BENT BUT NOT BROKEN: EVOLVING MEDICAL EDUCATION The COVID-19 pandemic turned life on its head; the realm of medical education is no exception as students adapted to abrupt changes in their learning environments. Some of these changes will continue to affect education in the near term and long term

  F E A T U R E 

Bent, but not broken: The 2020 medical student experience Danielle Coleman, Rocky Vista University College of Osteopathic Medicine Jacob Leary, University of Colorado School of Medicine

Danielle Coleman Jacob Leary

The COVID-19 pandemic has turned life in

our country on its head, the realm of medi

cal education being no exception. Like a

whirlwind it came through – shaking up all

of our plans, then bringing everything to a

crashing halt. As with many other Amer

icans, students were forced to make an

abrupt transition to working from home,

all while worried about the safety of our

loved ones and the security of our careers.

The first wave pushed us to adapt to the unexpected and prepare for an uncertain future. This was a tumultuous time, as each class of medical students faced their own set of challenges. First- and second-year students, whose learning was still primarily campus-based, transitioned to watching pre-recorded lectures from home and completing small-group work and skills labs via Zoom.

In an effort to protect trainees and conserve PPE for frontline workers, students in their third and fourth years of training were rapidly pulled from clinical rotations. This left many of the thirdyear students, class of 2021, wondering whether they would be properly prepared to apply to residency programs in the fall. Many still face an uphill battle in their effort to secure sub-internships without the necessary letters of recommendation that would have come from their core clerkships. Others are scrambling to find new ways to augment their skillsets and expand their networks sans the opportunity for away rotations. These rising fourth years from both Rocky Vista and University of Colorado will also be forced to choose their future residency program having never visited it, as all upcoming interviews will be held in a virtual format. For the class of 2020, the Match Day and commencement ceremonies that typically mark the culmination of years of hard work and dedication for students finishing up their fourth year were transformed into anticlimactic virtual ceremonies. Celebrations too were socially distanced from the community of friends and classmates who had made the arduous journey together.

In addition to readjusting to learning from home, students preparing to take medical licensing exams this summer were thrown into another whirlwind as test reservations they had secured months in advance were suddenly canceled with

minimal communication from both the testing centers and medical examination boards. Even after the initial “culling” of 50 percent of reservations across the country, students still live with the uncertainty of whether or not they will have a seat when they show up on exam day. This is especially troubling for students who have had their preparation perpetually extended from weeks to months or those who have spent the money on air travel and overnight accommodations to take their exams outside of Colorado.

Along with the many obstacles the pandemic created for our academics, the societal implications have been profound. Increasingly, misinformation seemed to spread like wildfire on various media platforms and people began questioning the validity of medical research as well as the recommendations of physicians for health and safety. Protests sprang up calling for the reopening of businesses and a return to pre-pandemic normalcy, creating conflict between economic interests, personal liberties and public health. We are disheartened by the growing disregard for the advice of experts, painting a bleak picture of society’s trust in physicians. It saddens us to think that after years of hard work and countless sacrifices made pursuing our call to this profession, we would be met with doubt and even ridicule by the very people we’ve been entrusted to care for.

At the same time that we were grappling with this reality, reports emerged showing disturbing disparities in COVID-19 outcomes for racial and ethnic minority groups compared to White patients. According to a study by the Centers for Disease Control, Black patients with COVID-19 represented 33 percent of hospitalized individuals while comprising only 18 percent of the surrounding community, compared to White patients representing only 45 percent of hospitalized patients and making up 59 percent of the community. 1 Data from New York in May 2020 also suggests that mortality rates among Black and Latino patients are double that of White patients. 2

These differences are appalling, yet frustratingly unsurprising. Communities of color are challenged by a multitude of contributing forces, including housing segregation and discrimination that lead

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to more crowded living conditions in urban settings; higher rates of public-facing employment; and a disproportionate burden of underlying comorbidities that can in major part be attributed to systemic and institutional racism, to name just a few. We are taught in medical school to treat all patients with equally high standards of care and to strive for the best possible outcomes for everyone we treat. These data trouble us deeply. Our Black and Brown classmates have been forced to try to maintain focus and composure, while grappling with these disparate findings in the backdrop of the ongoing murders of people of color at the hands of police. The ensuing protests and calls for action to reform our society have united students with a common goal, but also laid bare certain tensions, and have led to personal reflections that in many cases cause discomfort as we realize our own intrinsic biases and harmful behaviors.

