Research article
Open Access

European medical students’ attitudes on distance learning during COVID-19 pandemic [Version 2]

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: 01/10/2021

Author Revision Notes

1- All references rechecked and updated according to the new version text
2- Questinary is added as a supplementary file
3- Detailed explanation added to the questionary ( how it is created etc.)
4- Figures details updated (title, explanations, etc.)
5- The response rates added and results percentages' written as 2 decimal places
6- Figure-3 is changed, and a new explanation added
7- Limitations part added to article
8- Some explanations added to platform design and teaching environment parameters
9- The discussion section updated. Unrelated new findings were deleted from this section.
10- Conclusion section updated according to reviewer suggestions


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 into 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; the first applications go back to the 19th century where face-to-face education was not possible (Berg and Simonson, 2016). 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. 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. Nevertheless, distance learning evolved rapidly with the advances in technology and gradually transformed into an entirely online with more interactive learning experience between student and teacher (Crow and Murray, 2020). Nowadays, distance learning enables students to access education wherever and whenever they want (Beldarrain, 2012). Distance learning is a highly utilized sector; according to certain estimates the number of e-students will be 160 million and the budget will be $325 Billion by 2025 (Roach, 2001) (Li and Lalani, 2020). 

Various definitions have been used to describe the phenomenon of distance learning. Strictly speaking, distance learning (the student’s activity) and distance teaching (the teacher’s activity) together make up distance education. According to Britannica, "distance learning" is, also called distance education, e-learning, and online learning, a form of education in which the main elements include physical separation of teachers and students during instruction and the use of various technologies to facilitate student-teacher and student-student communication (Berg and Simonson, 2016). According to Grant, 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 (Grant, 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. 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 into the health workforce (Li and Lalani, 2020). 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).

It is important to understand how medical students and faculties are being impacted and what adaptations must be considered. Therefore, 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 feedbacks for the present and future.


We have conducted a survey study on “Attitudes of Medical Students to Distance Education” between 28 July-13 September 2020. We sent a 24-item online questionnaire to the European Medical Students’ Association's (EMSA) local coordinators. EMSA local coordinators are student representatives of EMSA member medical faculties. These local coordinators act as a bridge between medical students and EMSA. 

The study investigators developed a self-administered online questionnaire using Google Forms® (Google LLC, Mountain View, CA). The survey contained an introductory paragraph informing participants of the study’s aims, the confidentiality of their responses, and the freedom to decline to answer any question or withdraw from the study altogether. Questions were in two formats, multiple-choice and rating questions on a five-point scale (Likert scale). The questionnaire was grouped into two. In the first part of the study, we asked questions about communication between student-faculty 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 (See Supplementary File 1). 

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 seventy-six medical faculty representatives of EMSA (local coordinators) that come from thirteen different European countries: Austria, Germany, Greece, Hungary, Italy, the Netherlands, Portugal, Romania, Russia, Serbia, Spain, Turkey, and Ukraine.

According to the answers, usual physical medical education has stopped during the pandemic, with the exception of four faculties. The first part of our questionnaire was on the level of satisfaction with the announcements made by the medical faculty. Seventy-two faculty representatives of EMSA (94,7%) responded that they have been receiving announcements on ongoing changes in their education regularly (See Figure 1). 

Figure 1: Satisfaction rate on announcements 


To the question “Are there any online courses in your faculty?”, thirty-seven representatives answered “Partially Yes” (48,6%), twenty-two answered “Totally Yes” (28,9%), ten answered “Soon” (13,1%) and seven answered “No” (9,2%). The representatives that answered “Partially Yes” and “Totally Yes” to this question accounted for fifty-nine representatives out of a total of seventy-six (77,6%) (See Table 1). Thirty-one representatives (40.7%) declared that feedback mechanisms exist to evaluate online courses although eighteen representatives (23.7%) declared that they do not know if there is one. Twenty-seven representatives (35.6%) mentioned "No" for any kind of feedback system.

