Available videoconferencing freeware and medical education.

BACKGROUND: Traditionally medical education involves classroom teaching, small group discussions and bed-side clinics. These have become difficult to conduct in times of the COVID-19 pandemic. Video-conferencing software and apps provide pragmatic alternatives for medical education in this scenario. However, the apps are not designed specifically for medical education. In this background, we aimed to review available video-conferencing freeware (platforms/apps) for their suitability in imparting post-graduate medical education.
METHODOLOGY: Software and apps were searched on Android and iOS platforms. Freeware were selected based on pre-defined criteria. They were evaluated for features supporting post-graduate medical education like participant numbers, time limit, user comfort and security features.
RESULTS: Our search yielded 118 video conferencing software and apps. Of these, 07 free apps met the initial inclusion and exclusion criteria. 'Say Namaste' was included post-hoc. Most apps allowed adequate numbers of participants and were comfortable for users. Only two apps had end-to-end encryption.
CONCLUSION: Video-conferencing freeware can serve as a viable alternative for some aspects of medical teaching. Provision of certain additional features would make these apps more effective for post-graduate medical education. Copyright:

During the recent COVID-19 pandemic, there has been a huge increase in the use of videoconferencing software and apps to ensure communication while maintaining distancing during Lockdown and work from home. Medical teaching is faced with unique challenges as medical colleges and hospitals focus on preventing COVID-19 transmission. They have strictly enforced distancing norms that make traditional classroom teaching impossible. Medical teaching and assessments [Figure 1] have involved both classroom/small-group interactions, and bed-side skills training.[123]

Figure 1

Miller's Pyramid

Providing medical education and training using synchronous videoconferencing software is a pragmatic substitute for classroom and small-group interactions. Videoconferencing freeware has limitations like lack of contact with the patient during case presentation, limitations in the supervision of interview, and examination skills etc. Another alternative is massive online open courses (MOOCs), which however lacks the immediacy of synchronous learning.[4]

Currently, there is no free video-conferencing platform specifically directed at tele-medical education. We sought to evaluate the suitability of available video-conferencing freeware for medical teaching. In this article, we have aimed to review the features of video-conferencing platforms/apps for use in post-graduate medical education. Additionally, we aimed to recommend features to optimise video-conferencing freeware for post-graduate medical teaching.

METHODOLOGY

Software search and selection for review was done according to algorithm in Figure 2. Two of the authors (AC and VSC) searched Android Play Store and Apple App Store for videoconferencing apps. Two authors (AC and KC) drafted the inclusion and exclusion criteria. Any disagreement was resolved by consultation with the other authors. As there was no published literature, inclusion and exclusion criteria were based on consensus.

Figure 2

Software search and review process

Inclusion Criteria for software and apps

Free to download and use.

Accessible on both laptop and smartphone.

At least 1 million downloads.

A rating of 3.8 or more, from at least 10,000 reviews.

Available in English. (The medium of medical education in India)

Exclusion Criteria:

Paid software or app.

In languages other than English

Period of study

The study was conducted from 20 Apr 2020 to 14 Jun 2020.

Evaluation process

The authors verified features of each software/ app by holding meetings on these platforms. Additionally, features were checked from webpage of the individual software, Android play-store and Apple app-store. The following features were evaluated –

Number of participants and time duration permitted.

User comfort and utility features: Like screen sharing, provision of scheduling or recording meetings, availability of white board etc.

Security features: Like availability of waiting rooms, meeting password and lock, provision of removing participants and end to end (E2E) encryption.

RESULTS

The search yielded 118 video conferencing software and applications. After sieving through inclusion and exclusion criteria, 07 met the requirements. They were Zoom Cloud Meeting, Cisco WebEx, Google Meet, Microsoft Teams, Skype, FreeConference Call and GoToMeeting.

Post-hoc search yielded “Say Namaste” platform released as beta version.[5] Being a late entrant and indigenous software, we included it in our evaluation process. The 08 apps were evaluated for utility in post-graduate medical education (Table 1). Most apps allowed adequate number of participants and most of them restricted duration of meeting, leading to requirement of logging in again, which was disruptive to the teaching-learning process.

