Madeline Paton, MS1, Gavriel Roda, BS1, and Emily Gottenborg, MD1
1University of Colorado School of Medicine, Aurora, CO 80045, USA
Correspondence concerning this article and requests for reprints should be addressed to Madeline Paton (madeline.paton@cuanschutz.edu)
ABSTRACT
Purpose: As a result of the coronavirus disease 2019 (COVID-19) pandemic, medical education has experienced an unprecedented interruption, with a significant impact on clinical phase medical students, who were considered non-essential healthcare workers and removed from clinical settings. We sought to better understand the challenges experienced by third and fourth-year medical students to inform future decisions around medical education during global crises.
Methods: We conducted a qualitative descriptive study including eleven interviews of clinical phase medical students from a single institution. Interview guides were based on the following domains: 1) experience during the COVID-19 pandemic, 2) fears and challenges faced, and 3) recommendations for the future. Interviews were recorded, transcribed verbatim, and analyzed using a general inductive approach until thematic saturation was achieved, using the Dedoose web application, Version 8.3.17 (2008).
Results: The following themes emerged regarding the participants’ experience during the COVID-19 pandemic: they reported feeling 1) capable of doing more, 2) a burden to the healthcare system, and 3) loss of control, but they also reported achieving a better understanding of healthcare systems and inequities in healthcare delivery. Finally, they offered recommendations for educational leaders to consider for similar circumstances in the future.
Conclusion: Medical students experienced many challenges as a result of the COVID-19 pandemic, but they were able to offer recommendations and solutions to ameliorate these challenges in future similar circumstances.
INTRODUCTION
Medical education has experienced an unprecedented interruption as a result of the coronavirus disease 2019 (COVID-19) pandemic, with a significant impact on clinical phase medical students who were removed from clinical settings. In response to the declaration of the COVID-19 pandemic in March 2020, the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recommended a strategy of social distancing to prevent ongoing spread of the disease [1]. Additionally, the CDC offered recommendations to institutions of higher education that included consideration of suspension of classes and group events [2]. On March 17, the Association of American Medical Colleges (AAMC) called for a halt of all student clinical duties for two weeks in order to comply with social distancing and remove unnecessary individuals from the clinical space [3]. On March 30, the AAMC requested removal of students from participation in direct patient care, barring a critical health care workforce need, as students were deemed non-essential healthcare workers [4].
The COVID-19 pandemic raises questions regarding the impact of this interruption on medical education and the appropriate response of medical educators in the event of a national or global crisis in order to protect the safety of medical students, while also utilizing them in the response effort. The decision to remove students from clinical facilities has precedence, which occurred during the 2003 SARS epidemic in Toronto, Canada [5]. Yet medical students have a wide breadth of clinical knowledge and skills, and have been called upon to serve during national crises in the past. During the 1918 Spanish flu pandemic, medical students acted as both intern physicians and nursing staff at the University of Pennsylvania School of Medicine [6]. In the current COVID-19 pandemic, final year medical students were fast-tracked to graduation in Britain, Italy, and American medical schools such as Grossman School of Medicine at New York University and Tufts University in order to expand the medical work force [7]. However, current medical students have expressed opposing opinions regarding desired to be involved in COVID 19 response in the clinical setting [8,9].
The goal of this investigation was to learn the perspectives of medical students at a single institution regarding the impact on their education, identify common challenges that they faced, and gather recommendations to approach medical education during similar national or global crises in the future.
METHODS
Study Design
Using grounded theory methodology, we conducted a qualitative study of clinical phase, third and fourth-year medical students at the University of Colorado School of Medicine [10]. Semi-structured interviews were conducted from March 30, 2020 to April 8, 2020. We recruited participants through an invitation to participate posted on class-specific social media pages. Informed consent was performed prior to each interview through email. An interview guide was used to assess the following domains: 1) experience and impact on education, 2) fears and challenges, and 3) recommendations (Supplemental Digital Appendix 1). Telephone interviews were recorded and transcribed verbatim. Interviews were conducted until thematic saturation was achieved, which occurred after 11 interviews. Similar protocols have been established in prior publications [11]. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado.
