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Klein A, Muller D, Silverstein Z. Medical school during a pandemic: a retrospective study on U.S. medical school reopening policies. HPHR. 2021;48.
DOI:10.54111/0001/VV4
The COVID-19 pandemic has resulted in innumerable unprecedented challenges in the medical education system. Among other factors, personal protective equipment restrictions, contact limitations, and social distancing measures have all significantly altered the structure of undergraduate medical education and have required rapid adaptation to an ever-changing environment. For the majority of institutions, in-person courses and clerkships were halted abruptly in mid-March as schools were forced to transition to a completely virtual learning environment for the remainder of the 2019-2020 academic year. Heading into the 2020-2021 academic year with the knowledge that the COVID-19 pandemic would affect the fall semester at the very least, many medical schools developed plans to reopen in some capacity.
The publicly available reopening plans of U.S. MD programs were evaluated at the start of fall semester and at the end of fall semester.
All schools adopted a version of hybrid medical education, and mask use, social distancing of more than 6 feet at all times, and enhanced disinfection of common areas were universally implemented. 23 of 25 medical schools continued to require that students attend activities like anatomy lab and clinical skills simulations in-person. Every school prohibited clinical students from taking care of patients with a confirmed or suspected diagnosis of COVID-19.
As the pandemic surpasses one year in duration and the undergraduate medical education system concludes its first full pandemic year, this paper focuses on how medical schools have responded thus far to this crisis, where the current data stands in relation to safety of school reopening, and how the structure of undergraduate medical education has been changed forever.
The COVID-19 pandemic has resulted in innumerable unprecedented challenges in the medical education system. Among other factors, personal protective equipment (PPE) restrictions, contact limitations, and social distancing measures have all significantly altered the structure of undergraduate medical education and have required rapid adaptation to an ever-changing environment. As the pandemic surpasses one year in duration and the undergraduate medical education system concludes its first full pandemic year, we reflect on how medical schools have responded thus far to this crisis, where the current data stands in relation to safety of school reopening, and how the structure of undergraduate medical education has been changed forever.
For the majority of institutions, in-person courses and rotations were halted abruptly in mid-March as schools were forced to transition to a completely virtual learning environment for the remainder of the 2019-2020 academic year1. Anatomy, skills labs, and in-person problem based learning sessions ceased2. Instead of traditional clinical work, students on rotations completed their clinical training using virtual cases3. A subset of second-year preclinical students (including the author, Klein) became trapped in a cycle of exam cancellations and clerkship delays. Away acting internships, international electives, conference attendance, and interviews were prohibited immediately due to travel restrictions3,4. Lab closures effectively quelled many significant summer research projects4,5. In effect, undergraduate medical education came to a screeching halt, and school administrators had to act swiftly to ensure that student training proceeded as safely as possible. The 2019-2020 academic year ended with most students (pre-clinical and clinical) learning from home, wondering whether or not they would be returning to campus in the fall.
As the authors all attend an allopathic medical school and recognize that allopathic and osteopathic medical schools have different curricula and emphases, the choice was made to focus on allopathic medical programs. In order to select reopening plans to evaluate, the American Association of Medical Colleges (AAMC) website was filtered for allopathic medical schools located in the United States, including territories and commonwealths, that had incoming and returning medical students arriving for the Fall 2020 semester. 155 allopathic medical schools listed by their full names were placed alphabetically into a “random order generator” on www.random.org/lists and the first 25 allopathic medical schools were analyzed for reopening plans for the Fall 2020 semester. For each school examined, “[Medical school full name] COVID-19 reopening plan” was entered into Google and then links within the school’s website were followed until a plan was found. If no plan pertaining specifically to the medical school was publicly available on a school’s website, or if the plan’s applicability to medical students was not referenced in the reopening guidelines for the larger university, the next school on the randomly generated list was substituted for analysis.
Heading into the 2020-2021 academic year with the knowledge that the COVID-19 pandemic would affect the fall semester at the very least, many medical schools developed plans to reopen in some capacity. We randomly selected 100 of the 155 U.S. MD programs for evaluation of their COVID-19 reopening policies, of which 25 were found to have publicly available medical school-specific plans. Among these schools, all adopted a version of hybrid medical education, and mask use, social distancing of more than six feet at all times, and enhanced disinfection of common areas were universally implemented early in the fall semester (Table 1). Most schools required some form of daily screening before arriving on campus, which often consisted of students manually entering symptoms into a mobile app that would issue guidance on whether they should be physically present, stay home, or seek COVID-19 testing. Other schools either screened entering faculty and students at the door or required students to self-monitor without formal documentation of their symptoms.
In regard to the preclinical curriculum, didactic lectures and most small group discussions moved completely online for the fall semester. Remote teaching technologies were used to deliver content through either live or pre-recorded lectures and small group sessions aiming to reinforce this material generally followed suit, as well. Still, 23 of 25 medical schools continued to require that students attend activities like anatomy lab and clinical skills simulations in-person, relying on the aforementioned risk mitigation tactics.
