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

Clinical placements for medical students are the central element in the teaching and learning of any medical program. In later years, medical students generally undertake rotations in disciplines such as general practice, general medicine, paediatrics, psychiatry, surgery, anaesthesia, obstetrics and gynaecology.  In our medical program, there are 475 students currently enrolled in the two final years. Despite the current COVID-19 pandemic, Flinders has remained committed to providing medical students with clinical placements, a stance which aligns with the Medical Deans of Australia and New Zealand (1), all state and territory health authorities and the Australian Health Protection Principal Committee. Local consensus reached between all stakeholders has been that we have an obligation to treat all patients with appropriate safeguards in place. Given the longer-term response to COVID-19 is unknown, removing students from clinical placements may not prepare them for their career in health care and may have significant implications for future workforce planning (1).

There are however 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. The local transmission of SARS in Toronto caused a significant interruption to usual teaching, particularly clinical methods skills teaching and the cessation of third and fourth clerkships. This impacted 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 the virus. This can lead to differing opinions among clinical supervisors as to the merits of continuing clinical placements. At our university we have addressed this by writing and widely distributing clear guidelines for clinical placements in partnership with medical students and health care provider partners. In some high-risk placements such as endoscopy and other aerosol-generating procedures, we have encouraged the clinical supervisors and students to negotiate appropriate activities that do not increase the risk of COVID-19 exposure to either 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 personal protective equipment (PPE) training was previously embedded within clinical rotations. In response to COVID-19 we have instigated refresher training for students on hand washing, N95/P2 mask fitting and donning and doffing of protective clothing with formal certification on completion.

To date, we have not had any students choose to withdraw from 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, the “real-life” learning in the current situation may be invaluable. Students have seen health system governance operationalised, witnessed senior clinicians act thoughtfully and with intent despite their own anxiety, and watched professional practice role modelled in the provision of good communication and a sense of humanity and compassion for sick patients.

COVID-19 presents significant challenges to medical schools who 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 re-allocation. However, it is important to remember that considerable clinical work unrelated to COVID-19 still needs to continue. On-going 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 scenario, help us to identify if clinical placements are no longer tenable.

References

1. Medical Deans of Australia and New Zealand. Principles for medical student roles in COVID-19 health workforce, 2020. Available from: https://medicaldeans.org.au/md/2020/03/2020-March-20_principles-for-medical-student-roles-in-COVID-19-health-workforce.pdf
2. Rieder M, Salvadori M, Bannister S, Kenyon C. Collateral damage: the effect of SARS on medical education. The Clinical Teacher. 2004; 1: 85-89. Available from:  https://onlinelibrary.wiley.com/doi/full/10.1111/j.1743-498X.2004.00026.x
3. Patil N, Yan Y. SARS and its effect on medical education in Hong Kong. Medical Education. 2003; 37: 1127-1128. Available from: https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2923.2003.01723.x?sid=nlm%3Apubmed