POST 147. April 5, 2021. CORONAVIRUS. “The pandemic helped cement the shift to “a philosophy of really focusing on the role of the physician in reasoning through ambiguous and unknown problems as the focus of education, rather than teaching students that the role of physician was to memorize a body of knowledge that was already in existence and good enough for what usually happens.”

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“Jerrel Catlett’s eyes narrowed on the large intestine, a gloppy, glow stick-like object whose color matched the stool stored inside of it. He chose to isolate the organ, and it expanded on his screen as the body parts surrounding it receded — the gall bladder bright green with bile, the ribs white and curved like half moons.

“My old boss used to tell me that when I did this, I’d be so wowed by how complex the human body is,” said Mr. Catlett, 25, a first-year student at Icahn School of Medicine at Mount Sinai, gesturing to the image of a body on his laptop screen. “But it feels like there’s something missing from the experience right now.”

For generations, medical students were initiated to their training by a ritual as gory as it was awe-inducing: the cadaver dissection. Since at least the 14th century, physicians have honed their understanding of human anatomy by examining dead bodies. But amid the coronavirus pandemic, the cadaver dissection — like many hands-on aspects of the medical curriculum — turned virtual, using a three-dimensional simulation software.

Of the country’s 155 medical schools, a majority transitioned at least part of their first and second-year curriculums to remote learning during the pandemic. Nearly three-quarters offered lectures virtually, according to a survey by the Association of American Medical Colleges, and 40 percent used virtual platforms to teach students how to interview patients about their symptoms and take their medical histories. Though the cadaver dissection posed a trickier challenge, nearly 30 percent of medical schools, including Mount Sinai, used online platforms to teach anatomy.

Though medical students in many states have been eligible for and able to receive the vaccines, some have not yet fully shifted back to in-person learning, with school administrators saying they preferred to wait until Covid case rates decline further. Some in-person training, like practicing clinical skills, has largely resumed.”  (A)

“In terms of the potential impact of postponing rotations, the Liaison Committee on Medical Education (LCME) offered this advice to faculty members: “From national data that you have shared, the LCME knows that most of our medical schools have several elective weeks (or) months in the last year or phase of the curriculum. Should you need to interrupt or postpone clerkships or other required clinical experiences because of the real and important pressures and stresses of the clinical environment, these elective weeks are available to adjust your students’ clinical training schedules without having to delay completion of these required experiences before graduation.”

Away rotations tend to offer exposure to different specialties and facilities to medical students late in their training. The AAMC is encouraging medical schools to help find “local alternatives” for students who planned away rotations in the coming months. The organization also recommends medical schools postpone rotations for students coming in from other medical schools.

While it seems most schools are heeding the AAMC advice, one contributor to the discussion found that students have concerns about how the lack of away rotations may impact their residency applications.

“I am worried that students may feel caught between the perceived or explicit expectations of their schools and those of residency programs, while public health and personal safety fit somewhere between them,” said Daniel Corson-Knowles, MD, Director of Phase 3 curriculum at Indiana University School of Medicine.

A National Board of Medical Examiners (NBME) Subject Exam—commonly called a shelf exam—is often administered with each clerkship rotation. The NBME’s vice president addressed the status of those exams, which are delivered to large groups in-person, in a recent statement.

“We recognize that preparing for and taking scheduled assessments at medical schools during [COVID-19] outbreak is causing uncertainty for everyone,” said Agata Butler, vice president of the NBME. “NBME is actively working with our service providers to coordinate operating plans. We are also investigating all possible options for assessment delivery and are certainly viewing this with urgency.”

To date, the NBME has suspended one exam under its umbrella. The United States Medical Licensing Exam Step 2 Clinical Skills portion was put on hold on March 16.

The teachable moment

Discussion participants universally called for putting student safety at the top of mind in terms of any educational decision that is made, but they also worried about sending the right message.

“While it is important to try to protect students, we also should help them understand that providing care to patients does sometimes require placing oneself at risk,” said David Henderson, MD, associate dean for multicultural and community affairs, at the University of Connecticut School of Medicine and Dentistry, one of the 37 member schools of AMA’s Accelerating Change in Medical Education Consortium. 

