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Maximizing the Value of Asynchronous Learning in Pre-clerkship Medical Education

Special Issue: Blended Learning Technologies in Healthcare

By Phorum Sheth, Anita Samuel, Eulho Jung, Jacob Collen / February 2023

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In the late 1990s, changes to how students learned were already apparent: most students were studying on their own using a mix of class content provided by their professors, home grown study tools (note taking services or previous years’ exams or assignments), and commercial study and test preparation content.1 This trend has only grown in the last two decades. In many medical schools, students do not attend in-person lectures, preferring instead to watch lecture videos or access other educational resources [1]. Although medical students have been engaging in asynchronous learning, medical schools have been slow to adopt online education. While there has been a boom in online education, medical schools were behind in joining this effort. But this all changed with the COVID-19 pandemic, which forced medical schools to adopt online education.

The pandemic has debunked the notion that all educational activities must occur within the confines of a classroom. Many of the educational activities we historically did in person can be done just as well or better in the comfort of one’s home and on our own time. Leveraging asynchronous learning allows for this broadening of the educational environment.

Defining Asynchronous Learning

Asynchronous learning can be defined as a learning environment where students can access educational materials “at their own pace” and interact with peers and instructors “over longer periods” [2]. Students can engage with course content and course activities even when they are not located in the same place at the same time.

In medical schools, asynchronous learning usually refers to content that is delivered outside the traditional in-person classroom. This content can include instructor recorded lectures, YouTube videos, and other online apps and resources such as Pathoma [1]. In this article, we refer to two asynchronous learning activities: recorded lectures and online communications with instructors.

Asynchronous Learning in Pre-Clerkship Medical Education

The pre-clerkship curriculum at our institution comprises nine modules. The cardiopulmonary and renal organ systems module spans nine weeks, encompassing a fast-paced schedule of lecture, laboratory, clinical simulation, and small group exercises. There is a tremendous volume of complex material that is tested on the medical licensing examination. As a module director for this module, mapping and ensuring the content meets specified learning objectives in the limited block of time is paramount.

Asynchronous education methods provide an attractive tool to mitigate many of the logistical challenges in the module. Students can learn content on their own time at home, rather than filling a lecture hall at a predetermined time. Standard in-person classroom hours can then be utilized more efficiently for synchronous and in-person active learning small group exercises (laboratory, clinical reasoning, simulation, physical exam, and medical interviewing). Asynchronous learning is a force multiplier that can dramatically improve value for time that might otherwise be spent passively learning in a lecture hall.

In this article, we explore the affordances of asynchronous learning within the pre-clerkship medical education context. We discuss three benefits of asynchronous learning in the pre-clerkship curriculum: (1) efficiency, (2) helping the dialogue between student and faculty to evolve, and (3) increasing the transparency of the educational process. We then highlight some of the limitations of asynchronous learning that need to be considered.

Balancing Volume, Complexity and Efficiency

Medical students seek the highest yield ways to learn. Social media and nearly universal access to high-speed internet has generated high expectations for efficiency and immediate gratification [3]. Asynchronous education has been a game changer in the pre-clerkship period. A one-hour lecture, with extraneous conversations removed, can be delivered in 30 minutes. The content is reproducible. Faculty theoretically can reuse lectures indefinitely, and even make revisions without having to re-record the entire lecture. Students can watch the lectures at 1.5–2x speed, and they can go back and review those concepts they find confusing [1].

This efficiency perspective, however, needs to be juxtaposed with considerations of volume and complexity. During pre-clerkship, there is more content volume than can possibly be learned by students. Asynchronous curricular development is not simply a matter of pre-recording lectures and putting them online for students. This approach ignores the notion of cognitive load [4]. Medical students are high academic performers, but there are limits on how much cognitive bandwidth they have available to translate lecture content to working memory. Educators must understand cognitive learning theory with respect to asynchronous curriculum development [5]. This entails evidence based, best practices for developing asynchronous prerecorded educational content that accounts for cognitive load, learner attention and engagement, and schema construction. Best practices for asynchronous content include shorter lectures (10–15 minutes) and inserting frequent knowledge checks with practice questions [5].

