Education

Review of Learning Tools for Effective

Radiology Education During the
COVID-19 Era
David Chen, BS, Andres Ayoob, MD, Terry S. Desser, MD, Aman Khurana, MD

Coronavirus disease 2019 (COVID-19) has significantly disrupted medical education around the world and created the risk of students
missing vital education and experience previously held within actively engaging in-person activities by switching to online leaning and
teaching activities. To retain educational yield, active learning strategies, such as microlearning and visual learning tools are increasingly
utilized in the new digital format. This article will introduce the challenges of a digital learning environment, review the efficacy of applying
microlearning and visual learning strategies, and demonstrate tools that can reinforce radiology education in this constantly evolving digi-
tal era such as innovative tablet apps and tools. This will be key in preserving and augmenting essential medical teaching in the currently
trying socially and physically distant times of COVID-19 as well as in similar future scenarios.
Key Words: SARS-Cov-2; Coronavirus; Radiology; Medical education; Electronic teaching tools; Online education.
© 2021 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

INTRODUCTION sudden surge in its use (14). With this shift to online formats,
schools unaccustomed to this methodology are at risk of

I
n recent decades, there has been a shift in medical teach-
defaulting back into the primarily didactic passive lecturing
ing from passive didactic formats to more active learning
styles of the past, such as simple uploads of PowerPoint lecture
strategies (1-4). This is due to the greater education yields
videos etc. (15). This could prove problematic for the current
produced by these active learning methods compared to pas-
generation of future physicians as the training they receive will
sive learning (5-8). There has also been a gradual trend
be less interactive compared to the traditional, in-person, small
towards moving certain aspects of education online due to
group-based teaching methods available to their predecessors
the practicality and cost-efficiency offered (9,10). These
and successors who trained in normal societal conditions.
online modules are not chosen because of their ability to out-
To retain educational yield on par with levels of recent
perform traditional in-person teaching models but because
times, creative strategies that involve active learning through
they can provide additional benefits when paired with sup-
digital technology are necessary. Ideas have already been pro-
plementary active learning strategies, such as lessening geo-
posed on how to make learning more engaging, effective, and
graphical and temporal constraints upon students, allowing
appealing during this time for students such as gamification,
for a greater range of material dissemination by various online
synchronous case reviews, and flipped classroom techniques
platforms, and increasing adaptability based on the needs of
(16-18). Another such method is the strategy of microlearning
each student (10-12).
which can address the concerns of passive learning formats and
During the novel coronavirus disease 2019 (COVID-19)
recover educational yield lost with an online transition. Micro-
pandemic, there has been an abrupt change in the curricula of
learning revolves around lessons utilizing small, bite-sized
medical institutions (13). The most effective method for cur-
amounts of information that is easily digestible for students in
tailing the rapid spread of the virus is through physical distanc-
one sitting and taught in a step-by-step manner. This strategy
ing and therefore the online mode of teaching has seen a
is primarily focused upon making short and readily repeatable
connections between small learning units which hastens devel-
Acad Radiol 2022; 29:129–136 opment of critical thinking and clinical reasoning. Microlearn-
From the University of Kentucky College of Medicine, Lexington, Kentucky ing has commonly been implemented inside digital teaching
(D.C.); Department of Radiology, University of Kentucky Chandler Medical
Center, 800 Rose St, HX 316, Lexington, KY 40536 (A.A., A.K.); Department of frameworks and can have significant performance benefits with
Radiology, Stanford University, Stanford, California (T.S.D.). Received June examples such as mobile apps for nursing, interactive online
16, 2021; revised October 11, 2021; accepted October 12, 2021. Address
correspondence to: A.K. e-mail: [email protected]
case-based medical trainings, social media group learning, and
© 2021 The Association of University Radiologists. Published by Elsevier Inc.
more (12,19,20). Microlearning has been coupled with visual
All rights reserved. learning tools to further leverage teaching benefits (21-23).
https://doi.org/10.1016/j.acra.2021.10.006

