As the COVID-19 pandemic increased rapidly in the U.S. in March and April 2020, the Association of American Medical Colleges (AAMC) released guidance strongly supporting medical school closings. On April 14, it advised that “medical schools in locales with significant, active current, or anticipated COVID-19 community spread, and/or limited availability of personal protective equipment, and/or limited availability of COVID-19 testing [should] pause all medical student participation in activities that involve direct patient contact.”1
The AAMC made clear, however, that decisions should be made on a school-by-school basis, urging “medical schools, with their clinical partners’ knowledge and input, [to] carefully evaluate their local situation on a regular basis to make determinations about their medical students’ participation in direct patient contact activities.”
At the time, nearly every medical school fell into at least one of the recommended closing categories outlined in the April 14 notice, but 4 months later, the organization updated its guidance, acknowledging a better understanding of COVID-19 and the impact of public health measures to limit its spread.
“Medical students are the essential, emerging physician workforce,” the AAMC wrote. “The clinical education of our medical students – including their involvement in direct patient contact activities (which may involve patients with and those without known or suspected COVID-19) – must continue, with appropriate attention to safety.”2 The organization’s revised guidance stressed the importance of planning for adequate personal protective equipment (PPE), conducting sufficient testing and monitoring, and training students in safety precautions specifically related to COVID-19.
Medical schools are now facing a dilemma: How can they continue to teach students while maintaining their safety, and the safety of the patients that the students encounter?
To learn more about how academic medical centers are adapting to “the new normal,” ASH Clinical News spoke with medical educators Ariela Marshall, MD; Navneet Majhail, MD; and Marc Kahn, MD, MBA, about the challenges and unexpected opportunities of training the future hematology/oncology workforce during a pandemic.
How did your institute react when the pandemic started? What changes were made early on?
Dr. Marshall: We had a brisk and timely response. We switched many nonessential patient visits to virtual visits. We had a robust tech support team and were able to conduct a lot of video visits and conferences. If patients did not have video capability, phone visits were used.
Within our training program, we made a number of changes to try to keep our fellows as safe as possible. Fellows conducted virtual visits and were not required to be on campus for that. Most of our fellows who were in their research time were asked to work from home. Some laboratories closed temporarily.
The time that fellows were outside their normal clinical rotations was relatively brief – I’m thankful for that. We also have been lucky in Minnesota to not have as big a burden of sick patients as many other areas. We did not have to do anything like redeploy fellows to inpatient COVID units or have fellows do medical duties that were outside their scope of hematology/oncology training.
Dr. Majhail: In the spring, there were many unknowns about how medical education would look. We work in cancer centers and mostly with cancer patients, many of whom are immunocompromised or on active treatment. When the pandemic started, we did not know the full extent of how the virus would affect our patients.
We curtailed many of our services. Like many other institutions, we cut down a lot of the in-person visits and elective procedures for a period of time. And, obviously, we had to be more creative as we talked about how and what we did with our patients coming in. As we learned more about the virus, we gained a better sense of the prevalence of COVID-19 infections in the local community. We gradually opened things a bit more and [at the time this interview was conducted in August 2020] we are mostly back to business “as usual,” while following safety precautions.
Dr. Kahn: After being on the faculty at Tulane University for 25 years, I became Dean of the University of Nevada, Las Vegas School of Medicine on April 1. I was a new dean at a new medical school. Yes, our students were converted to online education. And yes, our clinics were closed for a period. But we also set up the first curbside testing program – and first overall testing program – for the virus in the entire state of Nevada. We also set up the state’s first convalescent plasma program, which was up and running in 3.5 weeks.
The state of Nevada does not have a training program in hematology/oncology. Care is extremely fragmented. Right now, many Nevadans with cancer leave the state and go to Southern California or Utah for their care – we have to change that. So, when the pandemic hit, one of my messages as dean was to convey what an academic medical center could bring to the community. Between our curbside testing and convalescent plasma programs, we were able to articulate why this community needed a medical school.
When and how did your programs reopen? Were students hesitant to come back?
Dr. Kahn: The students realize we’re in the middle of a pandemic and that this is an all-hands-on-deck situation. Even when our clinical rotations were suspended, from about April through June, our students were active: managing call centers, getting patients registered for curbside testing, communicating results to patients who had been tested, recruiting COVID-19–positive patients to donate plasma. They were actively involved in our response.
Dr. Marshall: Overall, I think people felt safe and were glad to get back to patient care. We had protocols in place for universal masking and universal eyewear in patient care areas. We have plenty of PPE available and have not had any problem with shortages of that.
