Background and Introduction
It is important to note that we are providing the following while being mindful that the federal CDC guidance is calling for continued social distancing, even though the federal directive for social distancing ended on April 30. We will continue to update this document as information warrants.
The COVID-19 pandemic continues to unfold across the nation and the world, impacting nearly all aspects of life. Heterogeneous conditions exist across the country, with some areas still heavily impacted, some beginning to see a reduction in new cases, and some relatively untouched by the virus.
Despite steady progress, many of our teaching institutions continue to work under unprecedented conditions to address the challenges related to COVID-19. Depending upon location, they may face shortages of trained medical personnel, personal protective equipment (PPE), and supplies critically needed to assure delivery of patient care.
In our last update on April 14, AACOM suggested that a continuation of the pause in medical student clinical education activities be extended. This suggestion was dependent upon the needs of the local community, state, and region, leaving the ultimate decision about returning medical students to the clinical learning environment to each COM Dean. The memorandum also included a set of basic principles intended to assist, but not supersede, the judgement and authority of the COM and its leadership to make decisions that are appropriate for their unique situations.
Today, AACOM is offering this document to the osteopathic medical education community as a source of information that may assist COMs with reopening the clinical learning environment. Student wellness and safety remains a core component of the message.
A New Era in Medical Education
An important challenge will be to inform students, residents, program directors, hospital educators, accrediting bodies and others that we have moved into a new era of medical education. We will be defining the new normal in terms of what will be expected from students, educators, COMs, and residency programs in the months ahead. All phases of medical education, including medical school recruitment, preclinical curriculum, clinical training, assessment requirements, residency application, and selection are being affected. Therefore, it will be beneficial for COM actions and COCA requirements to remain flexible. The ability to demonstrate student competency by the end of the UME program will be essential to the future of medical education and its recognition at the GME level and by licensing boards.
It remains unclear whether COVID-19 has altered what is expected from a professional on the “front lines” of patient care and what, if any, expectations change for medical students as learners. The practice of medicine has always carried with it risks of infection from known illnesses, such as TB, HIV and Hepatitis. The novel coronavirus outbreak has been highlighting the reality of such risks. Adaptations to reduce individual risk continue as our understanding of the virus increases.
Due to this issue of risk, it is important to address volunteerism. Assuming they are provided with as much protection, guidance and training as possible and practical, an important question is whether medical students demonstrating necessary competence can choose to participate in direct patient care for those suspected of or diagnosed with COVID-19. It is important to remember that the medical student remains first and foremost a learner, focused on the continuation of their medical education—not an employee or licensed medical professional. Consideration also should be given to student personal health and family situations that may limit their participation in the clinical learning environment.
Balancing Colleges of Osteopathic Medicine and Association Roles and Responsibilities
The needs of the local community, state, or region must determine each COM’s response to the COVID-19 situation. Each COM and its teaching affiliates will have a unique path to reentry for students.
AACOM's position as a national health professions education association allows it to provide system-level input such as describing a framework for reopening. AACOM’s framework provides COMs with information to be used with teaching institutions hosting students to promote and prioritize student safety upon return to clinical activities and for standardizing messages regarding the medical student's role in the health care environment. AACOM is also able to provide access to broad programming on a variety of topics and to act as a connector for its members.
Planning and Communication
Regular communication across stakeholders remains essential. COM leaders should communicate clearly and regularly with students, staff, and faculty, as well as with leaders of teaching institutions, clinical faculty, and public officials. Timing, frequency, and content of communications are critical.
Each COM should communicate clearly with all students when and how clinical rotation sites will open, particularly those with a widely distributed model of clinical education. Communication should describe how the COM plans to make clinical experiences as equitable as possible across sites throughout the academic year. Extensive outreach will be necessary to make sure each student in the third and fourth year understands the challenges and solutions in place.
Some students will consider themselves disadvantaged. Openly addressing what is known and unknown is suggested, as is providing answers to their questions as much as possible. AACOM and COMs have already heard from students concerned about the rapidly changing environment. Communication materials should be made widely available online and through social channels to ensure information is reaching everyone.
Connecting with preceptors and understanding their needs is critically important, potentially creating unique connections with clinical faculty that did not previously exist.
There is opportunity for our COMs and their affiliated teaching institutions to work together to develop plans for how medical students contribute to a pandemic response. Dialogue should address the appropriate roles for medical students while responding to the public health crisis.
Medical Student Wellness, Precautions and Preparedness
It is critically important to be aware of factors affecting student wellness and safety. Maintaining student safety is a primary concern.
Assuring availability of appropriate personal protective equipment (PPE) is an important key to reopening clinical education, as is assuring appropriate student education and training related to COVID-19 and use of PPE. Student education addressing COVID-19 and proper use of PPE should be provided before any return to the clinical learning environment occurs. Appropriate PPE should be available for medical students returning to the clinical learning environment before beginning direct patient care; otherwise, non-patient care assignments should be made. Local training related to infectious disease exposure is typically an expectation of affiliation agreements, but it should augment, not replace, what each COM provides to its students.
Students should be educated to prepare them to operate in environments where provider and staff trauma arising from the care of the severely ill and dealing with effects of the COVID-19 pandemic are likely.