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This is relevant for radiologists in training because they need to and certain clinical experiences have been curtailed, which
develop a high degree of visual acuity and familiarity with a can ultimately result in a reduced knowledge base and hin-
multitude of imaging features to differentiate the spectrum of dered advancement to independent practice (14,28).
normal from pathological conditions and be prepared for inde- Nevertheless, one upside to the disruptions of the COVID
pendence in the field. Visual learning tools like 3D imaging pandemic was the forced re-imagining of radiology operations,
software have been shown to improve diagnostic abilities in including clinical care, and teaching, necessitated by social dis-
undergraduate radiology (24). tancing mandates (32). Over time, strategies have emerged for
This article will introduce digital learning, review the effi- digital teaching and remote learning that offer more opportuni-
cacy of applying microlearning and visual learning, and dem- ties for scheduling flexibility, work-life integration, and access.
onstrate some of the tools that can serve to bolster medical For example, video conferencing over platforms such as Zoom
and radiology education during this era where the newer enable sharing of educational conferences in real time with
teaching strategies are in demand. trainees dispersed among multiple sites such as outpatient clinics,
affiliated hospitals, or even providing childcare at home. Inter-
esting case or “hot-seat” type conferences can potentially be
IMPACT OF COVID-19
held with multiple training programs sharing cases with one
In response to the novel COVID-19 pandemic, the primary another, and didactic conferences can be archived for trainees to
goal of many countries was to protect the most vulnerable from view on demand when convenient. With “necessity as the
infection and decrease major surges that overwhelm hospital mother of invention,” new paradigms such as these may ulti-
capacities. To accomplish this, many nations’ responses included mately prove to be advantageous and sustainable even after the
public health initiatives like handwashing, mask-wearing, con- COVID pandemic subsides.
tact tracing, and social distancing (25). One of these initiatives
involved minimizing viral transmission risk by mandating social
DIGITAL LEARNING
distancing practices in areas where large groups gather such as
educational institutions. At the height of this response on April Digital learning has been a growing trend in recent years but
24 2020, approximately 1.48 billion learners around the world now has been thrust into the mainstream spotlight with the
had education impacted by COVID-19, which represents shift of teaching onto online platforms due to safety concerns
84.5% of the entire global education population (26,27). of the COVID-19 pandemic.
As a result, medical institutions in all fields were forced to Even before the pandemic, medical schools were put under
implement changes to their teaching curricula on very short increasing pressure to adopt digital methods due to decreasing
notice (28). For preclinical medical students, their anatomy funding, increased geographical dispersal of students, rising stu-
and radiology curricula were unable to employ previously dent body populations, and competition from other global
commonplace teaching methods of the past like face-to-face schools advancing their teaching efficacy (33). In terms of edu-
teaching, cadaver dissections, ultrasound practice, and labora- cational yield, these distance learning environments are favored
tory sessions (15). The legacy of curricular gaps has the poten- because, when using interactive means, they can have equal or
tial to lead to struggles within their clinical years and better outcomes than similar in-person methods but also offer
shortcomings in their foundational knowledge that will be additional benefits over in-person settings (10). Before the pan-
carried forward with them long term. The primary radiology demic required physical distancing, eLearning’s main advan-
pedagogical methods for medical students in clinical years tages came from its potential to offer greater degrees of
before the pandemic held great weight for in-person teaching convenience, customization, and cost-efficiency compared to
methods such as hands-on workshops, team-based learning, that of a traditional classroom. Some schools have also
and clinical shadowing which have been difficult to keep employed web-based teaching in the past as a solution to the
afloat during the pandemic (15,29). In respect to radiology problems of ensuring a consistent curriculum across their
residents and fellows, the pandemic resulted in academic radi- spread-out facilities (34). In radiology teaching, web-based
ologists spreading out within their medical facilities or in their methods have shown greater educational yield for image inter-
homes. This rapid change from the traditional shoulder to pretation and case studies (9,35-37). The main disadvantages
shoulder workstation approach has disrupted teaching which with supplementing traditional curricula with digital learning
previously involved learning from radiologists on rotation portions involved the learning curve to utilize the technology
and in-person teaching formats like hot-seat type question- and the extra financial burden that exacerbates the conditions
ing, reviewing peers’ scans, and hands-on procedures (14). of less socioeconomically fortunate students (38).
With respect to radiology residents and fellows, their edu- There are two main differences in the digital learning of the
cational part of the training has also been deprioritized in present compared to that of the past. One is that medical
favor of providing urgently needed clinical service amid the learners will have less exposure to core in-person activities such
growing pandemic. Residents and fellows may now feel as as interventional procedures, conferences, and patient encoun-
though their role is more ambiguous due to experiencing ters. The other difference is that the institutions that imple-
lower volumes of elective and nonurgent clinical procedures mented this digital methodology in the past were able to
(30,31). Learning-related travel to onsite radiology meetings carefully craft a curriculum to effectively teach their students

