America as the Reluctant Patient: What Medical Students Can Learn From Dr. Fauci’s Response to the Coronavirus

Palak V. Patel1,2
1 Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
2 Stanford Medical School, Dept. of Ophthalmology, Stanford, CA 94305, USA

Correspondence concerning this article and requests for reprints should be addressed to Palak V. Patel (palakvpa@stanford.edu)

Abstract

In the modern clinical era, physicians, even those with Dr. Anthony Fauci’s expertise, are no longer seen as the unerring gatekeepers of medicine. The “Faucisian” model of care embraces this shift in the patient-provider relationship: the model’s central tenants, as exemplified by Dr. Fauci himself, are collaboration and emotional regulation. Dr. Fauci has practiced these principles during the coronavirus pandemic, allowing him to spur targeted, nonpartisan response. This article explores how Faucisian principles could help physicians better treat noncompliant patients, and how these principles might improve coronavirus response. It also explores how current clinical curricula fall short of teaching medical students how to handle challenging clinical encounters. Students trained in collaboration and emotional regulation could take a more Faucisian approach to medicine, developing treatment plans with, rather than for, their patients.

On April 12, President Donald Trump retweeted the hashtag “#FireFauci” amid conflict on coronavirus legislation [1]. The post sparked a media blitzkrieg, with reporters speculating that Dr. Anthony Fauci, the nation’s leading infectious disease specialist, had been ousted by the President. In his interviews, Dr. Fauci was unflapped. “My job always is…to give advice on the basis of evidence and science,” he said, a neutral smile playing over his lips, “[firing me is] not even on the table” [2].

Since lockdown, Dr. Fauci has become a political lightning rod – critics have called him reckless, a conspiracist, and a fascist [3]. But despite a dozen opportunities to defend himself, the NIH director has refused to pit himself against the President or the American people. Instead, Dr. Fauci has treated America like a reluctant patient: he’s offered a clinical diagnosis (COVID-19), suggested treatment alternatives (strict quarantine measures), and heard the patient’s concerns (an economic collapse). But what is most striking, and perhaps most educational for medical students, is Dr. Fauci’s commitment to the physician-patient partnership: he’s offered America his best advice but does not balk at the patient’s pushback, as the final treatment plan should be rooted in mutual understanding.

In the modern clinical era, physicians, even those with Dr. Fauci’s expertise, are no longer seen as the unerring gatekeepers of medicine. Today’s model prioritizes shared decision making -- the physician and patient develop a treatment plan together, after non-judgmental discussion and debate [4]. Many doctors have resisted this shift, mourning the time when their patients answered to them, rather than the other way around.

The “Faucisian” model scoffs, albeit politely, at such sentiment. According to Dr. Fauci, collaboration should undergird all medical interactions, and the patient should have final say on any proposed treatments. This philosophy was evidenced in a recent conversation with Senator Rand Paul: Dr. Fauci advised against reopening Kentucky schools, but Senator Paul disagreed, arguing that students without access to homeschooling would fall behind, widening the education gap between the privileged and the poor. “I respect [Dr. Fauci]…but I don’t think [he’s] the person who gets to make [the final] decision [for Kentuckians],” Senator Paul said. Rather than reprimanding the Senator for noncompliance, Dr. Fauci respected Mr. Paul’s priorities and judgment-call. He’d offered his guidance; any decisions made beyond that were at the discretion of the Senator and his constituents [5]. 

Teaching medical students that noncompliance is a common phenomenon, and should be expected in clinical encounters, is an important step in teaching patient care. Learners that want to be effective under the new model of physician-patient interaction should expect their choices to be questioned, rather than take offense to such dialogue. However, research shows that recent medical graduates have a negative perception of argumentative and noncompliant patients [6]. For example, a resident in Oliver’s study described a patient who wanted oxycodone over the drug she recommended as “a drug seeker who was just here for the pills” [6].

This troubling “my way or the highway” attitude can stanch response to national emergencies such as the COVID-19 pandemic. While social distancing dramatically slashes the spread of COVID-19, not all patients can afford the luxury of staying at home – 30 million Americans have filed for unemployment since mid-March, sparking nationwide protests to reopen the economy [7]. Instead of seeking a middle ground, some healthcare workers are describing patient noncompliance as a “slap in the face” [8]. This indignance precludes investigation into alternative mitigation strategies. If some Americans can’t stay home, can they commit to wearing face masks? Avoid nonessential travel? Maintain a six-foot distance from their neighbors? Such compromise is surely better than the alternative reality, which is playing out across the United States – Americans who have opted for the metaphorical highway are protesting in large groups, many of them sans-mask, creating a ripe breeding ground for the coronavirus [9].

If the foundation of the Faucisian model is physician-patient collaboration, the keystone tenant is emotional regulation. To watch Dr. Fauci in interviews is to observe an elegant example of this philosophy. At a news conference on March 20, President Trump touted the anti-malarial drug hydroxychloroquine as a “game-changer” for coronavirus treatment. Dr. Fauci politely disagreed with him, stating that the drug’s promise had been “anecdotal…so [it’s hard to] make a definitive statement about it” [10]. 

Like the resident and the oxycodone-seeker, Dr. Fauci and the President had a difference in opinion regarding treatment options.  However, unlike the resident, Dr. Fauci has six decades of experience with “difficult” patients – and it shows. Rather than expressing ill will towards the President, Dr. Fauci stepped out of his scrubs and into Mr. Trump’s shoes: “I was taking a purely medical, scientific standpoint, [while] the President was trying to bring hope to the people” [11]. By recognizing context, Dr. Fauci effectively kept a discussion from spiraling into a publicized argument.

Doug Oliver has developed a framework that teaches medical students how to appreciate difficult patients, individuals he describes as argumentative, noncompliant, or skeptical [6]. The framework hinges on emotional regulation. Medical students need to do more than evaluate the behavior of a patient; they must also understand how their own emotional responses affect the outcomes of difficult encounters. 

This framework helps students gauge the behaviors that throw off their emotional balance and practice response techniques in a controlled environment. Students who have seen a difficult patient might feel angry, frustrated, or disrespected, but reflecting on these feelings can yield discussion on counter-transference and teach students how to change the tone of a challenging clinical encounter. Further, if students hope to understand patient behavior, they must take the time to understand each visit in the context of a patient’s life. This exercise can help medical students understand that while a clinical encounter was “difficult,” broadly applying that label to an individual is unfair.

The coronavirus has left many patients with their backs against a wall: diagnostic kits are in short supply, remdesivir remains elusive, and antibody tests are failing quality standards [12]. Patients navigating such systematic healthcare inefficiencies might redirect their frustrations onto individual providers, causing clinical encounters to go less than smoothly [13]. Emotional regulation training helps physicians deescalate such encounters--instead of automatically assigning “argumentative” patients a negative label, caregivers learn to think of them as patients facing tough circumstances. By recognizing the power of context, physicians can shunt patient frustrations towards a productive end and ask meaningful, empathetic questions. This re-contextualizes the encounter; it’s no longer physician versus patient, but both versus a clinical challenge.

When the resident in Oliver’s study encountered a difficult patient, she decided she didn’t “want to see that guy again, because [she] didn’t think [she] could help him” [6]. This negative attitude reflects the outdated clinical curricula of medical schools: students learn to doctor under the old, authoritarian model of medicine, but are expected to practice in the new one – where shared decision making is highly valued. It should come as no surprise that they’re struggling. Rather than waiting for years of clinical experience to lend them Dr. Fauci’s calm manner, students should advocate for more realistic clinical encounters in medical school. Students trained in collaboration and emotional regulation could take a more Faucisian approach to medicine – developing treatment plans with, rather than for, their patients. If America’s dependence on Dr. Fauci has demonstrated one thing, it’s that these skills are essential during crisis.

REFERENCE

  1. Sherman M, Superville D. President Trump Promotes 'Fire Fauci' Tweet After Disease Doctor Critiques White House Coronavirus Response. Time Magazine 2020.

