COVID-19 Effects on Medical Education: A Viral Transfer of Knowledge to Radiation Oncology

Abstract

The COVID-19 pandemic has been transformative with broad effects across international health care systems. Medical education, and specifically education in radiation oncology, has not been spared. The effects have spanned the continuum of education on all disciplines including radiation oncologists, radiation therapists, medical physicists, and all educational phases from undergraduate medical education (UME) to graduate and postgraduate education (GME) and continuing medical activities (CME).1Coles CE Choudhury A Hoskin PJ et al.COVID-19: A catalyst for change for UK clinical oncology.Int J Radiat Oncol Biol Phys. 2020; 108: 462-465Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 2Sherry AD Rooney MK Bernard V Seo A Marqueen KE Schrank BR. Residency interviews in radiation oncology after COVID-19: Perspectives from recently matched applicants.Int J Radiat Oncol Biol Phys. 2020; 10: 452-454Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 3DeWeese TL Thevenot L. Is this au revoir or a permanent farewell to in-person meetings?.Int J Radiat Oncol Biol Phys. 2020; 108: 470-471Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In the early days of the pandemic medical schools were closed, lectures transitioned to online delivery, clinical rotations were halted, radiation oncology residents and practicing oncologists were redeployed, residency interviews were converted to a virtual format and medical conferences were delayed or even cancelled. Broad effects have been seen in both formal and informal or hidden curriculums (ie, those curricula that impart knowledge, attitudes, and behaviors implicitly).4Alsubaie MA. Hidden curriculum as one of current issue of curriculum.Journal of Education and Practice. 2015; 6: 125-128Google Scholar Although the past 2 years have been wrought with change, they have been ripe with lessons that may be transformative in medical education. The literature specific to the effects of the pandemic on radiation oncology is evolving, but by noting the landscape in other areas of medical education we can draw this knowledge into our specialty. There has been a push for medical education to “share stories; share practice,” learning from each other through the pandemic.5Cleland J McKimm J Fuller R Taylor D Janczukowicz J Gibbs T. Adapting to the impact of COVID-19: Sharing stories, sharing practice.Med Teach. 2020; 42: 772-775Crossref PubMed Scopus (57) Google Scholar In this oncology scan we review the literature regarding effects of the pandemic on medical education in a broad sense, discuss potential roles for e-learning in radiation oncology, and highlight adaptations of 1 radiation oncology residency training program and the effects of the pandemic on the well-being of learners. As we bring educational lessons into radiation oncology, we must draw on best practices with educational rigor. It is not enough to simply report on experiences, but there must be a foundation in educational pedagogy that is built on.6Eva KW. Publishing during COVID-19: Lessons for health professions education research.Med Educ. 2021; 55: 278-280Crossref PubMed Scopus (5) Google Scholar The first 2 articles in this scan summarize Best Evidence Medical Education (BEME) systematic reviews. The BEME collaboration is a well-established international educational consortium dedicated “to the development of evidence informed education in the medical and health professions.”7Harden RM Grant J Buckley G Hart IR. BEME guide No. 1: Best evidence medical education.Med Teach. 1999; 21: 553-562Crossref PubMed Scopus (3) Google Scholar BEME reviews are key to the work of the collaboration and systematically synthesize the best available evidence in medical education. The BEME initiative could be considered analogous to the Cochrane Collaboration in clinical medicine and the reviews likened to the gold standard of systematic reviews in medical education.8Patrício M Vaz Carneiro A Systematic reviews of evidence in medical education and clinical medicine: Is the nature of evidence similar?.Med Teach. 2012; 34: 474-482Crossref PubMed Scopus (8) Google Scholar In both BEME reviews there is an emphasis on evaluation. Throughout the medical education literature there is a continuous push to rigorously evaluate outcomes using established frameworks.9Beckman TJ Cook DA. Developing scholarly projects in education: A primer for medical teachers.Med Teach. 2007; 29: 210-218Crossref PubMed Scopus (69) Google Scholar One of the most common frameworks for evaluation is Kirkpatrick's reaction to learning.10Kirkpatrick D. Great ideas revisited. Techniques for evaluating training programs. revisiting Kirkpatrick's four-level model.Training & Development. 