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    Back to medical school during COVID-19

    Educators have had to rebuild courses, reconfigure spaces, and adapt to unfolding challenges in order to ensure that future physicians get the training they need while still staying safe. How is it all going to work?

    Tulane University School of Medicine students talk with an attending physician (center) during OB/GYN rounds in August
    Tulane University School of Medicine students talk with an attending physician (center) during OB/GYN rounds in August.
    Courtesy: Tulane University School of Medicine

    When Daniel Alban heads back to Florida State University (FSU) College of Medicine next week, the second-year student says he’ll be excited but also somewhat nervous. Since COVID-19 ended his in-person classes months ago, so many aspects of medical education have changed — from strict safety protocols to dramatically different modes of learning.

    “The upcoming semester feels like a test run for all of us, maybe even a bit of a mess,” Alban says. “But we’re up to the challenge. Students are resilient.”

    For months after COVID-19 hit, schools stopped many aspects of student involvement in patient care to free up faculty to focus on battling COVID-19 and conserve personal protective equipment (PPE).

    Now, a new year is beginning. Though the virus is far from contained, experts note that medical education still needs to keep rolling forward.

    Across the country, leaders in medical education are churning out creative ways to balance training future physicians with ensuring the safety of students, patients, staff, and communities.

    Some schools have already launched the 2020-2021 academic year, and others will do so by September. An AAMC survey of 155 member medical schools showed that more than 80% of respondents plan to return third- and fourth-year students to required clinical clerkships by the end of August. The survey indicates that first- and second-year students, who generally receive less hands-on clinical training, will largely be studying online — at least initially.

    Gearing up for this school year has meant reconfiguring rooms for social distancing, boosting student supports, adjusting calendars to make up for lost time, and much more.

    “The upcoming semester feels like a test run for all of us, maybe even a bit of a mess. But we’re up to the challenge.”

    Daniel Alban
    FSU College of Medicine

    “School leaders are dealing with a puzzle, putting together the pieces to make sure students receive all the experiences they need,” says Katherine McOwen, AAMC senior director of educational affairs. “They know that without sound educational and safety decisions, students could suffer greatly.”

    Some decisions still lie ahead. Not all schools have figured out whether students will treat COVID-19-positive patients, for example. Others are watching local COVID-19 cases and PPE supplies to adjust educational plans accordingly.

    Still, leaders say they’ve made great strides in understanding how to train medical students during a pandemic.

    “It’s amazing how much teaching we can do via Zoom. We also know much better how to teach students safely in hospitals and clinics,” says Donna Elliott, MD, EdD, vice dean of medical education at the Keck School of Medicine at the University of Southern California. “There are still many challenges, but August looks completely different from March.”

    Fitting the same educational pegs into new holes

    As educators prepare for this school year, they’ve had to decide which students will return in-person — as well as how and when.

    Leaders say they intend to achieve the same fundamental educational goals, though they may use altered timelines and formats. For example, some clinical rotations will have an online component, such as watching morning rounds via Zoom or working with patients via telemedicine.

    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.”

    Daniel Alban will soon resume classes at FSU College of Medicine, where COVID-19 closed down in-person learning for months in the spring
    Daniel Alban will soon resume classes at FSU College of Medicine, where COVID-19 closed down in-person learning for months in the spring.
    Credit: Colin Hackley

    Another key concern is having enough non-COVID-19 cases to ensure a range of learning opportunities. “So far we’ve been able to manage,” says Alma Littles, MD, FSU senior associate dean for medical education and academic affairs. “It could become an issue as some of our affiliated hospitals decrease elective surgeries. If necessary, we may be able to move students from one facility to another.”

    Anachebe is not particularly concerned about numbers. “The number of patients students can see likely will vary,” she says. “But Morehouse School of Medicine moved to competency-based education. That means students demonstrate they have certain skills rather than certain numbers.”

    As leaders grapple with educational issues, they’re turning to resources from groups like the AAMC, including curricula for teaching remotely, guidelines for involving students in patient care, and webinars on returning to campus.

    They’re also turning to students for their thoughts. At Albert Einstein College of Medicine, students are serving on working groups that are exploring how to accelerate courses, notes Josh Nosanchuk, MD, senior associate dean for medical education. “We want to make sure we balance Einstein’s mission and our accreditation requirements with the evolving vision of our students,” he says.

    Zooming in on creativity

    The toolbox for teaching medicine remotely contains elements created quickly last year as well as fresh innovations.

    Popular options include step-by-step videos that teach skills like inserting an IV and virtual cases that provide numerous pieces of patient information so that students can hone their diagnostic abilities.

    One thorny issue has been how to handle anatomy lessons traditionally taught using cadavers. Last year, schools often relied on sophisticated 3D software to replace dissection. Now that in-person training is an option in some places, educators have more options.

