key: cord-1006741-vf1p932d
authors: Hilburg, Rachel; Patel, Niralee; Ambruso, Sophia; Biewald, Mollie A.; Farouk, Samira S.
title: Medical Education During the COVID-19 Pandemic: Learning From A Distance
date: 2020-06-23
journal: Adv Chronic Kidney Dis
DOI: 10.1053/j.ackd.2020.05.017
sha: 2ca8d23443aa825ad33bb46643fec2403e228e0c
doc_id: 1006741
cord_uid: vf1p932d

Abstract As paradigms of clinical care delivery have been significantly impacted by the novel coronavirus disease 2019 (COVID-19) 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.

The novel coronavirus disease 2019 (COVID- 19) pandemic has disrupted and challenged the well-established, traditional structure of both undergraduate and graduate medical educationwhose backbone has been in-person teaching. Even for medical students who may be accustomed to viewing pre-recorded 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 (PPE), those who have graduated early from medical school have been assigned to previously unfamiliar clinical environments. 1 Some medical schools have graduated students earlier than scheduled to contribute additional trainees to a strained workforce. 2 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 pre-clinical months of training, the COVID-19 pandemic has had a gentler impact on the day-to-day routine compared to 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 while others use the lecture format as little as 20% of the time. 3 Over the last decade, in-person attendance to lectures has declined. A 2017 American Association of Medical Colleges (AAMC) 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 pre-recorded material to be more efficient. [4] [5] 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. 6 Basic clinical training experiences during the pre-clinical years (e.g. history taking, physical examination) have also been affected, raising concern for inadequate preparation of students beginning clinical rotations.

Though the majority of pre-clinical experiences can be substituted with pre-recorded 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." 7 During the clinical years, students join multidisciplinary teams and practice newly learned clinical skills, while seeing first-hand 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 (PPE) shortages, and lower the risk for student infection -a measure supported by an AAMC recommendation which advises that they be removed from direct patient care activities "unless there is a critical health care workforce need." 8, 9 Some have suggested that this strategy undermines medical professionalism and sidelines individuals willing to provide patient care. 10, 11 Though having optional clinical experiences has been proposed, this strategy may be perceived as inequitable to those students not electing to participate. 11 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, over 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 US. 12 In anticipation of the pandemic peak, the ACGME implemented three 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), Stage 3 -pandemic emergency status (majority of residents/fellows shifted to patient care and most educational activities suspended). 13 Many housestaff 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. 14 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. 15 At Mount Sinai Hospital in New York City, the Department of Medicine established a three-tier system led by a hospitalist who supervised a team of individuals, some of which may not have had internal medicine training. 16, 17 Many trainees were immersed in telehealth patient encounters as in-person clinic visits were cancelled. 18 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.

Though 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. 19 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. 23 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. [20] [21] [22] [23] 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. 24 Zoom features important tools useful in education such as shared screens, whiteboard, polling, breakout rooms and annotation to facilitate interaction. The option to change one's background to a photo of their choice creates a playful, light hearted environment. The whiteboard, helpful for those accustomed to "chalk talks" allows both the educator and learner to draw on a blank screen. Breakout groups facilitate small group work or discussion. Polling features mimic audience response systems and the chat feature provides another venue of conversation. Table   1 

Free open access medical education (FOAMed, e.g. blogs, websites, and videos) and social media platforms (e.g. WhatsApp, Twitter, Instagram, Slack) that had served as adjuncts to core curricula have now come to the forefront. In nephrology, these resources have grown over the last decade. 25 Anecdotally, pre-existing web-based resources like NephSIM 26 have been adapted to develop virtual elective experiences in nephrology, radiology, and dermatology. In nephrology specifically, learners have had opportunities to join virtual educational experiences shared on social media including the online game NephMadness, 27 NephSIM Live, 28 Live Arkana Nephropathology sessions, NephroTalk, 29 and national and international conferences. 30 Table 2 summarizes examples of other virtual educational activities.