1996; 50: 54-59Google Scholar The Kirkpatrick model is commonly displayed as a 4-level pyramid. The base, level 1, is demonstrating a reaction to learning. This includes “Were the learners satisfied?” Level 2 asks if learning took place with a change in knowledge, skills, or attitudes. Level 3 demonstrates a change in behaviors and effect on clinical practice, and level 4 evaluates the effect on the system, patients, or organizational practice.11Hutchinson L. Evaluating and researching the effectiveness of educational interventions.BMJ. 1999; 318: 1267-1269Crossref PubMed Scopus (191) Google Scholar Although it may be difficult for programs to develop an evaluation to address all 4 domains, many programs stop at level 1 without consideration of more robust levels of evaluation.12Moreau KA. Has the new Kirkpatrick generation built a better hammer for our evaluation toolbox?.Med Teach. 2017; 39: 999-1001PubMed Google Scholar The key to a robust educational evaluation is in clearly defining the educational evaluation to be used at the outset and striking a reasonable balance between the evaluation and feasibility.9Beckman TJ Cook DA. Developing scholarly projects in education: A primer for medical teachers.Med Teach. 2007; 29: 210-218Crossref PubMed Scopus (69) Google Scholar,13Shea JA. Mind the gap: Some reasons why medical education research is different from health services research.Med Edu. 2001; 35: 319-320Crossref PubMed Scopus (28) Google Scholar Although reading the articles in this oncology scan, we challenge the readers to think about the evaluation frameworks used here and within their own research to advance the rigor of radiation oncology education studies. This BEME review was a “rapid” systematic review designed to highlight the response of medical education community to the COVID-19 pandemic, the effect of this response, and collate lessons learned by implementation of these changes.14Daniel M Gordon M Patricio M et al.An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME guide no. 64.Med Teach. 2021; 43: 253-271Crossref PubMed Scopus (43) Google Scholar The review built on a previous BEME review with the same search strategy and objectives completed early in the pandemic (December 2019-May 2020).15Gordon M Patricio M Horne L et al.Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME guide no. 63.Med Teach. 2020; 42: 1202-1215Crossref PubMed Scopus (89) Google Scholar This review followed the Arskey and O'Malley stages of a scoping review16Arksey H O'Malley L Scoping studies: Towards a methodological framework.International Journal of Social Research Methodology. 2005; 8: 19-32Crossref Scopus (10562) Google Scholar and examined literature published between May 1 and September 19, 2020. Four databases (MEDLINE, Embase, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and PsychINFO) were included in the study, searched using PubMed and a hand search of MedEdPublish. Studies in any language were included if they described medical education interventions related to COVID-19 and involved any level of medical learner from medical student to physician and the continuum of undergraduate to continuing medical education. Studies without evaluation or studies included in the prior systematic review (BEME 63) were excluded. In the study, 12,627 records were identified by search of the databases and 31 from the hand search. After screening and application of inclusion criteria, 127 reports were identified. In addition, 50.4% of the studies were from North America (46.5% United States, 3.9% Canada), and 5 of the studies were international collaborations. Of the 127 studies, 51 (40.2%) were in UME, 41 (32.3%) in GME, and 22 (17.3%) in CME. There was a broad number of participants in the studies ranging from 5 to 30,000, with one-third of studies having 100 or more subjects. Reports covered a wide range of disciplines with the most common being surgical subspecialties (17), general surgery (10), pediatrics (10) emergency medicine (8), and 22 spanning multiple disciplines. Only 1 study included discussed an educational intervention in radiation oncology in the UME setting.17Sandhu N Frank J von Eyben R et al.Virtual radiation oncology clerkship during the COVID-19 pandemic and beyond.Int J Radiat Oncol Biol Phys. 2020; 108: 444-451Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Nine focus areas were identified (number of studies in parentheses); a description of pivot to online learning (58), simulation or training for patients with COVID-19 (24), assessment (11), well-being and metal health (8), telehealth (5), clinical service changes to support pandemic response (4), medical school and residency application process changes (4), service provision (2) and faculty development (2). A pivot to online learning was the most topic reported on in UME (31/51) and GME (20/41) studies. The majority of CME studies focused on simulation or training for care for patients with COVID-19 (14/22). With respect to the evaluation of intervention on learning