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whereas those affected by the pandemic did not have enough material, encourages peer learning and knowledge sharing,
time to implement it. Reliance upon passive didactic eLearning and increases student ownership of the learning process (50).
in place of active learning methods can jeopardize the future of Flipped teaching has been studied across the educational spec-
not just radiology learners but those of all disciplines as this trum from secondary to professional schools. Benefits to
sudden shift impacts the essential areas of education (28,29,39). flipped teaching include improved student satisfaction,
Active learning has been defined as “involving students in increased attendance, and decreased failure rates (51).
doing things and thinking about the things they are doing” Digital learning alone is usually not enough and therefore
(40). In contradistinction to passive listening during a traditional coupling with microlearning strategies increases the palatabil-
lecture, students are engaged to think at higher cognitive levels ity and breadth of these teaching methods as described in
through purposefully crafted learning activities. Active learning detail in the following section.
has been shown to have several benefits including improved
learner attention and increased learner motivation.
MICROLEARNING
In regards to this online transition, various active learning
methods such as a) procedural simulations, b) case-based Microlearning is a teaching methodology that involves con-
learning, c) gamification, and d) flipped classroom teaching densing learning units into an appropriate amount of infor-
have been popular suggestions (41,42). mation to achieve specific short-term learning goals. This
For many hospitals, a) procedural simulation equipment methodology gives users more opportunities to learn when-
can be split into time blocks for small-groups or individual ever convenient to them as they no longer are restricted by
use to maintain physical distancing which has re-sparked lengthy material that requires large blocks of time.
interest in this field in the COVID-19 era. Ideas to move sim- This strategy is more readily implemented into online for-
ulations outside of the hospital like computer-based virtual mats rather than in-person formats due to the individualiza-
reality have also been proposed which could also serve tion offered. In a traditional lecture class, the instructor must
towards both retaining educational yield within pandemic consider the progression of all learners together and the
times but also potentially add more hours of practice to previ- course would progress without skipping information. In a
ously constrained training areas like interventional radiology digital format, the learner is progressing at their own pace so
and surgery (43). b) Case-based learning (CBL) is a method they can decide the time allocation based on their familiarity
of teaching in which active learning occurs in the context of with the topic/topics. This allows the usage of microlearning
clinical cases. CBL “links theory to practice, through the specific subject blocks that the individual deems right for
application of knowledge to the cases using inquiry-based themselves which increases information retention compared
learning methods” (44). It helps prepare students for clinical to spreading equal amounts of time over all subjects and
practice through emphasizing problem-solving and clinical allows for students to feel increased satisfaction as they possess
reasoning. c) Gamification uses game design elements, such as more control of their schedule (19).
point systems, leaderboards, badges, and rewards, in tradi- Microlearning’s increase in learning efficacy stems from its
tional nongame contexts (45,46). Regarding education, game utilization of short learning periods and small blocks of informa-
design elements can be applied to existing learning activities tion. Learners are able to repeat previously learned sections in
to facilitate achievement of the activities’ learning objectives shorter bursts of time which according to cognitive load theory,
(47). Gamification has been applied to education in an effort allows for more rehearsal, stronger neural network connections,
to improve learning outcomes by fostering motivation to and more conversion of short term to long-term memory (52).
learn, increasing engagement and interaction, providing real Due to these advantages, microlearning-based formats have seen
time feedback to the learner, and lessening learners’ fear of increased use as a refresher before undertaking rare, new, or dif-
failure (48). d) Flipped classroom teaching is a “pedagogical ficult procedures to promote safety and refine care (12).
approach in which instruction moves from the group learning There is also the benefit of increased engagement from
space to the individual learning space and the resulting group allowing new out-of-classroom ways to have students work
space is transformed into a dynamic, interactive learning envi- together in familiar digital settings like online or social media
ronment where the educator guides students as they apply (53,54). Microlearning has been seen to have a significant
concepts and engage creatively in the subject matter” (49). advantage in reaching a greater audience through platforms like
With flipped teaching, students are introduced to material social media because of an increased ease at grabbing and keep-
before group instruction occurs in the classroom. Pre-class ing one’s attention through these short and concise formats.
material can be delivered through a variety of methods such This has led to studies designed around incorporating micro-
as podcasts, screencasts, or readings from books or articles and learning formats to initially draw in interested learners and lead
can be learned by students at their own pace. The classroom them towards teaching methods that are more detailed like full
or group space used for student-centered active learning online modules and courses to balance the measured quality of
activities is designed to simulate higher-order cognitive skills continuing medical education outcomes (55).
and demonstrate clinical relevance. This format maximizes A disadvantage brought about by microlearning concerns
use of face-time with the instructor, fosters deep learning the discomfort felt by traditional teachers having to switch
through engagement, illustrates clinical application of and learn the emerging digital technologies commonly