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




Partially Yes

Totally Yes








Percent (%)







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 forty-nine representatives (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 students’ distance learning experiences. These were the following: Learning outcomes coverage in lectures (Q12), presenters’ clothing (Q13), teaching environment (classroom/environment design, lightning)(Q14), technical knowledge/preparedness (Q15); educational content used in lectures (Q16), presentation (Q17), provided resources (reading recommendations, booklets, articles, audibles, etc.) (Q18), online course platforms’ accessibility (Q19), platform’s design (illustrations, graphic elements, templates, etc.) (Q20) and user interface (simple or complicated to use) (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

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 educational resources 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 satisfaction rate on the distance learning 

  1 2 3 4 5 Total
Frequency 4 6 22 20 7 59
Percent 6,77 10,16 37,28 33,89 11,86 100


We asked the satisfaction rates on student involvement during the decision-making processes about the planned education programs. Faculty representatives have answered the question on 1-5 Likert scale. Nine representatives (11,8%) answered “1”, sixteen representatives (21%) answered “2”, twenty-three representatives (30,5%) answered “3”, sixteen representatives (21%) answered “4” and twelve representatives (15,7%) answered “5” (See Figure 4).

Figure 4: Satisfaction rate on student involvement


Medical education is already a distributed learning system globally and distance learning is quality assured, a managed extension of it. Furthermore, distance learning provides a rich, planned experience for learners offering quality, flexibility, and cost-effectiveness (Grant and Zachariaharden, 2007). According to AMEE Guide-32, “all medical students are distance students, in that they study at home or while traveling, and they are usually required to attend rotations or attachments away from the main campus” (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 component of practical knowledge will not have been taught via distance learning. According to several articles, the rapid responses to the pandemic by universities have shown that medical faculties and medical teachers are largely prepared to switch to a distance learning modality of teaching (Li and Lalani, 2020), (Zhao et al., 2020). All of the faculty representatives of EMSA responded that they have been receiving announcements on ongoing changes in their education regularly. According to our study, fifty-nine (78%) out of seventy-six universities switched to distance learning during the pandemic bans. This result shows that most of the medical faculties have successfully transferred to distance learning. On the other hand, some less technologically advanced medical faculties should 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 (Commonwealth of Learning, 2020).

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 learning effective (Yalman, 2013). In another study by Levy showed that student’s satisfaction with distance learning courses is a key aspect to measure the effectiveness of distance learning. In our study, the overall satisfaction of students with distance learning was three (1-5 Likert scale) and provided resources were the most influence on overall satisfaction. In distance learning, the roles of the teachers changed from being the main resource of students’ knowledge to being the organizer of the knowledge resources for students (Romiszowski, 2004). As it showed in our study, providing good resources by teachers is essential to producing a high-quality distance learning program as they will give the student grounding and information to refer back as and when queries arise.

Even when the pandemic dies down, accessible, flexible, and effective online educational systems will be an important part of distance learning. But in the past, online educational systems had a bad reputation for being slow, difficult to navigate, and lack of creativity in design caused unnecessary friction in the learning experience (Mahlangu, 2018). In our study, there was another important factor that influences overall satisfaction was learning platform designs. The learning platform’s design had a significant impact on overall satisfaction of distance learning (rs= 0.68, p < 0.01). In order to implement online distance learning effectively, there must be more interest given to the learning platform's structure design (Abuhassna et al., 2020). 

In our study, the level of satisfaction on the student involvement during decision-making processes has been voted approximately three out of five most. Several other surveys showed that the representation of students in the decision-making process at the 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 are concerned (Luescher-Mamashela, 2013).

This research study has few limitations. Although this study collected data from seventy-six medical faculties from thirteen different European countries, the selected sample size may not be completely representative of the majority of students of distance learning in Europe. Thus, there may be a possibility that these results may not reflect the whole medical faculties in Europe. For the future, one can consider the students of other countries and medical faculties to find out their attitudes level towards distance learning. Additionally, the study is limited in that it was conducted in unprecedented times, where there was a high likelihood that students' emotional levels could have affected their perceptions of the impact of distance learning. 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.


Distance education is a true part of medical education. Although the teacher’s role in distance education is transforming from facilitating to being a “partner in learning,” their roles should not be ruled out. Therefore, educators and administrators need to supply good educational resources and better platform designs to producing high-quality distance learning programs. Pandemic guidelines should establish ground rules for the educational system to ensure better and fair distance learning opportunities. Furthermore, policymakers need to consider the rapid changes in technology and distance learning solutions when planning for future states of emergency. It must be ensured that universities stay up to date with these regulations so as not to be unprepared should a similar situation arise.

