Medical Education During the Coronavirus Disease-2019 Pandemic: Learning From a Distance

As paradigms of clinical care delivery have been significantly impacted by the novel coronavirus disease-2019 pandemic, so has the structure, delivery, and future of medical education. Both undergraduate and graduate medical education have seen disruptions ranging from fully virtual delivery of educational content and limited clinical care for medical students to increased clinical demands with redeployment for residents and fellows. Adherence to social distancing has led to the adoption and implementation of already available technologies in medical education, including video conferencing softwares and social media platforms. Efficient and effective use of these technologies requires an understanding not only of these platforms and their features but also of their inherent limitations. During a time of uncertainty and increased clinical demands, the approach to medical education must be thoughtful with attention to wellness of both the educator and learner. In this review, we discuss the influence of the pandemic on the existing medical education landscape, outline existing and proposed adaptations to social distancing, and describe challenges that lie ahead. As paradigms of clinical care delivery have been significantly impacted by the novel coronavirus disease-2019 pandemic, so has the structure, delivery, and future of medical education. Both undergraduate and graduate medical education have seen disruptions ranging from fully virtual delivery of educational content and limited clinical care for medical students to increased clinical demands with redeployment for residents and fellows. Adherence to social distancing has led to the adoption and implementation of already available technologies in medical education, including video conferencing softwares and social media platforms. Efficient and effective use of these technologies requires an understanding not only of these platforms and their features but also of their inherent limitations. During a time of uncertainty and increased clinical demands, the approach to medical education must be thoughtful with attention to wellness of both the educator and learner. In this review, we discuss the influence of the pandemic on the existing medical education landscape, outline existing and proposed adaptations to social distancing, and describe challenges that lie ahead. Clinical Summary•The novel coronavirus disease-2019 pandemic has challenged the structure and delivery of undergraduate and graduate medical education. •Adaptations to social distancing in medical education include creative uses of video conferencing softwares, social media platforms, and Free Open Access Medical education tools•In-person clinical experiences are difficult to replicate virtually, and missed experiences present challenges for the training of those preparing to join the healthcare workforce•Challenges to medical education during the coronavirus disease-2019 era include engagement over video conferencing and social media platforms, balancing of home and work life, and heightened concerns for provider burnout. •The novel coronavirus disease-2019 pandemic has challenged the structure and delivery of undergraduate and graduate medical education. •Adaptations to social distancing in medical education include creative uses of video conferencing softwares, social media platforms, and Free Open Access Medical education tools•In-person clinical experiences are difficult to replicate virtually, and missed experiences present challenges for the training of those preparing to join the healthcare workforce•Challenges to medical education during the coronavirus disease-2019 era include engagement over video conferencing and social media platforms, balancing of home and work life, and heightened concerns for provider burnout. The novel coronavirus disease-2019 (COVID-19) pandemic has disrupted and challenged the well-established, traditional structure of both undergraduate and graduate medical education – whose backbone has been in-person teaching. Even for medical students who may be accustomed to viewing prerecorded content from the comfort of their homes, in-person sessions exist to strengthen concepts and prepare them for the rigors of clinical training. While many medical students have been removed from patient care areas to minimize exposures and preserve personal protective equipment, those who have graduated early from medical school have been assigned to previously unfamiliar clinical environments. 1COVID-19 and early medical school graduation: a primer for M4s. American Medical Association. https: //www. ama-assn. org/residents-students/residency/covid-19-and-early-medical-school-graduation-primer-m4sDate accessed: May 21, 2020Google Scholar Some medical schools have graduated students earlier than scheduled to contribute additional trainees to a strained workforce. 