The new physician training environment: How medical schools are navigating students' return

The COVID-19 pandemic disrupted traditional learning processes and environments for medical schools nationwide this spring.

Many ended in-person classes, suspended student clinical rotations, switched to remote learning options and stopped students' interaction with patients. Others allowed students to graduate early and be involved in patient care during critical healthcare workforce shortages at hospitals.

Now, medical schools are adapting spaces and practices to ensure students are safe during their physician training ahead of the upcoming fall semester. 

Some medical schools have started the 2020-21 academic year, and others will start in September, according to the Association of American Medical Colleges. The association's survey of more than 150 medical schools found most respondents (more than 80 percent) plan to return third- and fourth-year students to clerkships by the end of August. First- and second-year students will largely learn online, the survey found. 

Medical schools' plans 

At the University of Washington School of Medicine in Seattle, third- and fourth-year students began clinical rotations June 29. For first- and second-year students, a hybrid model will be used this fall. Large lectures and small group learning will be done virtually. Anatomy lab and clinical skills education will be done in person, with small groups and staggered scheduling for social-distancing purposes, said Suzanne Allen, MD, the medical school's vice dean for academic, rural and regional affairs. Classes begin Sept. 8 across the University of Washington School of Medicine's six campuses.  

At the University of California, San Francisco School of Medicine, third-year students returned to clinical environments July 13, and first- and second-year students are returning this fall. First-year students will start out with predominantly remote learning, although they will also have some in-person class sessions in a simulation center, said John Davis, PhD, MD, professor of medicine and associate dean for curriculum at UCSF School of Medicine. The medical school will have some clinical activities for second-year students as they prepare to enter their clerkship phase, depending on how many learners can be accommodated in clinical sites. 

The Stanford (Calif.) University School of Medicine is moving forward with its plan for a hybrid curriculum for preclinical students this fall, which combines remote learning via Zoom with in-person small group sessions, said Daniel Bernstein, MD, associate dean for curriculum and scholarship, and the Alfred Woodley Salter and Mabel G. Salter Endowed Professor of Pediatrics at the medical school. He said clinical rotations restarted at Stanford training sites at the end of June.  

Mel Rosenfeld, PhD, senior associate dean for medical education at NYU Grossman School of Medicine in New York City, said second-year students returned to onsite learning activities Aug. 17. He said those students' fall semester will include onsite didactics and remote learning activities via Zoom. For first-year medical students, the fall semester will be taught entirely remotely. They will return for onsite classes in January. Third-year students returned to NYU training hospitals July 1.


Dr. Allen, with the University of Washington School of Medicine, said one of the biggest challenges with restarting physician training so far involves messaging to students about proper personal protective equipment.

 "At first, there was slight confusion about what PPE students should be wearing," she said. "But now students at clinical sites have figured it out. We instructed them to follow their site's instructions [on mask use]."

Another challenge is ensuring attending physicians and students can still function in the training environment together as safely as possible with social distancing in place, said Dr. Davis with UCSF School of Medicine. 

For example, in the clinical training space, the University of Washington School of Medicine assessed how many people — faculty, resident, student, patient, patient's family — can be in an exam room at a given time safely. Dr. Allen said the medical school is doing rounds in a different way and trying to minimize how often clinical teams move around in big groups. 

While medical schools face challenges in terms of social distancing and space, they are also working out logistics for testing students for COVID-19. 

At first, there was variability across the clinical training sites where University of Washington Medical School students do clerkships as far as how often students need to get tested and in what situations a quarantine is required, said Dr. Allen. But the medical school now has a system where students can call a central phone number, regardless of their clinical site, to get consistent instructions about testing and quarantining. 

Medical schools are also taking steps to ensure students have proper protective equipment.  Dr. Rosenfeld, at the NYU Grossman School of Medicine, said all students will be tested for COVID-19 and fit tested for an N95 mask before returning to the medical school. Students returning to their clinical rotations also attended a three-hour safety training session, including proper use of PPE, at the medical school's simulation center. 

"Because there are so many 'moving parts' the logistics of organizing this effort was challenging," said Dr. Rosenfeld.


To overcome these challenges related to students' clinical training during this unprecedented time, leaders said medical schools should:

1. Overcommunicate with students. "It doesn't hurt to say the same thing again," Dr. Allen noted."This will get easier for us over time. I think there have been so many changes as we've all tried to figure this out, but communication has been one of the keys."

2. Think about medical students as essential healthcare team members. "Students are eager to be helpful, and I think if we all work together and think of the students as essential members of our healthcare teams, they get the education they need and we keep our workforce vibrant, meaning we have people to graduate and replace people who are retiring," said Dr. Allen.

3. Collaborate with clinical sites and university leaders on educational decisions as COVID-19 and PPE requirements change. "As all of these factors change, there needs to be constant dialogue about what the implications might be from the educational standpoint," Dr. Davis said. 

Dr. Rosenfeld agreed, noting that NYU's offices of medical education, student affairs, diversity affairs, and the simulation center, worked in collaboration with the hospital system's supply chain, emergency management and enterprise resilience teams on plans for students' return. "In addition, keeping the students informed, and seeking their input, were also critical in developing our plan," he said.   



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