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employed. Another worry is the potential for learning to sharing learned information has been shown to have effica-
become too passive when formats such as podcasts are cious mnemonic properties through the utilization of elabo-
recorded and relied upon as the main teaching material and rative processing (67). The act of drawing out learned
not supplemented with active lessons (56). Inequalities also information is not a new concept, but what is notable is the
exist as not all students possess the same degree of access to increased ease of drawing and sharing this information on
technologies which is something universities must consider digital platforms with no physical constraints. In recent years,
and account for when implementing these strategies (38). Pri- technological innovations have made readily available resour-
vacy concerns exist for faculty members as some may not be ces for visual learning in radiology like tablet drawing applica-
aware that policies at their institutions consider this online tions and 3D human atlases which allow increased
course material as employer property. This could be worri- comprehension of difficult anatomy (68).
some if these materials become reused and outdated which Education costs can be further decreased through the usage of
would poorly reflect upon the creators so guidelines should online visual learning tools like 3D Human atlas technology,
be clearly made for instructors’ development purposes (12). which can help conceptualize anatomical areas without the
A range of previous studies have endorsed the efficacy of need for expensive cadaver dissections nor the safety risk of caus-
using microlearning techniques for health care professionals. tic chemicals (33). The 3D atlas technology additionally can
Social media formats have been positively received such as 5 allow students to view past what is feasible in traditional cadaver
Minute Medicine which creates short links upon platforms labs by giving them microdetails of anatomical structures, joint
such as Twitter and YouTube to view common disorders movements, muscle attachments, and muscle actions. Compared
internal medicine residents would encounter in their patients to learning these anatomical concepts from a 2D textbook, the
(57). Another such usage of digital social media platforms 3D atlases allows the ability to add or remove layers and rotate
involves the Chinese Sina Weibo platform similar to Twitter, the anatomical structures in real-time to gain a greater sense of
where students completed case studies in groups and the structure’s three-dimensionality (24).
addressed disease states, drug information, patient plans, and Visual learning can be readily introduced through iPadÒ
more which was seen to improve student interaction and tools like ProcreateÒ , Visible Body Human AtlasÒ , etc. The
communication (58). Mobile devices have also been utilized following sections will highlight the features of the Procre-
to deliver supplemental text messages after class to students ateÒ drawing tool and Visible Body Human AtlasÒ and its
about pharmacological information in a way to promote rep- application in digital radiologic microteaching/microlearning.
etition of cardiovascular medications which showed signifi- In the recent decades, websites such as StatDxÒ and
cant improvement compared to those students that did not RadprimerÒ have been popular and successful by combining
participate (59). Another model applied within microlearning the previous methods of digital, visual and microlearning
is just-in-time-training which provides immediate informa- opportunities for learners to complete on their own time
tion at moments where it is needed such as letting medical with directed questions and links to topics while providing
students watch these videos right before they were required artistic renderings of pathologies to assist in understanding
to perform wrist splint procedures which was seen to decrease various pathologic entities and anatomy. A few of these visual
overall learning time, bolster performance, and can provide learning applications used in day-to-day teaching at our med-
immense value to remote areas of the world where trained ical center are introduced in the following.
health professionals or educational resources are scarce (60).
Another study made use of digital recording technologies by
creating audiovisual screencasts of embryology for medical VISUAL AND DIGITAL LEARNING TOOLS
students to help supplement the course material and allow for HIGHLIGHTS
quick reviews outside of class (61).
ProcreateÒ
The utilization of microlearning often comes with supple-
mentary visual learning cues to further leverage the teaching Tablet drawing apps such as ProcreateÒ are very commonly
benefits (21-23) which are discussed below. used by artists but are excellent for creating radiology figures.
It includes various drawing tools such as brushes, pencils,
charcoals etc. to create the perfect anatomical graphic and an
VISUAL LEARNING
eraser tool to edit a pre-created anatomical graphic to high-
Visual learning has long been used as a supplementary tool to light different anatomical variants or pathological entities
teach a variety of skill levels ranging from young children to when creating teaching material (Fig 1A). Multiple layers can
medical professionals (62,63). An inherent advantage of visual be embedded in the same figure for added functionalities
teaching is allowing the learner the ability to utilize dual cod- such as highlighting and editing specific portions of the figure
ing of information into memory via both verbal association (Fig 1B). These features are also highlighted by this example
and visual imagery, which aids learning (64). of perianal fistulas which was achieved by copying and past-
For radiology, the ability to have effective visual learning ing the same coronal anatomical graphic multiple times in
tools in place has been seen to significantly enhance learning this figure and then drawing out the different pathologies
and engagement (24,65,66). The concept of drawing and (perianal fistulas) for comprehensive teaching (Fig 2). Crisp

