Tarika Srinivasan1 and Bethany Brumbaugh1
1 Harvard Medical School, Boston, MA 02115, USA
ABSTRACT
Due to the COVID-19 pandemic, several medical schools have opted to reformat preclinical instruction for online delivery to reduce the risk of transmission among faculty and students in classrooms. However, enthusiasm for adaptation has preceded current necessity, as some scholars’ have foretold an eventual “reimagining” of entirely online, open-access preclinical curricula. We, two first-year medical students, express concerns about the compromise of the student experience in service of this goal. Unexamined implementation of an online preclinical curriculum may threaten student satisfaction, class interconnectedness, professional development, student diversity, and overall attrition – potentially countering the efforts of recent decades of medical education reform. We ask the academic medical community to refrain from viewing interim online adaptations as a test-run for a supposed inevitability in preclinical medical instruction.
In an article published before COVID-19 began ravaging the United States, physician and bioethicist Ezekiel Emanuel almost prophetically wrote about a time in the not-so-distant future in which preclinical medical education would be transitioned to an online format [1]. He articulates that “reconfiguration of medical education seems inevitable, fueled by online educational technology and the need to transform clinical training to more outpatient settings with promotion based on competency, not time.” When writing this article, Emanuel likely did not imagine how serious consideration of this vision would soon be accelerated. As incoming first-year students at Harvard Medical School, we are grappling with the fact that our first semester will be delivered entirely online due to concerns related to the pandemic’s trajectory. There is no doubt that significant adjustments to preclinical education stand to be made in light of present circumstances. However, we are concerned an online preclerkship phase may counteract the improvements that medical educators have sought over the several years preceding this pandemic. Such improvements include integrating basic science knowledge for applicability, better facilitating the formation of medical professionalism, and attracting a diversity of students into the traditionally homogeneous medical profession [2-7]. We worry that an online preclinical curriculum may relegate these ideals in favor of economizing medical education.
Before critiquing the implementation of an online preclinical education, it is important to acknowledge the merits of this immediate transition. At first glance, medical schools appear to be in a prime position to embark on preclerkship education online. Several schools have adopted shortened basic science curriculum, from the traditional 2 years to 12-18 months. Most medical students at institutions without the requirement of attendance at lectures instead opt for streaming them in the comfort of their apartments, a practice bearing striking resemblance to those changes necessitated by pandemic’s closure of schools. However, outside of the context of COVID-19, Emanuel describes these changes as necessary steps in quality improvement and efficiency to quickly mold future physicians who are eager to enter into patient care. Against the backdrop of the COVID-19 pandemic, the risk-averse would naturally conclude that the scales weigh in favor of transitioning the majority of in-person instruction to a virtual format. Indeed, institutions (including Harvard Medical School) have made laudable steps to push through barriers to shift lectures and case-based group learning entirely online. Yet, it is unclear just how much will be lost on behalf of the student during this time.
Even though we are neophytes with respect to physical exams, life support skills, and medical procedures, even first year medical students perceive an overwhelming responsibility--whether self-derived or socially thrust--to be active in the face of the pandemic. That perceived responsibility is manifested in the acquisition of knowledge, but this has increasingly come from much more than conveniently streamed or pre-recorded lectures. Recently reformed curricula typically integrate longitudinal clinical preceptorships and clinical skill simulation over the course of the preclinical phase. Basic science knowledge is increasingly delivered in a “flipped,” case-based format, demanding that students learn foundational concepts independently and participate heavily in small group sessions that apply this information to familiar clinical cases [8]. Through major systemic overhaul, the first few graduating classes of medical students have appeared to have performed substantially secondary to this educational format [9-11]. However, given that this success cannot easily be attributed to a discernible variable, virtual transition may compromise this curricular format. Medical educators might appraise whether they can faithfully recreate the case-based learning experience online. Might we be undoing the great strides that have been made in streamlining and modernizing medical curricula? The potential compromise of quality for these first few classes of students receiving virtual preclinical education should be addressed as a research priority rather than an accepted next step for improvement.