While all 25 schools examined brought back clinical students for their rotations in the fall, medical schools generally did not draft (publically available) policies universally applicable to their student bodies. Every school prohibited clinical students from taking care of patients with a confirmed or suspected diagnosis of COVID-19, with several institutions going so far as to create graphics and/or algorithms to determine whether or not a student should be allowed to see any given patient (figure 1). Regardless, every school discussed the need for PPE and emphasized that the students’ ability to participate in clinical rotations was contingent on sufficient PPE supply, however defined by the institution. These definitions varied between schools, ranging from the provision of masks and face shields to clinical students to the assurance that clinical students would have access to the same in-hospital protections as the full-time medical team. Other schools deferred this decision to their affiliated hospitals and thus lacked a coherent PPE policy that applied to all of their clinical students.
Strategic testing of asymptomatic medical students for COVID-19 was not widely implemented.
Of the 25 schools examined, only nine had explicit plans to test asymptomatic students for reasons other than probable exposure, with five schools requiring that students be tested upon their arrival back on campus for the fall semester and four requiring that students participate in routine testing over the course of the academic year. The remaining 16 schools either noted that COVID-19 tests were available should a student wish to be tested, explicitly stated that they would not be requiring testing of their students except following a probable exposure, or did not mention asymptomatic testing of students at all.
The relative homogeneity of the core policies implemented at these institutions is unsurprising. Masks, social distancing, personal hygiene, and screening for symptoms are vital to the global strategy for combating COVID-19, and have been emphasized by the Centers for Disease Control and Prevention (CDC) and/or the National Academies of Sciences, Engineering, and Medicine in their guidance regarding the reopening of primary schools, secondary schools, and universities.6,7 Additionally, the Association of American Medical Colleges (AAMC) has stressed the importance of these measures in a statement to the general public in August.8 Other publicly available AAMC guidance documents directed towards medical school deans underscore the importance of contact tracing and testing; encouraging direct patient contact — broadly defined — to be avoided wherever possible, and for students to be provided sufficient PPE where it cannot; and putting in place “reasonable safeguards… to minimize medical students’ risk of contracting COVID-19”.9,10
Differences between the policies of the individual institutions examined can largely be attributed to the AAMC’s belief that this “guidance… is intended to add to, but not supersede, an academic medical center’s independent judgment of the immediate needs of its patients and preparation of its students,” as well as differing local regulations, transmission patterns, and available resources.9,11 The CDC takes a similar approach, seeking to “assist institutes of higher education… in making decisions rather than establishing regulatory requirements”.12 Even against this backdrop, however, the divergent approaches of the examined institutions towards testing asymptomatic students with no probable exposure to SARS-CoV-2 appears especially stark, with policies ranging from no testing at all to multiple tests per week. While the available evidence on the utility of routine testing of asymptomatic students in higher education settings is quite limited, the little that does exist confirms its benefits, even if whether those benefits justify the associated costs is debated.13,14 Some have advocated for this approach to be adopted extensively by universities15,16 as well as in a myriad of other settings including healthcare facilities,17-20 K-12 schools,21 and the population at large.22-25 But here, too, the evidence is less than definitive and generally only certain types of healthcare facilities26-32 and well-resourced professional sports leagues33-38 have adopted routine testing, with the latter mostly avoiding any large-scale, uncontrollable outbreaks. Still, 45,000+ cases at colleges across the United States have occurred since the end of July, including high profile outbreaks that forced schools like the University of North Carolina at Chapel Hill and Notre Dame to pause their reopening plans and move classes entirely online.39-41 Therefore, it should be noted that, despite the inherent differences between undergraduate universities and medical schools, the reopening plans of the latter may have been insufficient as currently constructed and additional measures such as routine testing could have been necessary to prevent cases. There is no publicly available database of cases by school, so the actual efficacy of routine testing among medical schools could not be effectively evaluated in this study (the nearest available proxy was county data, which is a poor representation of these measures).
The structural divergence from the pre-pandemic academic status quo is notable and has posed significant challenges for some, largely due to an abrupt transition to self-directed learning and the necessity for consistent access to reliable internet. However, in many ways the organization of the lectures and emphasis on self-directed learning are remarkably similar to the structure created by students at numerous medical schools who did not regularly attend non-mandatory classes before the pandemic — an option long afforded to students using recordings of lectures as a proxy for attendance. Indeed, many students were already studying on their own schedules and utilizing various outside resources (e.g., First Aid, SketchyMedical, Pathoma, Boards and Beyond) prior to this semester and its transition to a more self-guided approach. The main issue early on — that was resolved quickly but should be addressed in future rapid curriculum changes — was difficulty in translating clinical skills to online learning modules.