  2. Park A. Dr. Anthony Fauci 'Not Overly Confident' With U.S. COVID-19 Testing Capabilities. Time Magazine 2020.

  3. Wilson J. Why Trump’s media allies are turning against Fauci amid the pandemic. The Guardian 2020.

  4. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221–2226. doi:10.1001/jama.1992.03480160079038

  5. Top health experts paint a bleak picture of pandemic. The New York Times 2020.

  6. Oliver D. Teaching medical learners to appreciate “difficult” patients. Can Fam Physician. 2011;57(4):506‐508.

  7. Tappe A. 30 million Americans have filed initial unemployment claims since mid-March. CNN Business 2020.

  8. Eastman K. This is a Denver nurse's message to protesters. 9News 2020. (Accessed on April 30, 2020 at https://www.9news.com/article/news/local/denver-nurse-has-a-message-for-protesters/73-10e04b93-eb2a-4d4a-8c01-f47481dd8168).

  9. Abrams F, Langford J. The right of the people to protest lockdown. The New York Times 2020.

  10. Chiu, A. Fauci gets frank about Trump: ‘I can’t jump in front of the microphone and push him down.’ The Washington Post 2020.

  11. Brennan M. Transcript: Dr. Anthony Fauci discusses coronavirus on "Face the Nation," March 22, 2020. (Accessed April 29,, 2020 at https://www.cbsnews.com/news/transcript-dr-anthony-fauci-discusses-coronavirus-on-face-the-nation-march-22-2020/).

  12. Abdelmalek M, Christi M. Mayo Clinic doctors find many COVID-19 antibody tests fail their quality standards: ABC News exclusive. ABC News 2020. (Accessed on May 23, 2020 at https://abcnews.go.com/US/mayo-clinic-doctors-find-covid-19-antibody-tests/story?id=70803740).

  13. Chipidza F, Wallwork RS, Adams TN, Stern TA. Evaluation and Treatment of the Angry Patient. Prim Care Companion CNS Disord. 2016;18(3):10.4088/PCC.16f01951. Published 2016 Jun 23. doi:10.4088/PCC.16f01951

The Latino Medical Student Association COVID-19 Response

Zach Jaeger, B.S.1,4, José G. Grajales-Reyes, B.S.1,4, Richard Ferro, MSc.2,4, and Donald Rodríguez, B.S.3,4

1Washington University School of Medicine, St. Louis, MO 63110, USA
2Quinnipiac University, Frank H. Netter MD School of Medicine, Hamden, CT 06518, USA
3University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
4Latino Medical Student Association, Tallahassee, FL 32301, USA

Correspondence concerning this article and for further communications should be addressed to Zach Jaeger (service@lmsa.net)

Abstract

The Latino Medical Student Association (LMSA) is a national non-profit organization with the mission to unite and empower medical students through service, mentorship, education, and advocacy for the health of the Latinx community. In response to the COVID-19 pandemic that has magnified health inequities, our group of nearly 150 active chapters has unified to meet community needs. At a local and regional level, many have provided services and created resource archives to support frontline providers and other essential workers. To address the language barrier for many Latinxs, some chapters have developed and distributed video series and infographics in Spanish to dispel myths and educate the public on the coronavirus and public health. At a national level, the LMSA supports its members through wellness initiatives and webinars, pre-medical student mentorship, continuing medical Spanish curricula, and promoting research. As an organization of future physicians, we admire and appreciate our role models risking their lives on the front lines. To fulfill our duties to each other and to the community, we aim to answer the needs of our community during this difficult time with a unified, robust response.

Disclosures

All of the authors hold a position on the National Executive Board of the LMSA. Zach Jaeger is the National Service Chair of the LMSA. José G Grajales-Reyes is the Vice-Chair of Internal Affairs of the LMSA. Richard Ferro is the Vice-Chair of External Affairs of the LMSA. Donald Rodríguez is the National President of the LMSA.

In the wake of the COVID-19 crisis in the United States, members of the Latino Medical Student Association (LMSA) have grappled with both their innate desire to help others in times of need and their duty to advocate for the health of underserved communities. As a national, student- run, 501(c)(3) non-profit organization with nearly 150 active chapters, LMSA exists to unite and empower medical students through service, education, and mentorship to advocate for the health of the U.S. Latinx population. In this vein, we have developed and supported grassroots efforts to promote the well-being of our patients and peers. These efforts include the creation of a national archive of COVID-19 resources in Spanish and English, the dissemination of service opportunities to aid healthcare workers at the frontlines of COVID-19 care, and the expansion of mentorship initiatives to support trainees from backgrounds historically underrepresented in medicine (URiM).

In several U.S. metropolitan areas, COVID-19 has disproportionately affected communities of color, with Hispanic patients experiencing higher infection and mortality rates compared to non-Hispanic whites. To address this disparity, LMSA has sought to provide Spanish-speaking patients with culturally and linguistically relevant resources for them to better protect themselves against SARS-CoV-2. At a chapter level, members at various medical schools have recorded informational videos in Spanish to educate the public and dispel myths that recur in Latinx social media. Accompanying infographics highlight these videos’ major points in an accessible manner, and Spanish-speaking physicians participate in and review these productions to ensure medical accuracy before distribution. At a regional level, our students have published comprehensive summaries of resources available to inhabitants within a particular city or area, often leveraging support of multiple medical schools and enhancing local outreach. At a national level, LMSA continues to compile bilingual patient education materials. We welcome additional content from academic and community partners to further empower our patients.

Moreover, LMSA has sought to alleviate the added burden placed on healthcare providers. In concert with our efforts to bolster medical Spanish education and practice, LMSA members have helped provide unofficial Spanish interpreter services for hospitals and clinics. Our members have also played integral roles in sourcing commercial and homemade PPE; recruiting volunteers for blood and plasma donation; and supporting frontline healthcare workers through childcare, tutoring, and food delivery.

Lastly, in striving to ensure the welfare and success of URiM medical students, LMSA has significantly increased its programming to support trainees in their academic, clinical, and extracurricular endeavors. We provide virtual forums for our members to connect regarding the status of licensure examinations, visiting clinical clerkships, and residency interviews. We host mentorship videoconferences for premedical students to help them navigate the medical school application process. LMSA also educates members on how to draft policy resolutions for medical organizations to adopt, thereby encouraging them to actively advocate for communities in need.

Through these initiatives and others, LMSA and its members proudly support our communities and our colleagues as we all work to overcome this COVID-19 challenge.

Links: LMSA COVID-19 Response Google Drive; LMSA Website; LMSA Mission
Twitter: @LMSA_National
Instagram: lmsa_national
Facebook: @LMSANational

Contacts:
Zach Jaeger, B.S. (zjaeger@wustl.edu)
National Service Chair, Latino Medical Student Association (service@lmsa.net, covid19@lmsa.net)

José G Grajales-Reyes, B.S. (grajalesj@wustl.edu)
Vice-Chair of Internal Affairs, Latino Medical Student Association (internal@lmsa.net)

Richard Ferro, B.S., MSc. (richard.ferro@quinnipiac.edu)
Vice-Chair of External Affairs, Latino Medical Student Association (external@lmsa.net)

Donald Rodríguez, B.S. (dmrodriguez@uchicago.edu)
National President, Latino Medical Student Association (president@lmsa.net)

From the Sidelines

Jin Kyung Kim
Virginia Commonwealth School of Medicine

As a third year medical student waiting for the transition from pre-clinical didactic learning to hands-on clinical learning, I was faced with an unexpected halt in my long awaited clinical training with the onset of COVID-19. I wondered what best I could do as a student without any licensure in medicine as I read about the brave front-line healthcare workers I aspire to be. One of the ways I chose to utilize this uncertain time in-between online electives is to enlist myself as a volunteer for the Virginia Medical Reserve Corps. My application was marked as a “non-medical volunteer” as a student without a medical license and I expected to help with administrative items. When I showed up for my first assignment as a language interpreter for Korean at a local county COVID-19 drive-thru screening site, I was fitted in extensive personal protective equipment and the reality of this pandemic suddenly hit me. The following poem in iambic pentameter with rhyme scheme is a reflection of my experience as a medical student yearning to be of help during this pandemic from the sidelines at a COVID-19 screening site.

