On January 7, health officials confirmed that cases of pneumonia in Wuhan, China, which Chinese authorities had notified the World Health Organization about in late December, were due to COVID-19 – the illness associated with a novel coronavirus-SARS2 infection. In mid-January, the U.S. saw its first reported case. The epidemic has now exploded into a global pandemic, sending shock waves across the world and killing thousands. Strategies to address this devastating infection have moved from containment to mitigation and the need for social distancing.
These effective and lifesaving strategies were first deployed to combat the 1918 H1N1 influenza pandemic, also referred to as the “Spanish flu,” which affected more than 500 million people and killed an estimated 50 million people worldwide, including about 675,000 people in the U.S., many of them young adults.¹
In a tale of two cities, Philadelphia’s health commissioner at the time ignored warnings of contagious illness among soldiers preparing for World War I and allowed the city to proceed with a large-scale march to support the war effort. More than 200,000 people gathered in close proximity to one another to watch the event.² A few days later, Philadelphia’s hospitals were filled with infected patients. By the end of the week, more than 4,500 people had died. Philadelphia’s politicians then decided to shut down the city, but the several-week delay resulted in overwhelmed hospitals and burial sites.
In contrast, 900 miles away in St. Louis, officials took a different approach. Within 2 days of the first cases among the local population, the city took drastic measures to limit social gatherings. Schools, playgrounds, libraries, courtrooms, and churches were closed. These extreme measures kept the city’s influenza-related death rates at less than half of Philadelphia’s.
In effect, this was an early example of what is currently being called “social distancing,” which is now an essential element of global recommendations to mitigate the community spread of the novel coronavirus.
In the U.S., after initial dismissal of the danger of the new illness by national leaders in February, calls to practice extreme social distancing escalated quickly. Governors declared states of emergency, travel restrictions multiplied, and most public schools and higher education institutions closed. This preemptive step was felt to be necessary to allow educators time to adapt their curricula to virtual learning. Within medical education, however, we are facing several additional layers of complexity.
The structure of medical education has not evolved substantially since the Flexner Report of 1910, which called for American medical schools to transition from bedside apprenticeship to a 4-year training program, divided equally between basic science instruction in the classroom and patient-centered teaching in the clinic.
In the context of patient-centered teaching, today’s mandate to “flatten the curve” raises many questions that may reshape medical education. How can we train future doctors within the limitations of social distancing? In addition to web-based learning and digital content, can we simulate virtual patient encounters? How should we protect students who may feel obligated to care for ill patients due to a supervisory and grading aspect? How do we determine who are essential medical personnel in the era of responsible use of personal protective equipment? What are the implications of avoiding patient encounters for our learners’ professional identities and responsibilities as members of health-care teams? How can we help residents tackle the challenges of this pandemic as competent graduate physicians?
The answers to these questions will depend on the duration of this pandemic and associated behavioral changes, which are anticipated to remain in effect well beyond original estimates.
On March 17, the Association of American Medical Colleges issued guidance recommending that its member medical schools place, at minimum, a 2-week suspension on their medical students’ participation in any activities that involve patients.³ “Individual schools may determine that a longer suspension is indicated,” they said. The hiatus will allow learners, faculty, and educators “to compile and disseminate information and resources for alternative clinical learning approaches … that support patient care but may not necessarily involve direct patient contact.” Medical schools are urged to follow institutional policies and local public and national health agencies’ recommendations, which has resulted in shifting almost entirely to virtual delivery for nonclinical courses. Exposure to organ-based systems including the hematopoietic system occur during these crucial preclinical years, where faculty mentors can have a profound impact on the specialty and subspecialty medical students ultimately choose.
Ezekiel J. Emanuel, MD, PhD, Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, seemed to foreshadow the transformative disruption that the COVID-19 pandemic has inflicted upon medical education in an essay published in JAMA in February.⁴ “The reconfiguration of medical education seems inevitable,” he wrote, “fueled by online educational technology and the need to transform clinical training to more outpatient settings with promotion based on competency, not time.”
The coronavirus pandemic appears to be an inflection point that is forcing disruption in how we teach medicine. Change and transformation are inevitably coming. We must begin to think creatively about teaching hematology if we cannot rely on the standard in-person preclinical course. How will we foster a medical student’s budding interest in our field if we as hematologists may no longer have a presence in the classroom? How will this distance learning affect the mentoring relationships that often lead to an academic career in hematology? We will need to consider these questions carefully to ensure the sustainability of our subspecialty – and we should consider them now.
As was the case in 1918, our society will be disruptively transformed by this pandemic. That includes how we deliver medical education. The future will tell if the disruption will be transient or permanent.
To quote Dr. Emanuel: “This transformation will not be easy. Transformations never are.”
- Centers for Disease Control and Prevention. The Deadliest Flu: The Complete Story of the Discovery and Reconstruction of the 1918 Pandemic Virus. Accessed March 18, 2020, from https://www.cdc.gov/flu/pandemic-resources/reconstruction-1918-virus.html.
- Quartz. This chart of the 1918 Spanish flu shows why social distancing works. Accessed March 18, 2020, from https://qz.com/1816060/a-chart-of-the-1918-spanish-flu-shows-why-social-distancing-works/.
- Association of American Medical Colleges. Guidance on Medical Students’ Clinical Participation: Effective Immediately. Accessed March 18, 2020, from https://www.aamc.org/system/files/202003/Guidance%20on%20Student%20
- Emanuel EJ. The inevitable reimagining of medical education. JAMA. 2020 February 27. [Epub ahead of print]