“Recalling the reluctance of some providers to treat HIV infected patients early in the epidemic, are we considering the message that we may be sending students about the obligation to treat all patients, with the proper precautions and protections, of course, regardless of the nature of the illness as we craft educational policies. I have heard that some schools are considering restricting student involvement with patients with COVID-19. I am not sure such broad bans send the proper message about our basic responsibility to patients.”

“It is important to acknowledge that clinical students are more than learners—they serve many value-added roles in the provision of care,” Dr Lomis said in a statement. “As the U.S. health system responds to this challenge, we may well rely upon our talented, dedicated students as a critical element of our provider workforce. We have been preparing them for this.” (B)

“There is uncertainty regarding how long this situation will persist and increasing recognition that there may be periods in the future after reengagement in a “new normal” environment, in which quarantines and social distancing may again be required. The challenge is in providing authentic patient experiences for medical students as a key component of medical education under these circumstances. If schools defer clinical immersion experiences, there could be 2 full cohort classes of students in the clinical environment simultaneously and education could be adversely affected by the density of learners (which is already a problem in many geographic locations). Regarding accreditation, the Liaison Committee on Medical Education has provided resources to help medical schools.6

The medical education environment is cross-generational. The former mindset that physicians would work when they were ill was considered to be altruistic and professional, with prioritization of the patient above the physician. However, the situation that COVID-19 represents is different. Clinicians who come to work while they are ill, as well as those who may be asymptomatic and silently incubating the virus, might facilitate transmitting the virus to others. Therefore, the culture of professionalism and altruism must be redefined and take into consideration the effects of potential actions, even with good intentions. This is all the more difficult because of the lack of COVID-19 testing and limited availability of PPE.

Additional unknown academic issues will require attention, including standardized examinations when testing centers are closed, the timeline for residency applications for current third-year students, and the ability to meet requirements for certain subspecialties prior to applying to residency (eg, away rotations).

However, learners across the continuum of education have participated in many ways to care for patients and communities in this crisis. In medical schools across the country, students are volunteering in call centers, creating patient education materials, and helping with grocery shopping, among other activities, while adhering to physical separation, safe travel (walking, biking, or personal car), and supervision.

Recognizing the possibility that the COVID-19 pandemic could result in a health care worker shortage, students may need to be engaged as part of the workforce and embedded in the clinical environment. This situation could change rapidly, and medical schools will need to be nimble and flexible in their response. Some schools are considering early graduation with preparation of fourth-year students to engage as either volunteers or as residents earlier in the clinical environment. The latter may require university flexibility with regard to the conferring of degrees as well as revised processes for licensure.

While in the midst of this COVID-19 crisis, it is crucial that the academic educational community learns from the experience and prioritizes a forward-thinking and scholarly approach as practical solutions are implemented. Reflection and evaluation must follow. For educators, the expression “make your work count twice” (the first time for the job you are doing and the second to get the work published and disseminated [eg, creating a curriculum that you plan to use for scholarship by publishing it]) and the plan for educational scholarship has never been more imperative. One area in which students can serve and have a positive effect is as educators to their peers, patients, and communities, using the tools available through social media and other modalities to help influence behaviors in a positive way.

The COVID-19 epidemic may represent an enduring transformation in medicine with the advancement of telehealth, adaptive research protocols, and clinical trials with flexible approaches to achieve solutions. There are many examples whereby learning from difficult experiences (eg, emergence of HIV, response to disasters) changed discovery, science, and patient care. Students and educators can help document and analyze the effects of current changes to learn and apply new principles and practices to the future. This is not only a time to contribute to the advancement of medical education in the setting of active curricular innovation and transformation, but it may be a seminal moment for many disciplines in medicine.” (C)

“One top priority for leaders is ensuring that students finish clerkships that were upended when learning went virtual in March.

At Morehouse School of Medicine (MSM), last year’s third-year students started their fourth year later than usual so they could first take could take a catch-up clinical skills boot camp. To avoid overcrowding clerkships, the new third-year students temporarily studied remotely, explains Ngozi Anachebe, MD, PharmD, associate dean for admissions and student affairs.

A similar bottleneck is being handled differently by Icahn School of Medicine at Mount Sinai (ISMMS). “We’re allowing third- and fourth-year students in the same clerkships,” says Michelle Sainté Willis, senior associate dean for medical education administration. “Third-years are going to be training alongside more experienced students, so we’ve been working hard to ensure a supportive environment for those newbies.”..