outcomes (effectiveness) the overwhelming majority (99/127) focused on level 1 Kirkpatrick outcomes (reaction to learning/learner satisfaction) and 73 of 127 on level 2, with 26 describing a change in attitudes and 47 changes in knowledge or skills. Changes in behaviors (Kirkpatrick level 3) were reported in 2 papers, with 7 noting level 4 outcomes (6 change in organizational practices, 1 change in clinical outcomes). Only 1 simulation article reported on all 4 levels of Kirkpatrick's outcomes.18Cheung VKL So EHK Ng GWY So SS Hung JLK Chia NH. Investigating effects of healthcare simulation on personal strengths and organizational impacts for healthcare workers during COVID-19 pandemic: A cross-sectional study.Integr Med Res. 2020; 9100476Crossref PubMed Scopus (10) Google Scholar BEME review 64 builds on BEME review 63,15Gordon M Patricio M Horne L et al.Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME guide no. 63.Med Teach. 2020; 42: 1202-1215Crossref PubMed Scopus (89) Google Scholar a similar review earlier in the pandemic both with the shared purpose of describing medical education research related to COVID-19 and highlighting strengths and gaps to direct future scholarship. Not surprisingly, there was an increase in COVID-19 educational scholarship between May and September 2020 (127 articles identified with approximately 30 articles/month) compared with the earlier review completed between December 2019 and May 2020 (49 articles total, with the first articles appearing in March and approximately 20 articles/month in April and May). As noted by many, academic productivity expanded through the past 2 years, and undoubtedly, if this review was repeated in 2022, there would be an exponential increase of research in this field.6Eva KW. Publishing during COVID-19: Lessons for health professions education research.Med Educ. 2021; 55: 278-280Crossref PubMed Scopus (5) Google Scholar,19Yom SS Zietman AL. Imagining our lives post-pandemic.Int J Radiat Oncol Biol Phys. 2020; 108: 331-332Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,20Miller RC Tsai CJ. Scholarly publishing in the wake of COVID-19.Int J Radiat Oncol Biol Phys. 2020; 108: 491-495Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar This review identified a paucity of articles in radiation oncology with only 1 article describing a virtual radiation oncology elective in radiation oncology.17Sandhu N Frank J von Eyben R et al.Virtual radiation oncology clerkship during the COVID-19 pandemic and beyond.Int J Radiat Oncol Biol Phys. 2020; 108: 444-451Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Three additional articles highlighted the effect of the pandemic on surgical oncology fellowship application and interview processes,21Day RW Taylor BM Bednarski BK et al.Virtual interviews for surgical training program applicants during COVID-19: Lessons learned and recommendations.Ann Surg. 2020; 272: e144-e147Crossref PubMed Scopus (30) Google Scholar, 22Molina G Mehtsun WT Qadan M Hause KC Raut CP Fairweather M. Virtual interviews for the complex general surgical oncology fellowship: The Dana-Farber/Partners experience.Ann Surg Oncol. 2020; 27: 3103-3106Crossref PubMed Scopus (16) Google Scholar, 23Vining CC Eng OS Hogg ME et al.Virtual surgical fellowship recruitment during COVID-19 and its implications for resident/fellow recruitment in the future.Ann Surg Oncol. 2020; 27: 911-915Crossref PubMed Scopus (54) Google Scholar and 1 article highlighted the pivot of a medical oncology curriculum to online delivery.24Singhi EK Dupuis MM Ross JA Rieber AG Bhadkamkar NA. Medical hematology/oncology fellows’ perceptions of online medical education during the COVID-19 pandemic.J Cancer Edu. 2020; 35: 1034-1040Crossref PubMed Scopus (16) Google Scholar This is not to say there has been an absence of radiation oncology scholarship in COVID-19 medical education literature, but does reflect trends early in the pandemic. Many journals devoted full or part of issues to articles related to the pandemic, and in October 2020, the International Journal of Radiation Oncology • Biology • Physics published a COVID-19–focused issue, with a number of medical education articles ranging from UME to CME.1Coles CE Choudhury A Hoskin PJ et al.COVID-19: A catalyst for change for UK clinical oncology.Int J Radiat Oncol Biol Phys. 2020; 108: 462-465Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 2Sherry AD Rooney MK Bernard V Seo A Marqueen KE Schrank BR. Residency interviews in radiation oncology after COVID-19: Perspectives from recently matched applicants.Int J Radiat Oncol Biol Phys. 2020; 10: 452-454Abstract Full Text Full Text PDF Scopus (4) Google Scholar, 3DeWeese TL Thevenot L. Is this au revoir or a permanent farewell to in-person meetings?.Int J Radiat Oncol Biol Phys. 2020; 108: 470-471Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,17Sandhu N Frank J von Eyben R et