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Figure 1. ProcreateÒ erasing and layering: (A) Eraser function-

ality (circle) to erase content from an anatomical graphic to high-
light certain pathological processes, for example differences
between renal scarring & fetal lobulation in the left graphic. (B)
Layers off & on functionality (circle) to showcase gross and
intraoperative correlation to highlight the hand-drawn pathologi-
cal abnormality. (Color version of figure is available online.)

Figure 2. ProcreateÒ copy and pasting: (A) Functionality to

copy an anatomical graphic (circle) and paste it across a figure
to highlight different pathological processes. (B) Multiple Coro-
nal anal canal graphics copy and pasted in the previous subpart
now showing various types of Perianal fistulae (arrows). (Color
version of figure is available online.)

Figure 3. ProcreateÒ add text and drawing guide: (A) Func-

tionality to add crisp text (circle) when creating figure titles and
labels. (B) In-built grid pattern can be used as a guide to adjust
the positioning of figures and text labels (arrows). (Color version
of figure is available online.)

formattable text can be added to any figure (Fig 3A) and where students can rotate anatomical structures in real time
by using the grid pattern as a drawing guide, text labels using applications such as the Visible Body Human AtlasÒ
can be carefully adjusted to create publication quality fig- app. One such example is to highlight the spatial correlation
ures (Fig 3B). of celiac ganglion to the peripancreatic vasculature to teach
its involvement in pancreatic cancer especially when the stu-
dent can rotate the 3D rendered model to match the plane
Visible Body Human AtlasÒ
used for axial CT examinations (Fig 4). This application even
Digital human atlases have pioneered anatomical teaching in provides side-by-side comparisons of cross-sectional radiolog-
the last few decades providing an excellent alternative to ical images with 3D rendered models of abdominal anatomy
cadaveric dissection. Recently this technology is widely avail- which are essential for first year radiology resident and medi-
able on touch screen devices such as tablets and smartphones cal student education (Fig 5). Different anatomical structures

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Figure 4. Visible Body Human AtlasÒ 3D rotation: Screenshot demonstrating 3D correlation of celiac ganglion (arrows) to adjacent anatomi-
cal structures with ability to rotate this three dimensional anatomy to match an axial CT scan for better understanding of celiac ganglion’s cor-
relation to the peripancreatic vasculature. (Color version of figure is available online.)

Figure 5. Visible Body Human AtlasÒ cross sectional correlation: Functionality to make cross sectional radiological image comparisons with
a 3D rendered model of abdominal anatomy at similar levels for a more comprehensive anatomical-radiologic correlation. (Color version of
figure is available online.)

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Figure 6. Visible Body Human AtlasÒ tag and export function:

(A) Ability to add or delete anatomical structures with appropri-
ate tags (arrows) in a 3D rendered model. (B) Anatomical
graphics from Visible Body Human AtlasÒ can be exported to
applications like ProcreateÒ to create and showcase different
anatomical variants. (Color version of figure is available online.)

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