Analysis
Codes were inductively developed from the interview data by a team of one internal medicine doctor (E.G.), who had prior experience in qualitative methodology, and two medical students (M.P. and G.R.). Code disparities were reconciled by team consensus. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using the Dedoose web application, Version 8.3.17 (2018, Los Angeles, CA, www.dedoose.com).
RESULTS
Demographics of the participants are shown in Table 1 and represent a diversity of future specialty choice. The major themes generated by the participants focused on the challenges they experienced, and the tension between wanting to participate to a greater extent to support the healthcare system while also feeling like a burden. This tension resulted in a sense of loss of control over their educational experience. However, the participants gained a meaningful understanding of the healthcare system and associated inequities, allowing them to offer actionable recommendations for educational leaders to consider regarding medical student involvement in global crises in the future.
Table 1: Demographic Information of the 11 participants, 2020, Aurora, CO
Capable of Doing More
“We’re a resource that is not being fully tapped,” was a sentiment that was echoed by all of the participants. In response to removing students from the clinical setting, various volunteer opportunities were created, such as hospital mask distribution, phone correspondence with patients with negative viral testing, virtual rounding with inpatients, and coffee delivery to frontline workers. However, some students expressed that there were not enough opportunities for everyone to participate, leaving many sitting idly at home.
“I’ve wanted to do so much more, but there have been so many volunteers and so many people who have wanted to step up, that there’s not always room for everybody.”
Most students felt that their training thus far had prepared them to assist in the clinical setting and that they were not being used to their fullest potential.
“We are all going through this extensive training to become these very specialized tools, and the second that this erupted we got put on the back shelf in the work room. . . I could be doing infinitely more than I am now from a clinical perspective.”
All of the fourth-year participants expressed that they felt prepared work on the front lines. Collectively, they believed that they would contribute more to frontline clinical care now rather than waiting for the official start of their internship year.
“I’d argue that I’ll probably know a little bit less in two months than I do now. . . if I can learn now when we’re still on the upswing, rather than in two months when potentially we’re hitting the peak, I feel like I could be a much more valuable asset.”
The tension created by having invested much of their lives training for a medical career and suddenly being pulled from their roles created an identity crisis for many of the students.
“I have never felt closer with the medical system, but also, I think it’s one of the times I’ve felt the farthest from it and the most removed.”
Burden to Healthcare System
“The overwhelming sense that I’ve gotten from classmates, that I would agree with, is that people want to help if we can [but] also don’t want to be a burden on the system.” Nearly every student referred to themselves as a “burden” to the healthcare team or system and was especially prominent in interviews with the third-year students.
“The idea of being sent to the front lines stresses me out a lot. I think part of that has to do with the theme that I brought up earlier of feeling like I am burdening a team as a medical student.”
Participants described that hospital staff were already working under high levels of stress, and the presence of a medical student could be detrimental to workflow.
“The mental load that it would take to also be aware of a medical student and supervise what they are doing would perhaps detract from patient care overall.”
Many students stated specifically that their use of personal protective equipment (PPE) would burden the healthcare system and that the decision to remove students was justified by efforts to reduce its use. Interestingly, many of these same students expressed ways in which they could be in service without creating a burden.
Loss of Control
“It’s a lot of control that I have to let go ... I can’t control my schedule. I can’t control my rotations. I can’t control away rotations.”Much of a medical student’s life is under the control of scheduling lotteries and algorithms, but the interruption due to COVID-19 created a sense of a more devastating loss of control, especially among the third-year medical students. Third-year students expressed deep concern for loss of sub-internship rotations, visiting student rotations, letters of recommendation, Step 2 cancellations and the associated impact on their residency match, and future career success.
“I think that has been the hardest thing: Recognizing that the application that I dreamt up for myself isn’t going to be the application I am going to be turning in anymore. [There is] a lot of uncertainty about whether or not I am going to [be] as competitive of an applicant as I anticipated that I would be, and to what extent other students are going to be affected by this and whether that is going to change how I appear relative to them.”