Some wore medical grade clean in all white
Some wore fashion studded with polka dots
Some wore a bandana wrapped around tight 
Some wore a piece of an old shirt in knots

Some born in the sixties like my own mom
Some leaned as thin as their own walking cane
Some young students who should have been at prom
Some in strollers with their blue toy airplane

Some did not need me to translate the form
Some asked me for my language assistance
Some approached me close I could feel their warmth
Some made my voice grow hoarse from a distance

Some told me they have never been sick, ever
Some said they lost their sense of taste and smell
Some revealed shortness of breath and fever 
Some scrolled through the news and felt more unwell

We all stood under the Virginia sun:
A line of over a thousand patients,
Tables of nurses faced them one-on-one,
Volunteers united under patience

I stood drenched in sweat writing intake forms,
In N95, gown, gloves, and face shield,
Hoping I made no mistakes on the forms,
My own fears of infection well concealed 

I stood wondering and dripping with sweat
When will I finally start my third year?
As a student without a license yet,
Am I at all making a difference here?

A Plea for Evidence-Based Policy in the Era of COVID-19

Neda Ashtari
UCLA David Geffen School of Medicine

One term has dominated medical education and the medical field over the last decade: evidence-based medicine. When facing decisions regarding various treatments, or telling caregivers how long loved ones will live, physicians may not rely on gut instincts or personal experience. Instead, they ask: “What does the peer-reviewed evidence say?” We ensure patients have the information they need to make informed decisions, which ultimately are based not only on scientific evidence, but also on finances, beliefs, and personal values. There’s a reason we turn to evidence, and it’s because the decisions we make as healthcare providers directly influence patients’ lives. But as we’ve witnessed with the coronavirus pandemic, so do the decisions of policymakers. Why then, has research evidence played such a minor role in pandemic-era policymaking?

Competing factors in decision-making

Almost immediately after the first reports of the novel coronavirus, scientists and epidemiologists across the globe began studying the mysterious pathogen—its spread, virulence, and clinical outcomes. These early studies revealed important characteristics of the virus—including an extended asymptomatic period and an uncontrolled doubling time of cases from four to seven days—corresponding to alarming growth rates of 10.4% to 26% per day [1]. These findings led to a consensus among the scientific community: social distancing and widespread testing were essential for slowing the spread of the virus. But despite experts’ urgent recommendations to mandate social distancing and vastly expand testing capacity, the federal government and many states were slow to act. Scientific skepticism, political motives, and competing social values can explain why policy decisions often stray from evidence and lead to worse outcomes—in this pandemic and long before it.

The federal government has been a leading force for scientific skepticism in recent years. The Trump administration’s slow dismantling of scientific institutions hindered the country’s ability to combat a public health emergency. In 2017, President Donald Trump signed a bill that cut $1.35 billion of funding from the CDC’s Prevention and Public Health Fund, a resource that supports programs to monitor rapidly emerging diseases and improve public health immunization infrastructure [2]. In 2018, the National Security Council removed the top official responsible for pandemic response and disbanded the global health security team. That same year, Trump’s drastic cuts to the CDC budget forced the CDC to cut 80% of its efforts combating disease outbreaks overseas, even as CDC experts warned that a public health emergency was inevitable [3]. And in 2019, the Department of Health and Human Services discontinued a maintenance contract for over 2100 ventilators in the federal government’s emergency supply, foreshadowing the disastrous shortage of medical and personal protective equipment we face today [4].

It comes as no surprise, then, that Trump has failed to adopt, in many circumstances, evidence-based policies throughout the coronavirus pandemic. For example, the government’s initial response to the COVID-19 outbreak centered solely around containment, funneling limited federal resources into a strategy that experts gravely warned against [5]. The president also ignored experts’ pleas to mandate a national lockdown and to use the Defense Production Act to mass-produce desperately needed ventilators and medical equipment [6]. Decisions regarding allocation of these scarce resources have also failed to incorporate data and evidence. Research shows that unhealthier states, defined as those with higher age-adjusted all-cause mortality rates, have lower testing rates than healthy states, putting populations with the highest risk of morbidity and mortality at even greater risk [7].

Trump’s rhetoric, including contradiction of scientific facts and spread of misinformation, has also endangered American lives. On March 4, Trump insisted that COVID-19 was similar to the flu; two days later, he incorrectly claimed the situation in Italy was improving, and that the US was handling coronavirus better than other industrialized countries [8]. In addition, his unsubstantiated statement regarding the effectiveness of treatments such as hydroxychloroquine and chloroquine have not only caused fatalities but have also led to a shortage of the medications for patients with conditions that require them [9,10].

State governors have also been slow to heed the advice of experts in adopting strict social distancing measures. A recent study across all 50 states found that the single greatest predictor of governors’ decisions to mandate social distancing was not scientific evidence but political partisanship [2]. Researchers found that states with Republican governors and Republican electorates were slower to adopt social distancing policies, which may have substantially influenced health outcomes. In Kentucky, for example, Democratic governor Andy Beshear took early measures to halt the spread of COVID-19, declaring a state of emergency on March 6, 2020, immediately after the state’s first diagnosed case [11]. Across its southern border, however, Tennessee’s Republican governor Bill Lee waited until March 12, 2020—when 18 cases had already been confirmed—to issue stay-at-home orders. Despite being one of the top 10 “at risk” states for COVID-related hospitalizations, Lee explained he would not issue a mandated shelter in place order because it was "deeply important” to him to protect personal liberties [12,13]. Tennessee’s week-long delay in adopting social distancing policies led to a steep rise of cases, while Kentucky maintained a flatter curve [11].

Preventing the next pandemic

With modern advances in research technology and data-sharing, we’ve made discoveries about the virus and how to curb its spread at an unprecedented rate. But knowledge has no value if it doesn’t reach and influence those who shape our most critical policies. Thankfully, there are evidence-based solutions that demonstrate how.

Develop decision-maker and researcher competencies

Policymakers must be trained to access and effectively utilize research evidence. This begins with expanding access to reputable sources of information, including journals, research articles, and academic search engines (i.e., PubMed).  Today, because lawmakers and staffers lack access to peer-reviewed sources, many rely on Google searches and lobbyists. Even with access to research evidence, lack of experience interpreting studies has been shown to decrease evidence use in decision-making [14]. To help policymakers engage with research effectively, governments can offer scientific literacy training. For example, the Ontario Ministry of Health offers policymakers one-day seminars intended to help ensure that they have access to rigorous, relevant research and can draw upon it as they make policy decisions.

Researchers, too, must develop their knowledge of policymaking. This includes understanding the timing of the legislative cycle, the importance of providing objective evidence without advocating, and the value of building relationships with policymakers. In addition, researchers must learn to adapt their language and their medium to their audience. It has been shown that policymakers are more likely to uptake research evidence with relevant policy implications that is presented without academic jargon as a short brief. This means scientists must develop the capacity to communicate research findings in a way that is clear, concise, and fits lawmakers’ specific needs.

Facilitate researcher-policymaker interactions

Over decades, many studies have proposed methods of increasing evidence use in policymaking. But among almost all of them, one concept remerges repeatedly: relationships are the currency of the capitol [16]. Policymakers are more likely to use research if they trust the knowledge-broker bringing it to them. And although building strong relationships takes time and commitment on behalf of both parties, it can be done. The Wisconsin Family Impact Seminars, an initiative of the Robert M. La Follette School of Public Affairs at University of Wisconsin-Madison, demonstrates how institutions can facilitate relationship-building. Each year, the seminars bring together academic experts and policymakers to discuss one to two topics of legislative interest, and the program’s success has since become a model for similar programs in 35 other states.

Institutional change

Rather than relying on the efforts of individual researchers or policymakers, institutions can facilitate the uptake of evidence in policymaking.  For example, governments may enact internal procedures that address bias and lack of transparency in decision-making. Alternatively, governments can improve channels of communication between various departments to address complex issues that require multidisciplinary expertise. One study in the UK found the division of responsibilities within government bureaucracies limited the use of evidence, arguing that “individual civil servants are compelled to focus on small, specific areas of policy activity, making it extremely difficult for them to engage with ideas beyond their immediate area of responsibility” [15]. Universities can also serve as knowledge brokers by changing the current academic model to incentivize researchers to conduct policy-relevant research and disseminate the results. 