2From medical school to fighting COVID-19 on the front lines at Bellevue hospital. NPR. org. https: //www. npr. org/sections/coronavirus-live-updates/2020/05/15/853545647/from-medical-school-to-fighting-covid-19-on-the-front-lines-at-bellevue-hospitalDate accessed: May 20, 2020Google Scholar Growing clinical and administrative demands as well as illness have redirected faculty time and energy away from medical education, impacting their availability for trainees. Many questions remain for the future of medicine and, particularly, medical education. Here, we describe the disruptive impact of the pandemic on the current medical education landscape, existing and proposed adaptations to social distancing, the balance between learning and wellness during this time, and challenges that lie ahead. For medical students in the preclinical months of training, the COVID-19 pandemic has had a gentler impact on the day-to-day routine compared with the clinical years. The percentage of preclinical scheduled activities that are lecture based varies by medical school, with some schools conducting the majority of teaching in lectures, whereas others use the lecture format as little as 20% of the time. 3Flipped classrooms: scrapping lectures in favor of active learning. AAMC. https: //www. aamc. org/news-insights/flipped-classrooms-scrapping-lectures-favor-active-learningDate accessed: May 21, 2020Google Scholar Over the last decade, in-person attendance to lectures has declined. A 2017 American Association of Medical Colleges survey found that fewer than 50% of second-year medical students attended lectures either “most of the time” or “often, ” likely as they perceive viewing of prerecorded material to be more efficient. 4Data 323: 1127-1128Crossref PubMed Scopus (180) Google Scholar Adherence to social distancing has eliminated in-person small group sessions and workshops during which students discuss concepts with peers and faculty, with some being replaced by video conferencing sessions. Learning and study spaces such as libraries and anatomy laboratories have been shut down. 6Rose S. Medical student education in the time of COVID-19. JAMA. 2020; 323: 2131-2132Crossref PubMed Scopus (1021) Google Scholar Basic clinical training experiences during the preclinical years (eg, history taking, physical examination) have also been affected, raising concern for inadequate preparation of students beginning clinical rotations. Although most preclinical experiences can be substituted with prerecorded lectures and video conferencing sessions, such replacements do not exist for in-person, clinical training. William Osler once said, “Medicine is learned by the bedside and not in the classroom. ”710 osler-isms to remember in your daily practice. Stanford medicine 25. https: //stanfordmedicine25. stanford. edu/blog/archive/2014/10-Osler-isms-to-Remember-in-Your-Daily-Practice. htmlDate accessed: May 21, 2020Google Scholar During the clinical years, students join multidisciplinary teams and practice newly learned clinical skills, while seeing firsthand how the healthcare system functions. These early experiences likely influence their ultimate specialty selection. During the pandemic, medical students have evacuated inpatient and outpatient arenas in an effort to reduce viral transmission, mitigate personal protective equipment shortages, and lower the risk for student infection – a measure supported by an American Association of Medical Colleges recommendation that advises that they be removed from direct patient care activities “unless there is a critical healthcare workforce need. ”8Ahle S. COVID-19: the global disrupter of medical education. ASH Clin News. https: //www. ashclinicalnews. org/viewpoints/editors-corner/covid-19-global-disrupter-medical-education/Date: 2020Date accessed: May 19, 2020Google Scholar, 9COVID-19: updated guidance for medical students' roles in direct patient care. AAMC. https: //www. aamc. org/news-insights/press-releases/covid-19-updated-guidance-medical-students-roles-direct-patient-careDate accessed: May 21, 2020Google Scholar Some have suggested that this strategy undermines medical professionalism and sidelines individuals willing to provide patient care. 10Excluding medical students from Covid-19 care is bad for medicine. STAT. https: //www. statnews. com/2020/04/08/excluding-medical-students-trainees-opting-out-covid-19-care-bad-for-medicine/Date: 2020Date accessed: May 21, 2020Google Scholar, 11Miller D. G. Pierson L. Doernberg S. The role of medical students during the COVID-19 pandemic. Ann Intern Med. Published online ahead of print. April 7, 2020;: M20-M1281https: //doi. org/10. 7326/M20-1281Crossref Scopus (181) Google Scholar Although having optional clinical experiences has been proposed, this strategy may be perceived as inequitable to those students not electing to participate. 11Miller D. G. Pierson L. Doernberg S. The role of medical students during the COVID-19 pandemic. Ann Intern Med. Published online ahead of print. April 7, 2020;: M20-M1281https: //doi. org/10. 