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During a family medicine rotation at Oregon Health and Sciences University (OHSU), third-year medical students are preparing for a patient visit. Only, instead of entering a clinic room, students sit down at a computer. The patient they're virtually examining — a 42-year-old male cattle rancher with knee problems — is an actor.
He asks for an MRI. A student explains that kneecap pain calls for rehab rather than a scan. The patient pushes back. "It would ease my mind," he says. "I really need to make sure I can keep the ranch running." The student must now try to digitally maintain rapport while explaining why imaging isn't necessary.
When COVID-19 hit, telehealth training and remote learning became major parts of medical education, seemingly overnight. Since the start of the pandemic, students have contended with canceled classes, missed rotations, and revised training timelines, even as the demand for new doctors grows ever more pressing.
Institutions have been forced to rethink how to best establish solid, long-term foundations to ensure that young doctors are adequately trained. "They may find themselves the only doctors to be practicing in a small town," said Stephen G. Post, PhD, bioethicist and professor at New York's Renaissance School of Medicine at Stony Brook University. "They have to be ready."
With limited hands-on access to patients, students must learn in ways most never have before. Medical schools are now test-driving a mix of new and reimagined teaching strategies that aim to produce doctors who will enter medicine just as prepared as their more seasoned peers.
Soon after starting her pediatrics rotation in March, recent Stanford University School of Medicine graduate Paloma Marin-Nevarez, MD, heard that children were being admitted to her hospital for evaluation to rule out COVID-19. Marin-Nevarez was assigned to help care for them but never physically met any — an approach called "virtual rounding."
In virtual rounding, a provider typically goes in, examines a patient, and uses a portable device such as an iPad to send video or take notes about the encounter. Students or others in another room then give input on the patient's care. "It was bizarre doing rounds on patients I had not met yet, discussing their treatment plans in one of the team rooms," Marin-Nevarez said. "There was something very eerie about passing that particular unit that said, 'Do Not Enter,' and never being able to go inside."
Within weeks, the Association of American Medical Colleges (AAMC) advised medical schools to suspend any activities — including clinical rotations — that involved direct student contact with patients, even those who weren't COVID-19–positive.
Many schools hope to have students back and participating in some degree of patient care at non–COVID-19 hospital wards as early as July 1, says Michael Gisondi, MD, vice chair of education at Stanford's Department of Emergency Medicine. Returning students must now adapt to a restricted training environment, often while scrambling to make up training time. "This is uncharted territory for medical schools," Gisondi said. "Elective cases are down, surgical cases are down. That's potentially going to decrease exposure to training opportunities."
When students come back, lectures are still likely to remain on hold at most schools, replaced by Zoom conferences and virtual presentations. That's not completely new: A trend away from large, traditional classes predated the pandemic. In a 2017–2018 AAMC survey, 1 in 4 second-year medical students said they almost never went to in-person lectures. COVID-19 has accelerated this shift.
For faculty who have long emphasized hands-on, in-person learning, the shift presents "a whole pedagogical issue — you don't necessarily know how to adjust your practices to an online format," Gisondi said. Instructors have to be even more flexible in order to engage students. "Every week I ask the students, 'What's working? What's not working?' " Gisondi said about his online classes. "We have to solicit feedback."
Changes to lectures are the easy part, says Elisabeth Fassas, a second-year student at the University of Maryland School of Medicine. Before the pandemic, she was taking a clinical medicine course that involved time in the hospital, something that helped link the academic with the practical. "You really get to see the stuff you're learning being relevant: 'Here's a patient who has a cardiology problem,' " she said. "[Capturing] that piece of connection to what you're working toward is going to be tricky, I think."
Some students who graduated this past spring worry about that clinical time they lost. Many remain acutely conscious of specific knowledge gaps. "I did not get a ton of experience examining crying children or holding babies," said Marin-Nevarez, who starts an emergency medicine residency this year. "I am going to have to be transparent with my future instructors and let them know I missed out because of the pandemic."
Such knowledge gaps mean new doctors will have to make up ground, says Jeremiah Tao, MD, who trains ophthalmology residents at the University of California, Irvine, School of Medicine. But Tao doesn't see these setbacks as a major long-term problem. His residents are already starting to make up the patient hours they missed in the spring and are refining the skills that got short shrift earlier on. For eligibility, "most boards require a certain number of days of experience," he said. "But most of the message from our board is [that] they're understanding, and they're going to leave it to the program directors to declare someone competent."
Robert Johnson, MD, dean of Rutgers New Jersey Medical School, in Newark, says short-term setbacks in training likely won't translate into longer-term skill deficits. "What most schools have done is overprepare students. We're sure they have acquired all the skills they need to practice."
Closing the Gaps
To fill existing knowledge gaps and prevent future deficits, institutions hope to strike a balance between keeping trainees safe and providing necessary on-site learning. In line with ongoing AAMC recommendations, which suggest schools curtail student involvement in direct patient care in areas with significant COVID-19 spread, virtual rounding will likely continue.