As medical students were removed from essentially all clinical care venues, some institutions continued efforts to develop interpersonal skills by encouraging students to provide virtual patient updates to family and friends. Institutions may provide opportunities for students to join clinical teaching sessions (e.g. morning report) via video conferencing platforms. Motivated medical students wasted no time finding other avenues to be active within the medical community following the suspension of inpatient clinical rotations. Some have continued participation in mentored research projects. Others have mobilized to form response teams to serve as activists, advocates, and educators in their communities. 31, 32 At the Icahn School of Medicine at Mount Sinai (ISMMS), a Medical Corps program was developed to allow students who had matched at ISMMS for residency to assist with tasks such as entering orders, scribing, relaying updates to patient families, and facilitating discharge planning. 33

Anecdotal reports suggest that conference attendance has improved with the adoption of video conferencing, presumably due to availability on computers and mobile devices. However, this accelerated implementation of virtual educational content delivery has challenges. In Table 3, we summarize strategies and tips to optimize effectiveness and efficacy of virtual medical education. First, effective participation in video conferencing platforms requires a quiet environment with minimal disruptions and a stable internet connection. Additionally, faculty accustomed to "chalk-talks," where pictures are traditionally drawn on a whiteboard to illustrate a concept, are now expected to create content to convey the same points through video conferencing.

In an era where clinical and administrative responsibilities encroach upon educational time, creating images using presentation programs can be time consuming. Development of new educational content may be particularly cumbersome in such a time of uncertainty and increased clinical demands. In person, educators rely upon audience interaction to guide content and topic emphasis based on apparent knowledge gaps. Interaction is possible with video conferencing, though gauging audience understanding and identifying knowledge gaps can be a challenge, particularly for those who may be using conferencing softwares for the first time. Lastly, there remains a population of faculty who may be reticent to or uncomfortable with the adoption of virtual educational platforms. Motivated learners and educators will be tasked with providing technological support for those less savvy to overcome these barriers. Faculty development geared towards these technologies will be required effectively use virtual platforms to address learners needs, implement learning objectives, and deliver educational content. 34 The seemingly greatest challenge is the suboptimal replication of patient encounters experienced during the undergraduate medical education years. While case simulations and virtual standardized patients can provide some training of skills like physical examination and clinical reasoning, these activities are generally supplementary rather than a replacement of inperson teaching. [35] [36] [37] [38] [39] [40] Moreover, competency based assessments of student skills through these virtual simulations are limited. Anecdotally, virtual Objective Structured Clinical Examinations (OSCE) can be used to evaluate remaining competencies required for graduation, but these techniques have never before served as substitutes for direct patient care. 

It is no secret that social distancing has created a rift in our traditional methods of gathering and sense of community. It is well documented that social isolation often negatively impacts psychological health, with increased rates of stress, anxiety, depression and other negative feelings. 42 While similar psychological sequelae have been observed during the COVID-19 pandemic related isolation, the full impact on mental health remains to be seen. On the other hand, while faculty and trainees alike find themselves physically separated during this imposed isolation, our existing virtual communication platforms enable connection with friends, family and colleagues as well as social and work related communities. In nephrology, trainees have anecdotally reported improved communication amongst one another. Chief residents and fellows across specialties have shared experiences of virtually gathering for weekly updates, emotional support, and COVID-19 management tips. This sense of community has even expanded greater than before, with lecture invitations extended beyond individuals specialties and institutions. In the heavily affected pandemic areas in Boston, ophthalmology residents are sharing virtual lectures with colleagues beyond the institution and into the community. 43 To show their support for one another, residents in Boston sent t-shirts to their New York City counterparts. 44 Trainees were under not just the stress of taking care of patients with this novel and tenuous disease, but also their own personal apprehensions. 45 During the peak of the pandemic, these frontline caregivers were redeployed into unfamiliar departments or even different hospitals.

