As the wave of closures swept across the U.S. due to the COVID-19 pandemic this spring, Jason Rosenstock, M.D. found himself among the educators scrambling to totally rethink how school would work.
For the interim associate dean for medical education at the Univeristy of Pittsburgh School of Medicine, that meant rethinking the delivery of medical education using pre-recorded classes while lecturers connected with students in active discussions through online platforms like Zoom, Rosenstock said.
“It was okay, but it really wasn’t as good as doing synchronous discussions,” he said.
With COVID-19 shows no signs of letting up soon, leaders at medical schools like Rosenstock are adapting their plans for education in the fall to meet the new demands of the pandemic. That means going digital in an unprecedented way—both in terms of classes and in terms of the type of clinical care students are learning about.
“It’s the new normal, and we’re going to need to tailor our medical education curriculum and other health professions’ education curricula to train our students for that new normal,” Stephen Spann, M.D., founding dean of the College of Medicine and vice president for medical affairs at the University of Houston, told Fierce Healthcare.
At UH, Spann and his team have welcomed the university’s first class of medical students in July, saying they tried to strike a balance between the need for in-person clinical education with social distancing and the growing use of telehealth.
The challenges facing UH are emblematic of the same hurdles that medical schools across the country are navigating.
Alison Whelan, M.D., chief medical education officer at the Association of American Medical Colleges, told Fierce Healthcare that the pandemic has forced medical colleges to get back to basics and really suss out the key competencies that students must learn in reshaping the education experience.
“It’s taken a lot of sort of creative jimmying,” she said.
Zoom versus in-room learning
Medical schools were not alone in moving to remote learning in the spring as the novel coronavirus first began to spread in the U.S. Schools at all levels grappled with the same challenge, and are eyeing it again as we move into the fall.
Medical students in their first two years are largely engaged in more classroom-based activities so going online was a logical transition, Rosentock said about Pitt's move to online. But, he said, students miss something in being able to get together for a conversation so looking ahead to the fall, greater emphasis will be placed on active learning opportunities.
The bigger challenge, Rosenstock said, is effectively providing the hands-on clinical care for third- and fourth-year medical students, who engage more directly with patients. Pitt pulled its students out of clinical sites in the spring, a decision he said was “very hard.”
There are ways to conduct such training remotely—such as talk-through sessions or simulations—but it’s far less effective than conducting a physical exam in-person. Rosenstock said Pitt provided additional coaching and advising to students at all levels to help them through the shift to virtual education.
David Muller, M.D., dean of medical education at the Icahn School of Medicine at Mount Sinai, told Fierce Healthcare that Mount Sinai students have continued to conduct clinical education in-person for its third and fourth year students, as there are few viable alternatives.
And, he said, these students must realize that COVID-19 will be something they need to prepare for as physicians themselves.
"COVID is here to stay,” Muller said. “Even once we’re all miraculously vaccinated, this is going to become part of their clinical practice.”
The telehealth transition
As telehealth takes on an outsized role in navigating the pandemic, it’s also becoming a focal point in medical education. At the University of Houston, for example, nursing students that predated its first class of medical students were shadowing nurses on virtual visits as part of their clinical training, said Tray Cockerell, director of strategic relationships at Humana.
Humana and UH co-founded the medical school together, and it is under the university’s Humana Integrated Health Systems Science Institute.
Cockerell said that nursing students would join Humana nurses on in-home visits, so transitioning that experience to the virtual space was the logical step. He said there’s an interest from students in learning more about this kind of care.
“I think that’s something that is emerging and has been certainly an interest of all the clinical colleges to learn more about how we bring telehealth into education and leverage opportunities like this,” he said.
Spann said that interest extends to the new class of physician trainees as well. Pretty much all their educational journey has been influenced by the digital demands of COVID-19, starting with their admission interviews in the beginning of the year.
For the 170 applicants who made it to the interview stage, only 48 in-person interviews were conducted before the pandemic forced UH to take the interviews virtual.
And, as more practicing physicians expand their use of telehealth, it will become a critical piece of curricula moving forward, Spann said.
“This sounds strange to think there could be any benefits to this COVID pandemic,” he said. “One of the good outcomes, I think, is going to be expanding the use of telehealth in clinical care, and we’re going to need to teach students about that.”
Even before the pandemic began, the AAMC was looking at ways to assist medical schools in integrating telehealth into their curricula, Whelan said. The group assembled a group of clinicians and experts to outline a list of core competencies around telemedicine.
AAMC expects the guide to be released this fall, she said.
“That is where patient care is going to be happening,” she said.
Putting health disparities front and center
Cockerell said the pandemic is also putting a huge spotlight on another key focus area at the Humana Institute—the social determinants of health. One of the Institute’s goals is to integrate thinking about these social needs into the medical education it provides, and he said the pandemic is proving the value in that effort.
They also aim to show patients how to engage with companies like Humana and community partners "to think about how we work to help solve some of those issues,” he said. That includes, for example, providing training on how to use data to track referrals and patients’ use of services they need, including non-clinical services.
“Being able to close that loop is something we’re very interested in doing,” Cockerell said.
Spann said that education entails making students understand that non-clinical workers are a critical part of the care team in tackling these issues. For instance, if a child presents repeatedly to the emergency department with asthma issues, they can receive any number of medicines and treatments, but will continue to struggle if they’re returning to a home infested with mold and cockroaches.
Getting at that issue, he said, will require the assistance of a lawyer to hold a neglectful landlord accountable—a potential partner in medical care that most would not think of.
“It’s all about a team sport, and there are members of that team that we don’t typically think about as healthcare providers,” Spann said.
Muller said that the pandemic is also putting greater strain on the socioeconomic challenges the students themselves may be facing, and that must also be a greater consideration moving forward.
Mount Sinai, for example, accepts a number of students who are living in the U.S. under the Deferred Action for Childhood Arrivals (DACA) program. On top of trying to complete their medical education, many of these students are dealing with the pandemic having a disproportionate impact on their communities and any undocumented family members trying to seek care if they need while avoiding detection by Immigration and Customs Enforcement (ICE).
Muller said students like these may require greater resources and for their schools to better meet them whether they are.
“Medical schools need to acknowledge that and be cognizant of it,” he said.
Looking to the future
It’s likely that some of the changes brought on by the pandemic are here to stay in medical education. Industry experts largely agree that the telehealth boom is here to stay, which means the demand for training will stay in tandem.
Rosenstock said that the pandemic response has made a case at Pitt for continued use of remote assessment and learning, which is more convenient and effective for some students. Adjusting to digital learning was difficult, but the students did settle in, he said.
“We’re in a much better place now,” he said. “We’re used now to this hybrid of tele and in-person.”
He added that transitioning to providing education virtually has also required additional training for the educators, and planning for how to best integrate telehealth training into certain specialties.
Spann said that the pandemic has also proved the need to better educate students on public health and epidemiology so the clinical workforce has experience in those areas should another health crisis like COVID-19 emerge.
Muller said that going digital due to the pandemic has also emphasized that some of the more traditional approaches to education were on the way out, anyway, with or without the novel coronavirus.
Lecture attendance, for example, was already declining as students would instead listen to recordings on their own time, which was more convenient, he said. It’s also bringing back up longstanding questions about standardized testing—a method that has been criticized for decades as disadvantaging certain populations and for biases.
As students avoid testing centers for these exams amid social distancing, it proves that other ways to assess performance are just as workable, Muller said.
"The pandemic has revealed how really ridiculous all of that has always been,” he said.