The potential of evidence-based policy

It has long been known scientific evidence is underutilized in policy making decisions. But in the unprecedented time of the COVID-19 pandemic, we are reminded of the consequences: human lives.

Policymaking is inevitably influenced by factors besides research evidence, including shared values, political partisanship, and financial incentives. Research evidence alone doesn’t tell us whether an intervention is socially desirable, and unlike evidence-based medicine, policymakers and constituents rarely agree upon the optimal outcome. This means that, occasionally, the same evidence will lead to different decisions.

In the case of the COVID-19, businesses and governments have had to consider not only the public health risk but also the social and fiscal implications of their policies. They must weigh a society’s values—the American notion of autonomy—against the public health benefit of the common good. But to ensure the best health outcomes, we must start with the evidence. We must agree that evidence has value and should guide our decisions. Only then can we reaffirm the role of facts in decision-making and thereby transform our societies, governments, and institutions to best serve the people.

REFERENCE

  1. Adolph, Christopher, et al. “Pandemic Politics: Timing State-Level Social Distancing Responses to COVID-19.” University of Washington, 28 Mar. 2020, faculty.washington.edu/cadolph/papers/AABFW2020.pdf.

  2. Yeager, Ashley. “Cuts to Prevention and Public Health Fund Puts CDC Programs at Risk.” The Scientist Magazine®, www.the-scientist.com/daily-news/cuts-to-prevention-and-public-health-fund-puts-cdc-programs-at-risk-30298.

  3. Sheth, S., 2020. Trump spent the past 2 years slashing the government agencies responsible for handling the coronavirus outbreak. Business Insider. Available at: https://www.businessinsider.com/trump-cuts-programs-responsible-for-fighting-coronavirus-2020-2?utm_source=markets&utm_medium=ingest [Accessed April 22, 2020].

  4. Sanger, David E., et al. “A Ventilator Stockpile, With One Hitch: Thousands Do Not Work.” The New York Times, The New York Times, 1 Apr. 2020, www.nytimes.com/2020/04/01/us/politics/coronavirus-ventilators.html.

  5. Bergengruen, Vera, and W.J. Hennigan. “Why Trump's Coronavirus Response Was Never Going to Work.” Time, Time, 6 Mar. 2020, time.com/5797636/trump-botched-coronavirus-response/.

  6. Aizenman, Nurith. “Experts Say The U.S. Needs A National Shutdown ASAP - But Differ On What Comes Next.” NPR, NPR, 27 Mar. 2020, www.npr.org/sections/health-shots/2020/03/27/822146372/experts-say-the-u-s-needs-a-national-shutdown-asap-but-differ-on-what-comes-next.

  7. Cheng, Kent Jason. (2020). Unhealthier States have Lower COVID-19 Testing Rates.

  8. Lemos, Gregory. “Thousands of Tennessee Doctors and Local Officials Want the Governor to Issue Stay-at-Home Order.” CNN, Cable News Network, 1 Apr. 2020, www.cnn.com/2020/04/01/us/coronavirus-tennessee-doctors-bill-lee-stay-at-home-trnd/index.html.

  9. Polsky, Carol. “Doctors Warn of Side Effects of Drugs Seen as Promising for Coronavirus.” Newsday, Newsday, 25 Mar. 2020, www.newsday.com/news/health/coronavirus/drugs-treatment-risk-coronavirus-1.43420608.

  10. Bella Mehta. “Potential Shortages of Hydroxychloroquine for Patients with Lupus During the Coronavirus Disease 2019 Pandemic.” JAMA Health Forum, American Medical Association, 10 Apr. 2020, jamanetwork.com/channels/health-forum/fullarticle/2764607.

  11. Wood, Josh. “Two States: One Democrat, One Republican. Two Very Different Outcomes.” The Guardian, Guardian News and Media, 23 Apr. 2020, www.theguardian.com/world/2020/apr/23/us-coronavirus-outbreak-tennessee-kentucky.

  12. Koma, Wyatt, et al. “How Many Adults Are at Risk of Serious Illness If Infected with Coronavirus? Updated Data.” The Henry J. Kaiser Family Foundation, 23 Apr. 2020, www.kff.org/global-health-policy/issue-brief/how-many-adults-are-at-risk-of-serious-illness-if-infected-with-coronavirus/.

  13. “Gov. Lee Issues 'Safer at Home' Order for All of Tennessee.” Wbir.com, 30 Mar. 2020, www.wbir.com/article/news/health/coronavirus/gov-lee-issues-safer-at-home-order-for-all-of-tennessee/51-e48afb51-2f30-420c-b44a-4782b65958d6.

  14. Gold, M. (2009, August). Pathways to the use of health services research in policy. Retrieved May 14, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/19490163

  15. Liverani, M., Hawkins, B. & Parkhurst, J.O., Political and Institutional Influences on the Use of Evidence in Public Health Policy. A Systematic Review. PLOS ONE. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0077404 [Accessed April 22, 2020].

  16. Crewe, Emma, and John Young. Bridging Research and Policy: Context, Evidence and Links. Overseas Development Institute, 2002.

Telemedicine for Clinical Experiences in the COVID-19 Era of Medical Education: Two Student Perspectives

Tanir Moreno, MS1, John Rafael, BA1, Brianna Marschke, BS1, and Stephanie Bui, BS1
1 Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430, USA

Correspondence concerning this article and requests for reprints should be addressed to Tanir Moreno (Tanir.Moreno@ttuhsc.edu)

Abstract

Nationwide cancellations of clerkships for third- and fourth-year medical students due to COVID-19 spurred the quick implementation of alternative learning methods. Although the preclinical curriculum is less affected, widespread interruptions of student volunteerism involving patient care such as student-run free clinics contribute to the effective halt of clinical experience for medical students in all stages of their education. Due to this disruption, our institution implemented telemedicine as an alternative method of continuing clinical experience both in clerkship settings and at our free clinic. As four medical students of various years, and therefore varying experiences in using telemedicine, we hope to reflect on its effectiveness and implications for the future of medical education.

Background

Clinical experience as a medical student has consisted of practicing skills such as taking a detailed history and performing a thorough physical exam since the advent of modern medical education. However, COVID-19 abruptly altered today’s landscape of medical education due to the widespread cancellations of clerkships and extracurricular activities involving patient care. Medical schools across the nation have scrambled to create curriculum changes quickly to allow students to continue their education in some form, including the unique implementation of telemedicine.

Telemedicine is an established, evidence-based practice that has been in use for decades and involves “two-way, real time interactive communication between the patient and the physician or practitioner at [a] distance site” [1]. The World Health Organization (WHO) recommended the use of telemedicine to “complement, rather than replace the delivery of health services” and recognized it as a viable option for increasing access to health workers in rural areas [3]. At Texas Tech University Health Sciences Center (TTUHSC) School of Medicine in Lubbock, Texas, an institution that serves 108 counties and covers an area of 131,000 square miles [4], telehealth has long been a necessity to increase access to healthcare for the vast West Texas area. Thus, TTUHSC was one of the early pioneers of telehealth leading to its development into a robust department since 1989.

Our institution’s preexisting infrastructure with telehealth enabled a relatively seamless progression to its utilization in student clinical education in response to COVID-19. As four medical students in various stages of our education, we recognize the widespread applications of telemedicine as a response to mitigating the lack of clinical experience and perhaps even as a learning tool that will revolutionize medical education for years to come.  

Telemedicine in Third-Year Clerkships

As a third-year medical student, I was in my psychiatry clerkship when COVID-19 hit.  Clerkship directors struggled to find appropriate alternatives for me and my classmates to continue our final rotations without the option of in-person activities. I fully expected my level of clinical involvement in my psychiatry rotation to significantly decrease as a result. However, in a matter of weeks our psychiatry department created and implemented a telemedicine curriculum combining inpatient and outpatient experiences.