7326/M20-1281Crossref Scopus (181) Google Scholar As the 2020-2021 academic year begins, medical students beginning their final year of medical school may not have completed necessary requirements to participate in senior year rotations. In the 2018-2019 academic year, more than 140, 500 medical residents and fellows were enrolled in Accreditation Council for Graduate Medical Education (ACGME) –accredited training programs and make up about 14% of active physicians in the United States. 12ACGME Home. https: //acgme. org/Date accessed: May 19, 2020Google Scholar In anticipation of the pandemic peak, the ACGME implemented 3 stages of graduate medical education: stage 1, “business as usual” (no significant disruption of educational activities) ; stage 2, increased clinical demand (some residents/fellows shifted to patient care, some educational activities suspended) ; and stage 3, pandemic emergency status (majority of residents/fellows shifted to patient care and most educational activities suspended). 13ACGME response to pandemic crisis. https: //acgme. org/covid-19Date accessed: May 19, 2020Google Scholar Many house staff in the hardest hit areas were redeployed from their specialties to the front lines in emergency departments, hospital wards, and intensive care units. Residency and fellowship programs exist to train physicians through hands-on clinical experience and teaching. In the pre-COVID-19 era, trainees and attending physicians traditionally rounded together to see patients at the bedside and discuss teaching points. In light of social distancing and increased patient care demands, these established teaching and learning opportunities, as well as didactic conferences, largely dissolved. 14Ferrel M. N. Ryan J. J. The impact of COVID-19 on medical education. Cureus. 2020; 12: e7492PubMed Google Scholar On the wards, direct patient contact was often limited to more senior individuals, and supervised procedural training was reduced. Despite the emergency pandemic declaration, the ACGME mandated that trainees continue to receive adequate supervision and training while adhering to duty hours. 15Well-being in the time of COVID-19. https: //dl. acgme. org/pages/well-being-in-the-time-of-covid-19Date accessed: May 22, 2020Google Scholar At Mount Sinai Hospital in New York City, the Department of Medicine established a 3-tier system led by a hospitalist who supervised a team of individuals, some of which may not have had internal medicine training. 16Kim M K, Rabinowitz L G, N Satish, et al. A primer for clinician deployment to the medicine floors from an epicenter of Covid-19. Catal Non-issue Content. 1 (3). 2020 https: //doi. org/10. 1056/CAT. 20. 0180. Accessed May 19, 2020Google Scholar, 17I'm A Doctor in A COVID-19 Unit. Before you call Me A Hero, Here's what you Should Know. | HuffPost. https: //www. huffpost. com/entry/doctor-covid-19-pandemic-heroₙ₅eac470dc5b65156135ccc9eDate accessed: May 19, 2020Google Scholar Many trainees were immersed in telehealth patient encounters as in-person clinic visits were canceled. 18Mehrotra A. Ray K. Brockmeyer D. M. Barnett M. L. Bender J. A. Rapidly converting to “virtual practices”: outpatient care in the era of Covid-19. NEJM Catal Innov Care Deliv. https: //catalyst. nejm. org/doi/abs/10. 1056/CAT. 20. 0091Date: 2020Date accessed: May 21, 2020Google Scholar With appropriate attending supervision via an additional mobile device, these telehealth encounters can approximate lessons learned in person at the bedside but lack opportunities to practice direct patient interaction and physical examination skills. Although trainees continued to staff inpatient services, they were unable to participate in prescheduled electives and other required rotations that may be important for subspecialty decisions and fulfill graduation requirements. Of note, accreditation bodies have given flexibility to program directors around the assessment of trainees' readiness for unsupervised practice. 19ABMS and ACGME joint principles: physician training during the COVID-2019 pandemic. https: //www. abms. org/news-events/abms-and-acgme-joint-principles-physician-training-during-the-covid-2019-pandemic/Date accessed: May 22, 2020Google Scholar With the limitations on elective surgeries, residents and fellows in surgical specialties may have struggled to perform procedures required by accreditation bodies for licensure and independent practice. The implication of these shortfalls remain uncertain, but there is concern for the possibility of inadequate training of proceduralists. 20Almarzooq Z. Lopes M. Kochar A. Virtual learning during the COVID-19 pandemic: a disruptive technology in graduate medical education. J Am Coll Cardiol. 2020; 75: 2635-2638Crossref PubMed Scopus (291) Google Scholar As this academic year comes to a close and new trainees enter the workforce, in-person orientation sessions will be condensed into virtual programs. Likewise, residency and fellowship interviews will be transitioned to a virtual format. The COVID-19 pandemic has necessitated adoption and implementation of already available technologies in medical education. In many institutions, Zoom and similar video conferencing platforms like BlueJeans and Microsoft Teams have now replaced the in-person lecture-style and small group meetings. 