Connecting with Peers and Faculty 

Asynchronous learning creates a distance between students and students and faculty [6]. If you no longer have students sitting to your left and right to connect with, you must find ways to interact in meaningful ways with your online colleagues to foster learning and social presence. While the online environment does create distance, it also provides more avenues for access.

Online access to faculty is better than ever. Today students can email professors any time of day and get a response in less than 24 hours. We do not view this as entitlement or over-stepping an institutional hierarchy. In a traditional and hierarchical environment such as medical education, improved access to faculty is a sign of progress. During our module, which runs for two months, an important interaction for the module directors and faculty members is email communication with. The electronic dialogue with students is time consuming, but an incredibly valuable way to be a part of students’ formative years of education while gaining insights into how students learn information and generate questions. Generating questions effectively is a critical skill for all physicians. This dialogue also forces educators to grow, forcing them to continually revise educational materials. Just as patients never fail to surprise you in clinical medicine, students continue to amaze faculty members with the tough questions they manage to ask about the basic elements of medical science.

Asynchronous Learning and Transparency in Educational Processes

Not only does asynchronous learning have benefits for efficiency and helping the dialogue between student and faculty to evolve, but it increases transparency within the educational process. Faculty and schools can get objective data on how well their curriculum is performing. Learning objectives can be linked to specific methods of assessment (exam questions) and results. If students are performing particularly poorly on examinations, it is easy to do a root-cause analysis. Each lecture and its individual learning objectives can be mapped to exam questions. There is increasing attention to this notion of transparency in medical education. Students have always been held responsible for learning content. In the past, it was rare to question the authority of a faculty member or the quality of their lecture. Virtual asynchronous learning evens the playing field. Now there is a parallel curriculum for faculty to follow.

To create high quality PowerPoint lectures, we followed an evidence-based approach [7]. The prerecorded lectures are mapped to learning objectives and those learning objectives are mapped to exam questions. We can now track quantitatively how students perform on various elements of the curriculum. Worsening performance on questions can be tracked to a specific lecture, and even learning objective. This does not necessarily mean the lecture or learning objective is poor, but it does help faculty figure out where students are struggling and make improvements. Student attendance, time spent, and feedback tracked by the video hosting platform.

This facilitates a mixed methods approach to curriculum appraisal and revision. The notion of a “bad professor that gives terrible lectures,” can be systematically analyzed. You can triangulate qualitative feedback from students (free text survey responses and feedback on the lecture in question), to quantitative data on the lecture itself (how long students spent logged into the lecture, how many students watched the lecture, how many students gave feedback), as well as quantitative data on student performance (on examination questions that map to that lecture and its learning objectives). If students did poorly on the exam questions that map to a given lecture, but their survey feedback is non-specific, only a minority of students provided feedback, or even watched the lecture, that is valuable information. Alternatively, if attendance and engagement metrics are high, and performance is poor, it raises questions about the quality of the content or speaker.

Considerations When Deploying Asynchronous Learning

Expectations are high for asynchronous learning. And, in addition to developing quality content, educators must do a better job of curating their content. Students demand high quality prerecorded lectures so they can learn at their own pace. Although prerecorded lectures should have a longer lifespan, students expect slide decks to be revised yearly. They notice if the date on the title slide is a year old. The increasing expectations for quality control and revisions leads to problems with version control. Our pre-clerkship modules last 8º9 weeks and usually include 60–90 lectures in addition to laboratory and small group activities. There are on average 25 hours of instruction per week. Student time is scarce and of great value. Any confusion about what lecture to review, or the last-minute posting of a revised lecture creates panic, as students struggle with how to allocate their time.