Students expressed experiencing high levels of distress and anxiety due to their “projected medical school path [being] radically changed.”
“It’s been pretty anxiety provoking to feel like the answers to a lot of big questions about direction that our careers are changing from day to day.”
Educational Impact and Healthcare Systems
“I really wish we could be in clinic right now because, I was really excited about wrapping up all of my clinical experiences this year… it was gonna bring everything together and provide a nice conclusion to 3rd year.” Overall, most students stated that the interruption in clinical rotations negatively affected their education due to the loss of hands-on clinical training, access to preceptors, career planning, and ‘missing out’ on critical clinical electives and opportunities. A fourth-year student entering emergency medicine had planned to participate in an ultrasound elective before the pandemic hit. He described the online adaptation of this hands-on elective:
“[it is] hard to do ultrasound if you don’t have a patient... Definitely the online version of it was less than ideal.”
Third-year medical students lost “non-essential” rotations, and one student felt they were missing key pieces of their education.
“I’m not going to get an emergency medicine experience. I’m not going to get an orthopedic experience. It’s kind of weird that those are considered expendable rotations.”
One fourth-year medical student expressed concern about beginning internship in a chaotic environment.
“I wonder how this affects our residency training when you’re about to enter an environment where doctors will have been, for the preceding three or four months, just inundated with this pandemic and stressed and overworked. Now we’re these new people going in, who usually can use a little more handholding. I just wonder, will people be able to do that? And will we feel safe going into this environment if we don’t have as much oversight as month-one interns would [usually] get?”
However, many students highlighted that this experience served as a crash course in the inner-workings of the healthcare system and “laid bare the issues … in terms of equity and health care access and how [the healthcare system] prioritizes individuals.” Students emphasized that this impacted their perspective of the system they are entering.
“I think I have been disappointed, but not hugely surprised, to see the way our country is handling this and the way that our health care system is set up to handle [the pandemic.] It confirmed for me that I am entering a career in a broken system.”
Although health inequities are a topic of discussion throughout the medical curriculum, some believed they would have benefited from a more robust curriculum on healthcare systems, vulnerable populations, and advocacy.
“My hope would be that our evidence based medicine curriculum and the public health thread that we have throughout the four years of medical education would be beefed up with a bit of additional training in epidemiology and how to control infection and manage large scale crisis … in a way that would make us a more empowered and a less confused if this were to happen again.”
Importantly, this experience confirmed some students calling to serve and advocate for vulnerable populations.
“I really want to work marginalized, underserved, and under-privileged populations. If anything, this experience has just furthered my desired to do that.”
Although this negatively affected students’ medical education, they largely found that they were learning critical aspects of the form and function of the healthcare system that could not otherwise be taught in a classroom setting.
RECOMMENDATIONS FOR THE FUTURE
“I am hopeful that because we have lived through this now, that medical education will evolve... to include some sort of training about what we do if this happens again.” Most students echoed this hope and were able to provide recommendations for how they believed they could be best utilized during the current and future crises. The overwhelming sentiment was that students could be used to support frontline clinical staff in various meaningful ways, acknowledging that this may require ample PPE.
“It hinges on having enough personal protective equipment to be useful and not a burden. If there were enough masks and gowns for us to be in the hospital we could function as support staff in a variety of ways, we write the notes. We have been doing it several years.”
“Allowing us to... take histories, talk to patients, explain plans, and take some of the load off the attendings and residents. We have enough capacity to do those sorts of things and be helpful.”
Students offered ideas for how they could continue to function within specific specialties less burdened by the pandemic, which would also offer them meaningful experiences in their future specialty choice.
“The decision to pull students from the clinical spaces policy was applied too broadly perhaps and we should have thought more specialty specific about what needs were going to look like in the clinical space. Women are still giving birth right now, and in a lot of places they are having to labor by themselves because of the policies that have been applied with regards to visitors. So, because I know that I know how to coach somebody through labor and I also know that it is bad for woman and babies to have to labor totally alone. I wish I had the ability to go into the hospital and just be with woman that is pretty formative in their own life experiences.
