All facets of human existence, including healthcare facilities, business prospects, travel and transportation, and social structure, have undergone significant changes as a result of the global spread of the coronavirus illness 2019 (COVID-19) brought on by SARS-CoV 2.1 Because of COVID-19's effects on the education sector, schools and universities including health area have had to close in the majority of the affected countries as well as teaching hospitals which are solely handling “on-duty” shifts.2

Distance learning (DL) is a technique that is frequently utilized as a tool to spread information and culture. The use of DL in the field of health is a topic that is frequently discussed. Many nations have used this tool, and in Tunisia, some specialty colleges have adopted it to ensure the sustainability of medical resident training. It has demonstrated its effectiveness of sharing knowledge.3

Given the particularity of the Pathology speciality, the importance of analyzing slides through traditional histology workshop in acquiring diagnostic skills and the manipulation of light microscopes in the training of residents, the substitution of face-to-face training devices by digital means is an unprecedented experience as pathology residents had to quickly adapt to learning exclusively online. Due to the absence of double-scoping, educational innovation has been required to keep teaching microscopy. Whole slide imaging (WSI) is one alternative for digital pathology, however due to funding restrictions experienced by many departments this option is frequently unaffordable, especially in Tunisia. Alternatively, a trend toward teaching pathology through dynamic virtual microscopy provides an easily available, physically distant, and cost-effective option. A standard light microscope, a mounted digital camera, laptops, and videoconferencing software are necessary tools to share a slide image with the student (s).4 Thus, the question of DL impact on the pathology residency curriculum was raised.

In this study, we propose to evaluate this teaching method of the Pathology College with reference to the learner's point of view.

Consent was obtained from all students included in this study to conduct this work. There were no conflicts of interest.

A total of 26 pathology residents participated in the study among the 33 invited. The characteristics of the cohort are presented in Table 1.

Out of the 33 pathology residents, 22 (84.6%) were females. They were from Faculty of Medicine of Tunis in 10 (38.5%) cases and Monastir in 7 (26.9%) cases. Regarding the level of residency, 16 (61.5%) were in 4th year. Twenty-four residents (92.3%) had already an E-learning experience. The most used tool to follow DL was the laptop in 23 (88.5%) cases. All residents had access to internet connection, and it was through WIFI in 22 (88%) cases. Residents followed the courses at home in 25 (96%) cases and only one at a stage (4%). The time spent for DL was ≥ 4 hours in 14 (54%) cases. PowerPoint was the most used presentation program (81%).

Almost 70% of participants were satisfied with their DL experience. Thirty percent of the participants thought that DL should replace face-to-face theoretical courses.

All participants reported that they were informed of the date of the online course in time. Nearly 54% of participants said they did not have the resources available in time.

Technical difficulties were encountered in 42% of cases. The most common difficulty was related to internet connection (66.7%). More than half of the residents (53.8%) felt that DL should be complementary to face-to-face teaching. Student involvement in DL was rated low to moderate in 69% of cases. Most of participants agreed, either totally (38.5%) or partially (34.6%), that the environment offered in the DL was as realistic as the one offered in the classroom/amphitheater. Over 73% of participants rated the level of technical support provided by course coordinators as at least satisfactory. More than 90% of participants were at least satisfied with the level of teacher involvement in the online training. Interaction with teachers during DL courses was considered more difficult than face-to-face by 61.5% of participants. Only 38.5% of the participants thought that the time management of DL course by the teachers was more difficult than in the classroom.

Participants felt that face-to-face courses were presented in a clearer manner compared to online courses in 73% of cases. Nearly 90% of participants found the course materials used by teachers interactive.

Concerning virtual pathology slides, participants found that acquiring diagnostic skills via the virtual slide websites was better than learning in the traditional double or multi-headed scope in 53.8% of cases. The main two reasons were: more time to analyze virtual slides than in the traditional histology workshop (42.9%) and the ability to view virtual slides at any time (35.7%). Only 11.5% felt that DL was not beneficial for life skills. More than 90% of the participants felt confident in making diagnoses after attending DL via the virtual slides. More than 60% of participants felt able to take exams on courses taught online in actual practice. The main strength identified by participants was the flexibility of learning locations and schedules (73.1%). The main weaknesses of DL were the dependence on technical means (42.3%), the lack of interactivity with colleagues (26.9%) and the lack of interactivity with teachers (26.9%). The main conditions for a successful DL experience identified by participants were willingness to adapt to a new technology (38.5%) and acceptability by students and teachers (34.6%). The suggestions and proposals of the participants were the creation of a media library gathering all the video presentations and virtual slides. Finally, learners' choices for how to teach future college courses was not in favor of online courses (70%).