Now, as highly efficacious vaccines become readily available and schools begin to plan for the next academic year, a sense of normalcy has begun to emerge. Universities across the country are reopening for the 2021-2022 year with vaccine requirements, and state and local governments in regions with high vaccination rates have begun to loosen restrictions. Perhaps the next academic year will represent a return to pre-pandemic academic structure; however with the successful advent of remote learning technology, it is to be expected that some elements of pandemic learning will remain in place, serving not only as an effective learning tool but also as a reminder of one of the most memorable years in recent history.
The COVID-19 pandemic has resulted in a radical upheaval of undergraduate medical education at both the preclinical and clinical levels. In the span of one year, preclinical education transitioned from traditional, classroom-based learning to a predominantly hybrid model. The elimination of in-person large lectures and focus on small group discussion has generated a much more interactive learning environment, despite, in some cases, students being dispersed across the country. Additionally, clinical students are learning in a completely different environment from their predecessors and will be more prepared than previous generations to handle similar crises in their own careers.
Although the COVID-19 pandemic has had an unconscionable impact on our society, it is important to recognize the good that has come out of it, as well. Critical structural and systemic issues in healthcare systems have been identified, novel vaccine technologies and therapeutics have been developed at a rapid pace, and public health has entered the media spotlight and is now a dinner table conversation topic.
As students in the field of medicine, our nature is to help however we can; we are drawn towards medicine because it allows us to use our scientific knowledge to alleviate suffering. Medical students across the U.S. have contributed to COVID-19 response efforts in numerous ways, including creating community health information websites, staffing COVID-19 hotlines, providing childcare and grocery services to essential workers, volunteering at testing sites, assisting in public health studies, contact tracing (including author Silverstein), and joining vaccine research efforts (including authors Klein and Muller). COVID-19 has affected every organ system and specialty in medicine, and we hope that our experience as students in these times will enable us to handle similar situations in the future, regardless of where our careers take us.
universities in the context of SARS-CoV-2. The Independent Scientific Advisory Group for Emergencies. 8/20/20.
Table 1: Medical Schools
Total Number of U.S. MD Schools | 155 |
Number of Schools Examined | 100 |
Number of Schools with School-Specific Plans | 25 |
Mandatory mask usage | 25 (100%) |
Social distancing regulations | 25 (100%) |
Enhanced disinfection techniques (responsibility of individual and by paid staff) | 25 (100%) |
Daily screening of symptoms | 19 (76%) |
COVID-19 testing of asymptomatic students | 4 (16%) |
COVID-19 testing on return to campus | 5 (20%) |
Pre-clinical option of entirely virtual vs. in-person for small group activities | 2 (8%) |
As the authors all attend an allopathic medical school and recognize that allopathic and osteopathic medical schools have different curricula and emphases, the choice was made to focus on allopathic medical programs. In order to select reopening plans to evaluate, the AAMC website was filtered for allopathic medical schools located in the United States, including territories and commonwealths, that had incoming and returning medical students arriving for the Fall 2020 semester. The 155 allopathic medical schools in the United States were listed by their full names and placed alphabetically into a “random order generator” on www.random.org/lists. School websites were analyzed for reopening plans for the Fall 2020 semester until 25 plans were identified, which occurred after 100 school websites were analyzed, indicating a yield of 25%. Due to an error collecting names from the AAMC website, the Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine was accidentally omitted from the list entered into the random order generator. On examination of that school’s website, however, no reopening plan could be found. For each school examined, “[Medical school full name] COVID-19 reopening plan” was entered into Google and then links within the school’s website were followed until a plan was found. If no plan pertaining specifically to the medical school was publicly available on a school’s website, or if the plan’s applicability to medical students was not referenced in the reopening guidelines for the larger university, the next school on the randomly generated list was substituted for analysis. The randomly generated list of allopathic medical schools is below:
(Accidentally omitted from random number generator due to similarity to #40)
Andrea L. Klein is a fourth year MD student at The George Washington University School of Medicine and Health Sciences in Washington, DC. She graduated from the University of California San Diego with honors in Biochemistry and Cell Biology, specializing in neuroscience and molecular genetics. She has published and presented extensively in neurosurgical oncology and is pursuing a career in academic neurosurgery.
Daniel J. Muller is a third-year medical student at the George Washington University School of Medicine and Health Sciences. Daniel graduated with a BA in History from Brown University in 2017 and with a Master of Philosophy degree in History and Philosophy of Science and Medicine from the University of Cambridge in 2018. He hopes to pursue a career in Infectious Disease and global health policy development, specifically focusing on improving accessibility to and quality of healthcare for underserved patient populations.
Daniel J. Muller is a third-year medical student at the George Washington University School of Medicine and Health Sciences. Daniel graduated with a BA in History from Brown University in 2017 and with a Master of Philosophy degree in History and Philosophy of Science and Medicine from the University of Cambridge in 2018. He hopes to pursue a career in Infectious Disease and global health policy development, specifically focusing on improving accessibility to and quality of healthcare for underserved patient populations.
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