al.Virtual radiation oncology clerkship during the COVID-19 pandemic and beyond.Int J Radiat Oncol Biol Phys. 2020; 108: 444-451Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,19Yom SS Zietman AL. Imagining our lives post-pandemic.Int J Radiat Oncol Biol Phys. 2020; 108: 331-332Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,25Dooley S Sim AJ Campbell SR et al.Opportunities to improve radiation oncology medical education in the post-pandemic era.Int J Radiat Oncol Biol Phys. 2020; 108: 455-457Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Medical education literature in radiation oncology is growing but still has significant room to expand compared with other disciplines,26Lee CH Chen PJ Lai HY et al.A scoping review of medical education research for residents in radiation oncology.BMC Med Educ. 2020; 20: 13Crossref PubMed Scopus (3) Google Scholar, 27Giuliani M Ingledew PA. IROC illuminates a transition to discipline and a transition of medical education research in radiation oncology.Int J Radiat Oncol Biol Phys. 2020; 107: 417-418Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 28Rosenberg DM Rooney MK Abrams MJ et al.Gaps in radiation oncology training: A scoping study of radiation oncology medical education literature.Int J Radiat Oncol Biol Phys. 2019; 105: E155Abstract Full Text Full Text PDF PubMed Google Scholar and the effect of the pandemic on medical education research in radiation oncology represents a significant scholarly opportunity. This review highlighted several gaps in research. First, although a significant number of articles discuss a transition to online learning, many only report on the pivot from in-person learning to online synchronous formats and few detailed novel approaches to delivery. As we move forward and transition to sustained online learning, educators should challenge themselves not to just pivot but to consider if unique educational approaches are required to address learning needs and rigorously evaluate the outcomes. In this review the bulk of articles were within the realm of UME or GME. Less research was done in CME, and where CME was explored, most studies were related to COVID-19 training and simulation. With the prolonged duration of the pandemic, many CME events and conferences went online and the need for novel approaches to delivering CME was heightened.3DeWeese TL Thevenot L. Is this au revoir or a permanent farewell to in-person meetings?.Int J Radiat Oncol Biol Phys. 2020; 108: 470-471Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Several professional societies, including ASTRO, capitalized on social media platforms for delivery of CME content.29Knoll MA Chowdhary M Dicker A Eichler T. Virtual connectivity during quarantine: the role of social media for radiation oncology during COVID-19.Int J Radiat Oncol Biol Phys. 2020; 108: 506-508Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar A silver lining of virtual meetings is improved flexibility of conference attendance, at reduced cost of time and money, improving diversity of attendees. There may be unique areas of research on the effect of these changes in the realm of diversity, equity, and inclusion. Additionally, virtual CME has led organizers to explore novel ways to recreate networking virtually which may be another opportunity for scholarship. There was a notable absence of articles (2 in total), focusing on faculty development. Although faculty have been charged during the pandemic to pivot their instruction and assessment very little research has been done in this realm. To empower faculty to continue to address the challenges of the pandemic we must not only note best practices but evaluate the best methods for education and disseminate this knowledge broadly.5Cleland J McKimm J Fuller R Taylor D Janczukowicz J Gibbs T. Adapting to the impact of COVID-19: Sharing stories, sharing practice.Med Teach. 2020; 42: 772-775Crossref PubMed Scopus (57) Google Scholar Finally, the pandemic has had a profound effect on the well-being of health care professionals.30Hlubocky FJ Symington BE McFarland DC et al.Impact of the COVID-19 pandemic on oncologist burnout, emotional well-being, and moral distress: Considerations for the cancer organization's response for readiness, mitigation, and resilience.JCO Oncol Pract. 2021; 17: 365-374Crossref PubMed Scopus (21) Google Scholar Only 8 of the 127 articles looked at related educational research in this domain and hence represents a unique and untapped opportunity. Taken altogether, this review identified at least 4 unmet research needs that could be explored with application to radiation oncology including implementation and evaluation of novel online learning approaches, effects of virtual CME, pandemic effects on faculty development, and learner and faculty well-being. With respect to evaluation, the vast majority of studies only looked at level 1 of Kirkpatrick's hierarchy. The phenomena of only examining a reaction to learning is noted throughout the medical education literature.12Moreau KA. Has the new Kirkpatrick generation built a better hammer for our evaluation toolbox?.Med Teach. 