At ISMMS, leaders have been hosting weekly town halls so learners can get updates and ask questions. “All of our senior team is on, and students can address any domain, from financial aid to curriculum,” says Sainté.

Housing is among the many concerns. ISMMS has been working to reduce occupancy in its 600-person residence hall to help prevent disease spread, Sainté explains. Still, leaders there recognize that some students — even first- and second-year students, who are studying 100% remotely — may need a place to live.

“A person can’t necessarily study medicine in their two-bedroom apartment with their parents and siblings,” says Sainté. “We set up a special process for anyone who felt their current environment was not conducive to learning.” Once on-site, residential students have many rules to follow to help them stay safe.” (D)

“UCSF’s professional programs, which enroll about 2,000 students each year, face unique challenges compared to primarily undergraduate institutions because the education is so hands-on, says Elizabeth Watkins, PhD, vice chancellor of Student Academic Affairs and dean of the UCSF Graduate Division. In addition, PhD students across the Graduate Division and other departments are embedded in biomedical research labs throughout campus and face their own challenges in completing research projects.

As the thousands of students head back to UCSF this fall, educators across campus have had to balance innovative distance learning opportunities with safely bringing learners back together for experiences that must take place in simulation labs, clinical settings, research labs, and more.

Through it all, education leaders across UCSF have seized on the current situation to make the curriculum more relevant to the times.

“There’s going to be change, and it’s been catalyzed by the pandemic,” said Davis. “There’s nothing like a crisis to make you focus on your principles.”

Each of the schools has been experimenting with how to translate the hands-on UCSF learning style to an environment in which face-to-face communication may pose dangers.

Under normal circumstances, each school  provides skills labs where students practice with drills, become familiar with glucose monitors or learn to work with catheters. In some instances, the learning has become almost fully remote, while in other cases it is split between online instruction and in-person work on campus in small groups.

The School of Pharmacy, for example, has moved almost all education online, sending students devices like glucose monitors and then using Zoom to teach hands-on demonstrations and letting students practice together in small, online breakout groups.

The School of Dentistry has provided students with kits that allow them to practice with their drills at home, and the school and has invested in new cameras to shoot classroom demos in detail. The recorded demos done during online classes will go into a library of resources that will be available to students in future years as well.

UCSF nursing and medical students are also practicing skills using advanced virtual patient  simulations that help them learn to evaluate patients and propose diagnoses and treatments.

“The virtual simulations provide our students with interactive, life-like patient experiences that allow them to practice critical skills such as diagnostic reasoning and patient assessment,” said School of Nursing Dean Catherine L. Gilliss, PhD, RN, FAAN. “Adopting these types of innovative tools allows us to continue to prepare the next generation of nurse leaders.”

Medical students, who in their second year usually get to practice clinical skills in encounters with actors playing a patient, are able to meet with some of those “patients” online.

“It’s good because we still get the experience of working through a case with an unknown patient who has a whole bunch of symptoms, and we have to figure out the mystery,” said second-year medical student Joshi about the simulations and actor encounters. “It’s important for us to learn, because the future of practicing medicine will involve a lot more telemedicine. But it doesn’t fully replace the clinical experience of being able to do a physical exam.”

Adopting these types of innovative tools allows us to continue to prepare the next generation of nurse leaders.

In collaboration with the Kanbar Center, the School of Nursing and Medicine have transitioned these patient interactions to virtual telehealth visits. Students still get the experience of interacting with a live standardized patient and receive real time feedback from their faculty through Zoom.

Some learning experiences, however, must be done in person.

Graduate students pursuing PhDs typically spend much of their time working with colleagues in the lab. This year’s crop of new students are doing rotations in labs that are operating at only 50 percent capacity in order to maintain social distancing, meaning that their time in the lab will be significantly reduced.” (E)

“The challenges and procedures vary by year and discipline. Ninety-four students are beginning their first year in the Doctor of Physical Therapy (DPT) program, the school’s second-largest student cohort, after the MD program.

“People who want to train as physical therapists are typically people who seek personal connections and caregiving,” says Tiffany Hilton, PT, PhD, assistant program director and director of curriculum for the DPT program. “The isolation and distancing have been difficult. Most of the first-years are in a new environment where they want to make connections, but that’s hard right now. But we’re doing everything we can to prioritize the student experience and give them the education they need to be excellent physical therapists.”

