key: cord-0851080-522pmfzk authors: Bongomin, F.; Olum, R.; Nakiyingi, L.; Rejani, L.; Ssinabulya, I.; Sekaggya-Wiltshire, C.; Ocama, P.; Byakika-Kibwika, P. title: Internal medicine clerkship amidst COVID-19 pandemic: clinical learning experience of undergraduate medical students at Makerere University, Uganda: a cross-sectional study date: 2020-12-18 journal: nan DOI: 10.1101/2020.12.16.20248110 sha: 8252f7c6d03c488c8900f5e063629d13c4d100ab doc_id: 851080 cord_uid: 522pmfzk Background: The coronavirus-2019 (COVID-19) pandemic continues to impose a significant impact on medical education. We aimed to describe the clinical learning experience of undergraduate medical students undertaking internal medicine clerkship during the COVID-19 pandemic at Makerere University, Uganda. Methods: A descriptive, cross-sectional study among medical students in clinical years of study pursuing the Bachelor of Medicine and Bachelor of Surgery undergraduate degree program was conducted in November 2020. Only 3rd (junior clerks) and 5th (senior clerks) year medical students whose internal medicine clerkships were interrupted by the COVID-19 pandemic were studied. Results: Data of 188 (95%) eligible clinical year students; junior (101, 54.0%) and senior (86, 46.0%) were analysed. Median age was 24 (range: 22-42) years. Majority (70.1%) were male and Ugandan nationals (94.1%). Sixty-four (30.3%) students reported inadequate personal protective equipment, 152 (81.7%) felt at risk of contracting COVID-19, and 127 (67.9%) said it was difficult to observe COVID-19 standard operating procedures. Twenty-two students (11.9%) were discouraged from pursuing a career in internal medicine. Overall, most students reported good or excellent clinical experience pre-COVID-19 era compared to during the COVID-19 era (4.0 vs. 3.5, p<0.0001). Senior clerks significantly believed that the time allocated for the rotation was adequate (p<0.0001) and they were able to complete their study objectives (p<0.001), compared to the junior clerks. Senior clerks believed that learning was difficult when combined with junior clerks (p=0.013). About half of the students (51.4%, n=95) reported clinical teaching should remain as it was in the pre-COVID-19 era. Conclusions: The COVID-19 pandemic has had a significantly negative effect on the clinical learning experience of the students. There is need to review the current teaching and learning methods to suit teaching and learning during pandemics of highly infectious diseases to ensure safe and effective learning experience. The on-going coronavirus disease -2019 pandemic, caused by 74 the novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) 75 continues to be a global crisis with devastating effects across all sectors, 76 including healthcare and medical education [1, 2] . Within a year, the highly 77 infectious SARS-CoV-2 virus has rapidly spread in all continents of the 78 world infecting over 74 million persons resulting in approximately 1.6 79 million deaths worldwide [3] . Preventive approaches such as physical 80 distancing, wearing of face masks, and observing respiratory and hand 81 hygiene remains the mainstay of averting the spread of the virus [4] [5] [6] . 82 Healthcare systems across the world have been over-stretched by the 83 increasing number of patients with COVID-19 [7] . In fact, in some countries In Uganda, as lockdown was being eased, following standard operating 91 procedures (SOPs) outlined by the Ministry of Health, medical students in 92 their clinical years of training at Makerere University were allowed back on 93 the hospital wards to continue with their clinical learning in early October 94 2020 [9] . 95 As the number of COVID-19 cases in Uganda continues to exponentially 96 increase in excess of 28,168 cases with over 225 deaths including frontline 97 healthcare workers [3] , the fear of contracting the disease from patients may 98 have a significant effect on the learning experience of medical students. The 99 teachers were concerned that students' acquisition of clinical skills 100 competence may be compromised as patient access is limited and some of 101 the routine clinical examination procedures could be affected by the 102 standard operating procedures for preventing The clinical learning experience of the medical students during the 104 pandemic in Uganda is poorly understood and not documented. We 105 therefore aimed to describe the clinical learning experience of medical 106 students who undertook internal medicine clerkship during the pandemic at 107 Makerere University, Uganda. 108 This was a descriptive, cross-sectional study conducted in the last week of 111 November 2020. 112 The study was conducted at the Department of Medicine, School of 114 Medicine, Makerere University College of Health Sciences (MakCHS). 115 MakCHS is located at Mulago Hospital Complex, Mulago Hill, 5 kilometres 116 North-East of Kampala, Uganda's Capital. MakCHS has four schools offering 117 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 with each semester having 2 groups rotating in internal medicine each for a 126 period of 7.5 weeks. 127 All 3 rd and 5 th Year MBChB students who undertook the internal medicine 129 rotation during the October -November 2020 clinical clerkship period were 130 included in the study after informed consent was obtained. 