I was initially concerned that telemedicine as a medium of patient care would be impersonal, a concern shared by many new users of telehealth. In fact, “resistance to change” is the second largest barrier to telemedicine behind the technological challenge [5]. However, I found that the patient visits were not at all compromised during my clerkship. In fact, virtual interactions with patients became even more meaningful, as the limited human interaction both students and patients were experieincing increased the value of each visit beyond its clinical context.    

It is also an important consideration as to whether telemedicine is generalizable to other rotations beyond psychiatry; this clerkship generally involves limited “hands-on” interaction compared to other rotations, such as surgery, which are comprised of more technical skills.  Telemedicine’s compatibility with these rotations is not proven,  but I consider it the best option we currently have during clinical cancellations. At the very least, telemedicine allows for observation of physicians performing physical exam techniques and allows students to practice interviewing patients, which would otherwise be unavailable at this time.

Although I wish that the circumstances were different, I am thankful to have continued my clinical experience through telemedicine in the midst of COVID-19 and hope to see its broader implementation in medical schools around the nation. Telemedicine’s drastic increase out of necessity during a global public health emergency suggests that the future holds increased roles for digital healthcare solutions and more widespread acceptance of their usage. Hence, it will likely also have a lasting role in medical education in the coming years, as clerkships tend to mirror the current trends and techniques utilized in practice.

Telemedicine in Student-Run Free Clinics

As first-year medical students at TTUHSC serving on The Free Clinic leadership team, we struggled to facilitate patient care for the uninsured and indigent population of Lubbock when COVID-19 restrictions began. In-person patient visits and student participation were curtailed, meaning that patients were losing their only source of healthcare and students were losing a valuable clinical learning opportunity. Student-run free clinics across the nation faced the same problem and models of telemedicine were created and shared with promising results. Understanding that effective care was still possible even in the face of the pandemic, our leadership team worked quickly to finalize the protocol and smooth out logistics for the implementation of telemedicine at our clinic. Within a couple of weeks, telemedicine at the TTUHSC Free Clinic came to fruition.

The benefits of this new telemedicine protocol are far-reaching. Not only are we able to allow students of all years to continue gaining experience seeing patients independently, but we are also able to provide direct care to patients in need. Furthermore, the future applications of this method of healthcare are particularly exciting. We have discussed its continued usage when clinic operations return to normal as an additional tool to allow medical students and patients unable to physically appear in clinic to still participate in the provision and receipt of care, respectively. Additionally, telemedicine can expand our services, particularly in mental health, to patients in the region and serve as an educational tool for students interested in using telemedicine in their respective careers.  

Although we feel that the benefits of offering telemedicine far outweigh any costs, some challenges continue to need further attention. Not all established patients at our free clinic have access to or knowledge of how to seek care through telehealth. Some patients also report hesitancy in adopting telemedicine, instead insisting on waiting for physical visits or more established models of communication such as phone calls. Even with our clinic’s emphasis on bridging the technological gap (e.g. providing tablets for telehealth visits, sending clear instructions to access telehealth visits, etc.), it is difficult to control for variables such as a stable internet connection or a private space in which to conduct the appointment. Given the correlation of low health literacy with a lower likelihood of using newer forms of health technology [6], increasing both health and technological literacy of patients drives our refinement of telemedicine use for the benefit of our patients.   

The COVID-19 pandemic may have altered our respective clinical educations, but it has also reaffirmed our desire to find innovative ways to serve the community. Both our students who make up the backbone of our operations and the patients we serve constantly remind us that, even in the face of adversity, a collective of mission-driven stakeholders can still work together to serve others.

Final Thoughts

Virtual options such as telemedicine are already rising in popularity as modalities to continue medical education. The United States Medical Licensing Examination (USMLE) has released a statement that accelerated plans are being made for a “testing solution that employs a telehealth model, where examinees and standardized patients would interact online, via a web browser” for the Step 2 Clinical Skills (CS) exam [7]. Additionally, “virtual sub-internships” are being created in multiple specialties for fourth-year students unable to participate in typical away rotations. Overall, it seems that telemedicine drastically increased its presence within the medical school curriculum in the span of a few short months.

The WHO outlined potential limitations to telemedicine’s widespread implementation, including infrastructure requirements, costs, and training requirements of health workers to use these technologies [3]. From our experience, these limitations are not significant barriers to telemedicine in medical education evidenced by our institution’s successful implementation in our student-run free clinic and psychiatry clerkship within one to two months. Despite minor issues with internet connectivity, both medical students and patients were able to utilize telemedicine effectively with limited training.

Ultimately, we believe that telemedicine has the same applications for medical school curricula as for patient care described by the WHO; it is not a substitute for clinical experience, but a reasonable and effective alternative when options are limited. Caution should be exercised in implementing telemedicine where it is not regularly used, such as an assessment tool for student clinical skills for Step 2 CS or individual schools’ Objective Structured Clinical Exams. Further research and data are needed to understand the full scope of telemedicine’s curricular applications, but it is undoubtedly a promising new practice for the future of medical education.

References

  1. Centers for Medicare and Medicaid Services. Telemedicine. Medicaid.gov: Keeping America Healthy (Accessed May 18th, 2020, at at: https://www.medicaid.gov/medicaid/benefits/telemed/index.html).

  2. WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019. License: CC BY-NC-SA 3.0 IGO.

  3. Roodenbeke Ed, Lucas S, Rouzaut A, et al. Outreach Services as a Strategy to Increase Access to Health Workers in Remote and Rural Areas: Increasing Access to Health Workers in Rural and Remote Areas. Geneva: World Health Organization; 2011. (Technical Report, No. 2.) 4, Results. 

  4. Texas Tech University Health Sciences Center Factbook: 26th Edition. History. Texas Tech University Health Science Center. December 2019. (Accessed May 18th, 2020, at https://www.ttuhsc.edu/about/factbook.aspx).

  5. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018;24(1):4‐12.

  6. Mackert, Michael, et al. Health literacy and health information technology adoption: the potential for a new digital divide. Journal of medical Internet research 18.10 (2016): e264.

  7. Announcements. United States Medical Licensing Examination website. Updated April 3, 2020. (Accessed May 18, 2020, at https://www.usmle.org/announcements/default.aspx?ContentId=266).

The Mask

Alisha Poppen
University College of Cork, Ireland

Wearing a mask has become a sign of utmost empathy one can show to another
We do not wear a mask to protect our self, but rather to protect others
 It is an implicit statement of love, not fear 

I wear my mask to prevent the spread of the virus that can make you sick
Not because I think everyone around me has the virus and wants to infect me
Not because I am afraid of the virus

I wear my mask to comfort you, not to make you feel apprehensive
I wear my mask as a solider in this war against a microscopic threat that spares nobody
It is armor

Six feet apart and a piece of fabric to cover our face
It is all that we have to protect life and prevent death
No borders that separate us, no vaccine to save us
No person too big or too small, too rich or too poor, too red or too blue is immune 

We all play for the same team

The mask, a symbol of unity, a symbol of hope and a symbol of love

The Mask.png

A Month of Reflection: Ramadan, Medical School, and COVID-19

Abdurrahman Abdurrob, MSc
Tufts University School of Medicine

In the space of a few weeks, the impact of COVID-19 has been felt all around the world. Social distancing, face masks, and non-stop handwashing are now the new normal. Thousands of people have tragically lost their lives, many unable to say goodbye to their loved ones. While countless more are struggling to make ends meet as the damage is compounded by underlying systemic problems. Furthermore, as an immigrant to America, I particularly felt how COVID-19 has ravaged our communities here and across the world. Bangladesh, my place of birth, has been hit hard, as millions are forced to choose between safety or food, in what is typically a joyous time – the month of Ramadan.

For those who don’t know, Ramadan is the 9th month of the Islamic Calendar in which Muslims, who are able, abstain from food and drink between sunrise to sunset for the whole month. There are many reasons why Muslims fast this month. Ramadan is not only one of the five major pillars of the religion, but it is also an important opportunity for Muslims to reflect on the struggles of those less fortunate, many of whom have been hit the hardest by this pandemic.