Second, whether the medium be lectures or more applied early clinical endeavors, the preclinical experience encompasses far more than the absorption of discrete medical knowledge. Preclinical students are encouraged to be involved in research, specialty exploration, and community service, as they are viewed as effective facilitators of professional identity formation. With recent pressure on physicians to be more engaged in advocacy activities and be able to address systemic issues that impact health, the narrowing of preclinical exposure seems a detriment to the development of future holistically-minded physicians. This then brings up the question of the implicit messages given by those with seniority and received by preclinical students, those necessarily at the bottom of the physician hierarchy. The “hidden curriculum” is a parallel educational experience that involves the swath of learning that occurs outside of the explicit, endorsed curriculum [12,13]. Even more than in previous years, preclinical medical students like ourselves are grappling with mixed messages regarding our roles and responsibilities as budding medical professionals. Although preclinical students spend little to no time in clinical settings during the basic science curriculum anyway, the risk of bringing them to learn in-person is still deemed too great by some institutions. However, there is no signed agreement distinguishing the preclinical and clinical phases to accommodate for the increased risk of exposure to illness (such as COVID-19) in clinical settings. To the incoming preclinical medical student, the subtext of this relegation of our education may appear to be a reinforcement of the sense of entrenched hierarchy within medical education, a trend that institutions have sought to eradicate for the past several years [14-16].
Preclinical students occupy a unique liminal stage of their medical education. They have passed the gauntlet of competitive medical admissions to gain coveted spots within a medical institution. Even with an online virtual semester, medical students will still be initiated into the fraternity of medicine virtually by taking some form of a modern Hippocratic Oath and receiving a white coat [17,18]. Yet, medical students have largely been kept out of the loop in the decision-making that will formulate their medical education experience. In the hard years leading up to our matriculation, we have looked forward to the preclinical phase as a dedicated time for forming deep, interpersonal bonds among classmates and faculty. Without the benefit of an interconnected class, students may fail to cultivate the innate virtues of collaboration and teamwork that have been increasingly emphasized along all stages of medical education [19,20]. In addition, role modeling and mentorship have been demonstrated as a cornerstone of professional development [21,22]. Students may lose the sense of motivation and expectation that comes through deep relationships with mentors. The erosion of these bonds may subvert efforts to reform the hidden curriculum of medical school from traditionally entrenched hierarchical structures to humanistic, ethical patient care and relationship-building among healthcare teams.
Finally, those who foretell a permanent shift to online preclinical education might consider how the effects of this transition might reverberate through the physician workforce. Research suggests that the flexibility and convenience conferred by online courses may not lead to better educational outcomes, especially for those starting out on unequal footing with peers [23,24]. Overall failed retention rates for online education programs, even with the promise of course credit, range from 20 to 50% [1,25]. It is possible that transition would erect even more barriers for students from underrepresented, disadvantaged groups to overcome, especially those for whom a secure Wi-Fi connection, continual course access, and a safe, suitable learning environment is not a given. Emanuel optimistically describes a massive open online course (MOOC) -like system in which every preclinical student would have access to the same world-renowned set of lectures. But the capitalization of the medical school application process--as evidenced by the exorbitant cost of private advising, MCAT preparation courses, and application feeds--might influence preclerkship education to reward the privilege of those in the highest echelons of our society with the deepest pockets. In fact, these courses have struggled to lift retention rates and expand their user base beyond affluent students [26]. Shifting preclinical medical education entirely into an open, online format may reify medical practice as an elite profession that easily advances those with means and further disadvantages those without, unraveling the goals of equitable professional opportunities among racial and socioeconomic subgroups.
Medical institutions might consider the classes of students that they will create due to this temporary shift of the preclinical medical curriculum to a virtual format. While idealists might consider that the COVID-19 pandemic is exactly the impetus to kickstart a virtual overhaul of preclinical education, educators should beware of unbridled enthusiasm when appraising its implementation. We implore medical educators to consider: are world changers, medical researchers, and public health leaders born at home, or in the context of a rich, diverse community that is physically present throughout the entirety of the medical education experience? As institutions have worked for years to maintain the ambition and optimism of incoming students and diversify identities and skills through which they are able to contribute, virtual transitions that might reverse those efforts should not be taken lightly. Though we, as first-year medical students, accept the necessity of this accommodation under the circumstances of today, we caveat those who might herald virtual preclinical education as the irrefutable model of tomorrow.
Disclosures: None.
Funding: None.
Acknowledgements: The authors would like to express their gratitude to the faculty of the Mayo Clinic Biomedical Ethics Research Program, the Hastings Center, and Yale’s Interdisciplinary Center for Bioethics for facilitating our development as ethical thinkers. They also thank the faculty and administrators of the Harvard Medical School Pathways curriculum for enthusiastically involving students in the COVID-19 adaptation process. Special thanks to Drs. Randall King, MD, PhD, Henrike Besche, PhD, Fidencio Saldaña, MD, MPH, and Edward Hundert, MD.
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