131 We employed purposive sampling. For the quantitative study, paper-printed 133 semi-structured questionnaires were self-administered. Data was collected 134 immediately after candidates wrote their final internal medicine theory 135 exams. In all settings during data collection, COVID-19 standard operating 136 procedures (SOPs) as outlined by Ministry of Health, Uganda [9] were 137 observed. 138 139 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 140 Independent variables were demographic characteristics including sex, age, 142 year of study, and nationality. Dependent variables were teaching and 143 learning experience and challenges to clinical clerkship during COVID-19 144 pandemic. A 5-point Likert scale (very poor [1] , poor, fair, good and excellent 145 [5] OR strongly agree [5] , agree, neutral, disagree and strongly disagree [1] ) 146 was used to evaluate overall learning experience of the learners during the 147 study period. The study questionnaire was adapted from a previously 148 validated and published tool [10] . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 All 201 eligible medical students completed the survey (response rate= 165 100%). However, 13 participants had incomplete questionnaires and were 166 therefore excluded from the final analysis. 167 Overall, data of 188 medical students with a median age of 24 (interquartile 168 range: 21 to 40) years were analysed ( Table 1) . Majority of the participants 169 were Ugandans (94.2%, n=177), male (70.7%, n=133) and residing in 170 university halls (50%, n=94). About 72% (n=161) of the participants got food 171 from nearby restaurants and the median daily expenditure on food was CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 1,000 to 50,000 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020 Learning experience during the COVID-19 pandemic. 186 Table 2 summarizes the experiences of medical students during internal 187 medicine rotation amidst the pandemic. The mean experience scores for 188 most items assessed were ≥ 4 indicating good experiences for the respective 189 items assessed ( Table 3) . 190 Of concern, experiences on opportunities for outpatient contacts (mean: 191 2.8±1.2), emergency care contacts (mean: 3.0±1.0) and teaching from nurses 192 (mean: 2.9±1.1) were generally poor. On bivariate analysis ( Table 3) CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; pandemic. The majority of participants reported feeling safe with and having opportunity to learn from their senior or junior counterparts (Table 4) . Overall, 81.7% (n=152) of the medical students felt at risk of contracting COVID-19 during the rotation and more than two-thirds (67.9%, n=127) agreed that it was difficult to follow the standard operating procedures for control of COVID-19 while clerking patients. In addition, about one-third (34.2%) felt that they did not have adequate personal protective equipment during the rotation. However, 124 participants (67.8%) agreed that they had a sufficient number of patients for them to learn from during the rotation. Notably, 86 participants (46%) agreed that assessments by tutors were difficult when senior and junior clerks were combined together. About one fifth of the medical students (11.9%, n=22) felt discouraged from pursuing a career in Internal Medicine during the rotation. Table 5 summarizes the mean attitude scores for each of the items assessed. Overall, attitudes were moderately positive for most of the items. On bivariate analysis (Table 5) , senior clerks significantly believed that the time allocated for the rotation was adequate (P<.0001) and they were able to complete their study objectives (P<.001), compared to their junior counterparts. Senior clerks also significantly believed that learning is difficult when combined with junior clerks (mean attitude score: 3.0 vs 2.5, P=0.013). . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted December 18, 2020. ; . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. preprint The copyright holder for this this version posted December 18, 2020. More than half (51%) of the medical students preferred the status quo, as it 2 was pre-COVID-19, that is, ward based teaching and traditional face to face 3 lectures (Figure 1) . Whereas up to 45% preferred blended online and 4 conventional classroom teaching, only 2% selected simulations and 5 mannequins. Preferences did not differ significantly among junior and senior 6 clerks (P=0.653). 7 8 Figure 1 . Preferences of teaching modes during the COVID- 19 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; 14 For the senior clerks who rotated in internal medicine in the pre-COVID 16 era, the overall experience scores were higher before the COVID- 19 17 pandemic compared to the rotation during the pandemic (4 vs. 3.5, 18 P<0.0001), Figure 2 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 Besides interrupting with clinical clerkships, the COVID-19 pandemic has 26 brought a myriad of challenges in clinical bedside teaching since medical 27 students now have limited direct patient care activities, such as physical 28 examinations and procedures [11, 12] . In this study, we found that nearly 29 half of the medical students felt at risk of contracting SARS-COV-2, had 30 difficulties in observing COVID-19 preventive SOPS, and had inadequate 31 exposures to outpatient and emergency departments. This was consistent 32 with anecdotal observations by the clinical supervisors during the course of 33 the clinical rotation. 