key: cord-1042924-c6iql84p
authors: Liesman, Daniel R; Pumiglia, Luke; Kemp, Michael T; Alam, Hasan B
title: Perspectives From Rising Fourth Year Medical Students Regarding Strategies to Counteract the Effects of COVID-19 on Medical Education
date: 2020-07-13
journal: J Med Educ Curric Dev
DOI: 10.1177/2382120520940659
sha: b063814dfc5747f4e133d167fb638f9c6797525a
doc_id: 1042924
cord_uid: c6iql84p

The COVID-19 pandemic has put those who oversee medical education in a challenging position. Medical school administrators, students, and national governing bodies have been forced to make difficult decision as a result of public health concerns and government-enforced restrictions. We, as rising fourth-year medical students, would like to shed light upon the hard work that many of those in leadership positions have done as well as lay out some concerns that medical students who are preparing to apply to residency have. Additionally, we would like to suggest several potential approaches that attempt to address some of the problems arising from the pandemic. Continuing to balance education with the hurdles presented by COVID-19 will require a multi-faceted and coordinated approach. We believe that implementing virtual rotations, delaying the opening of the application, decentralizing clinical skills evaluations, and modifying graduation requirements are possible options among many that could aid in addressing some of the current challenges presented by COVID-19.

Medical students and administrators across the country are currently faced with the difficult and harsh realities of the COVID-19 pandemic. At many medical schools, rising fourth-year medical students have been pulled from rotations during a critical period of career exploration and residency application building. The pandemic has created anxiety from medical students all the way up to hospital administration on how to continue with medical education amid the uncertainty. As 2 rising fourth-year medical students, we understand that students may be anxious regarding their ability to build relationships with faculty mentors, explore all possible specialties, and bolster a residency application due in the fall of 2020. Already, attention has been paid to COVID-19's implications on the general surgery match and its effect on subinternships and visiting rotations. 1 We would like to expand further on this topic and offer additional perspectives that are generalizable to all medical students interested in various specialties.

The Association of American Medical College's (AAMC) concern for student safety and recommended removal of students from clinical rotations is laudable. There is no doubt that this recommendation was made with the utmost consideration of all involved parties. However, these clinical limitations will have clear implications for students during the upcoming residency application cycle. As the country continues fighting the pandemic, decisions must account for not only continued uncertainty but also their potential long-term implications and ripple effects. Graduating competent physicians takes remarkable coordination between schools, health systems, physicians, and support staff outside the context of a pandemic. Therefore, we hope to contribute to this early discussion to identify possible avenues that residency programs, administration, and students may find useful as they approach some of the developing issues of clinical learning, licensing examinations, and graduation requirements in the wake of COVID-19.

Although many institutions have similar core rotations or clerkships required of students, they do not include all potential specialties. In order to explore interests outside of the core rotations, a student needs to allocate time after completion of core clerkships. For example, Physical Medicine and Rehabilitation and Neurosurgery are not included as core rotations at many institutions. Therefore, time must typically be allocated after finishing core rotations to explore these specialties. In addition, rotations completed after core clerkships often are where students build meaningful relationships with faculty in their intended specialty as well as work on developing basic intern-level skills related to floor management, calling consults, and the patient discharge process. Most importantly, the faculty relationships provide mentorship, career advising, research opportunities, and can be essential in facilitating the transition from student to a junior member of that particular field. As a result of the limitations imposed by COVID-19, the removal from clinical rotations means that students may be unable to fully explore their clinical interests prior to applying for residency and therefore less able to build relationships with several faculty mentors. 

Additionally, following core rotations, many students aim to perform visiting rotations in their specialty of choice to gain further exposure and experience in other health systems. Recently, the Coalition for Physician Accountability, comprised of representatives from many bodies, including the AAMC and Accreditation Council for Graduate Medical Education (ACGME), released recommendations that no away rotations should take place during this residency application cycle except in extenuating circumstances. 2 Given that some students rely on visiting rotations for their only exposure to a specialty unavailable at their home institution, the loss of these away rotation opportunities will weigh particularly heavy on certain students. The concurrent loss of core clinical and visiting rotations may put students in the unenviable position of applying to a specialty they may not have explored. It may also mean that they do not have faculty mentors to help guide them through the residency application process. Since telehealth has expanded across the country, medical schools may consider mitigating the effects of losing away rotations by building virtual away rotations in some specialties to provide opportunities to students who would otherwise have no exposure to those fields. Already at our home institution, we are involving our students in virtual patient care.

One other important consideration is how the AAMC guidance will impact the diversity of the medical student residency applicant pool for various specialties. For example, the effect that the loss of visiting rotations will have on diversity is unknown. Already there is conflicting evidence on whether or not visiting rotations promote equity. The cost of visiting rotations is prohibitive for many students as the average amount paid for one rotation is $958. 3 Furthermore, some students complete several visiting rotations for specialties considered to be competitive making the cumulative cost of visiting rotations much higher. In addition, the current differential statewide travel restrictions could allow only a fraction of the student population the privilege of traveling for away rotations. 4 These differential restrictions coupled with the already reduced population of students eligible to travel for away rotations due to recent AAMC/ACGME recommendations could likely further exacerbate existing disparities 2 . Conversely, evidence exists that suggests visiting rotations can be an important tool for improving the diversity of underrepresented minorities who practice medicine. In Emergency Medicine, for example, 30 programs exist nationally that aim to give visiting underrepresented students spots in their rotation. 5 Furthermore, outreach programs and funded rotations are available at Johns Hopkins for underrepresented students in medicine interested in pathology. As a direct result of this program, there were 18 underrepresented rotators in July 2019 in comparison to 1 in July 2013. 6 These data suggest that, when structured appropriately, visiting rotations can play a role in increasing the diversity of the physician workforce. Given the uncertainty around the effects that COVID-19 will have on diversity, future investigations should assess outcomes to develop strategies that can be implemented even outside of the pandemic context.

