0.68, p < 0.01). Overall satisfaction level can be examined in Table 2 (See Table 2).

Table 2: Overall satisfication rate on distance learning platform























Medical education is already a distributed learning system globally and distance learning is a quality assured, managed extension of it. Furthermore, distance learning provides a rich, planned experience for learners offering quality, flexibility, and cost effectiveness (Dent, Harden and Hunt, 2017). According to AMEE Guide-32, “all medical students are distance students, in that they study at home or while travelling, and they are usually required to attend rotations or attachments away from the main campus” (Ellaway and Masters, 2008).

One of the studies titled "Education Faculty Students' Level of Satisfaction with the Computer-Assisted Distance Education System", revealed that the students find courses delivered through distance education effective (Yalman, 2013). In our survey, nearly a third of medical faculty representatives surveyed rated their educational resources and their use in distance learning as less than satisfactory. Furthermore, our survey inquired if the institutions provided mobile devices to students in need and 64.9% responded “No” to this question. Mobile devices (or handheld computer) help teachers, faculties, and school administrators to facilitate student learning and provide interaction and social care during periods of school closure (Ellaway and Masters, 2008).

Medical education specifically poses an additional challenge during the pandemic, as its curriculum is greatly based on clinical practice in many faculties. The question arises as to the degree to which this situation would impact medical students in training as future physicians, given that essential components of practical knowledge will not have been taught via distance learning. As our survey shows, medical faculties have pledged to offer summer schools or other modalities of face-to-face training once this is possible again in order to make up for lost training. However, this is largely a capacity issue and will thus pose a challenge to many medical faculties that need to account for several classes of students. Especially some of the larger medical faculties might face issues in enabling equal chances for every student to obtain their missed practical courses. Thus, distance learning solutions will most likely be necessary for many practical subjects as well, which might have consequences for involved students. On the other hand, lack of face-to-face interaction between the teacher and the students might affect the sense of belonging to an academic society (Rovai, 2001). As a result, continuous online education might cause students to feel isolated and insecure (Knapper, 1988), and this might increase the risk of interruption in students’ training (Peters, 1992). Knowledge is constructed by the interaction between students and takes its final form with abilities and skills within the educational values. Because of that, teachers play a crucial role in shaping the educational process and supporting the development of knowledge interpretation. Teachers’ role in online education is different than in traditional face-to-face education (Crow and Murray, 2020) and teachers need to be more careful about students’ perception and satisfaction.

In our study, the average satisfaction with distance education was 3 (1-5 Likert scale). According to several articles, the rapid responses to pandemic by universities have shown that medical faculties and medical teachers are largely prepared to switch to a distance learning modality of teaching (Li Cathy, 2020), (Zhao et al., 2020). On the other hand, some less technologically advanced medical faculties will have come to realize shortcomings in their digital education possibilities. This discrepancy in the quality of distance learning across medical faculties could be avoided in the future if clear guidelines were in place defining distance learning modalities for universities in exceptional circumstances like a pandemic (UNESCO, 2020).

In our survey, the level of satisfaction on the student involvement during decision-making processes has been voted approximately 3 out of 5 most. Several other surveys showed that the representation of students in decision making process at institutional level is close to universal, though there is important variability between institutions so far as representation at lower organizational levels and across different issue-based governance domains is concerned (Luescher-Mamashela, 2013).


Today, education is not limited to geographical regions. Students can access various educational programs from all over the world (Peacock et al., 2012), (Murphy and Farley, 2017). This situation brings learning freedom to students in a way that is best suited to their lifestyles (Brown, 2001), (Bolliger and Inan, 2012). Isolation can be considered as a disadvantage for online distance learning; however, with the appropriate techniques and tools to support communication, online distance learning can be advantageous for both students and academic staff. Efforts should be put on maintaining interaction in online distance learning courses, programs and transition to online distance learning for both partners.

Communication gap between students and teachers, social isolation, and missing interaction between peers have been reported more in online distance learning, compared to face-to-face education (van Tryon and Bishop, 2009). Thus, fostering interaction in digital education is as fundamental as the connectivity in face-to-face context in terms of maintaining the effectiveness of digital education practices (Fulford and Zhang, 1993). Team based activities, peer feedback and peer support have been enabled with the advances in technology. Learning, criticizing on content and re-creating content is also possible for students in a collaborative way. As proposed by Garrison and Arbaugh, “deep and meaningful learning experience” could be achieved by these types of activities (Garrison and Arbaugh, 2007). The community of inquiry framework outlines three main areas to create this learning experience. Therefore, teacher’s role in online distance learning is transforming from facilitating to being “partner in learning” (Beldarrain, 2012), allowing teachers to accept students as contributors of knowledge and creators of content (Collis and Moonen, 2005). Academic staff might need time to adjust to this new approach. It may also be necessary for students to accommodate themselves for being independent learners.