Another major part of Ramadan is community. Our local mosque in Boston usually hosts lectures, prayer services, and dinners with hundreds of people in attendance every night. It is a deeply spiritual time for reflection and prayer. It is also a time of joy for kids who are able to see friends, and an opportunity for families to mingle over dinner. Most importantly, at the end of the month, it is a chance for the community to celebrate the end of Ramadan with Eid, the biggest holiday of the Islamic Calendar. However, mosques all around America, including my own, have shut their doors this Ramadan following guidelines around social distancing. Understandably, communities have had to drastically rethink how services are run as we deal with COVID-19. Instead of community gatherings to break our fast and nightly prayer services, we tune in for a nightly lecture on Zoom and break our fasts from home – the prospect of having a normal Eid is almost nonexistent. While these measures are not the same, we are all having to adapt to this new reality.

As a first-year medical student in Boston, I remember coming into medical school worrying about Ramadan. The prospect of fasting 16-hour days while balancing the workload of medical school seemed daunting. Fasting at this time of year means studying at night, eating breakfast at 3:00am, sleeping through the early morning, then trying to focus on an empty stomach before breaking my fast at 8:00pm. All this without coffee!

However, when our medical education moved online for the Spring semester, we similarly had to adapt. Many of us left campus within the week, packing up, and flying out of Boston to finish the rest of the semester in different cities around the country. While overall the experience has been smooth, and my medical school supportive, there have certainly been growing pains to learning online and a lot more independent studying. And of course, without the physical support of peers, these long hours of studying and fasting have been incredibly isolating.

Nonetheless, many of my professors, friends, and colleagues are on the frontlines, conducting vital research or working in essential roles in various fields. My classmates are mobilizing support and communities are rallying to help each other in these difficult times. Many others are self-isolating at home hoping to help stop the spread of the virus. Everywhere people from all walks of life are making sacrifices during these difficult times. As first-year medical students, we have been told by our school that our main focus should be our coursework. We just finished our Respiratory Block, so having studied Acute Respiratory Distress Syndrome in depth, I am grateful more than ever to have the privilege of studying medicine.

Somewhat fittingly, this “socially distanced” Ramadan has given me this opportunity for reflection. I reflect on all the ways COVID-19 has forced us to adapt to these difficult times: virtual Ramadan, school, graduations, work, and all the social distancing measures that are in place. While we may not be physically together right now, we can all play our part especially as COVID-19 has forced magnified the health disparities in our system. Just as community is important in Ramadan, I believe it is only through community we can address these challenges and adapt to these new changes.  While the future does seem uncertain at times, I hope through these experiences my classmates and I will be able to help bridge these gaps in the not too distant future.

Am I Useful?

Nicholas Bellacicco
Lake Erie College of Osteopathic Medicine at Bradenton

A dusty white coat is what I see
When will I get an opportunity?
To serve and love like I know best
Giving my all, and nothing less.

“Am I useful?” I often think
As I watch my mentors start to sink
I hear of fear in wards I thought immune
Sincere prayers that this be over soon.

We are pulled in two opposite directions
One of battle another of hesitation
We remain at home and do what we know
Reading books until the sun goes low.

Our futures uncertain, our careers in limbo
Secure behind a closed window
We see it all as we shelter in place
Should I take a mask, or would that be a waste?

A Call-To-Action: Addressing the Technological Gap in Predoctoral Dental Education

Leela S. Breitman, BA1, Aisha K. Ba, BS1, Emily J. Van Doren, BS1, and Jennifer E. Lee, BS1
1 Harvard School of Dental Medicine, Boston, MA 02115, USA

Correspondence concerning this article and requests for reprints should be addressed to Emily J. Van Doren (Emily_VanDoren@hsdm.harvard.edu)

The views expressed in this article are those of the authors and do not reflect the opinions of the Harvard School of Dental Medicine. The authors disclosed no conflicts of interest.

ABSTRACT

Dental students often feel underprepared for their clinical duties upon graduation. Educators must investigate the current state of predoctoral dental education to better understand this trend. Currently, PowerPoints and live demonstrations are the primary tools for teaching preclinical dentistry. Concerns with these modalities are that: two-dimensional PowerPoints cannot reliably explain concepts that require three-dimensional visualization; live demonstrations cannot be replayed and do not accommodate different learning paces; and live demonstrations occupy a large percentage of class time that could be otherwise allocated to practicing clinical skills. Having grown up during the technological revolution, modern students expect the integration of technology into all aspects of their lives. Beyond student expectations, the COVID-19 pandemic demands that dental education embrace online learning. Educational videos provide the opportunity to address the shortcomings of current teaching methods, satisfy students’ need for educational technology, and effectively communicate clinical skills in the context of social-distancing precautions. At present, few academically verified, online dental educational videos exist. To fill this void, dental educators should enlist their students to work as their co-educators and collaborators to create a library of academically verified videos. Beyond improving and modernizing dental education, the increased production and utilization of academically verified videos in preclinical dental education will help galvanize interest in dental academia among the next generation of dental clinicians. Work of this kind has the potential to dramatically improve dental education around the world, including in dentally-underserved areas.

INTRODUCTION

Effectively preparing dentists is critical to address the global oral health needs. Unfortunately, there is a worldwide shortage of dental educators. Among dentists graduating from predoctoral programs, many report feeling “unprepared” to meet the clinical needs of their patients [1]. To better understand why dental students feel underprepared, we must examine the current state of dental education and compare this to current educational trends in related disciplines. To date, related health care specialties have made use of online educational tools, including internet-based course content, online interactive learning modules, virtual communications, and evaluations [2]. At present, dental education has not explored these modalities to the same extent. We must consider solutions to the problems outlined above: namely, the global shortage of academic dentists, students’ feelings of unpreparedness, and the lack of online educational tools in clinical dentistry.

Figure 1. Video collaboration as a means of addressing the technological gap in predoctoral dental education. Original illustration by Leela Breitman.

Figure 1. Video collaboration as a means of addressing the technological gap in predoctoral dental education. Original illustration by Leela Breitman.

SITUATION ANALYSIS

Current teaching modalities

The field of dentistry faces the unique challenge of preparing students to rapidly achieve proficiency in clinical techniques before practicing with patients. Currently, most dental schools accomplish this by presenting PowerPoint lectures that explain procedural steps, followed by live demonstrations in the preclinical laboratory. In the setting of the COVID-19 pandemic, students are able to receive lectures delivered through video-conferencing, but the use of live demonstrations in the preclinical laboratory is no longer possible. Additional concerns are: first, PowerPoints rely on two-dimensional imagery to explain concepts that require three-dimensional visualization. Second, live demonstrations cannot be replayed and therefore, do not accommodate students who learn at different paces. Lastly, live demonstrations occupy a large percentage of class time that could be otherwise allocated to more active forms of student learning.

Technology in education

The majority of current dental students grew up in the context of the technological revolution. As such, we have come to expect the integration of technology into all aspects of our lives, including in our education. We, as “digital natives,” gravitate toward video-based technologies over traditional teaching modalities such as PowerPoint lectures and textbooks. Rather than combing through slides and books for answers, modern students prefer searching for information online. Most dental students turn to electronic applications to learn anatomy, and to e-flashcards and websites to study for exams.

Beyond simple preference, the use of modern technologies such as video-recorded clinical techniques enhances student learning and procedural outcomes [3,4].Video-recorded clinical demonstrations communicate three-dimensional spatial information which is particularly crucial to dental learning. Further, students may pause, slow-down, replay, and easily navigate to different time points in videos, providing them with the necessary autonomy to learn at an individualized speed. Given the fast pace, vastness, and diversity of procedures that dental students must master, recorded video demonstrations allow students to refresh their memory of procedures at any time during their education.