As fourth-year students return to the CLE for audition rotations, they should be educated to properly frame their disrupted experiences when interviewing for residency positions—including any alternative efforts to learn, grow, and serve.
Recovery in the Clinical Learning Environment
Returning medical students to the clinical learning environment is affected by each teaching institution’s ability to maintain a safe and stable learning environment and the faculty’s ability to deliver a curriculum. Variability is expected. Consideration should be given to the impact of COVID-19 in the communities where students are training, as well as the demands currently being placed upon the health care system; therefore, an assessment of community impact needs to occur.
Ideally, each rotation site needs to provide regularly updated COVID-19 data so that COMs can complete their own risk assessment. Where possible, data about the predicted peak in these communities should help guide decisions.
Recovery will likely need to be individualized by each COM and its affiliated teaching institutions. A one-sized approach does not exist, given the tremendous
variations in approaches to learning and the geographic distribution of teaching locations associated with each COM.
It is possible the clinical learning environment will be disrupted for an extended period, with full "recovery" being varied and taking longer than anticipated. The duration will be determined by many factors, with preceptors in many locations experiencing extreme fatigue and others overwhelmed by a backlog of patients that have delayed their routine and elective care. Provider and staff trauma should be addressed in advance if possible, both through provider/staff evaluation and student education.
Patients, providers, and even hospital systems may fear that having students present will not only utilize PPE and other resources, but they may also view them as a vector for exposure of the COVID-19 naive patients. To address this fear, conservation of PPE for front-line responders remains important, as does the availability of widespread testing.
There will be differences between teaching locations. COMs should endeavor to create equitable student experiences to the degree it is possible using resources as they become available. The timing and sequencing of experiences will vary. Most likely, there will be a partial return to clinical experiences for some, balanced with strong virtual experiences for others. There may be a need to use less stressed sites more extensively until others are ready to have students return.
Availability of Quality Clinical Experiences
COMs need to determine if their clinical rotation sites have the necessary preceptor capacity and energy before allowing students to return. Preceptors and/or teaching institutions may not be prepared for students simply because COVID-19 cases have declined. There may be decreased case volumes on rotations as some patients may continue to self-isolate, with prioritization to other learners needing to meet training requirements (such as residents), thus limiting student education.
Credentialed physicians and other licensed health care professionals acting within their scope of practice as faculty must be able to provide the necessary supervision and education to medical students returning to the clinical learning environment.
Audition rotations are likely to be limited, and it will be challenging to provide all students with their desired experiences. Importantly, this will affect all students to some degree as disruptions are dealt with across the country.
Inadequate rotation availability may require alterations to the historical practice of completing all, or nearly all, core rotations first. Limited core rotation availability may, in fact, require educators to rethink how clinical experiences are delivered.
It will likely be challenging to define what constitutes an “adequate” clinical experience. Students will be particularly concerned that any make-up time may have a negative impact on fourth-year rotation experiences. Academic counseling will be an important part of determining appropriate make-up experiences.
Decisions regarding medical students returning to the clinical learning environment should be made in a manner that will ultimately create as equitable of a learning experience as possible for all, with the intention of preparing them for a role on the health care team that is appropriate for a learner and for future practice.
The clinical education curriculum may require significant modifications now and into the foreseeable future. Students may need to complete an alternative curriculum pathway to assure necessary clinical experiences for them. Keeping students in a learning mode and maintaining a clinical focus while incorporating online core rotations will likely be difficult.
Most COMs have moved forward with developing online rotations that include core rotations. Defining competency for experiences missed will be key and it will likely need to be defined without adding rotations or rescheduling any core rotation time. Student exposure to learning objectives, faculty use of assessment tools, and involvement with patient care may be different than in the past.
Alternative approaches for core (third-year) rotations that will look different and may provide a different level of experience should be considered. Although there may be a perception by students that this modified approach is “less than adequate” in comparison to their peers, it may prove to be an advance toward competency-based education.
Consideration should be given to how core clinical experiences might be ‘re-mixed’ to maximize time where gaps previously existed (days off from service, short days, no weekends, etc.). The use of a longitudinal competency portfolio may also be of value as students are asked to have increased ownership for completing their education—especially in this varied environment.
Telehealth and virtual visits have now become accepted by patients, payers and providers. Their ideal role in the learning environment is unclear. Providers of the future will certainly need to be well-informed and proficient in delivering this type of care. There are limitations, but a comprehensive curriculum for telehealth will be required upon returning to the CLE.
Without question, the COVID-19 public health crisis has significantly altered medical education efforts and will continue to do so. As stated in the beginning, this information is intended to ensure student safety is considered as COMs work to create a clinical learning environment that is as equitable as possible for all involved, depending on factors such as geographic location and others. It should be noted that further disruptions are likely, but AACOM, member COM Deans and other leaders are working diligently to address challenges as they arise. Communication remains a high priority, especially with students.
As such, AACOM will continue to work closely with organizations comprising the osteopathic community (AOA, NBOME, specialty colleges, etc.) and other national organizations involved with medical education across the continuum (AAMC, ACGME, FSMB, CPA, etc.).