The constraints required by the pandemic can be cumbersome, says Glenda Holcomb, a second-year DPT student.

“When we practice physical therapy skills, some techniques require the subject to lie face down on the table, and that’s a bit awkward when you’re wearing a face shield,” Holcomb says. “But we’re all in the same boat, so that helps. I have my ‘village,’ my little group of friends, and we’re able to get together and study safely, practice skills, and so on. That’s important. It’s easy for your mental health to go haywire in these times, and you have to find ways to connect.”

The Duke Physician Assistant (PA) program, one of the largest in the country with a total of 180 students and nearly 40 faculty, had to rapidly revise its education and clinical rotation offerings last spring to meet the new reality. “The wonderful curriculum that we had nicely prepared to deliver is not a remote, virtual curriculum,” says Program Director Jacqueline S. Barnett, DHSc, MHS, PA-C. “We did not want to try to force a square into a circle, but we had to take that square curriculum and chisel it into a circle to make it fit into this new virtual paradigm.”

The PA faculty has crafted a curriculum with virtual electives and scrambled to schedule rotations for clinical-year students. Some PA students chose a rotation working with the Durham County Department of Public Health to conduct COVID-19 contact tracing. Tara Blackley, MBA, MPH, deputy public health director of the Durham County Department of Public Health, called them “an incredible asset.” The incoming class of 92 PA students is doing mostly online instruction supplemented by small-group in-person activities. For in-person activities, students submit symptom monitoring and use appropriate PPE.” (F)

“The pandemic’s onset was a teachable moment for any health professional. In her JAMA Viewpoint essay, Dr. Lucey outlined what that meant for medical students and how it could be adapted going forward.

The pandemic helped cement the shift to “a philosophy of really focusing on the role of the physician in reasoning through ambiguous and unknown problems as the focus of education, rather than teaching students that the role of physician was to memorize a body of knowledge that was already in existence and good enough for what usually happens,” Dr. Lucey said. “That’s a really important philosophic difference. The first approach really creates physician problem-solvers who are capable of addressing both enduring and emerging threats to health.”

When the physician workforce proved to be overwhelmed in certain hot spots, states called on medical schools to graduate their fourth-year students months early to help bolster the response. The measures required navigating somewhat cumbersome red tape but demonstrated that move could be an option in the future.

“The pandemic showed us an example of why we need to think about early graduation for our students, and it showed us all the hurdles we will need to jump over to do it,” Dr. Lucey said. “It’s a shock to the system that asks the question: if we are willing to attest that our students are competent to graduate early in the pandemic, could we not also do so as a matter of usual practice?” 

The pandemic caused the cancellation of most away or visiting rotations. That could create a more level playing field going forward, since not all students can access such experiences. 

COVID-19 shows why health systems science matters so much

“The opportunity to go around the country and do audition rotations is a clear legacy practice,” Dr. Lucey said. “When you talk with people about it, it’s not clear who it benefits the most. Does it benefit the students or the programs?”

In spite of the absence of away rotations, “I don’t believe that programs will see a big difference in the quality of  that they recruit and match into their programs,” Dr. Lucey said. “As such, it is possible that we will be rethinking whether these rotations should be restarted next season.”

Medical schools were proactive in communicating expectations and restrictions with students. Going forward, Dr. Lucey envisions a more dedicated approach to student outreach during turbulence. She pointed to the civil unrest surrounding police brutality that took place on the heels of the pandemic as a potential example of a time in which that new approach had paid off in medical education.

“It created another really existential disruption to the way many of our learners were approaching their education,” Lucey said. “Our faculty of color and students of color, and the allies that work with them, were really shaken to the bone by this vivid reminder of the elements of structural racism that exist within our communities.  In situations like this, leaders of educational programs need to be facile with crisis communication strategies that support all stakeholders during these crises.”

The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time. “ (G)

“In 2013 the American Medical Association (AMA) started the “Accelerating Change in Medical Education Initiative” to help pave the way for medical schools of the future. Today, 37 medical schools are part of this consortium with the goal of disseminating ideas to positively transform medical education. One of the tasks of the group has been to make technology work for learning, something that the Covid-19 pandemic put front and center.