Since E-learning is the predominate method of academic activities among medical residents during the COVID19 pandemic, it is essential to evaluate their perception and satisfaction with the method to find weaknesses, enhance the program's quality, and make necessary revisions.5 Thus, the current study sought to evaluate how pathology residents perceived and were satisfied with DL during the COVID-19 epidemic.

The main results of the study showed that DL is a satisfactory method from the learner's point of view. Students believe in 70% of cases that DL is a useful tool for carrying out academic activities. The main benefits identified by the residents were accessibility to the sessions from any location and schedules and the possibility of reviewing virtual slides at any time. However, only 30% of the participants think that DL should replace face-to-face theoretical courses.

The lack of face-to-face connection with the teachers and colleagues and the incidence of technological issues that occasionally hindered the smooth running of the sessions were the shortcomings highlighted by pathology residents.

The Pathology College chose to carry on its training programs for residents at various levels during the period of confinement imposed by our nation's government due to the worldwide health crisis. The only viable choice in these circumstances was DL.

Several authors have compared real audience teaching versus DL.6–8 They have concluded that they were equivalent in terms of knowledge improvement. In our study, participants felt that face-to-face courses were presented in a clearer manner compared to online courses in 73% of cases. On contrary, according to several reports, the instructor's presentation style and visual presence play a key role in getting students interested in the content.9 In traditional courses, pathologists typically focus their teaching efforts on tumor boards, conferences on medical autopsies, and directly under the microscope with visiting clinical teams. However, in a synchronous e-learning environment, the professor has additional responsibilities as a teacher, including helping students transition smoothly from traditional classroom settings to online classes, engaging the audience in conversation, and ensuring that everyone has a positive and active e-learning experience.

To overcome some of the drawbacks of e-pathology courses, one study proposed to combine the two teaching methods into a so-called hybrid “bent learning”.5 Recent studies proposed game-based learning, like “Kahoot!” which is a mobile game-based online digital formative assessment tool that has recently been examined by medical students.10,11 Since gaming technologies are thought to be suitable for opportunistic learning and offer helpful learning techniques that promote continuing academic results,12 pathology department should take this new tool into account to promote e-pathology courses. In our study, residents suggested the creation of a media library gathering all the video presentations and virtual slides which can be viewed at any time.

There are several obvious and evident benefits to using WSI instead of glass slides in acquiring diagnostic skills in DL pathology lessons. Scanning the original glass slide allows for the dissemination of a precisely replicated reproduction of the slide without having to resort to cutting more sections (which may or may not be representative of the original slide/pathology), depletion of a tissue block, which is important for ancillary studies that frequently affect patient treatment, obviating the necessity for packaging and posting slides, the possibility of glass slide breakage and delays/losses in transit, and the time WSI offers the students and teachers the chance to view the slide in real time while geographically apart, despite certain technical difficulties.13 The latter capacity strengthens and even encourages distance education because glass slides do not allow both participants to see the slide at the same time. Therefore, there are many and significant benefits of adopting WSI that much outweigh any drawbacks.13 However, the deployment of WSI is within the means of several departments in Tunisia. The routine currency in all pathology departments are glass slides and, for teaching purpose, scanning slides via a mounted digital camera and a standard light microscope. In our study, participants found that acquiring diagnostic skills via the scanned images slides was better than learning in the traditional double or multi-headed scope in 53.8% of cases as they had more time to analyze virtual slides than in the traditional histology workshop and were able to view them at any time. More than 90% of the participants felt confident in making diagnoses after attending DL via the virtual slides.

In order to encourage and enable ongoing support and motivation of the learner, a continuous formative evaluation procedure is also to be carefully considered in this learning process.

The main limitation of our study is the small number of participants included. Indeed, this is a preliminary experiment, and the study should be extended to other groups of students with an inclusion of a control group for more objectivity.

Despite some limitations, the experience in e-pathology courses was efficient and welcomed by residents. In order to improve our understanding of the online teaching process and its quality, we also think that more research in the area of e-learning pathology should be done in the future.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The present study has been conducted according to the principles of the declaration of Helsinki. Ethical approval for the study was not required. Participants were made aware of the purpose of the study, the anonymous nature of the purpose, the anonymous nature of the dataset generated and the option to not respond if they so wished.

Not commissioned, externally peer-reviewed.

All the authors read and approved the final version of the manuscript.