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When Medical Education Moves Online

December 21, 2021

The COVID-19 pandemic necessitated an unprecedented shift to virtual learning for trainees, and long-term effects of the anomaly remain to be seen.

 

 

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Training to be a physician requires a lot of hands-on experiences, from labs to patient interactions to study groups, but the COVID-19 pandemic changed many of these in-person activities for medical students, residents, and fellows. In some cases, the changes were improvements, but not always, which forced medical trainees and faculty to do the best they could to overcome the disruptions to their lives and training.

“It was very overwhelming for that first month [after the start of the pandemic],” said Urshila Durani, MD, MPH, senior associate consultant in the division of hematology at Mayo Clinic in Rochester, Minnesota. “People were scared. Hematology education was basically put on pause those first few weeks.”

Dr. Durani, who was a third-year chief fellow in the spring of 2020, was part of a study that surveyed hematology/oncology fellows on the effects of COVID-19. Study results showed the pandemic “deeply impacted” participants’ training experiences.1 The study elucidated trainees’ concerns about virtual education, missed hands-on experiences, clinical practice preparations, and post-training career prospects.

ASH Clinical News spoke with Dr. Durani and others about their experiences with tele-education during the pandemic, the pros and cons of virtual training programs, and what post-pandemic programs might look like.

The Lockdown

At the time that U.S. workplaces and schools started responding to the reality of the COVID-19 pandemic, Dr. Durani was on a research rotation that was scheduled to last for the rest of the academic year. The 32 participating fellows agreed that being in a room together might not be safe, so the fellows who were working on research and outpatient elective cases agreed to work from home.

Dr. Durani was one whose schedule changed from daily in-person interactions to remote work.

“It was very isolating. That was the biggest downside,” she said. “I usually spent every day in the same work room as my co-fellows, discussing cases or talking to people about how they were doing. That daily interaction is something a lot of us value.”

Mazie Tsang, MD, a fellow in the division of hematology and medical oncology at the University of California, San Francisco (UCSF), still had daily interactions during the pandemic, but suddenly they were all virtual. Technical difficulties presented issues that made it challenging to contribute effectively to her team and limited her educational experience.

“My work became telehealth, which made it difficult to do consults and talk to patients,” Dr. Tsang said. “I also lived in an area where the Wi-Fi signal and cellular data were fairly weak, so my patients and colleagues voiced that they had difficulty understanding me or that my video would freeze.”

The anxiety of the pandemic also affected medical teams, which were forced to adapt quickly to new norms in hospital life. In March 2020, Caleb J. Smith, MD, was on an inpatient pulmonary service as an internal medicine resident and was involved in the care of some of the first COVID-19 cases in the hospital.

“There was obviously a great deal of anxiety during the initial phase of the pandemic,” said Dr. Smith, who is now a first-year hematology/oncology fellow at Mayo Clinic. “One day at our in-person noon conference there were some announcements from the infectious diseases department discussing PPE [personal protective equipment] and changes to procedures. COVID-19 cases started coming in, and from that point on, all educational conferences were virtual.”

The Move to Online

The move of medical training from in-person to online affected everyone, from medical students to deans. Considerations were made for social distancing as well as to safeguard the rigor of medical training programs.

At the University of North Carolina (UNC) School of Medicine, auditoriums that would normally seat 800 people were restricted to allow a maximum of 26, said Alice D. Ma, MD, associate professor of medicine in the division of ­hematology/oncology at UNC and former ASH Clinical News associate editor.

In 2020, everything had to be done virtually, including small group exercises, large group exercises, and exams. Dr. Ma, who is also the course director for hematology at the medical school that runs in October each year, remembered a distraught student who came to the faculty to report that a number of classmates were cheating on the virtual exams.

“We ended up requiring individuals to have two web cams open: one for taking the exam and one with a wider view pointed at them so we could see them taking the exam,” Dr. Ma said. “We also had to have discussions about what it meant not to cheat ... to act as a professional and uphold standards of the university.”

For third- and fourth-year medical students, a lot of the in-person learning was also restricted in the spring of 2020.

“We were limited by lack of PPE, and students were restricted from coming in to help take care of patients,” Dr. Ma said. “Because of that, some of the mandatory clinical rotations were shortened in duration.”

Pros and Cons of Virtual Life

The pandemic brought changes that forced department heads to assess what online education would look like and how much of the programming would work virtually. Darcy Reed, MD, senior associate dean for academic affairs at Mayo Clinic, said several positives emerged from that push although there were drawbacks, too.

“[Virtual education] offers a lot of flexibility for students to choose if they want to be remote or in-person,” Dr. Reed said.