One fourth-year student suggested working with palliative care teams to be with patients who were alone as a result of visitor restriction policy.
“We are just dealing with something that is devastating and sudden for people. A lot of us have an interest in palliative care or just we have the time... we could be there for families.”
In addition to contributing as support staff, students recommended using their skills to support and advocate for their community in times of need, which could strengthen their commitment to advocating for change in the future.
"Advocacy -- which we can do. . . and take these lessons and be like, ‘hey I was there, I saw how it affected these populations,’ and when I’m an attending physician I can say, ‘I’m gonna work to try and get things changed so that, maybe policies are different next time something like this happens.”
DISCUSSION
This study described the impact that the COVID-19 pandemic is having on clinical phase medical students, and highlights the tension between their desire and ability to contribute and feeling like a burden. Medical students spend a significant portion of their training rotating through various clinical specialties and transitioning across healthcare teams, where adapting to new roles and environments is critical to their success. The students in our study felt they could use this flexibility to provide meaningful clinical support to participate in COVID-19 efforts. Two solutions were proposed to better incorporate medical students clinically, in the event of future infectious outbreaks or clinical crises: (1) recruit students to serve as support staff with the main objective to reduce the workload faced by attending and resident doctors, and (2) allow students to continue seeing patients in specialties that were affected to a lesser extent. Overall, the adaptability of medical students makes them uniquely equipped to participate in clinical efforts, and by providing them with clinical opportunities it both supports their educational development and creates a qualified work force.
Though students expressed their desire to participate in clinical support roles, they were hesitant to share their disappointment upon removal from clinical settings. Nearly all interviewees prefaced negative emotions by rationalizing the justification cited by educational leadership, largely centered around preservation of PPE. Surprisingly, they did not perceive that decisions were made in order to protect their health and safety, a sentiment noted by trainees at other institutions during this and historical crises.11,12 In the context of limited PPE, nearly every student considered the broader implications of the pandemic as it related to the functionality of the health care system and its associated inequities and disparities, causing students to call for increased curricular offerings on advocacy, public health, infection control and epidemiology. While most graduating medical students have a shared sense of duty and wanting to help people, there was overwhelming report that this confirmed, or in some cases ignited, a calling for working with marginalized populations. Due to the significance impact of this pandemic, we hypothesize that we will see a change in this generation of physicians’ ability and desire to advocate for systematic change.
Perhaps the most concerning finding was the overwhelming sense that students believe they are a burden to healthcare teams and systems, and we are concerned about the long-term consequences of this sentiment. Medical students are encouraged by their colleagues and mentors to function as an integral part of the health care team. They are told to act as their patients’ primary provider and were included in all aspects of care. Yet during the pandemic, this sense of ownership and inclusion dissipated rapidly to feelings of unimportance and being burdensome. We hypothesize that the language used to describe PPE conservation efforts contributed, based on the overlapping thematic analysis between “burden” and “PPE.” Preserving PPE as a vital resource is a necessary strategy, however, the messaging communicated to students that they are not critical to delivery of patient care. We uncovered an emerging “identity crisis,” where students felt the tension between undergoing years of training to serve an integral role in society, and being told to “take a backseat” during a crisis.
CONCLUSION
Medical students experienced many challenges as a result of the COVID-19 pandemic, but they were able to provide solutions and ways in which the medical education community can grow from this experience. As an educational community we need to support students to return to their previous level of autonomy and ownership, and acknowledge that the sense of burden could have lasting psychological consequences following them into residency, and preventing their development into confident physicians. In the ongoing efforts to combat the COVID-19 pandemic, we can incorporate some of the valuable recommendations shared in this manuscript to embed medical students as essential members of the clinical healthcare team.
Acknowledgements: None
Funding/Support: None
Other Disclosures: None
Ethics Approval: This study was deemed exempt by the Colorado Multiple Institutional Review Board (COMIRB)
Disclaimers: None
Previous Presentations: None
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