2017; 39: 999-1001PubMed Google Scholar Although acknowledging that all 4 levels of evaluation are not always feasible, or even desirable, pushing forward through the pandemic, medical education researchers should work to purposefully develop evaluation strategies that move beyond a sole reaction to learning. The article by Cheung et al18Cheung VKL So EHK Ng GWY So SS Hung JLK Chia NH. Investigating effects of healthcare simulation on personal strengths and organizational impacts for healthcare workers during COVID-19 pandemic: A cross-sectional study.Integr Med Res. 2020; 9100476Crossref PubMed Scopus (10) Google Scholar highlighted within this review expertly reflected on all 4 levels and could serve as a template for radiation oncology researchers looking to advance educational evaluation. In this BEME analysis authors performed a rapid, high-quality review of literature focusing on adaptation to online learning for continuing workplace-based clinical learning in medical education as a result of the pandemic.31Grafton-Clarke C Uraiby H Gordon M et al.Pivot to online learning for adapting or continuing workplace-based clinical learning in medical education following the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 70.Med Teach. 2021; 23: 1-17Google Scholar This analysis builds on BEME Guide 63 and 64.14Daniel M Gordon M Patricio M et al.An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME guide no. 64.Med Teach. 2021; 43: 253-271Crossref PubMed Scopus (43) Google Scholar,15Gordon M Patricio M Horne L et al.Developments in medical education in response to the COVID-19 pandemic: A rapid BEME systematic review: BEME guide no. 63.Med Teach. 2020; 42: 1202-1215Crossref PubMed Scopus (89) Google Scholar There are 2 additional follow-up publications that focus on adaptation of traditional classroom learning to an online format,32Stojan J Haas M Thammasitboon S et al.Online learning developments in undergraduate medical education in response to the COVID-19 pandemic: A BEME systematic review: BEME Guide No. 69.Med Teach. 2022; 44: 109-129Crossref PubMed Scopus (5) Google Scholar,33Bastos RA Carvalho DR dos S Brandão CFS et al.Solutions, enablers and barriers to online learning in clinical medical education during the first year of the Covid19 pandemic: A rapid review.Med Teach. 2022; 44: 187-195Crossref PubMed Scopus (5) Google Scholar whereas here the focus is on transition of education delivered in the workplace or clinical setting, analogous to the effect on clerkship students and residents in radiation oncology. This analysis followed similar search strategies as reported in BEME 64.14Daniel M Gordon M Patricio M et al.An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME guide no. 64.Med Teach. 2021; 43: 253-271Crossref PubMed Scopus (43) Google Scholar Databases were searched for records between January and December 2020. In addition, 11,111 records were identified by search of the databases and 23 from the hand search. After screening and application of inclusion criteria, 55 reports were identified addressing learning adaptations deployed to continue workplace-based clinical learning, the effect of these innovations on learners, and why these specific methods were used by educators. The publication of these articles increased significantly throughout 2020, with only 10 studies from January to June and 45 studies published July to November. Most publications were original research articles (60%) or brief reports or innovations (27%), and they were largely (69%) published in specialty-specific journals over education focused journals (30%). Most of the articles detailed interventions in UME (69%) with GME noted in 27%. Eight focus areas were identified. These included a description of the following (number of articles in parentheses): adaptation to online learning (33), online simulation (9), remote clinical interactions mostly orientated to telehealth (8), remote multidisciplinary ward rounds (6), remote adaptation of multidisciplinary team meetings (2), and live-streaming of surgery or procedures (1). There was 1 radiation oncology specific article which reviewed the Radiation Oncology Virtual Elective Rotation (ROVER) program using remote image contouring and case review using archived images.17Sandhu N Frank J von Eyben R et al.Virtual radiation oncology clerkship during the COVID-19 pandemic and beyond.Int J Radiat Oncol Biol Phys. 2020; 108: 444-451Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The vast majority of studies (86%) focused on Kirkpatrick level 1 outcomes, 27 % noted level 2a (change in attitudes) and 31% of studies documented level 2b (changes in knowledge or skill). No