Planning around the issue of version control on the front end (months in advance of the module) will avoid confusion during the block of instruction. In our module, a lecture on acid-base physiology was posted in advance of the session. After the date of the lecture had passed, we realized we had inadvertently failed to post a revised and updated version of the lecture. Although the content in the original lecture was correct and would prepare students adequately for the test, the students were upset about the last-minute change. In their minds, they now had two lectures to review for the same content. Several hours were devoted to answering emails, correcting the online curriculum software platform, and responding to complaints from faculty. This specific issue was noted by many students at the end of module feedback. There is no room in the fast world of pre-clerkship medicine for redundancy, duplication of effort, or misinformation.

Ongoing, real-time edits of a virtual lecture creates challenges with version control. There are endless digital formats for delivering a lecture and to ensure quality control and consistency for curriculum delivery, we recommend adhering to a standard format. Institutional support, digital expertise and faculty development for execution is critical. The increased quality outlined in this article demands more time from faculty. Faculty will need support for this effort if they are to do this in conjunction with their regular clinical and teaching duties.

While asynchronous learning may optimize the use of time in class, there are pitfalls to consider. We may be losing sight of other traits crucial in developing future doctors when we become excessively focused on making learning more efficient by cramming as much content into a block of instruction as possible. Although being able to provide a vast amount of content online is satisfying to educators and students, students may not be able to (a) absorb the material and (b) translate the learning to effective performance (passing an exam, caring for a patient).

There are also issues with clarity and unpredictability regarding how students understand and triage virtual lecture content. Faculty noted during office hours, it was apparent students struggle to prioritize which elements of a lecture are most important and which are less so. For instance, several students became preoccupied with understanding the exact definitions of lung sounds (e.g., difference between wheezes, rales, rhonchi, and the anatomic and pathophysiologic correlates). I found myself fielding several emails about this and had trouble satisfying the students in my answers. This material was introduced as part of formative, low stakes clinical reasoning sessions on dyspnea and cough. The students perseverated on wanting exact correlates for which lung sound matches which anatomic location in the lung or specific disorder. Vague descriptions and correlates, such as the “dry Velcro crackles” seen in pulmonary fibrosis, the “wet” rales in congestive heart failure, the expiratory wheezing in asthma and COPD, the focal wheezing in a child with an aspirated foreign body, and so on, were not enough. As a faculty member, I could not understand what it would take to satisfy their curiosity. Then it dawned on me, we had recently taught them the heart sounds and how different heart sounds correlate to discrete physiologic phenomena in the cardiac cycle and how certain murmurs are very specific for conditions. They were expecting the same degree of exactness with the lung sounds and we weren’t giving it to them. In the past, in the live lecture hall environment, this confusion never emerged. But with fast-paced prerecorded lectures, the only avenue for questions was later, either through email, the follow-up clinical reasoning small groups, or in review sessions before the test. This is a minor point but highlights the potential for students to fixate on the wrong details in a lecture, intuit an incorrect interpretation of knowledge, and possibly detract from their learning.


Asynchronous learning is unique because of the lack of live engagement between faculty and learner. A recent editorial by Harvard medical students laments the loss of in-person pre-clerkship education [8]. Educators must redesign virtual, asynchronous learning to meet the needs of our current situation, and where possible, develop greater innovation in medical education. Fortunately, educators have stepped up to standardize this process, systematically reviewing best practices and offering tangible solutions for asynchronous learning [5, 7, 9, 10]. 

Although best practices in medical education will continue to evolve, and there will be conflict regarding in-person versus virtual asynchronous learning, the virtual learning environment is here to stay. Pre-clerkship medical education is no longer a passive process where students attend school during the day, study at night, and graduate with a degree. Educators and students should view their relationship as symbiotic. The pre-clerkship curriculum should be viewed as a living document that educators constantly revise in alignment with evidence-based practice and learner feedback. Our attitudes will require some adjustment, both for faculty and students, as we make this transition.