The proliferation of technology and distance learning will result in an explosion of even more simulation resources, such as watching practical videos on basic surgical techniques like knot tying and suturing. Wolters Kluwer provides digital learning resources such as illustrated books, exams and digitized anatomy atlases. Some companies have really upped the ante when it comes to leveraging the latest tech for medical training. Level Ex, a medical video game company, recently launched levels in their platform to help diagnose Covid-19 patients. OssoVR is on the leading edge of providing immersive virtual surgical training experiences and currently has over 20 residency partners.

Finding the right balance of in-person learning combined with digital platforms will most likely become the norm for current and future medical students. As businesses around the globe have resorted to remote work, as long as the right technology is available and output remains consistent, it could very well turn into a winning combination for medical school students, too.

The Schmidt College of Medicine at Florida Atlantic University embraced and swiftly adjusted to the challenge at hand. Dr. Wood shared, “In the face of this pandemic, medical schools have had to respond with rapid and transformational change. Yet with great change comes great opportunity. There has been a steep learning curve for our medical educators but an impactful one. We exponentially increased the integration of technology and educational platforms into our curriculum in a matter of weeks. We launched virtual multidisciplinary clinical skills training sessions so medical students could enhance their history taking and telehealth skills. Students interact remotely with standardized patients online as faculty observe and provide feedback. Educators use a mix of synchronous and asynchronous learning modalities to keep students engaged. I believe training in telehealth and virtual learning will remain a meaningful part of our medical education program.”

The addition and focus of telehealth curriculum will remain post-Covid-19 and will certainly be weaved into the academic and even clinical setting. Many would agree that the proliferation of telehealth in all capacities is a good change that Covid-19 brought about.

This global pandemic has shed even more light the importance of social determinants of health, and while the virus doesn’t discriminate, the impact it has varies based on numerous socioeconomic factors.  Areas of medicine like population health may become stronger points of focus in medical school curriculum and for students pursuing such avenues.” (H)

“Several months into this disruption, our focus has shifted toward creating a new normal. While a return to contact patient care and teaching remains highly desirable, we are carefully evaluating various formats for delivering other parts of the curriculum. What seems certain is that a return to a typical pre–COVID-19 teaching platform is unlikely, and that many creative changes are here to stay. Large-scale adoption of online education during the pandemic shows that it is possible to achieve a number of teaching objectives virtually. Faculty previously resistant to technology-enhanced learning now have evidence of its ability to meet the needs of preclinical students who value adaptive and self-directed study; some may need to review specific content several times, whereas others will proceed more rapidly. Augmented intelligence and machine learning will support this model by achieving the goal of a more tailored outcomes-based education. Undoubtedly, this undertaking will result in additional innovations, flexibility, and experimentation in areas such as anatomy, problem-based learning, clinical skills education, assessment of student well-being, and mentorship or career advising.

Many improvements to medical education are a natural consequence of disruptive moments. As we reflect on the COVID-19 pandemic, changes to the medical curriculum that ensure more focus on infection control, pandemic modeling, population and public health, telemedicine, and health equity are desirable. New learners need modern tools to prepare for a response to unexpected medical events in the future. In addition, we have witnessed the spreading value of resilience, grit, and tolerance for uncertainty on the front lines of patient care. We must continue to select for these qualities in future matriculants.

Despite the temptation for unfettered innovation, we also know that some elements of the curriculum cannot change. The heroic actions of health care workers currently treating patients with COVID-19 reaffirm professionalism and community service as core attributes of a well-taught student. Clinical competency also depends on reliable assessment tools that ensure that our graduates are prepared to enter residency training with the knowledge and skills to provide safe and effective patient care.

Sinek reminds us that “working hard for something we don’t care about is called stress, while working hard for something we love is called passion” (5). The latter is achieved by witnessing selflessness and a desire to make a difference, core traits that inspired our students to pursue careers in medicine in the first place. As we look toward the future, medical education may never be the same again, and our accrediting agencies will have to join in the adaptation. We now have an opportunity to create a better medical school experience with improved flexibility and outcomes that still ensures competence from this increasingly complex effort.” (I)

The Coronavirus Effect on 12 Types of Health Care Graduate Programs. (J)

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