The changes during the initial pandemic also allowed medical students to really step up and show professionalism and contribute to patient safety. Students demonstrated this with their willingness to move to virtual education, removing themselves from certain clinical environments, participating in clinical encounters via telehealth, helping with patient screening, or even babysitting for busy providers on occasion.

Moving to virtual learning has allowed schools to record lectures or other classes, Dr. Reed said. Having these online tools has made learning more accessible to students.

In some situations, virtual learning may be less expensive, too, depending on the educational modality it replaces.

“The biggest negative impact was on well-being,” Dr. Reed said. “There was a social isolation for students – and everyone. An important part of medical school is learning by doing and interacting with patients.”

While many programs adapted to tele-education and maximized the experiences for everyone as much as possible, in-person interactions can’t be replaced. There were lost opportunities for learning clinical skills and building relationships with patients, peers, and faculty.

“All of that is more difficult when we are remote, masked, and sitting far apart from each other,” Dr. Reed said.

Faculty also suffered some of the consequences of the move online, according to a June 2020 survey by the American Society of Hematology (ASH) and the American Society of Clinical Oncology (ASCO). Hematology/oncology program directors queried about program changes and perceived impacts during the COVID-19 pandemic voiced concern that there may be an increase in burnout among program directors after the pandemic compared to before.2

“We are all so tired of COVID,” Dr. Ma admitted. “The resilience well is running a bit dry.”

Permanent Changes?

Many of the initial adjustments made to medical education and training during early 2020 are no longer needed, but not everything is back to normal. And some of the positive changes may become permanent.

At UNC’s medical school, pre-pandemic breakfast meetings between fellow groups and fellowship directors hadn’t been reinstated as of November 2021, although all classes were being held in person. Even so, students could still choose to join virtually for larger lectures. Similarly, Mayo Clinic has kept some learning virtual, such as large lecture groups, and has given students the option to register for small group learning either in person or online.

Some schools are even teaching subjects like anatomy entirely virtually. “There are a lot of high-quality tools that can be used to allow that,” Dr. Reed said.

Some medical schools offered online learning options even before the pandemic, like the University of Kentucky’s introduction to regional anatomy course that met weekly via a 3D virtual platform.3 The Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, is equipped with both hands-on and virtual tools in its Anatomy Resource Center, which allows students to learn on-site or remotely.4 Similar virtual reality anatomy courses are offered at Stanford Medicine5 and the Perelman School of Medicine at the University of Pennsylvania.6

Other skills training has also shifted online. For example, when some patient simulation centers were closed during the pandemic, Dr. Reed used standardized patients online for skills training related to taking patient histories and conducting patient interviews.

As far as how faculty feel about the changes to teaching, it’s a mixed bag. The flexibility of being able to teach from remote locations is a positive, but the lack of personal interaction is generally seen as a negative. Online classes don’t lend themselves well to informal discussions or building relationships.

“The whole tele-education thing, for me, was terrible,” Dr. Ma said. “You just don’t get the support online. No one laughs at your jokes. It is hard to take an emotional temperature of your class. It is hard to open up or be vulnerable. People need to be around other people.”

While there are certainly drawbacks to online teaching, tele-education may have a permanent place in medical schools, Dr. Ma said, as the format could be helpful in the case of inclement weather or for students who are sick. Still, she said that in-person learning will likely be the best option for trainees.

Regardless of what happens with education programs, it seems likely that telehealth is going to become permanent. As such, how to work with patients virtually has become an increasingly important part of medical school training.

“We are teaching these skills and having medical students join in telehealth appointments much in the same way they would an in-person appointment,” Dr. Reed said. She added that it’s important to examine the best instructional methods to ensure trainees have the right experiences and develop the right skills for their practice.

Career Implications

Whether the group of trainees will be prepared for the workforce remains to be seen, and faculty and students alike are concerned about the potential effects COVID-19 could have on their careers. This is something that faculty are thinking about, according to the ASH/ASCO survey, which indicated faculty are worried about how pandemic-related budget cuts might affect fellows’ professional and career development.2

Beyond budgets, trainees in programs across the country missed out on in-person networking and mentoring experiences that in pre-pandemic times could have led to collaborations or long-term relationships with colleagues and mentors.

“The pandemic has hindered the development of valuable relationships that might have evolved over casual conversations in the hallway or after in-person meetings,” Dr. Tsang said. “As a result, I have experienced decreased life and career mentorship that I previously received through socializing at work or at events hosted by faculty.”

Professional conferences were another missed networking opportunity during the pandemic.