Students can access education anytime and at any place as best suited for themselves. Online distance learning provides excellent educational opportunities, but the lack of time in institutional settings, campus, and communication in face-to-face education might cause students to feel lonely (Crow and Murray, 2020). For the future, pandemic guidelines should work on establishing ground rules for the educational system to ensure adequate, high-quality distance learning opportunities. The necessity of electronic devices in such situations must be accounted for in the future, as results show that currently this is only the case in as little as almost a third of medical faculties. Policymakers need to take into account the rapid changes in technology and distance learning solutions when planning for future states of emergency, and it must be ensured that universities stay up to date with these regulations, so as not to be unprepared should a similar situation arise.

Distance learning should not compromise the quality of education, especially if it is carried out long-term. As future developments in this pandemic are currently unclear, medical faculties need to work on providing adequate resources to their students in order to ensure a continuous standard of medical education. Distance learning resources such as paid educational platforms and even free resources could be provided by faculties to facilitate remote education.

Evidence shows that e-learning can support traditional curricula by supporting clinical decision making, constructing a sense of learning responsibility. E-learning also helps students in developing positive attitudes regarding their learning abilities by employing end-user personalization of educational materials, games, mini-quizzes, and simulators. Considering the effectiveness of e-learning, the mainstream application, “blended education”, should not be ruled out. Real patient learning is essential and cannot be replaced because it helps the development of professional identity and helps in the student to junior doctor transition. Therefore, clinical skills and student-patient interaction should be exhibited in bedside education as well (Chipp, Stoneley and Cooper, 2004).

Take Home Messages

Universities must ensure a high quality of distance education in order to adequately provide students with their essential training. Therefore, we would like to make the following recommendations.

  • Medical faculties should consider expanding their repertoire of digital learning tools, as well as invest in additional resources to provide students with an adequate educational experience.
  • Quality of distance education should be closely monitored so as to ensure a continuous standard in training.
  • Distance learning should be offered in various modalities.
  • According to their capacity, medical faculties should offer in- person training of practical skills so as not to comprise the affected students’ practical skills and knowledge.
  • The specifics of medical education need to be taken into account by medical faculties and considered in the context of this pandemic.
  • Further surveys should be conducted in order to monitor the developments of distance learning as this pandemic carries on. As such, we hope to see improvements in the shortcomings of the current distance learning opportunities for medical students and thus be guaranteed a continuously valuable educational experience.

Notes On Contributors

Süleyman Yıldız is a clinician-educator and pediatrician. He was EMSA representative in AMEE Executive Committee between 2010-2014 and Ambassador of AMEE in Turkey between 2016-2018. He is in editorial board member of several intertnational journals. ORCiD: 

İhsan Selçuk Yurttaş is a fifth-year medical student at the Gazi University and past medical education director of the EMSA European Board. ORCID ID: 

Ayfer Gözü Pirinççioğlu is a clinical Professor and Head of the Pediatric Department at the Dicle University. Prof. Gözü Pirinççioğlu also has PhD degree in Adolescent Health (Hacettepe University). ORCiD:

Abdullah Yıldız is a Consultant General Surgeon at the University of Health Sciences Istanbul Umraniye Training and Research Hospital, who combines clinical practice with academic interests in distance learning and education management. ORCiD:

İrem Aktar is a fifth-year medical student at the Istanbul University and current medical education director of the EMSA European Board. ORCiD:

Emine Senkal is a clinical resident at the Chelsea and Westminster Hospital NHS Trust, United Kingdoml. Dr. Senkal also has master's degree in Global Health (Masstrich University, the Netherlands). ORCiD:

İlker Kelle is an Associate Professor and the Associate Dean at the Dicle University Faculty of Medicine. ORCiD:

İsmail Yildiz is an Associate Professor at the Dicle University Faculty of Medicine. He activetly works in the bioistatics department. ORCiD:


Special thanks to European Medical Students' Association and its member faculties. (

The authors are also grateful to Georgios Pantelias for his help with this paper.