20Almarzooq Z. Lopes M. Kochar A. Virtual learning during the COVID-19 pandemic: a disruptive technology in graduate medical education. J Am Coll Cardiol. 2020; 75: 2635-2638Crossref PubMed Scopus (291) Google Scholar, 21Video conferencing, web conferencing, webinars, screen sharing - Zoom. https: //zoom. us/Date accessed: May 21, 2020Google Scholar, 22Blue Jeans Network. Blue jeans network. Available at: https: //www. bluejeans. com, Accessed May 21, 2020. Google Scholar, 23Chat, meetings, calling, collaboration | Microsoft teams. https: //www. microsoft. com/en-us/microsoft-365/microsoft-teams/group-chat-softwareDate accessed: May 21, 2020Google Scholar Of note, these platforms are not new and have been a prevalent resource that allowed learners to attend lectures remotely. The pandemic has significantly expanded users of these softwares, with Zoom users growing from 10 million to 300 million users from December 2019 to April 2020. 24Warren T. Zoom grows to 300 million meeting participants despite security backlash. The Verge. https: //www. theverge. com/2020/4/23/21232401/zoom-300-million-users-growth-coronavirus-pandemic-security-privacy-concerns-responseDate: 2020Date accessed: May 21, 2020Google Scholar Zoom features important tools useful in education such as shared screens, whiteboard, polling, breakout rooms, and annotation to facilitate interaction. The option to to a of their a The whiteboard, for those accustomed to both the educator and to on a facilitate small group work or features response and the of video conferencing features and of their of and With either the meeting or participants to their screen with other lecture with on of can a seen by be to with or can be at the of the on can questions or with 10 that can be shared with the can be as during which participants practice can the group into for a of time as a group can with the to them to join their group to questions or medical student during which they in small of may use the tools that are available to on the to on screen that is the on a shared from the and to participants can with the group or questions during a lecture on the a with is shared with can with the (eg, and medical student their to a about a or uses existing (eg, to their an by learners to use a of their is and to either the or Zoom the screen sharing is the screen is with a of the in the sessions and an of the are also on a and the the Open in a new Free Open Access Medical education (eg, and and social media platforms (eg, that had as to have now to the In these have over the last and to a social media Google Scholar such as and assessment of a teaching PubMed Scopus Google Scholar have been to virtual elective experiences in and In learners have had opportunities to join virtual educational experiences shared on social media including the online lessons from years on the of social media medical education. accessed: Scholar on from Scopus Google Scholar At the of Medicine at Mount a Medical program was to students who had at the of Medicine at Mount Sinai for residency to with such as to and Sinai medical students graduate some to join a medical Mount Sinai 2020Date accessed: May 22, 2020Google Scholar that attendance has with the adoption of video conferencing, of availability of and mobile this implementation of virtual educational content delivery has In 3, we and to and of virtual medical education. effective in video conferencing platforms requires a with disruptions and a In faculty accustomed to are traditionally on a to a is now to content to the through video and to Virtual Medical and to Virtual Medical your to the and a learners to to both and minimize and them to as a video conferencing the a the as and participants once the is learners to to (eg, faculty or orientation sessions for to use of teaching the in a on the screen while or a to and up an and participants to the use of patients via video conferencing is a to that the meeting a like participants at the of a to for sharing meeting to minimize by shared more security (eg, to sessions with the meeting Open in a new In an era clinical and administrative on educational time, programs can be time of new educational content may be in such a time of uncertainty and increased clinical In on interaction to content and based on is with video conferencing, understanding and can be a for those who may be conferencing softwares for the there a of faculty who may be to or with the adoption of virtual educational platforms. learners and will be with for those to these these technologies will be required use virtual platforms to learners learning and educational A. a for Scopus Google Scholar The is the of patient encounters during the undergraduate medical education years. 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