“Scientific meetings are a great location for residents, fellows, and students to make connections, meet researchers or mentors, and potentially identify a residency program or institution where they would like to have a job,” Dr. Reed said.

Similarly, the pandemic may have affected residents as they applied to fellowship programs. While it was expected that interviews would move to an online format, this could have led to some bias toward familiar locations, Dr. Smith said.

“If I had visited a certain hospital during residency interviews or previously visited a city, it was easier for me to imagine training there compared with somewhere I had never been,” he added.

Conversely, Dr. Ma said that interviews being virtual may have encouraged residents to apply to more fellowship programs because they didn’t have to worry about the cost of traveling for interviews.

Hiring freezes have been another issue during the pandemic that stymied some trainees’ professional ambitions. Dr. Durani had already committed to a one-year bone marrow transplant fellowship at City of Hope National Medical Center in Duarte, California, that started the fall after the pandemic began, but she had to delay her job search by about six months as a result of hiring freezes.

During her third year of fellowship, Dr. Tsang found that many institutions had stopped hiring because of the pandemic, so she opted for a fourth year of fellowship to see if her options might change with time. Toward the end of 2021, Dr. Tsang – who is also a National Institute on Aging Research Fellow in the Division of Geriatric Care at UCSF – had begun her job search again, with a brighter outlook.

“More institutions have advertised open positions, and more division chiefs have said that they have the resources to hire new faculty,” Dr. Tsang said.

Long-Term Effects?

Feelings are mixed when it comes to whether the pandemic will have positive or negative long-term effects on the trainees’ careers.

Dr. Smith doesn’t think his training will be negatively affected long-term, despite his spending about one-third of his post-graduate medical education treating a disease that he was not asked about on his American Board of Internal Medicine certification exam. Now in his fellowship, Dr. Smith said that he sees all of the diseases that he would have expected pre-pandemic and he often jokes with residents about the changed priority.

During didactics, “I say, ‘Now we are going to learn about something that isn’t COVID! We are going to learn about thrombocytopenia and really dig into the details,’” he explained.

It’s possible that the education of some trainees may be temporarily impacted by the pandemic, but the effects should not be long term, Dr. Reed said.

“We may just have to look and see if they need anything in terms of ‘catch-up’ competency development,” Dr. Reed said. “There will need to be a careful assessment because timing of skill acquisition may be different.”

Any effect that COVID-19 had on trainees will be across the board, Dr. Ma noted. The pandemic affected everybody, and it will take time for the emotional and health care development effects to be realized. Indeed, for some trainees, the pandemic will be the only thing they have ever known.

“You only get to go through your first year of medical school or your second year of fellowship once,” Dr. Ma said. “We are all trying to make it the best possible education they can get, regardless.”

Although it has been a long, hard road, the trainees who learned and worked during the pandemic will have been part of an event that will shape health care and the global approach to medicine for decades to come.

Said Dr. Ma, “They will get to say that they were a part of the generation that provided health care during this pandemic.”

–By Leah Lawrence

References

  1. Durani U, Velazquez Manana AI, May J, et al. Measuring the impact of COVID-19 on hematology-oncology trainees: a quantitative and qualitative assessment. Abstract #2473. Presented at the 2020 American Society of Hematology Annual Meeting and Exposition, December 6, 2020.
  2. Velazquez Manana AI, Durani U, Reynolds R, et al. The impact of covid-19 on hematology-oncology fellowship programs: program director perspectives. Blood. 2020;136(S1):24-25.
  3. University of Kentucky College of Medicine. Virtual Laboratory Prepares UK Undergraduates for Professional-Level Anatomy. Accessed November 23, 2021. https://med.uky.edu/news/virtual-laboratory-prepares-uk-undergraduates-professional-level-anatomy.
  4. Kaiser Permanente. A modern approach to teaching anatomy. Published May 18, 2021. Accessed November 23, 2021. https://about.kaiserpermanente.org/our-story/news/announcements/a-modern-approach-to-teaching-anatomy.
  5. Erickson M. Stanford Medicine. Educators will use virtual reality to teach anatomy. Published October 16, 2020. Accessed November 29, 2021. https://med.stanford.edu/news/all-news/2020/10/educators-will-use-virtual-reality-to-teach-anatomy.html.
  6. Penn Medicine News. The Perelman School of Medicine Launches Online 3D Anatomy Courses in Collaboration with Elsevier and Sharecare Reality Lab. Published October 11, 2021. Accessed November 23, 2021. https://www.pennmedicine.org/news/news-releases/2016/october/the-perelman-school-of-medicin.

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