The corresponding author owns the complete copyright of all figures in the work.


Beldarrain, Y. (2012) ‘Distance education trends: Integrating new technologies to foster student interaction and collaboration’, Distance Education. 27(2), pp. 139-153.

Bolliger, D. U. and Inan, F. A. (2012) ‘Development and validation of the online student connectedness survey (OSCS)’, International Review of Research in Open and Distance Learning, 13(3), pp. 41-65.

Brown, R. E. (2001) ‘The process of community-building in distance learning classes’, Journal of Asynchronous Learning Network. 5(2), pp.18-35.

Chipp, E., Stoneley, S. and Cooper, K. (2004) ‘Clinical placements for medical students: Factors affecting patients’ involvement in medical education’, Medical Teacher, 26(2), pp. 114-119.

Collis, B. and Moonen, J. (2005) ‘Collaborative Learning in a Contribution-Oriented Pedagogy’, in Encyclopedia of Distance Learning, Second Edition. IGI Global, pp.7.

Crow, J. and Murray, J. (2020) ‘Online Distance Learning in Biomedical Sciences: Community, Belonging and Presence’, in Biomedical Visualisation, Advances in Experimental Medicine and Biology. Springer.

Dent, J. A, Harden, R. M. and Hunt, D. (2017) A Practical Guide for Medical Teachers. 5th edn. Edinburgh: Elsevier.

Ellaway, R. and Masters, K. (2008) ‘AMEE Guide 32: E-Learning in medical education Part 1: Learning, teaching and assessment’, Medical Teacher, 30(5), pp. 455-473.

Fulford, C. P. and Zhang, S. (1993) ‘Perceptions of Interaction: The Critical Predictor in Distance Education’, American Journal of Distance Education, 7(3), pp. 8-21.

Garrison, D. R. and Arbaugh, J. B. (2007) ‘Researching the community of inquiry framework: Review, issues, and future directions’, Internet and Higher Education, 10(3), pp. 157-172.

Hills, P. and Keegan, D. (2020) ‘Theoretical Principles of Distance Education’, British Journal of Educational Studies, 42(4), pp. 411.

Janicik, R. W. and Fletcher, K. E. (2003) ‘Teaching at the bedside: a new model’, Medical Teacher, 25(2), pp.127-130.

Knapper, C. (1988) ‘Lifelong Learning and Distance Education’, American Journal of Distance Education. Taylor & Francis Group, 2(1), pp. 63–72.

Li Cathy, L. F. (2020) The rise of online learning during the COVID-19 pandemic, World Economic Forum. Available at: (Accessed: 21 September 2020).

Lim, D. H., Morris, M. L. and Kupritz, V. W. (2019) ‘Online vs. Blended Learning: Differences In Instructional Outcomes And Learner Satisfaction’, Online Learning. Available at: (Accessed: 21 September 2020).

Luescher-Mamashela, T. M. (2013) ‘Student representation in university decision making: good reasons, a new lens?’, Studies in Higher Education. 38(10), pp.1442-1456.

Miller, G., Honeyman, M. (1993) ‘Agricultural Distance Education: A Valid Alternative for Higher Education?'. Proceeding of the Session C: Learning Styles of Students in Agricultural Education Programs, (December), pp. 67-75. Available at: (Accessed: 24 September 2020).

Murphy, A. and Farley, H. (2017) ‘Introduction: Supporting the sustainable implementation of mobile learning for higher education in the Asia-pacific region’, Education in the Asia-Pacific Region. 40, pp. 3-23.

Peacock, S., Murray, S., Dean, J., Brown, D., et al. (2012) ‘Exploring Tutor and Student Experiences in Online Synchronous Learning Environments in the Performing Arts’, Creative Education. 3(7), pp. 1269-1280.

Peters, O. (1992) ‘Some observations on dropping out in distance education’, Distance Education 13(2), pp.234-269.

Roach, J. O. (2001) 'E-learning: Is it the end of medical schools?', BMJ Open, 2001; 322: 0106174.

Rovai, A. P. (2001) ‘Building classroom community at a distance: A case study’, Educational Technology Research and Development. 49(4), pp.33-48.

