In a survey administered September 2020, 45% of 124 student respondents reported virtual learning was very or extremely effective, and 49% indicated it was moderately effective. Only 52% indicated they enjoyed virtual learning (64% of MS2 class, 44% of MS1 class), and 68% of MS2’s reported virtual learning was somewhat or much worse than in-person learning. Content analysis revealed both successes and challenges. Successes included effectiveness of chat moderators, displaying pronouns on Zoom, active learning technology tools, and captioning and transcription. Challenges included inadequate access to technology and bandwidth, limited social and community-building activities, and “Zoom fatigue.”

Overall course ratings were similar comparing in-person learning (seven courses, average 4.14, 1–5 scale) and VLE learning (seven courses, average 4.12, 1–5 scale).

Examination performance was similar comparing in-person learning (97.8% pass rate out of 2177 student examinations) and during VLE learning (97.9% pass rate out of 2426 student examinations). There were no incidents of unethical examination behavior.

Weekly work hours were similar comparing in-person learning (seven courses, average 48.9 h per week) and virtual learning (seven courses, average 49.7 h per week).

The VLE principles our working group developed were formally integrated into the standard annual course evaluation process.

The COVID-19 pandemic stimulated rapid change in medical school curricula. At the UCSF-SOM, we followed a rigorous, theory-informed process to promote learning during this time. While objective measures of students’ learning and work hours did not change, student perceptions of learning and enjoyment declined during the VLE. Taken within the context of our single-site experience, lessons learned have implications for pre-clerkship medical school curricula.

We identified sociocultural learning theory and cognitive load theory as relevant to VLE principles, yet sociocultural aspects of learning appeared more greatly impacted than cognitive learning. Barely half of students indicated they enjoyed learning in the VLE, and narrative comments suggested deficits in socioculturally oriented principles of professional identity formation, communities of practice, and wellness and fun. Curricula often focus on professional identity formation but leave tacit responsibility for the latter two principles to students. Our experience suggests schools ought to assume intentional roles in promoting community formation and wellness.

One positive sociocultural impact was instructors’ intentional efforts to make themselves known and available to students and their positioning of “being in this together” with students. We argue it is critical that faculty and staff engage with students and their communities to promote wellness and professional identity formation, as opposed to a stereotypical hierarchical approach.

Despite potentially high levels of extraneous load contributed by virtual learning and fears about pandemic, student performance on examinations did not diminish in the VLE. Likewise, course ratings suggested similar high quality of teaching. These findings suggest cognitive learning was maintained in the VLE, despite logistical changes.

In 2020, Emanuel wrote that the COVID-19 pandemic would spell the demise of classroom-based pre-clerkship instruction [5] and that schools would transition to exclusively online preclinical training. The commentary referred to in-person lectures as “a waste of everyone’s time.” The commentary hewed predominantly to a cognitive framework (minimally affected in our experience) and did not refer to sociocultural aspects of learning (highly affected in our experience). The commentary also did not mention “Zoom fatigue” (which was the single most commonly cited grievance of students and faculty alike) and did not address inequitable impacts on less privileged students entering medical school with less understanding of the culture of medicine[6], as well as those with learning disabilities or with limited access to technology. In contrast, our experience suggests that in-person pre-clerkship learning is of vital importance, particularly to support sociocultural learning and professional identity formation.

Our experience suggests virtual learning has potential advantages when used strategically. The ease and availability of virtual meeting platforms permits schools lacking local expertise to recruit faculty from other institutions to teach, benefitting student learning and faculty development alike. Strategies we “discovered” during the VLE experience, such as polling software, may help students remain engaged and promote learning during didactic sessions. The chat moderator role allows students to ask more detailed questions and better engage with the material. Encouraging faculty to present themselves authentically and providing dedicated time and space for students and faculty to get to know each other can promote professional identity and community formation. Finally, and perhaps of greatest future impact, schools can maintain the nimble and flexible approach required by the pandemic to continue improving curricula and combat the structural inertia present in many medical schools.

While the pandemic continues to wax and wane, we know that future novel challenges yet await. Our local experience supports a nimble, theory-informed approach engaging stakeholders across disciplines and levels of training in order to promote successful curricular adaptations in times of crisis, thereby promoting optimal medical education for our learners, teachers, and patients.