They may have been at high risk for virus exposure and worried about exposing their family members, or falling ill themselves. Vacations were shortened, postponed or cancelled all together. Half of trainees surveyed in one study expressed concern about overwork and burnout. 46 Over 24,000 trainees are international medical graduates, many of whom require a visa to work in the United States, anxiously awaiting word from the waiver system. Recognizing these stressors, the American Medical Association (AMA) wrote guidelines regarding trainee education and safety, including financial and personal wellbeing. Provider burnout has been a concern prior to the pandemic, and will remain an important area of concern as we move forward.

As programs adapt to an uncertain future, it is difficult to determine the optimal balance between resuming didactic teaching sessions versus allowing trainees time to decompress or attend to responsibilities outside of work. Some nephrology training programs have fully resumed traditional didactic sessions that have been transitioned to virtual platforms, advocating that a return to normalcy will help decrease trainee anxiety. 47 Others have implemented weekly program director check-ins or other supportive sessions in lieu of didactics. Trainee morale matters not only for current fellows but also for ongoing workforce recruitment. In a large survey about what matters most in selecting a residency program, medical students ranked resident morale and educational programming as the most important attributes. 48 It is important that training programs strive to reach a thoughtful balance between return to normal educational activities, with input from their trainees, while being mindful of added demands and stressors in trainee's lives.

In this uncertain COVID-19 era, we can be certain that medical education will likely never be the same. Both undergraduate and graduate medical education have been significantly disrupted, requiring educators and learners to adapt to learning at a distance while aiming for normalcy.

When used optimally and despite their inherent limitations, virtual tools can be used by both learners and educators to achieve a shared goal of providing effective and efficient medical education to train our next generation of physicians. This pandemic has provided educators with an unexpected opportunity to push forward innovations in medication education and rigorously study the impact of this emerging educational paradigm on our trainees. A nephrology board review session during which participants answer practice questions.

The host can separate the group into smaller groups for a specific period of time before recovening as a larger group. Each group can communicate with the host to ask them to join their group to answer questions or discuss.

A medical student session during which they solve acidbase disorder problems in small groups of 4 students.

Participants may use the same tools that are available to draw on the whiteboard to annotate on any screen that is shared.

A learner circles the basement membrane deposits on a pathology slide shared from the pathologist's microscope.

Chat and File Share Similar to instant messaging, participants can share messages with the whole group or individual participants.

Learners pose questions during a lecture on nephrolithiasis.

After the lecture, a file with slides is shared with all participants.

Nonverbal Feedback Participants can communicate with the host using preset reactions (e.g. yes, no, raise hand)

A medical student raises their hand to ask a question about hyponatremia.

The user uploads a photo or uses existing images (e.g. outer space) to change their own Create an ice breaker by asking learners to use a background of background. their favorite place.

The session is recorded and stored to either the host's computer or Zoom Cloud account . If the screen sharing is used, the screen is recorded with a thumbnail of the speaker in the corner. Chat sessions and an audio transcript of the session are also saved.

A nephrology fellow on night float misses a board review session and then views the session the following week. 

Adjust your camera to eye-level and find a quiet area Encourage learners to connect to both audio and video

To minimize background noise, mute participants and encourage them to unmute as needed If hosting a video conferencing session, start the session a few minutes early. Enable the "waiting room" as needed and admit participants once the speaker is ready Orient learners to all different options to interact (e.g. chat, nonverbal feedback, unmute)

Schedule faculty development or orientation sessions for educators to review use of software prior to teaching sessions Place the chat window in a visible location on the screen while teaching, or designate a chat moderator to consolidate and verbalize questions Set up an "ice breaker" poll and introduce participants to software features Consider the use of standardized patients via video conferencing platforms If internet connectivity is poor, consider assigning a co-host to ensure that the meeting remains active

In a setting like "Grand Rounds", consider unmuting all participants at the end of a session to allow for applause Consider sharing meeting links privately to minimize intrusion by unwanted participants. If shared more publicly, adjust security settings (e.g. limit chat, unmuting) to avoid disruptions.

For recurring sessions with the same group, consider using one meeting link

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