studies noted level 3 or 4 outcomes. In this systematic review the authors performed a detailed review of all published literature pertaining to the pivot to online learning for traditional workplace delivered education, highly pertinent to radiation oncology. Due to the rapid production of this work throughout the pandemic the authors executed this project from inception to completion over 15 weeks ensuring this publication remained relevant and contained the latest publications. The vast majority of articles were noted in the UME setting. Although senior medical students have been affected by the pandemic with a transition away from workplace learning, residents spend most of their education in such settings. Unique adaptations of programs, specifically radiation oncology residency programs to meet the needs of clinical learning during the pandemic would be a potential untapped area for research. As online learning has become widely accepted, we must focus to ensure not only is the formal curriculum encompassed but seek to incorporate informal teaching and that from the hidden curriculum. This includes unstructured time for free-flowing inquiries, engaged discussion, and learning that happens as a result of active feedback. Learners reported in several studies the advantage of feedback in virtual encounters, including live confidential feedback, which allowed them to adapt during an encounter, in addition to standard debriefing. When using online platforms, a main barrier to learning is limited interactivity between teacher and student as found by Bastos et al33Bastos RA Carvalho DR dos S Brandão CFS et al.Solutions, enablers and barriers to online learning in clinical medical education during the first year of the Covid19 pandemic: A rapid review.Med Teach. 2022; 44: 187-195Crossref PubMed Scopus (5) Google Scholar in a review evaluating solutions, enablers, and barriers in clinical medical education. In the virtual format, an authentic learning environment needs to be created which stimulates the student to think critically and communicate effectively to adequately prepare them for in-person encounters. The majority of articles identified in this study were a reaction to the pandemic and not purposeful planned educational interventions. Likewise, similar to BME 64, with respect to evaluation, most research focused on learner satisfaction and evaluation rather than higher levels of evaluation. Although the single radiation oncology experience identified in this study made efforts to evaluate both the reaction to learning and learners’ perceptions of knowledge acquisition, a robust description of curriculum design and educational underpinnings was absent.17Sandhu N Frank J von Eyben R et al.Virtual radiation oncology clerkship during the COVID-19 pandemic and beyond.Int J Radiat Oncol Biol Phys. 2020; 108: 444-451Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The trends noted were likely secondary to the rapid adoption of online learning with ongoing evaluation and adaptation, in contrast to the standard evidence-based development of medical education resources before implementation. Although this was understandable given the circumstances of the pandemic, it is critical moving forward that we do not assume our current online-learning models represent best practices but seek to critically evaluate and continue to improve.6Eva KW. Publishing during COVID-19: Lessons for health professions education research.Med Educ. 2021; 55: 278-280Crossref PubMed Scopus (5) Google Scholar In summary, there has been a significant increase in the publication of learner experience in the online pivot to previous workplace-based education, but there is a critical need to publish more in-depth research pertaining to the methodology and framework of the virtual learning environment to maximize engagement and effectiveness. The full details of materials, educational content and methods are needed so others can effectively recreate these learning environments, as online learning will continue to grow far beyond the pandemic days. With the evolution of magnetic resonance imaging–based image-guided adaptive brachytherapy for the treatment of cervical cancer, European Society for Therapeutic Radiology and Oncology (ESTRO) created a teaching course in 2004 to support training and dissemination of this technique. In 2011 the program was expanded to also include advanced external beam radiation therapy techniques.34Tan LT Tanderup K Nappa A et al.Impact of transitioning to an online course: A report from the ESTRO gyn teaching course.Clin Transl Radiat Oncol. 2021; 29: 85-92Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar From 2004 to 2018 this program evolved into a 5-day live program containing 41 hours of educational content. This was 80% synchronous activities with participants and faculty engaging in person (2/3 lectures and 1/3 hands on) and an add