Moreover, video demonstrations may be viewed and reviewed outside of academic settings. This is particularly pertinent during the COVID-19 pandemic, where the physical closure of schools has brought clinical learning to a grinding halt. Notably, continuous access to videos remains beneficial beyond the context of COVID-19, as pre-recorded videos may allow class time to be reallocated. For example, a video demonstration may be reviewed prior to class such that students are prepared to begin working upon arrival to the preclinical lab. Additionally, given the worldwide shortage of dental educators, video-recorded clinical techniques can act as a teaching force multiplier, delivering consistent and credible information to trainees with less reliance on the need for small faculty-to-student ratios. In sum, educational technologies — namely video-based technologies — have tremendous potential to enhance dental education and supplement the current teaching modalities both in the context of the COVID-19 pandemic and traditional academic circumstances.

Online learning in medical education

In the modern landscape of medical education, online platforms such as Osmosis, Sketchy Medical, and UpToDate have arisen to fulfill the demand for video-based e-learning. Medical students use these resources to learn and review content during their preclinical and clinical years. In fact, nearly 100% of medical students use supplemental online materials to revisit and reinforce traditional medical curricula [5]. These resources provide the academic backing that most Google searches lack, given that professors and physicians who represent medical and research institutions create and review the content on these platforms. Academic verification reassures students that the information they receive is accurate and up to date.

While similar educational products would enrich clinical dental learning, such resources do not currently exist. As few academically verified, online educational technologies exist for the modern dental learner, students, in search of information presented in a manner consistent with their fast-paced, tech-savvy lives, frequently turn to Google and YouTube [6,7]. While there is no shortage of healthcare information available on the internet, issues that arise with existing online dental educational materials include: (1) verification of the accuracy and quality; (2) control over the scope and modernity; and (3) discrepancies in standards of care. In the context of the COVID-19 pandemic where students have restricted access to their professors, lack of academic verification is of heightened risk. In order to curb the spread of misinformation and cater to the modern dental learner, we must develop academically verified, online, dental educational tools similar to those utilized by medical learners.

THE SOLUTION

Enlisting students to improve education

Fostering student-initiated projects is a proven method to encourage students to pursue academic careers. Beyond their affiliations with academic institutions, many of the aforementioned supplemental online medical education platforms were founded by medical students and residents. Through their collaborations with academic faculty, these students gained opportunities to share their visions for advancing medical education in the digital age. Many have gone on to pursue careers in medical education. With this framework in mind, engaging dental students in the ideation and creation of technologically-forward learning tools in dental education will encourage students interested in becoming dental educators.

To best prepare dental students to tackle the modern oral healthcare landscape, we need academically verified, online educational content for clinical dentistry. Current dental educators have a strong interest in creating innovative, online teaching materials, but often lack the time, resources, and expertise in the most up-to-date technology required for production of these resources. For these reasons, dental educators should enlist their tech savvy students to work as their co-educators and collaborators (see Figure 2). In doing so, dental educators will provide their students with increased opportunities to engage with dental academia, solidifying interest in dental education. This collaboration has the potential to blur the division between teacher and student, and ultimately to resolve the shortage of dental educators.

Figure 2. Guide to the production of successful, verified educational videos for first-time teams.

Figure 2. Guide to the production of successful, verified educational videos for first-time teams.

We believe that increased production and utilization of academically verified videos in dental education will help modern students feel more engaged with their clinical learning, increase the efficient use of class time, and ultimately help students feel more prepared to enter the dental workforce after graduation. Importantly, should students be physically separated from their faculty and academic institutions in the future — as during the COVID-19 pandemic — an existing video library would facilitate continuation of clinical learning. With support from academic and research-based dental educational institutions, we can tackle the weaknesses associated with traditional teaching modalities, provide the verification that online sources such as YouTube lack, and meet the educational demands of the modern dental student.

Impact of verified, online learning tools

We live in an increasingly globalized society where the vast majority of dental students have access to the internet. This level of interconnectivity presents opportunities to disseminate high quality information to communities across the world. Improved access to information has the potential to bridge dental educational gaps across geographic and language barriers. For instance, a library of verified clinical video demonstrations might be used in dentally underserved areas. These videos may teach providers standard of care techniques and level disparities in dental education. Moreover, the migration of educational content to digitized platforms offers potential to increase the standardization of care.

CONCLUSION

Online educational tools not only cater to the learning style of modern dental students, but also solve many of the issues associated with traditional learning tools. Students enjoy learning from online and computer-based learning tools, and therefore often look to Google and YouTube to meet their learning preferences [6,7]. However, Google and YouTube do not, for the most part, contain academically-verified resources on clinical dentistry. The recent COVID-19 pandemic has further reinforced the urgency of developing academically verified, online learning technologies for dental education. While lectures can be recorded or conducted over video chat, high-quality online clinical learning platforms with trustworthy content are hard to create on short notice. We propose that dental students and dental educators work together to increase the body of online, academically-verified dental educational tools such as clinical educational videos. Through this work, dental students can learn about careers in academic dentistry — a field in need of dentists. Finally, online learning tools have the capacity to help dental students all around the world, including in dentally underserved areas and during times of crisis, such as the COVID-19 pandemic.

Reference

  1. Gilmour ASM, Welply A, Cowpe JG, Bullock AD, Jones RJ. The undergraduate preparation of dentists: Confidence levels of final year dental students at the School of Dentistry in Cardiff. Br Dent J 2016;221(6):349–54.

  2. Liu L. Factors Influencing Students’ Preference to Online Learning: Development of an Initial Propensity Model. Int J of Technol in Teach and Learn 2011;7(2):93-108.

  3. Weber U, Constantinescu MA, Woermann U, Schmitz F, Schnabel K. Video-based instructions for surgical hand disinfection as a replacement for conventional tuition? A randomised, blind comparative study. GMS J Med Educ 2016;33(4):Doc57.

  4. Stein CD, Eisenberg ES, O’Donnell JA, Spallek H. What Dental Educators Need to Understand About Emerging Technologies to Incorporate Them Effectively into the Educational Process. J Dent Educ 2014;78(4):520-529.

  5. O’Malley D, Barry DS, Rae MG. How much do preclinical medical students utilize the internet to study physiology? Adv Physiol Educ 2019;43(3):383-391.

  6. Jackman WM, Roberts P. Students’ Perspectives on YouTube Video Usage as an E-Resource in the University Classroom. J of Educ Technol Sys 2014;42(3):273-296.

  7. Galanek JD, Gierdowski DC, Brooks DC. ECAR Study of Undergraduate Students and Information Technology, 2018. Louisville: Educause Center for Analysis and Research, 2018.

As the Toll Rises

Rohan Rao
Rutgers-Robert Wood Johnson Medical School

This is a reflective piece about my time volunteering in northern New Jersey in the early days of the COVID-19 pandemic. I worked as a specimen collector at a drive-thru testing site.

A cold, gloomy day was upon us, as we arrived
at the testing site. The sun was hiding
behind ominous storm clouds, as if it too felt
the unease that bloomed within me.
By a pale white tent,
whose flaps thrashed wildly in the wind,
we donned our protective gear. 

Tent B was our assignment. Specimen collection was our role.
A gaggle of new, partially obscured faces,
we unsaddled our unfamiliarity to shoulder a shared purpose.
Swimming, though more aptly it felt like drowning,
through a sea of PPE, emotions were lost beneath the swell.
A tide washing away smiles, ushering in
a foam of gravitas onto our beaches.
With our expressiveness swept off,
a double-gloved thumbs up would have to do. 

Cars arrived, in a trickle that quickly transformed
to a gushing stream. How fitting it was then, that
the sky began to shed tears on the passengers inside,
all anxiously awaiting their turn for testing.
To them, we were a spectacle. Aliens in our white protective suits.
Our approach induced eyes to widen or fingers to hit “record,”
even an audible gasp as I wielded the nasal swab. 

“That goes where?!” she exclaimed. “I think you poked my brain,”
remarked another. But after ten seconds,
which accordingly felt like ten years, they were done and on their way.
With the last car swabbed, we doffed our gear,
careful not to expose ourselves and end up in that very same line of cars.
We laughed jovially, and recounted our dreary morning,
before going our separate ways. 

But frequently, I find myself back in that parking lot,
watching the cars drive off, wondering how their stories ended.
Day by day, as I see the rising death toll in my state,
I strive to maintain my hopefulness, and stave off
that defeated sigh.