In clinical medicine, we recognize the importance of expectation management for our patients, and we need to apply this to the educational setting as well. Be more forgiving of mistakes. Virtual platforms are highly visible, which can increase faculty and learner anxiety. Mistakes will occur and efficient solutions to notify others and make corrections are paramount. They also offer opportunities to learn, not just about an error in a lecture and why it occurred, but about the process of medical education, and the flow of information in this new age.

Effective learning in medicine, or any performance-based profession, is also about struggling through doubt and adversity. Discomfort is a part of medicine (physician uncertainty, not just patient discomfort), and the path to growth as a physician is through mentorship and relationships with colleagues. Experiencing and growing from discomfort is crucial to becoming a physician and cannot be gained through streamlined online content alone [11]. 

Disclosure Statement

The authors have indicated no financial conflicts of interest. The views expressed in this paper are those of the authors and do not reflect the official policy of the Uniformed Services University of the Health Sciences, Department of the Army, Department of Defense, or the US Government.

1 Dr. Jacob Collen entered medical school in 1998, where he witnessed fewer students attending in-person lectures.


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[5] Taveira-Gomes, T., Ferreira, P., Taveira-Gomes, I., Severo, M., and Amélia Ferreira, M. What are we looking for in computer-based learning interventions in medical education? A systematic review. J Med Internet Res 18, 8 (2016), e204.

[6] Lee, Y. and Choi, J. 2010. A review of online course dropout research: Implications for practice and future research. Educational Technology Research and Development 59, 5 (2010), 593–618.

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About the Authors

Phorum Sheth graduated UCLA with a B.S. in biochemistry and a minor in theater in March 2016 and completed her M.S. in physiology at Georgetown University in 2019. Her goal is to become an astronaut to study biological systems in microgravity climates. She has participated in many research projects studying the transmission of Parkinson’s disease and was a clinical research coordinator for Operation Warp Speed working at the Walter Reed National Military Medical Center. on the COVID vaccines during the COVID-19 pandemic as well as a researcher within the Sleep laboratory at Walter Reed working on the SWIFT project. Her creative credits include performances and writings such as plays, poems, and songs. In her time as a Program Coordinator at CureCervicalCancer she led training programs for healthcare workers in low resource countries like Haiti, Vietnam, and Tanzania in cervical cancer prevention and set up a number of prevention clinics in these regions. As a future physician she is committed to providing improved care to servicemen and women and helping protect the American nation. She is currently planning to matriculate to the Uniformed Services University in August 2023 as a first-year medical student in the Navy.

Dr. Anita Samuel is Assistant Director of Distance Learning and an associate professor at the Center for Health Professions Education, Uniformed Services University of Health Sciences, Maryland. Her areas of expertise are online learning, educational technology, and adult education. Dr. Samuel’s research focuses on continuing professional development and workplace training for healthcare professionals. She explores online learning spaces as effective training environments for professionals. She has won the USU School of Medicine Impact Award for her work in facilitating distance education and the USU Education Day award for using videos in online courses to create presence for learners.

Dr. Eulho Jung has earned a doctorate in instructional systems technology from Indiana University Bloomington. He is currently serving as an assistant professor at the School of Medicine, Uniformed Services University of the Health Sciences (USUHS), a military medical school. His research interests revolve around intersecting expertise development and instructional systems design with the goals of realizing personalized learning.

Dr. Jacob Collen is a pulmonary, critical care and sleep medicine physician and professor of medicine at the Uniformed Services University and Walter Reed National Military Medical Center in Bethesda, Maryland. He has been the module director for the Cardiopulmonary Renal Module in the first year of medical school at the Uniformed Services University since 2017. Dr. Collen attended the Uniformed Services University of the Health Sciences, graduating with an M.D. in 2002. He has worked as an Army physician in San Antonio, Texas, Germany, Iraq, Afghanistan, and has been in Bethesda since 2015.

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