Taylor, D., Grant, J., Hamdy, H., Grant, L. (2020) ‘Transformation to learning from a distance’, MedEdPublish. 9, [1], 76,

van Tryon, P. J. S. and Bishop, M. J. (2009) ‘Theoretical foundations for enhancing social connectedness in online learning environments’, Distance Education. 30(3), pp.291-315.

UNESCO (2020) More on UNESCO’s COVID-19 Education Response. Available at: (Accessed: 28 September 2020).

University of Oxford (2020) Coronavirus Government Response Tracker | Blavatnik School of Government. Available at: (Accessed: 29 September 2020).

Yalman, M. (2013) ‘Eğitim Fakültesi Öğrencilerinin Bilgisayar Destekli Uzaktan Eğitim Sistemi (Moodle) Memnuniyet Düzey’ [Computer Aided Distance Education System (Moodle) Satisfaction Level of Faculty of Education Students], Journal of Turkish Studies. 8(8), pp.1395-1406.

Zhao, J., Xiao, H., Li, Y., Wen, D., et al. (2020) ‘Experience of Massive Distance Online Education for Medical Colleges and Universities in China to Counter the COVID-19 Pandemic’, Research Square.




There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (

Ethics Statement

Ethical approval for this study was obtained from Dicle University Medical Faculty Ethics Committee on June 2020 (Approval / ID number: 267).

External Funding

This article has not had any External Funding


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Ken Masters - (28/06/2021) Panel Member Icon
The paper covers a study of European medical students’ attitudes on distance learning during the COVID-19 pandemic.

The topic is important, but there are several issues that need to be addressed.

• “There are over...worldwide.” The disease needs to be specified. (It can be determined from the title, but should be specified).

• This Abstract gives a reasonably good background, but should be written with formal headings as a summary of the research article.

• “Distance learning is not a new paradigm; first applications go back to the 18th century where face-to-face education was not possible (Hills and Keegan, 2020)” That reference is given as “Hills, P. and Keegan, D. (2020) Theoretical Principles of Distance Education’British Journal of Educational Studies 42(4), pp. 411” Unfortunately, this citing and referencing has errors, and needs correcting:
o The DOI points to, a 1994 article by Hills.
o That 1994 article is a review of the 1993 book entitled “Theoretical Principles of Distance Education” edited by Desmond Kegan.
o The British Journal of Educational Studies 2020 volume is Volume 68, not 42.
It appears that authors are citing from a less-than complimentary book review in which the authors make that comment, but it is not supported by the original authors. So, this really does need to be corrected. I recommend that authors find stronger support for this contention, and I would strongly urge the authors to carefully check all their other citations and references. (It is unfortunate that this error has occurred with the first and opening statement of the paper, because it cannot be verified, and so much flows from it.)

• “Online distance learning is defined as ""the process of creating and providing the learning online by grounding on the resource of knowledge, learners or, both." (Miller, 1993).” There are similar problems with this citation and reference:
o The list of references does not have a text by Miller 1993, although it does have a text by Miller, G., Honeyman, M. (1993), so I am assuming that is the relevant text.
o I have searched that paper by Miller and Honeyman, and cannot find that quotation in that paper. Both a manual reading and an electronic search fail to find that quotation in that paper.
So, at this stage, it appears that something has gone wrong with the literature supporting the research. As a reader, I have to admit that this causes me to lose confidence in the researchers’ work – given that the background literature is crucial to placing the research and its impotence as a contribution, these kinds of errors would make most readers fearful of citing this paper. I have not checked the paper's other citations and references, as this crucial task is for the authors to perform.

• The reason for the paper should be more strongly grounded in similar studies (or lack of) in Europe, so it would be useful if the authors could cite some of those.

• It would be useful if the questionnaire could be published with the paper (appendix or supplementary file).

• More information on the questionnaire is required. How constructed (including the 10 parameters mentioned in the Results), how administered (“online” is not enough), etc.

• Given possible differences in gender satisfaction, the gender demographics of the results should be given. It would also be useful if that data analysis could be performed (although, with this sample size, statistically significant differences might not easily be found).

• There appears to be a problem between the text referring to Figure 1 and Figure 1’s title. In the text, the paper says: “Student involvement during decision-making processes... (See Figure 1).” But the title of Figure 1 is not student involvement, rather “Satisfaction rate on announcements”, and makes no reference to student involvement.

• The response rate (even estimated, if the exact total population is not known) should be given.

• Table 1: Percentages should be given to 2 decimal places.

