Clinical placements for medical students in the time of COVID‐19

Removing students from clinical placements may have significant implications for future workforce planning

Clinical placements for medical students are central to teaching and learning in any medical program, with students in the later years generally undertaking rotations in disciplines, such as general practice, general medicine, paediatrics, psychiatry, surgery, anaesthesia, obstetrics and gynaecology. In our medical program, there are close to 300 students currently enrolled in the 2 final years. Despite the current coronavirus disease 2019 (COVID‐19) pandemic, Flinders University has remained committed to providing medical students with clinical placements, a stance that aligns with the Medical Deans of Australia and New Zealand,1 all state and territory health authorities, and the Australian Health Protection Principal Committee. The local consensus between stakeholders is that we have an obligation to treat all patients with appropriate safeguards in place. Given that the longer term response to COVID‐19 is unknown, removing students from clinical placements may not only affect their medical training but may also have significant implications for future workforce planning.1

However, there are extraordinary challenges in the clinical and university environments. While COVID‐19 represents a unique situation in terms of world involvement, there are other examples of large‐scale disruption to medical education, including the severe acute respiratory syndrome (SARS) outbreak of 2003. In Canada, the local transmission of SARS in Toronto caused a significant interruption to usual teaching, particularly affecting the teaching of clinical methods skills and causing the cessation of third and fourth clerkships. This had an impact on all final year medical students and first year residency positions in Canada,2 an experience that was reflected in Hong Kong with the cancellation of ward teaching and delays in examinations.3 While we may wish to avoid this outcome, maintaining all medical students in their clinical placements can be challenging. There is heightened anxiety among the existing workforce, who are understandably concerned about the rapidly changing impact of COVID‐19, and this can lead to differing opinions among clinical supervisors as to the merits of continuing clinical placements. At our university, in partnership with medical students and health care providers, we have addressed this concern by writing and widely distributing clear guidelines for clinical placements. In some high risk placements, such as endoscopy and other aerosol generating procedures, we have encouraged clinical supervisors and students to negotiate appropriate activities that do not increase the risk of COVID‐19 exposure to the student, other staff or the patients, while still allowing the student to learn in the clinical environment.

The SARS experience in Canada highlighted the variability in standard precautions and infection control practices and teaching.2 In our medical program, training on the use of personal protective equipment was previously embedded within clinical rotations. In response to COVID‐19, we have instigated refresher training for students on handwashing, N95 (or P2) mask fitting, and donning and doffing of protective clothing, with formal certification on completion.

To date, students have chosen to remain on clinical placements. While they have concerns about their personal safety, they remain committed to both patient care and their own learning. This was also the case in Canada, where students took pride in their role as part of the health care team and understood that providing health care is not without risk.2 Furthermore, real‐life learning in the current situation may be invaluable. Students have seen health system governance operationalised, have witnessed senior clinicians act thoughtfully and with intent despite their own anxiety, and have watched professional practice in the provision of good communication and a sense of humanity and compassion for sick patients.

COVID‐19 presents significant challenges to medical schools that embed teaching and learning within the clinical environment. Our final year students are the future medical workforce and it is our job to ensure they are competent, undifferentiated, work‐ready practitioners. Furthermore, the wider community has reasonable expectations that the newly graduated workforce will be prepared for pandemics in addition to the provision of routine care. This situation reinforces the case for competency‐based teaching and learning. Education that is discipline‐focused is likely to be significantly disadvantaged by the cancellation of risky placements or by placements that have undergone substantial modifications as a result of health care resource reallocation. However, it is important to remember that considerable clinical work unrelated to COVID‐19 still needs to continue. Ongoing evaluation of the actual educational experience that students are receiving will assist us in the provision of additional learning if deficits arise, and, in the worst case scenario, help us identify if clinical placements are no longer tenable.