Before Lee Goeddel, MD, MPH, treats patients in the surgical intensive care unit (ICU) at Johns Hopkins Medicine, he dons gloves, a protective gown, and a negative air pressure hood that helps dispel pathogens. These days, he also puts on another essential piece of equipment: headgear that holds a cellphone to his forehead so remote students can continue learning during the COVID-19 pandemic.
Thanks to the contraption, students can tune in via their computers or iPads as Hopkins educators narrate the unfolding medical process, and they can shoot over any key questions through a live online chat function.
Goeddel is one of hundreds of U.S. medical educators taking innovative steps as they build remote learning options for students currently sidelined by the COVID-19 pandemic.
On March 17, the AAMC released guidance strongly suggesting that schools remove students from direct patient care to help staunch the virus’s spread and conserve dwindling personal protective equipment. Within days, schools were loading course materials online, and within weeks, the vast majority had developed ways to teach at least some clinical skills from afar.
Today, essential courses have moved over to digital formats, and students and teachers are gathering online for interactive classes and discussion sessions. Of the many necessary educational changes, leaders say, those have been relatively easy to achieve.
Other learning experiences usually offered during clinical clerkships — taking a patient’s medical history or learning hands-on procedures, for example — are tougher to replace. Not only are nonessential surgeries and appointments being postponed during the pandemic, but remote participation also can’t fully replicate real-life encounters. The struggle to address those parts of the curricula have yielded various solutions that — though not ideal — still advance students’ clinical education.
Although experts say the greatest challenges arise in educating third- and fourth-year students, all years are affected since medical education now frequently disperses clinical learning throughout the curriculum.
“I’ll be honest — I don’t know what the future of medicine or the future of medical education is going to look like. The pandemic has been a major disruptor. But it's also creating opportunities to think about new ways of learning and of delivering health care.”
Lisa Martinez, MD
Florida Atlantic University Charles E. Schmidt College of Medicine
“Medical training is a hands-on activity, so it isn’t feasible to provide comprehensive education remotely,” says Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships. “Still, schools are managing to find ways to adapt. What impresses me most is their ingenuity,” she says.
That ingenuity will certainly be vital as educators wrangle with the many challenges that lie ahead, say experts.
“I’ll be honest — I don’t know what the future of medicine or the future of medical education is going to look like. The pandemic has been a major disruptor,” says Lisa Martinez, MD, co-creator of a recent course on conducting telemedicine visits and assistant professor of medicine at the Florida Atlantic University (FAU) Charles E. Schmidt College of Medicine. “But,” she adds, “it’s also creating opportunities to think about new ways of learning and of delivering health care.”
Learning at home alone
Medical students studying at home during the pandemic can now access a vast array of online content at their own convenience.
Instructors are uploading previously taped lectures or recording new ones. Schools are suggesting step-by-step videos on skills, such as inserting a central line, that students will practice once clinics resume. And academic societies and commercial enterprises are offering free access to virtual cases that present a patient’s history, lab studies, and results of a physical exam so students can hone their diagnostic and analytical skills.
Sometimes, instructors are gathering all this — plus related journal articles, writing assignments, and more — into a robust educational package.
The eight-week Bridging Emergency Medicine unit, for example, uses podcasts, interactive websites, and other resources to teach future physicians how to address a variety of ailments from chest pains to dog bites. Originally meant for students transitioning to residency, creators at the University of North Carolina (UNC) at Chapel Hill School of Medicine quickly adapted the material as an online emergency medicine elective, explains Christina Shenvi, MD, PhD, associate residency director for the UNC Department of Emergency Medicine (EM).
Shenvi’s EM curriculum is one of nearly 200 free resources educators can access through the AAMC’s new iCollaborative collection, Clinical Teaching and Learning Experiences Without Physical Patient Contact.
But even with the best of resources, it can be tough — even impossible — to teach certain skills without the hands-on experience students often gain through clinical encounters.
That’s why some schools have been front-loading “book-learning” with the goal of freeing up time later for more in-person instruction.
“We are piling on the material we can do virtually now,” explains Elizabeth Baker, MD, senior associate dean of Rush Medical College of Rush University Medical Center. “Because students will have already learned the content, we’ll be able to give them as many patients as possible in fewer weeks once they get back on campus.”
“The interesting thing about such a disruption in education is that we’re forced to use new technologies. We’ll see how well it works.”
Elizabeth Baker, MD
Rush Medical College of Rush University Medical Center
Baker notes other ways her school has pivoted during the outbreak, including providing first-year students an online alternative to direct cadaver dissection.
“Special software allows students to see the different parts of the anatomy on many different planes in 3D,” she explains. “They can see it all right on their tablet or laptop.”
Until now, Rush has stuck with a fairly traditional, cadaver-based anatomy curriculum, Baker notes. “The interesting thing about such a disruption in education is that we’re forced to use new technologies. We’ll see how well it works,” she adds. “Down the road we’ll need to make decisions about what we might keep and what we might revert back to once the pandemic is over.”
Zooming to online classrooms
Because much of medical training focuses on learning to collaborate, communicate, and demonstrate analytical skills, educators have had to figure out how best to bring together classmates and instructors from afar.