Moving forward, constant adaptation to ongoing uncertainty is the name of the game – it’s our new normal. Rising thirdand fourth-year students are increasingly returning to clinical spaces as PPE supplies become available and state case numbers have stabilized, with most of the standard training experiences in places like operating rooms and emergency departments becoming reality once again. However, significant caution is still asked of us when dealing with possible or confirmed COVID-19 patients, and some hospitals continue to restrict student interactions and accessibility. Telemedicine curriculum has taken a more prominent role, as we try to maintain contact with patients who are doing their best to avoid unnecessary in-person clinic visits. Though this may be different than what our predecessors experienced in their clinical training, it is vital for us to prepare as telemedicine takes a prominent role in daily practice – even outside the context of a pandemic.

Meanwhile, students in their first and second years of medical school will proceed with primarily virtual curriculum moving into the new semester. That being said, CU and RVU campuses are both reopening in phases. Some, but not all, small group case-based learning will be returning in the fall at CU, and labs that require more direct interaction and hands-on training will be adjusted to maintain social distancing at RVU. For those struggling with the lack of face-toface contact, this will provide a welcome respite that should serve to benefit mental health and strengthen classmate connections.

Finally, our friends belonging to communities of color have been unfairly tasked with fighting for equal treatment in both health care spaces and the eyes of the law, protesting to finally be seen and negotiating policy reforms at the school and governmental levels to enact justice that is long overdue. Those of us not directly threatened by these racial injustices, meanwhile, must now commit to the essential work of examining our own privilege, understanding our implicit biases, and becoming the allies that our friends and future patients need and expect us to be. These challenges arguably are far greater than those posed by COVID-19, and will likely continue to impact us long after the pandemic has subsided.

Moving forward, constant adaptation to ongoing uncertainty is the name of the game – it’s our new normal.

The first half of 2020 caught our society off guard. Between COVID-19 and the fight for racial justice, the adversity that we’ve faced has given us an unexpected opportunity to learn rapid adaptation to ever-changing conditions and mentally prepared us for an uncertain future. The biggest question right now: Are we ready for a second wave?  ■

1. Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly

Rep 2020;69:458–464. DOI: http://dx.doi. org/10.15585/mmwr.mm6915e3external icon. 2. NYC Health. COVID-19: data. Accessed

May 7, 2020. https://www1.nyc.gov/site/ doh/covid/covid-19-data.page

Brigitta Robinson, MD, FACS

When it comes to the current hospital restrictions, it is difficult to consider how one would teach any aspect of medicine remotely. Surgery, being more hands-on, requires in-person learning more than most other specialties. At RVU we found a way to deliver as much information as we could in the time of COVID-19. Remote lectures are always a part of the curriculum but more details were added to help fill in the void left by being out of the hospital. The surgery skills weeklong course we teach was a truncated course via Zoom. Then suturing, tying, scrubbing, gowning and gloving were done with permission in person one morning with our seven students, in masks at the school. We are all hoping that the restrictions are fewer as we move into summer. We are doing the best we can, but it is not what we owe our medical students. COVID-19 has changed so many in so many ways.

Jan Kief, MD

I feel optimistic about medical education post COVID. I teach in the pre-clinical years of medical school. While there was already great progress in re-imagining medical school education, we can use what we have learned about virtual capabilities and how disruptive innovation can lead to some very positive change to deliver a quality medical school education in an efficient, effective and safe way. Students and faculty have answered the challenge with effective ideas that will help the education process. Didactic information can be provided in a more cost effective and timely manner, and new simulation platforms can be a valuable addition. I believe clinical encounters can be accomplished, provided there exists adequate amounts of PPE, in a structured, concentrated and safe way. As physician leaders, we can break through these challenges and deliver a very valuable education.

Deb Parsons, MD, MACP

As medical school and residency educational curricula evolve to meet the needs of the future physician, the core principles of professionalism, humanism, and patient-centeredness as well as the core values of providing safe, affordable and equitable care, will continue to be foundational.

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