• Figure 3 really needs to be corrected. Apart from the mis-placing of the percentage points, it is quite difficult to work out exactly what is being represented as it is a most unconventional method of representation.

• The small sample size needs to be mentioned as a limitation.

Smaller issues:
• “72 faculty representatives” A sentence should not begin with a number as a digit.

There may be some other issues, but reviewer space is limited. I look forward to Version 2 of the paper in which these are addressed.

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Davinder Sandhu - (25/06/2021) Panel Member Icon
I enjoyed reading this paper. With the crisis encountered in medical education from the current COVID-19 pandemic, it captures some essential points regarding distance learning. I would add that psychologists such as Seligman have outlined that those learners who are at an expansive phase of their career such as students, interns, residents, and young faculty have been seriously hit by the lack of exposure to face-to-face clinical training. This is particularly true for students in their clinical years. On the other hand, those who are in the contraction phase of their career such as faculty close to retirement the impact of COVID-19 has been less severe. It is also true that in the early phase of COVID-19 pandemic medical staff and residents were much more vulnerable with higher morbidity and mortality compared with the general public. The authors correctly point out the severity and traumatic experience that impacted students. Here the European medical students’ survey (EMSA) is a useful adjunct to the current literature. The response to the survey was from 76 representatives of EMSA from 13 different countries.
The authors expand on the fact that distance learning can provide a rich and planned experience for learners offering quality, flexibility, and cost effectiveness. This distance learning has given the students some freedom in adapting to way that is best suited to their lifestyles. I agree with the authors that online distance education has the advantage that students can access education wherever and whenever they want. The authors quote a staggering figure that by 2025 the number of e-students will be 160 million. However, what will be the long-term impact of e-learning on the professional identity development of medical students and competence remains to be seen.
The survey explores the universities’ ability to recover and make up for lost clinical training. There is a major issue of capacity, particularly when elective admissions are cancelled. Students have been affected by losing their sense of belonging to an academic environment. Teachers play a crucial role in not only shaping the education process, but in helping the students to develop their professional identity. It is encouraging to note that students and faculty were prepared to switch to distant learning modality of teaching when face-to-face learning was not possible. The teachers have transformed from being facilitators to partners in learning. Universities need to continue to adapt to such changes and be cognizant of the regulations in their country. The paper stresses that distance learning should not compromise the quality of education especially if this is going to be carried out in the long term. That is an admirable aim and something yet to be achieved. A repeat survey from EMSA in 2 years’ time should be worth pursuing to explore the above. We can agree though that face-to-face clinical training is essential for students to develop into young junior doctors.
Anita Samuel - (22/06/2021) Panel Member Icon
The scope of this study, incorporating responses from 13 different European countries, is impressive. The findings that access to resources and design of the online learning platform impact student satisfaction has implications for practice. It can inform the design of future distance education offerings.

Below are some suggestions to strengthen this article:

- Since this is a research article, it is advisable to use a structured abstract format.
- In your first paragraph, you claim that distance learning has ‘zeroed the distance between student and teacher. This is a bold statement given that the students and teachers are still separated by space and time in distance education. With synchronous technologies, immediacy is achieved, but spatial distance still exists. I would suggest avoiding such claims.
- You have introduced four different terms in this article – distance learning, online learning, online distance learning, and e-learning. It is unclear to me why you need to include all these terms. Your study is on attitudes to distance learning, and you are stating that in the 21st century, distance learning is primarily conducted online. Bringing in the other terms confuses the focus of your study since they all mean different things.
- How did you arrive at the 10 satisfaction parameters?
- It is unclear what some of the parameters refer to. For example, in the distance learning context, what do you mean by ‘teaching environment’? ‘Platform design’ is also confusing. Some clarification would be helpful.
- The discussion section should delve deeper into the findings reported in the Findings section. It is best not to introduce new findings in this section. Your discussion section does not really explore your two key findings of resources and platform design. In the Findings section, you mention feedback mechanisms. But you don’t raise it again in the discussion section.
- The conclusion section seems a little disconnected from the main article. You raise issues of isolation, interaction, and collaborative learning. All these are important considerations in distance learning. However, your study does not seem to focus on this. It would be helpful to keep a clear focus on the research question and frame your conclusion around that.
Possible Conflict of Interest:

For transparency, I am an Editorial Board Member of MedEdPublish.