Take Home Messages

  • Like every other pandemic in the past, the coronavirus pandemic is a crossroads at which important decisions must be made, bringing both the necessity and the opportunity for change. Medical faculties should consider expanding their repertoire of distance learning tools and invest in additional resources to provide students with an adequate educational experience.
  • Even when the pandemic dies down, accessible, flexible, and effective online educational systems will be an important part of distance learning.
  • 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.
  • The quality of distance education should be closely monitored so as to ensure a continuous standard in training.
  • The specifics of medical education need to be taken into account by medical faculties and considered in the context of this pandemic.

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:


EMSA has given permission for the document to be published. 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.


Abuhassna, H. et al. (2020) 'Development of a new model on utilizing online learning platforms to improve students’ academic achievements and satisfaction', International Journal Educational of Technology in Higher Education. Available at: (Accessed: 25 June 2021).

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

Berg, G. A. and Simonson, M. (2016) Distance learningEncyclopedia Britannica. Available at: (Accessed: 7 June 2021).

Commonwealth of Learning (2020) Guidelines on Distance Education during COVID-19. Available at: (Accessed: 8 June 2021).

Crow, J. and Murray, J. A. (2020) 'Online Distance Learning in Biomedical Sciences: Community, Belonging and Presence', Advances in Experimental Medicine and Biology1235, 165–178.

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.

Grant, J. (2008) Using open and distance learning to develop clinical reasoning skills, Basicmedical Key. Available at: (Accessed: 8 June 2021).

Grant, J. and Zachariah, A. (2007) 'Distance Education', Dent J., Harden R. and Hunt D. (eds) A Practical Guide for Medical Teachers. 5th edn. Edinburgh: Elsevier, Edinburg: Distance Education, pp:101-103.

Li, C. and Lalani, F. (2020) The rise of online learning during the COVID-19 pandemic, World Economic Forum. Available at: (Accessed: 7 June 2021).

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.

Mahlangu, V. P. (2018) The Good, the Bad, and the Ugly of Distance Learning in Higher Education, IntechOpen. Available at: (Accessed: 20 June 2021).

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

Romiszowski, A. J. (2004) How’s the E-learning Baby? Factors Leading to Success or Failure of an Educational Technology Innovation, Educational Technology. 

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

Yalman, M. (2013) 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 - (09/10/2021) Panel Member Icon
I can see that the authors have addressed some of the concerns raised in Version 1 and I am pleased to see that the references and citing have been corrected (although an encyclopaedia, even Britannica, should be cited in an academic paper only as a last resort). There are still, however, problems with the revised version.

• The Abstract is still not structed, and the disease is not identified until late in the Abstract.

• More importantly: The source of the parameters (how they were determined) has not, unfortunately, been addressed (I cannot see any material change in the description of the origin or justification for these parameters, so questions about where they came from, how they were derived, why others were not used, etc., remain unanswered, and this does weaken the paper substantially).

• Now that the survey form is available to the reader, one can see that the survey was not anonymous. In fact, when one clicks on the link and goes to the electronic version, the reader sees that, in addition to name, email address was a required answer. (It is unfortunate that the form shown in the supplementary file does not show that the email address was required). This is actually quite a large problem for this paper, because:
o When the Ethics Committee gave approval for the study, were the committee members aware that this survey would not be anonymous, and that participants would be identified by name and email address? The fact that the email address question is not in the supplementary file would lead one to believe that this was a late addition.
o This may have impacted on the participants’ willingness to peak openly (which is why surveys of this type are usually anonymous).

While I can understand that the researchers may have wished to verify that all participants were actually from the target group, and not outsiders, this is a complication that should have been mentioned in the paper.

• Because the survey form is now available, I can also see that the gender of the participants was not gathered. This should have been mentioned as a limitation.

So, the paper will be interesting for some readers, but the research does suffer from a few elementary issues that undermine it.

Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Julie Hunt - (06/10/2021) Panel Member Icon
This article describes a survey study of European medical students during the summer of 2020, while education was disrupted by the COVID-19 pandemic, and most schools were doing remote learning. The study's aims were to collect data about students' satisfaction with remote learning and to gather their feedback for remote learning in the future. The article does a good job of presenting data that meets its first aim, but the study falls short of reaching its second aim. I appreciate that the offers included the survey as a supplemental file. In order to gather students' feedback about remote learning, I believe that the survey should have included several open-ended questions that allowed for free-text entry about students' opinions of what went well during distance learning, what could have been improved, etc.

Perhaps the most valuable data that came from this study were that learning satisfaction was most closely correlated with the learning materials provided and with the LMS platform. This information may guide educators and administrators as they plan for distance education delivery in the future.
Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.