Enter the main classroom at Duke-NUS today and you’ll find a room full of inquisitive medical students actively engaged in discussions, facilitated by equally engaged faculty. Apart from their mask-covered faces, it would seem like any other day.

But for almost two years, this hadn’t been the case. And getting back to how things are today has been like running a marathon with many hurdles that the School overcame as they arose.

When face-to-face interactions were curtailed because of the COVID-19 pandemic, students from medical schools in Singapore and across the globe were forced to retreat from clinical and teaching spaces.

At Duke-NUS, the education team was quick to implement measures to make its medical education COVID-19 resilient, flip to virtual learning and roll out an expanded programme of simulations to ensure that students had plenty of opportunities to hone their clinical and procedural skills.

Similarly, the classroom-based teaching of the Phase One students, using the Duke-NUS-developed flipped classroom teaching method, TeamLEAD, had to move to the digital realm as well.

TeamLEAD—whereby LEAD stands for Learn, Engage, Apply and Develop—ensures that students come to class fully prepared and are engaged throughout. Individual and team knowledge checks enable the faculty to identify content that needs further focus, and application exercises ensure that groups of students are engaged in dialogue with their peers and faculty. Through this interactive approach to knowledge acquisition, students also have plenty of opportunities to practice teamwork, critical thinking and leadership skills.

Leveraging the maturation of technology, such as video-conferencing and online collaborative tools, and experiences from previously implemented pandemic preparation responses, the education team at Duke-NUS successfully pivoted TeamLEAD from in-person to online.

But mindful of the increasing sense of isolation that occurs due to prolonged online learning and the suboptimal team building experience, the team remained eager to bring more students back in-person as soon as it was safe to do so.

Professional identify formation, which is a highly dynamic and multi-faceted process, is crucial in a physician’s development. Published papers have also suggested that students in online learning environments perceived suboptimal team cohesion, delayed professional identity formation, feelings of social isolation and a range of negative psychological impacts.

“Given that interpersonal interactions and being part of the community of practice are crucial in many ways, how can we adapt and provide innovative solutions to the existing online TeamLEAD process while still ensuring the safety of our students and strict compliance to the prevailing social distancing measures?” Those were the most pressing concerns on the mind of Assistant Professor Irene Lee from the MD Programme Department of the Office of Education.

That’s why as soon as the restrictions let up in December 2020, Duke-NUS’ educators seized the opportunity to pilot a hybrid arrangement of synchronous in-person and online classes so that a fraction of students could resume in-person education. They first brought back three teams of five to six students—out of the 12 teams of the Class of 2024—in rotations to the campus.

“Given the high number of cases that we were encountering back then, we had to make sure that the students would be appropriately distanced from each other so that we could interact safely in the classroom."

Assistant Professor Wong Peiyan

Subsequently, with the success of the piloted hybrid arrangement and relaxing social distancing measures, half the cohort could come in, and students were able to meet their teammates in-person during every other TeamLEAD lesson.

Being able to return to the campus psyched many of the students. Ramalakshmi Gayathri Vinjamuri, from the Class of 2024, said: “Moving from online to hybrid was great. Though I miss the comfort of Zooming from home, finally getting to meet some classmates in person, learn from them, discuss together and study together enhanced the joy of learning medicine.”

Students safely distanced in the bespoke TeamLEAD room at Duke-NUS // Credit: Duke-NUS Medical School

 
Finding growth amid challenges

As it was Duke-NUS’ first time taking classes to a hybrid mode, the education team wanted to make sure that they were prepared for any potential curveballs that were tossed their way.

Keeping in mind that the students who were participating online might feel disconnected from their classmates who were attending in-person, the education team mitigated this by keeping a running tally of the participation frequency for each student to ensure that every student was given the opportunity to be heard.

Ramalakshmi said, “Although I was happy with the hybrid format, I quickly realised that it was not so easy for the education team to coordinate between those in the class and over Zoom. Even on those days that I was Zooming, I felt engaged, and this was definitely due to the education team’s effort to strike a balance by involving those at home and in the class equally. I truly appreciate their commitment to giving us the best in the situation.”