We did turn all of our planned in-person conferences – from teaching conferences for the fellows to administrative meetings with the fellows and the program leadership – into video conferences over Zoom or Skype within the first 2 weeks of the pandemic. We have kept that format, because we didn’t feel a need to return to in-person meetings for matters that weren’t directly related to clinical care. It’s another way we try to make people feel as safe as possible.
Dr. Majhail: Given the level of confidence in what our institution is doing, I think most faculty and trainees have felt comfortable in following those precautions and adapting to the changes we’re making locally so that we can all do what we do in a safe manner.
In blood and marrow transplantation, my area of focus, rounds are now conducted virtually. Our rounds are multidisciplinary. So, for example, in the past, 20 people would be sitting in a room and talking about patients; now, that discussion has been switched to a virtual platform. We still talk about patients with all those people present, but we’re not physically in one location.
How do you think this experience will affect the future health care workforce? Will today’s trainees suffer from the disruption and limited in-person encounters?
Dr. Marshall: As a medical community, there was already some move toward telehealth over the past 10 to 20 years, and COVID-19 has accelerated that shift. Personally, I think it’s good for our trainees to get trained in conducting video and phone visits during their fellowship. In our rural area of the country, there are a lot of patients who would travel 6 or 8 hours for a routine visit; we’ve seen that that’s not necessary.
Because we were able to get back to a more normal clinical environment relatively quickly, I don’t think our trainees have suffered from the clinical training perspective. I think the area where trainees will probably feel the disruption most is in their job searches. Our trainees who are starting their third or final year of fellowship and looking for employment opportunities may have limited options in their field of choice because of hiring freezes and financial instability related to the pandemic. I see that as a greater negative consequence of the pandemic than changes to clinical training.
Dr. Kahn: The pandemic has sharpened the focus on what it means to be a health-care provider and a physician. The goal of our center’s strategic plan is to care for the community. The pandemic has brought people together to realize this mission. I was in New Orleans during Hurricane Katrina, and New Orleanians define time as “pre- and post-Katrina.” In many ways, things post-Katrina are better than they were pre-Katrina. In much the same way, I think that the world will talk about things in “pre- and post-COVID” terms.
Dr. Majhail: There are some positives and opportunities amid the difficulties. First, the pandemic forced us all to think outside of the box. We have done things a certain way for a very long time, but now, we have had to take a step back and say, “Are some of the things that we do really worth doing? Is this still the right way to do things?”
Our challenge now is to ensure that we don’t compromise the educational mission that we all have in terms of training the next generation, while keeping everyone safe in this process. I think COVID-19 certainly has given our trainees a crash course on several aspects of health care in the U.S. – from witnessing the large disparities in care to realizing how important leadership, teamwork, basic public health principles, and the concept of evidence-based medicine are.
- Association of American Medical Colleges. “COVID-19: Updated Guidance for Medical Students’ Roles in Direct Patient Care.” April 7, 2020. Accessed September 7, 2020, from https://www.aamc.org/news-insights/press-releases/covid-19-updated-guidance-medical-students-roles-direct-patient-care.
- Association of American Medical Colleges. “Guidance on Medical Students’ Participation in Direct In-person Patient Contact Activities.” April 14, 2020. Accessed September 7, 2020, from https://www.aamc.org/system/files/2020-08/meded-August-14-Guidance-on-Medical-Students-on-Clinical-Rotations.pdf.
- Basen R. Med School to Students: Sign This COVID Waiver or Risk Graduation Delay. MedPage Today. May 29, 2020. Accessed September 7, 2020, from https://www.medpagetoday.com/publichealthpolicy/medicaleducation/86759.
On August 14, the AAMC updated its guidance for medical students participating in direct patient care activities. Below is a summary of the guidelines, which are available in full at the AAMC COVID-19 Resource Hub.
- PPE supplies should be sufficient for medical students to have consistent access to appropriate PPE for all situations in which PPE use is needed. The school should document that students have been specifically trained and assessed in PPE use and safety precautions in the context of the current COVID-19 pandemic.
- Results of SARS-CoV-2 polymerase chain reaction testing among medical students and graduate medical education (GME) trainees should be closely monitored for any increase in incidence of COVID-19 among students and/or GME trainees.
- In making decisions about the participation of medical students in direct patient contact activities as part of required clinical experiences and assessments, availability of faculty and residents for supervision and teaching, and adequacy of administrative staff should be regularly considered.
- Medical students’ participation in direct care of patients in an area where there is a critical health-care workforce need, outside of the required core curriculum, should be voluntary, not required.
- In this context, decisions about assignments should be based on the competence of the student to take on the responsibilities involved rather than on the student’s particular year in medical school; there may be responsibilities for which any medical student, regardless of their year in medical school, can be trained (e.g., checking vital signs).