Many schools may use a hybrid approach, in which students take turns entering patient rooms to perform checkups or observations while other students and instructors watch a video broadcast. "It's not that different from when I go into the room and supervise a trainee," Gisondi said.
Some schools are going even further, transforming education in ways that reflect the demands of a COVID-19–era medical marketplace. Institutions such as Weill Cornell Medicine and OHSU have invested in telemedicine training for years, but COVID-19 has given telehealth education an additional boost. These types of visits have surged dramatically, underscoring the importance of preparing new doctors to practice in a virtual setting — something that wasn't common previously. In a 2019 survey, only about a quarter of sampled medical schools offered a telemedicine curriculum.
Simulated telehealth consults such as OHSU's knee-pain scenario serve several purposes, says Ryan Palmer, EdD, associate dean of education at Northeast Ohio Medical University, in Rootstown. They virtually teach skills that students need — such as clearly explaining to patients why a care plan is called for — while allowing the trainees to practice forging an emotional connection with patients they are treating remotely.
"It's less about how you use a specific system," said Palmer, who developed OHSU's TeleOSCE, a telehealth training system that has interested other schools. He sees this as an opportunity, inasmuch as telemedicine is likely to remain an important part of practice for the foreseeable future.
To that end, the AAMC recently hosted an online seminar to help faculty with telehealth instruction. But training such as this can only go so far, says Rutgers' Johnson. "There are techniques you do have to learn at the patient's side."
Johnson says that a traditional part of medical school at Rutgers has been having students spend time in general practitioners' offices early on to see what the experience is like. "That's going to be a problem — I expect many primary care practices will go out of business. Those types of shadowing experiences will probably go away. They may be replaced by experiences at larger clinics."
Some learning in clinics may soon resume. Although fears about COVID-19 still loom large, Tao's ophthalmology residents have started taking on something closer to a normal workload, thanks to patients returning for regular office visits. As people return to medical facilities in larger numbers, hospitals around the country have started separating patients with COVID-19 from others. Gisondi suggests that this means medical students may be able to circulate in non–COVID-19 wards, provided the institution has enough personal protective equipment. "The inpatient wards are really safe — there's a low risk of transmission. That's where core rotations occur."
The Road Ahead
In settings where patients' viral status remains uncertain, such as emergency wards and off-site clinics without rapid testing, in-person learning may be slower to resume. That's where longer-term changes may come into play. Some schools are preparing digital learning platforms that have the potential to transform medical education.
For example, Haru Okuda, MD, an emergency medicine doctor and director of the Center for Advanced Medical Learning and Simulation at the University of South Florida, in Tampa, is testing a new virtual-reality platform called Immertec. Okuda says that, unlike older teaching tools, the system is not a stale, static virtual environment that will become obsolete. Instead, it uses a live camera to visually teleport students into the space of a real clinic or operating room.
"Let's say you have students learning gross anatomy, how to dissect the chest. You'd have a cadaver on the table, demonstrating anatomy. The student has a headset — you can see like you're in the room." The wrap-around visual device allows students to watch surgical maneuvers close up or view additional input from devices such as laparoscopes.
Okuda acknowledges that educators don't yet know whether this works as well as older, hands-on methods. As yet, no virtual reality system has touch-based sensors sophisticated enough to simulate even skills such as tying a basic surgical knot, Gisondi says. And immersive platforms are expensive, which means a gap may occur between schools that can afford them and those that can't.
The long-term consequences of COVID-19 go beyond costs that institutions may have to bear. Some students are concerned that the pandemic is affecting their mental well-being in ways that may make training a tougher slog. A few students graduated early to serve on the COVID-19 front lines. Others, rather than planning trips to celebrate the gap between medical school and residency, watched from home as young doctors they knew worked under abusive and unsafe conditions.
"Many of us felt powerless, given what we saw happening around us," said recent University of Michigan Medical School graduate Marina Haque, MD. She thinks those feelings, along with the rigors of practicing medicine during a pandemic, may leave her and her colleagues more prone to burnout.
The pandemic has also had a galvanizing effect on students — some excited new doctors are eager to line up for duty on COVID-19 wards. But supervisors say they must weigh young doctors' desire to serve against the possible risks. "You don't want people who have a big future ahead of them rushing into these situations and getting severely ill," said Stony Brook's Post. "There is a balance."
All these changes, temporary or lasting, have led many to question whether doctors who complete their training under the cloud of the pandemic will be more — or less — prepared than those who came before them. But it's not really a question of better or worse, says Rutgers' Johnson, who stresses that medical education has always required flexibility.
"You come into medicine with a plan in mind, but things happen," he said. He reflected on the HIV pandemic of the late 1980s and early 1990s that influenced his medical career. He hopes young doctors come through the COVID-19 crucible more seasoned, resilient, and confident in crisis situations.
"This is a pivotal event in their lives, and it will shape many careers."
Elizabeth Svoboda is a science writer in San Jose, California. Her work has appeared in the Washington Post, Discover, and elsewhere. She is also the author of What Makes a Hero?: The Surprising Science of Selflessness.
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Cite this: How Well Trained Is the Class of COVID-19? - Medscape - Jun 30, 2020.