In light of the loss of clinical time and significant limitation in away rotation opportunities, the same working group has recommended delaying the opening of the Electronic Residency Application Service (ERAS). 2 This delay could provide crucial time for students to complete rotations at home and outside institutions as well as develop basic clinical skills that will prove invaluable when they start their intern year. However, the benefit of this delay will only be realized if clinical rotations or similar opportunities return. If this happens, the clinical learning gained during the delay would be beneficial for students making decisions about their applications. It may also improve the ability of residency programs to distinguish between candidates. In order to maintain the amount of time necessary for residency programs to interview applicants and for applicants to explore all potential programs, a similar delay in rank submission and match day may be necessary. A later match day would impact the amount of time that students have to explore their potential new city and find housing. However, we believe that the benefit of extra time to explore clinical interests would outweigh the cost of less time post-match day.

The social distancing limitations have also had significant impacts on the scheduling of licensing exams. For example, the the Clinical Skills Evaluation Committee (CSEC) has suspended the Step 2 Clinical Skills (CS) exam for the next 12-18 months. 7 Assessing a student's ability to effectively communicate with and physically examine patients is vital. Given the current circumstances, it is likely many members of the graduating class of 2021 will not take Step 2 CS by the time they graduate. Rescheduling this buildup of examinees unable to take the test during this suspension could be a tremendous burden on the CSEC and current medical students.

According to the Liaison Committee on Medical Education (LCME) accreditation standards, accredited institutions must have a system in place to assess a student's core clinical skills (e.g. history-taking and physical examination). 8 Therefore, with national testing possibly becoming less available or accessible, it may be worth considering temporary school-administered clinical assessments as part of a hardship modification. We are not doubting the CSEC's ability to reschedule the students who need to take this exam, if that becomes necessary. Rather, school-administered assessments could reduce the burden on students, the CSEC, and its testing capabilities. Such a solution would take advantage of existing infrastructure to continue ensuring clinical competency of graduates. In addition, with the current economic downturn, school-administered exams could help lessen the economic impact of travel on students. The cost of the examination (approximately $1300) Liesman et al 3 coupled with varying expenses associated with flights, hotels, and food can be burdensome for some students. Due to the high rate of unemployment nationally, these costs may be insurmountable for some students, particularly those who rely on financial support from others who may now be unemployed. School-administered exams could help reduce this cost associated with examinations. Finally, medical school-based assessments could help mitigate any further spread of COVID-19 in the future as it would prevent students from convening in the 5 testing centers.

Due to current limitations, reforming educational approaches and clinical graduation requirements may be necessary for students to graduate on time. Our institution is considering reducing the number of in-person clinical months required for graduation. A plethora of online learning platforms and courses exist that medical schools can utilize to educate students on clinical hiatus. These online resources are opportunities for education on core competencies required of effective physicians such as systems-based practice, ethical reasoning, and leadership. In many cases, they are also opportunities to grow students' clinical knowledge and reasoning foundations through virtual patient cases and group discussions. At our institution, students are practicing oral presentations and case discussions via online platforms to maintain preparedness and clinical acumen. Since a diversity of valuable online clinical learning exists, consideration with regard to how these experiences will be valued on student transcripts is warranted. For example, our radiology department has assembled a graded 4-week virtual clinical rotation for the different services on radiology that fulfills a graduation requirement. Since quality learning can be done outside of traditional clinical duties, it may be worthwhile for the LCME to temporarily modify graduation requirements so that that this learning can be equally considered when determining eligibility for graduation.

These are unprecedented times. Negotiating the uncertainty brought by COVID-19 has been, is, and will continue to be extremely difficult. Medical educators and administrators are faced with significant challenges and are rising to the occasion. As students, we believe that implementing virtual rotations, delaying the opening of the application, decentralizing clinical skills evaluations, and modifying graduation requirements are possible options among many that could aid in addressing some of the current challenges presented by COVID-19.

Implications of COVID-19 on the general surgery match

The Coalition for Physician Accountability's Work Group on Medical Students in the Class of 2021 Moving Across Institutions for Post Graduate Training. Final Report and Recommendations for Medical Education Institutions of LCME-Accredited

The prevalence and cost of medical student visiting rotations

Driving and travel restrictions across the United States. The New York Times

Racial and ethnic diversity in academic emergency medicine: how far have we come? Next steps for the future

The "race" toward diversity, inclusion, and equity in pathology: the Johns Hopkins experience

USMLE Suspending Step 2 Clinical Skills (CS) Examination

Function and structure of a medical school

D.R.L. and L.P. contributed equally and are co-first authors.

Luke Pumiglia https://orcid.org/0000-0002-8179-2403