    “You can’t just move a traditional lecture online. Students would die of boredom if they sat home watching lectures all day.”

    Kevin Krane, MD
    Tulane University School of Medicine vice dean for academic affairs

    At FSU, leaders are planning to provide at least some anatomy education in person — though in smaller groups. “We think dissection is about more than being able to feel the physical structures,” says Littles. “It’s about the sacredness of interacting with the human body. Our students usually thank the cadaver as their first patient.”

    Keck is opting for a high-tech hybrid. There, faculty members will perform in-lab dissections while wearing body cameras, and students watching remotely will be able to experience different angles and degrees of zoom. “The student will see exactly what the faculty member is seeing,” Elliott says.

    All the changes have required extensive faculty development, say those involved. At Tulane University School of Medicine, for example, educators have been taught to break Zoom sessions into smaller group rooms and encourage interactive conversations. “We’ve learned that you can’t just move a traditional lecture online,” says Kevin Krane, MD, vice dean for academic affairs. “Students would die of boredom if they sat home watching lectures all day.”

    Keeping students safe

    Though much can be done remotely, educators say, some students must see patients in person, especially those getting closer to graduation.

    At some schools, even first- and second-year students will gather, although generally in small groups, to practice the patient interactions, hands-on skills, and teamwork that are central to medicine.

    So, leaders have been working hard to develop intricate plans to keep everyone safe.

    Among the many challenges is figuring out how much COVID-19 testing is ideal — and feasible. At MSM, learners will complete app-based health questions and have temperature checks before entering buildings, and all must test negative before returning to school. “I wish we could test frequently, but for now, we’ll have random testing to make sure there isn’t a lot of infection,” says Anachebe.

    “This pandemic is the kind of thing my generation only read about. Students need to learn this aspect of being a physician.”

    Alma Littles, MD
    FSU senior associate dean for medical education and academic affairs

    Adequate PPE is another issue schools must tackle. At FSU, for example, Littles learned from some of her local hospitals that they might have too little PPE to accommodate students. Her main campus quickly shipped out the needed equipment.

    “Since we have access to PPE, we’re actually more worried about a surge [in COVID-19 cases] that would require faculty to shift obligations away from education and toward patient care,” says Littles. “If that happens, we may need to pull some students.” But she’s determined to keep learners in clinics if possible. “This pandemic is the kind of thing my generation only read about,” she says. “Students need to learn this aspect of being a physician. We want them to stay safe, but we want them to learn what this is like.”

    Safety also involves appropriate social distancing. Keck did careful calculations to figure out how many students could safely fit in certain spaces, for example, and ISMMS distributed iPads to reduce the numbers of students in computer lounges.

    Meanwhile, experts say students themselves must step up. That means following school guidance and local rules, such as self-quarantining upon return from a hot spot.

    “We remind students to practice appropriate safety measures — and not just at work but also outside school,” says Krane. “We emphasize that this is a professional obligation. It’s part of developing their professional identity as physicians.”

    A little extra help from faculty and friends

    The school year entails much more than just didactics and clinical rotations. It also involves anticipating and addressing stacks of other student concerns.

    Leaders are monitoring needs closely, particularly among students from communities hit hard by the pandemic. In a recent AAMC survey, more than 60% of schools say they are reaching out individually to students identified as at-risk for academic setbacks.

    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.

    Schools are also preparing to help students who do contract COVID-19 or need to quarantine if exposed. Keck will provide a quarantine space if students need it. Tulane has built time into the calendar so that students who have to quarantine can make up in-person learning later. In addition, schools are providing accommodations for students who are immunocompromised or live with family members who are.

    “Starting medical school now has been very challenging for many reasons. Still, I believe all this is just another reminder of the reasons we want to become physicians.”

    Michael Hong
    FSU College of Medicine

    One concern emerges for many students: the risk of feeling isolated.

    Given that reality, some schools have opted to provide occasional in-person social interactions. At Tulane’s orientation, students rotated through small gatherings in large rooms. “They wore masks and lanyards with big photos of themselves and stayed socially distanced, but they were able to interact,” explains Krane.

    Other schools are trying their best to provide connection remotely. Alban, who is working as a teaching assistant, recently hosted a Zoom session for first-year students that covered key wellness domains. He’s also working hard to connect with first-years, who may find it easier to talk with a fellow student than faculty, he says.

    First-year student Michael Hong appreciates the assistance. “Medical school is hard enough, but you shouldn’t have to do it alone,” he says. “Having a support system has been essential.”

    “Starting medical school now has been very challenging for many reasons,” he adds. “Still, I believe all this is just another reminder of the reasons we want to become physicians. It also will help us advocate better for our future patients when they’re going through challenging times.”