Reflecting on COVID-era Abortion Bans

Margaret Okobi, BS1
1 Harvard Medical School, Boston, MA 02115, USA

With the current pandemic, providing healthcare leads to an inevitable tradeoff between serving patients and potentially exposing them to coronavirus infection. Seemingly in response to this concern, there has been immense, state-level pressure within the US, to limit abortion services indefinitely. As of April 30th, 2020, at least 11 states have issued orders limiting or banning abortions [5]. Interestingly, 100% of these states have Republican-controlled state legislatures, and several of them had been pushing increasingly restrictive abortion legislation prior to this pandemic [6,8]. The political undertones of these efforts are clear.

Outside of the political sphere, many organizations have released guidance as to which healthcare services and workers are considered essential during these times [1-4]. The American College of Obstetrics and Gynecology (ACOG) and the World Health Organization (WHO) recognize reproductive services as essential during this pandemic, with the latter explicitly recommending continued “access to contraception and safe abortion” [3,7].

Amid this polarizing debate, we cannot forget the people affected by these new policies. What happens to the women who cannot access safe abortions near their homes? Some will travel hundreds of miles to different abortion clinics. Prior to COVID-19, this was already a common occurrence. In 2018, Dr. Diane Horvath told the story of a 16-year old girl, who drove all night, from Michigan to Maryland, to receive a safe abortion [11]. If they cannot reach an abortion provider, some women will attempt dangerous abortions on their own, harkening back to the “coat hanger abortion” era before Roe v. Wade (1973) [12, 14]. Lastly, women who are unable to access some form of abortion may carry unwanted pregnancies to term and face long-term consequences, starting even before delivery. Unwanted pregnancies are associated with increased interpersonal violence and maternal mental health conditions. Women become less likely to finish college or enter the workforce. Their children are more likely to have social, cognitive, and emotional deficits [13,14].  By limiting access to safe abortions, we are forcing women into unsafe practices and unwanted pregnancies, which have life-changing, multi-generational consequences.  

With all that is at stake, abortion providers and other healthcare professionals can take this opportunity to be advocates, individually and organizationally (9). Providers can obviously contribute to this cause by continuing to perform surgical abortions, but also by challenging their affiliated organizations to take a firm stance on the issue. In terms of combatting governmental orders, ACOG has gathered numerous resources for providers and/or constituents to track legislation, contact legislators, or advocate as state legislators themselves [10]. Providers have powerful insight and authority on this topic, which can make public discussions less partisan and more evidence based [9]. Already, abortion providers and reproductive advocates have successfully resisted abortion-banning orders in six states [5].

Ultimately, as governed by federal law and health organization guidance, we have an imperative to help women access reproductive services, and avoid the emotional, psychological, medical, financial, and social burdens associated with unwanted pregnancies. During this pandemic, we should ensure that women have continued (or even better) access to abortions. Now is not the time for a referendum on the morality of abortion, and it is unconscionable to use COVID-19 as an excuse to block access. Now, more than ever, with a global pandemic threatening our health and livelihoods, women deserve to have control over their health and their futures.

REFERENCES

  1. Department of Homeland Security, Cybersecurity and Infrastructure Security Agency. (2020). Guidance on the Essential Critical Infrastructure Workforce. https://www.cisa.gov/publication/guidance-essential-critical-infrastructure-workforce

  2. Center for Medicaid and Medicare Services. (2020). Non-Emergent, Elective Medical Services and, Treatment Recommendations. https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf

  3. Ford, Liz. “Declare abortion a public health issue during pandemic, WHO urged.” The Guardian. April 10, 2020. https://www.theguardian.com/global-development/2020/apr/10/declare-abortion-a-public-health-issue-during-pandemic-who-urged

  4. “Helping private practices navigate non-essential care during COVID-19.” American Medical Association. April 14, 2020. https://www.ama-assn.org/delivering-care/public-health/helping-private-practices-navigate-non-essential-care-during-covid-19

  5. Sobel, Laurie et al. “State Action to Limit Abortion Access During the COVID-19 Pandemic.” Kaiser Family Foundation. April 27, 2020. https://www.kff.org/womens-health-policy/issue-brief/state-action-to-limit-abortion-access-during-the-covid-19-pandemic/

  6. “State Partisan Composition.” National Conference of State Legislatures. March 31, 2020. https://www.ncsl.org/research/about-state-legislatures/partisan-composition.aspx

  7. “Joint Statement on Abortion Access During the COVID-19 Outbreak.” The American College of Obstetricians and Gynecologists. March 18, 2020. https://www.acog.org/news/news-releases/2020/03/joint-statement-on-abortion-access-during-the-covid-19-outbreak

  8. Panetta, Grace. “The states passing strict abortion bans have some of the highest maternal and infant mortality rates in the country.” Insider, Inc. June 1, 2019. https://www.businessinsider.com/states-passing-abortion-bans-have-highest-infant-mortality-rates-2019-5

  9. Mark et al. “What can obstetrician/gynecologist do to support abortion access?” International Journal of Gynecology and Obstetrics. 131(1): S53-S55. https://www.sciencedirect.com/science/article/pii/S0020729215000909

  10. “Get involved.” The American College of Obstetricians and Gynecologists. (2020) https://www.acog.org/advocacy/get-involved

  11. Frye, John. “OB-GYN advocates for better abortion policy.” The Johns Hopkins News-Letter. April 15, 2018. https://www.jhunewsletter.com/article/2018/04/ob-gyn-advocates-for-better-abortion-policy

  12. Fox, Maggie “Abortion in the U.S.: Five key facts.” NBC News. July 5, 2018. https://www.nbcnews.com/health/health-news/abortion-u-s-five-key-facts-n889111

  13. Bernstein, Anna and Kelly Jones. “The Economic Effects of Abortion Access: A Review of the Evidence.” Institute for Women’s Policy Research. July 18, 2019. https://iwpr.org/publications/economic-effects-abortion-access-report/

  14. “Abortion and Mental Health.” American Psychological Association. (2020). https://www.apa.org/pi/women/programs/abortion/

White Noise

Devanshi Shah, MBBS
Seth GS Medical College and KEM Hospital, Mumbai

The bed is being emptied in front of me.
I sigh, I ponder.
Yesterday his vitals were improving
And today his oxygen tumbled.
He didn't open his eyes.
Neither did his wife, apparently,
In the room next door.
I close my eyes too, the sight too much for me to bear.

There's white noise all around me, a silence which screams, an agony only I can hear.

When I remove my mask at the end of the shift,
The lines are etched in my face.
Not the lines of the mask, no,
Lines of worry around my eyes,
Frowns on my forehead.
I look like I have aged from 24 to 42,
With every death adding a year to my age.

Around me, there's only white noise,
Only weak wails from the heartbroken.

I remove my gown carefully,
A bath from head to toe,
As if the water can rinse the memories,
Which the day has left in me.
As if the soap can erase the claw marks,
Which Death leaves in its wake.

Even when the water tumbles down from the faucet,
I hear nothing, only white noise.

 My heart beats erratically,
Everytime I pass by the ER,
Who will come in now?
Friend or foe?
Will I have to see them in the ICU?
It's as if my breaths are getting shallower,
As my mind rushes through the last few days,
Wives praying, children consoling,
Tears escaping, and hands shuddering.

No goodbyes were said, there were no sounds, only white noise all around. 

I return the next day,
It's hotter than usual, as I don the gown,
Sweat trickles down my forehead,
In anticipation of more deaths.
My chest tightens at thoughts,
Of how dark and empty their eyes look,
As they stare Death in the face.
Even when I'm pumping oxygen into their unwilling lungs,
I'm trying, I'm trying.

I'm shouting, pleading them to come back,
But they can't hear me, it's only white noise all around.

As the cursed clock's hands ticked by,
Nearing noon again,
I decided to confront my demons.
It was what I'd suspected.
I lay down in the very bed I'd seen being emptied,
After all, the very disease I fought against,
Came back to me with vengeance.
I don't close my eyes, worried,
That it might be the last time I open them.
On the other side of the wall,
I see my mother saying something.
She says, she's praying for me.
I wish I could hear her right now.
But it's all white noise around me.