34 Previous studies have evaluated the impact of the COVID-19 pandemic on 35 surgical training [13] and fellowships [14] , radiology residency [15] , 36 gastroenterology residency [16] and assessment of medical students [17] . 37 Between 40 and 100% of surgical residents reported severe impact of the 38 COVID-19 pandemic on their training [13] . However, there is no published 39 study examining experience of medical students or residence in general 40 internal medicine. For the senior clerks, majority reported a good or 41 excellent clinical experience pre-COVID-19 pandemic compared to clerkship 42 during the pandemic. 43 To minimise risks of contracting SARS-CoV-2 by the learners and their 44 teachers, many schools and universities have opted for blended online and 45 ward teachings. Due to the negative impact of COVID-19 pandemic on 46 medical education, there has been a shift towards e-learning at all levels of 47 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; education, which may represent an optimal solution to maintain learning 48 during this unprecedented time [18] . However, e-learning may not facilitate 49 acquisition of clinical skills and competencies. In resource limited settings 50 were online learning platforms are not well established it is essential that 51 the experience of medical students is described to guide future trainings in 52 the same setting. Despite the challenges, over half of the participants 53 reported clinical teaching should remain as it was in the pre COVID-19 era, 54 that is, uninterrupted clinical rotations along with class lectures. It was also 55 interesting to note that less than 4% of the medical students opted for 56 online only or use of simulations and mannequins as alternatives to 57 traditional clinical teaching. This is consistent with a previous study that 58 showed that e-learning in the clinical years is associated with low students' 59 satisfaction and technical challenges [18] . In Uganda, we have recently 60 reported that medical student think e-learning is inefficient and associated 61 with poor acquisition of knowledge [19] . Moreover, cost of data and internet 62 stability remains a big barrier to e-learning among medical students in 63 Uganda [19] . The use of simulations and mannequins have not been 64 frequently implemented at Makerere University hence the low number of 65 students who opted for it. 66 Notably, the costs incurred by the students during the rotation in the 67 COVID-19 pandemic era could have had an impact on the learning 68 experience. The government reduced the number of travellers that each 69 public transport means was supposed to carry to enforce social distancing 70 as a guideline for prevention of COVID-19 transmission. Costs of using 71 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; public transport therefore increased to more than twice the previous costs. 72 The means of transport provided by the university was also inadequate to 73 cater for all the students. 74 The impact of interruption of clinical clerkship in internal medicine due to 75 the COVID-19 pandemic and whether the experience of clinical clerkship 76 during the pandemic has affected performance in theory and clinical exams 77 of our students is not known. However, in Columbia [17] , students who sat 78 their exams during the pandemic had higher scores compared with historic 79 cohort. However, these high scores were attributed to the open book nature 80 of the exams and that students had more time to prepare for them. 81 Our study had some limitations. Firstly, there was no previously 83 standardized and validated tool to assess clinical learning experience during 84 this COVID-19. However, we adapted an existing validated and published 85 tool used in a similar setting but in a non-pandemic situation. Secondly, 86 there's paucity of published literature in this area and therefore not 87 sufficient published studies to compare and contrast our findings with. 88 However, to the best of our knowledge this is the first study to explore 89 clinical learning experience of medical students in their clinical years during 90 this pandemic in Uganda and Africa at large. Despite the above limitations, 91 our findings provide valuable information about teaching and learning 92 clinical medicine during the pandemic in resource-limited settings. 93 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; In this study, we have reported a considerable negative effect of the COVID-95 19 pandemic among undergraduate medical students clerking internal 96 medicine in Uganda. Direct patient care activities were adversely affected. 97 Clinical teaching of junior clerks should be separate from senior clerks to 98 maximise their clinical learning experience. 99 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 The study protocol was approved by the MakCHS School of Medicine 135 Research and Ethics Committee (reference number #REC REF 2020-221) . 136 All participants provided written informed consent. 137 138 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted December 18, 2020. ; https://doi.org/10.1101 https://doi.org/10. /2020 A pneumonia outbreak associated with a new coronavirus of probable bat origin World Health Organization, Coronavirus disease (COVID-19) outbreak, World Heal Hydroxychloroquine and dexamethasone in COVID-19: who won and who lost? 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