Table 1

Comparison of free videoconferencing software

Feature	Zoom cloud meetings	Cisco WebEx meetings	Google Meet	Microsoft Teams	Skype	FreeConferenceCall	GoToMeeting	Say Namaste
Developer	Zoom.us	Cisco Systems, Inc.	Google	Microsoft	Microsoft	FreeConferenceCall.com	LogMeIn, Inc	Inscripts
Limits
Participants	100	100	100	250	50	1000	03	50
Time limit	40 min	50 min	Unlimited till September 30, 2020	Unlimited	4 h/call	6 h	40 min	Unlimited
User comfort
Screen sharing	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes (only desktop)
Meeting recordings	Yes	Yes	No	No	Yes	Yes	Yes	No
Schedule meetings	Yes	Yes	Yes (requires Google calendar)	Yes	Yes (Outlook required)	Yes	Yes	No
White board	Yes	Yes	No	No	ON business version	Yes	Screen drawing available	No
Security
Waiting rooms/lobby	Yes	Yes	Yes	Yes	In Business version	Yes	Yes	No
Remove participants	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No
E2E encryption	No	Optional	No	No	No	No	Yes	No
Meeting lock	Yes	Yes	No	No	Optional (Outlook required)	Yes	Yes	No
Password/code	Yes	Yes	No	No	No	Yes	Yes	Yes
Constraints	Data encryption and security issues	Security concerns (phishing attacks)	Limited features in mobile app Some features require purchasing G-Suite	Separate app required for whiteboard function Recording requires Microsoft Stream	Scheduling and meeting lock requires MS outlook		Polling and raise a hand options are not available	Beta version Shared screen does not fit mobile screens properly

The above features were evaluated by the authors by hosting/attending meetings on these platforms

Most of the apps were easy to use. 'Say Namaste' however was not fully optimised for smartphone screens. All apps allowed screen sharing during video conferencing. Most apps allowed scheduling of meetings, however Google Meet and Skype required additional software like Google calendar and Outlook respectively.

Most apps provided adequate security protocols. Only WebEx and GoToMeeting provided end-to-end (E2E) encryption.[6]

DISCUSSION

There has been an explosion of video-conferencing platforms in the last three months. These platforms are basically meant for businesses, IT industry, etc., Teaching doctors online will require a secure, reliable, multi-user platform which allows live meetings with other features like file sharing etc. Some suggestions which can further optimise such platforms for medical teaching are:

Marking attendance and collation for record/maintaining personal longitudinal profile.

Login through virtual keyboards or use of captcha code to avoid intrusion by bots/malware.

Option to conduct Objective Structured Clinical Examination / Objective Structured Practical Examination (OSCE/ OSPE) and scoring through chat record.

Recording of informed consent when required.

Provision to blur face for confidentiality when a patient is examined, during an online case presentation.

Record of sessions and provision of recorded sessions on institutional MOOC page.

Option for asking questions by typing in chat or symbols for raising hand, etc.

Platforms may be customized for college/university with option to upgrade to paid software for wider service delivery.

The inclusion of these features will make the platforms more suitable for the conduct of medical education. They might even help reach the unreached and act as a force multiplier in the delivery of competence-based Medical Education. Some of the apps have evolved after 10 Jun 2020 and may contain new features which were not found at the time of study.

This was a quick and early study looking at the adaptation of available technology for distance education forced by the COVID situation. Since it was carried out by medical teachers, the relevant constructs were factored in. However, further detailed study requires IT professionals and educators for a more holistic assessment.

CONCLUSION

Every challenge is an opportunity. The COVID-19 pandemic has provided some unprecedented opportunities for medical professionals. Postgraduate medical education is unique in terms of requirement of clinical skills and knowledge with a steep learning curve. While it is neither feasible nor practical to shift the entire postgraduate medical education online, some training activities can be held through the use of synchronous video-conferencing platforms. The available platforms may prove to be handy in the short term. To be acceptable options for medical training in the long term, they need modifications to enhance effectiveness. The creators of such software (IT professionals) may consider collaboration with experts in Medical Education for optimising these platforms for medical teaching.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.