“It took a while to get used to everything—having to wake up earlier to travel to school, the lack of social distancing, being able to see everybody’s (masked) faces,” added Joey Yeo from the Class of 2025, about transitioning into in-person classes. “That being said, the small inconveniences are nothing compared to the benefits we gain from removing the physical barriers between us. The faculty members fully optimised our online education experience by providing us with a wide variety of learning resources in different modalities to fulfil our learning objectives.”

In the end, the main challenge that the education team faced was audio and visual syncing during hybrid classes. But those issues, too, were few thanks to the recently revamped AV system in the TeamLEAD room. On top of that, the dedicated administrative staff stayed on standby so that they could quickly solve any issues that cropped up during the classes.

But what foxed the team the most was not knowing who was speaking in the classroom.

“When we first started the hybrid classes, an unexpected challenge was figuring out which student was talking, because everyone had their masks on,” laughed Wong. “It was easy to tell over Zoom because all the students always had their videos turned on and Zoom would highlight whoever was talking. So, when in-person, we had to get students used to identifying themselves before they started talking.”

Wong went on to emphasise that despite the challenges faced, bringing as many students as it was safe to back to the campus was still of outmost importance for the education team due to the opportunities that the students would get to strengthen their team dynamics and build professional identity formation.

“In person, there are also many chances for informal chat interactions that online Zoom calls don’t allow. I think that this is really crucial because it allows you to build rapport to form a more cohesive team, particularly for a fresh cohort of students without any in-person interactions to begin with. When we were in the fully online TeamLEAD setting, it was less likely to have such interactions since you would have to make an extra effort just to arrange another Zoom call to chat with someone.”

Assistant Professor Irene Lee

Most of the students were excited to be surrounded by more of their peers. One student even commented that it was easier to concentrate and feel more invested in their classes since they were around other classmates who were focusing on the same thing.

Wong said, “In the journey of getting our hybrid team-based learning to a point where it worked well for all students and faculty, both in person and online, the students were really understanding and supportive about the whole process. That helped to make the transition a lot smoother.”

To empower other schools that are facing similar conflicting interests of promoting the critical competencies of healthcare professional learners and strict adherence to prevailing restrictions, Lee and Wong published a monograph in Medical Science Educator, detailing tips of implementing hybrid team-based learning for educators teaching large-sized classes.

While this hybrid arrangement of classes is borne out of necessity due to the prevailing pandemic, it remains relevant post-pandemic as it opens up possibilities for delivering engaging educational activities on a greater scale.

 
Easing back to the norm

With the restrictions further eased as time went by, the education team sought to find a way that would allow them to bring an entire class back to School at a time.

“The key focus of bringing all our students back to our School is still to ensure their safety while ensuring that they continue to receive the very best education that they can from our School. Duke-NUS strives to nurture compassionate, capable, team-centric doctors whose expertise will benefit patients and Singapore, regardless of the mode of learning.”

Professor Ian Curran, Vice-Dean for Education

He added, “And thanks to our education team’s creativity, hard work and dedication, we’ve been able to successfully bring back all our students back to their classrooms since the beginning of 2022.”

With the DORSCON level now at yellow, students are not just back to attending classes but also have plans to attend in person events, such as workshops and maybe even the Dean’s Pancake Breakfast—a yearly fundraising tradition during which leaders of both Duke-NUS and SingHealth make an appearance as special pancake chefs to support student-led community service initiatives and student financial aid.

“Before the pandemic, all the faculty members could easily meet the students in person and get to know them better,” said Assistant Professor Suzanne Goh, Associate Dean of Student Affairs. “In the last two years, we’ve been missing out on the spontaneous in-person interactions that are critical to building our vibrant community. It’s so wonderful that we are now able to return to that personal touch once more.”

When asked about how it felt to be back at the School as an entire class, Junsuk Ko from the Class of 2024 said, “It’s just like living the dream. This experience has only encouraged me even further to challenge myself to become a patient-oriented doctor who serves our community. And I’m sure my classmates—and those from the other classes—share the same sentiments as me.”