“A cornerstone of our first-year curriculum is case-based learning, in small groups,” explains Deborah Ziring, MD, senior associate dean for undergraduate medical education at Sidney Kimmel Medical College of Thomas Jefferson University. “Students get a case like, ‘Mrs. Jones is a 53-year-old presenting with shortness of breath and a fever of 102.’ Then they discuss such issues as diagnostic hypotheses and what they should do next,” she says. “There’s a lot of group dynamics.” Now, those interactions take place on Zoom, with students typing in chat boxes or raising virtual hands to share their thoughts.
Kimmel educators are also using online meetings to help some third-year students practice presenting cases. Provided with the necessary data, students write up a patient’s history and physical similar to how they would tackle the task back at the hospital. Then, as the case unfolds, they add progress notes and ultimately present during five-minute “virtual rounds” with a faculty member who can provide real-time feedback. Although there’s no patient interaction, students get to polish their analytical and communication skills.
Generally, students are liking the online interactions. “I find synchronous learning so much more engaging. I learn a lot better from something that’s interactive and live,” says Kimmel student Tyler Bauer.
But moving to remote platforms has not been without its bumps for some instructors. In addition to learning the technology, Rush’s Baker says she’s had to shift her teaching style somewhat. “Usually, the way I teach is very interactive,” she says. “I pretty much let everybody shout out answers, and they’re asking each other questions all the time.”
Last week, though, Baker taught her first remote session for a primary care clerkship, and she had to call on students rather than allow a more rapid-fire conversation. “It was much more complicated,” she adds, “but in the end, it was fine. Actually, once I got used to it, it was fun.”
The student will “see” you now
Among the toughest educational challenges has been jury-rigging a range of patient care experiences for sidelined students.
Hopkins third-year student Ambrose Rice describes his experience with Goeddel’s virtual rounds, which were designed for the ICU but have now been replicated in other departments.
“You can’t fully experience a physical exam virtually, such as how … a patient’s lungs sound today,” he explains, “but I can see exactly what the physician sees, like how the patient looks and ventilator settings. … Also, people often think medicine involves mostly what’s done in the patient’s room. But a lot of care is actually done outside the room, doing research on a patient’s condition and making recommendations based on that, and I can still help optimize care that way from home.”
At Jefferson, a “virtual clinical clerkship” has fourth-year students contacting heart patients who have been released earlier than usual because of the outbreak.
“We do essentially what we would do in the hospital,” explains Bauer. “We get the patient’s clinical picture, go over the medications, tell the resident about it, and discuss any needed changes or next steps.” In some ways, Bauer adds, the experience has been more eye-opening than traditional training.
"It's so useful to see how patients actually have adapted after going home,” he explains. He points to a case in which he discovered that a recent patient was confused by discharge instructions for her medications. “When I’m a resident next year, I feel like I’ll be able to communicate better now so patients understand what they need to know as they’re being discharged.”
Meanwhile, for students who can’t connect remotely with real patients, schools are providing the next best thing: online encounters with standardized patients (SPs), the trained laypeople who usually act out patient visits in person.
Thanks to off-site SPs, Martinez started teaching all first-year FAU students how to practice telemedicine two weeks ago. Among the skills participants learn is how to perform parts of the physical exam remotely. “You can talk the patient through taking certain steps themselves, like how to check their own pulse,” she explains.
Such telemedicine skills are increasingly useful now as social distancing and physician shortages make remote care essential, notes Valerie Fulmer, director of the standardized patient program at the University of Pittsburgh School of Medicine. One domain that requires particular attention is learning how to deliver bad news sensitively.
Conveying difficult news is always tough for doctors, but the pandemic has made the necessary skill both more vital and more painful. “There are so many terrible stories of having to give bad news to family members who cannot be in the hospital with their loved ones,” she notes.
What lies ahead?
Leaders in medical education now face looming questions: How can they chart future steps when the road itself is constantly shifting? And how long can they wait before delaying hands-on training becomes seriously problematic?
“We can manage only so long with current plans,” says Lyuba Konopasek, MD, senior associate dean of education at the Frank H. Netter MD School of Medicine at Quinnipiac University.
“We have to deal with the next set of challenges as the pandemic continues,” she says. “In many parts of the country, educators are worried that we will not be able to return all of our learners to clinical settings in June, so are already working on contingency plans.” For Konopasek, looking ahead entails determining whether student reentry is safe and can meet essential learning objectives.
“This is a crisis of a lifetime. If students can learn from it in appropriate ways, it’s going to make our future physician workforce better.”
Lee Goeddel, MD
Johns Hopkins Medicine
Meanwhile, Goeddel points to valuable opportunities for reimagining medical education. Virtual rounds like his, he notes, mean more people can participate from afar. “Not only could you possibly reach a greater volume of trainees,” he says, “but it’s also exciting to think that you might catch something significant in a patient’s care by leveraging the power of crowdsourcing.”
What’s more, he notes, the current educational landscape offers opportunities for students to grow in profound ways.
“This is a crisis of a lifetime,” he says. “If students can learn from it in appropriate ways, it’s going to make our future physician workforce better. There’s so much for them to be inspired by as they see the solutions that are being created for care and the professionalism that’s being modeled.”