Medical student engagement during COVID‐19: Lessons learned and areas for improvement

Abstract

As a consequence of the ever-changing circumstances that COVID-19 caused during the early stages of the pandemic, a large number of frontline health care workers were urgently needed in specific clinical environments, such as hospitals and Triage and Test Centers (TTCs). Some health care systems experienced short-term to mid-term staff re-structuring, re-deployment of physicians and trainees, the return of retired health care workers to frontline care, and the withdrawal of medical students from clinical encounters. The latter response included a broad range of reactions, including the indefinite postponement of bedside learning in hospitals, the transition of educational and clinical activities to virtual formats1-3 (including assessments of clinical performance4), the revision of medical curricula,5 and novel engagement of medical students on the frontlines.6 Further, many medical students actively found ways to participate in volunteerism to replace some of their lost clinical experiences.7 Throughout, it has been clear that medical students often possess inherent motivation (and clinical competence) to continue their educational and training endeavours while also contributing to frontline care.8 Recognising this, some countries decided to promote medical students to resident positions while bringing forward or even skipping the final examination.9 These, among other innovative and creative approaches, provide an important opportunity for educators to re-think how to effectively engage medical students in both didactic and clinical teaching environments. Indeed, evaluation of the myriad new pedagogical approaches is essential to help educational and clinical leaders better prepare for future public health crises, including the second wave of COVID-19 that has begun hitting many parts of the world. evaluation of the myriad new pedagogical approaches is essential to help educational and clinical leaders better prepare for future public health crises To guide current decision making, educators have looked to the 2003 SARS epidemic where medical students were similarly removed from clinical exposures in many settings.10 Important insights were gained from this crisis, including the need to protect physicians-in-training from an infectious disease by way of removal from clinical practice.11 Compared with past experiences, however, our community has recently observed an even more dramatic shift in medical student engagement with students taking on broad and multidimensional roles to help combat the educational and psychological challenges created by their removal from the clinical environment. our community has recently observed an even more dramatic shift in medical student engagement with students taking on broad and multidimensional roles to help combat the educational and psychological challenges created by their removal from the clinical environment. Through student-led initiatives to provide voluntary work in support of the efforts against COVID-19 across many countries, medical students spread their availability through social media and web platforms. They offered free child or pet care, pickups and drop-offs, and to complete errands for the elderly and/or frontline workers. They even offered more direct support for frontline health care workers by collecting and distributing personal protective equipment and coordinating community mask sewing.12 Other medical students volunteered to support frontline patient care in TTCs, on hospital wards, and in ICUs.6, 13 In Denmark, such willingness to support the frontline workforce took on new dimensions at a rapid pace.14 For example, all Aalborg University master's students volunteered on the frontlines within two weeks of the pandemic (47% worked as temporary residents, 28% as ventilator therapy assistants, and 19% as nursing assistants). Within the first week of the pandemic, over 70% of bachelor students had volunteered, with 31% working across nine pandemic emergency departments. These extraordinary examples not only highlight medical students’ readiness to engage in supporting frontline efforts to combat COVID-19, but they also remind us of just how strongly motivation drives behaviour. That is, while such anecdotes demonstrate the many opportunities educators have had to engage medical students into clinical care scenarios where they can contribute to the fight against the pandemic, they simultaneously remind us of our role as educators to create opportunities that will engage medical students in the learning they require to ensure that the strength of their contributions continues to grow. our role as educators [is] to create opportunities that will engage medical students in the learning they require to ensure that the strength of their contributions continues to grow. Even before the emergence of COVID-19, the era of competency-based medical education was prompting medical schools around the world to move away from didactic learning and towards active self- and team-directed, case-based learning.15 In part, this evolution is an effort to establish teaching practices in ways that help students remain mentally active and engaged with the material they need to learn. As the circumstances of the pandemic have amplified concerns about student well-being, medical educators have also become acutely aware of the need to help students connect with one another as education has moved increasingly to an online modality and its new emphasis on both synchronous and asynchronous virtual learning.15 This strategy does not necessarily lend itself well to promoting student engagement and, thus, has required that careful attention be paid to revising the method of content delivery. In one rich example, Durrani devised a debate-style, small group virtual learning environment that included post-debate debriefing, discussion and spaced repetition/review of content.1 This approach yielded a high level of learner engagement and enjoyment with the content material, despite the loss of opportunities to interact more naturally in a physical classroom. Throughout these transitions, we have also learned how important it is to recognise that it is not just our trainees who have experienced anxiety and, thus, have felt a need to engage meaningfully with one another. Veerapen and colleagues identified this challenge and developed a constructivist framework to train medical educators in how to promote student engagement in small group virtual sessions.2 They fostered online teaching skills by offering continuous training/support to educators in the form of pre-session, post-session, and drop-in session training. They concluded that the approach was valuable, not just because educators learned to teach online, but because they "created a sense of community and peer support", allowing educators to focus their efforts on providing engaging learning sessions instead of on the logistical minutiae of delivering virtual learning. Throughout these transitions, we have also learned how important it is to recognise that it is not just our trainees who have experienced anxiety Of course, most challenging of all has been creating opportunities for students to engage with real patients as clinical encounters are often difficult to transition to online formats. Regardless of that difficulty, such experiences remain crucial (especially during the clerkship years) to the development and practical use of clinical skills. Here, again, educators’ ingenuity has been on display as several innovative approaches have been piloted to address the concerns surrounding medical students’ loss of in-person clinical time. Chandra and colleagues, for example, implemented an educational intervention wherein senior medical students reviewed the electronic medical records of patients who had presented to the emergency department.16 They then performed virtual follow-ups, or "callbacks", under faculty supervision. While the researchers noted some logistical difficulties concerning patients’ response to the callbacks, there was generally positive feedback from participating patients, faculty, and medical students, with the latter group reporting feeling highly engaged and valued in the process. Similarly, Tsang and colleagues transitioned the traditional bedside clinical encounters of a neurology clerkship rotation to virtual "webside teaching" encounters.3 Here, through a virtual platform, medical students interacted with patients in real-time, practicing interviewing skills and directing the physical examination process through their preceptor. Discussions subsequently involved further investigations, management, and treatment plans. The researchers concluded that this intervention elicited a high level of student engagement and resulted in teaching that was "comparable to or better than [the traditional] bedside teaching". While only examples, each of these interventions represents evidence that it is possible to replace the loss of in-person clinical time with alternative modes of training that can still engage students towards achieving most of their learning objectives. We are right to remain critical as there has been intense concern surrounding how the transition to online platforms might negatively affect medical students and their acquisition of knowledge and clinical skills. In doing so, however, we must also remain open to the unintended positive outcomes that have arisen through this transition, using the increased demands of deliberate creation of innovative online formats for medical education delivery to help promote and facilitate student engagement if or when classrooms do return to a more familiar state. The solutions that have been developed will need further refinement and integration into the traditional medical curricula as modern medicine and medical education experience a progressive transition to increased telemedicine. Reflecting on the broad range of solutions that have been developed, and the continued creation and implementation of new interventions, will help us continue to learn how to engage medical students much more actively in virtual settings, both clinical and otherwise. Reflecting on the broad range of solutions that have been developed, and the continued creation and implementation of new interventions, will help us continue to learn how to engage medical students much more actively in virtual settings, both clinical and otherwise. Online tools and formats to optimise the delivery of medical education have existed for ages but are now being developed much more quickly in our field. The innovations will continue as the pandemic endures around the world. Medical schools must, therefore, be prepared to provide support for the implementation of such tools and resources while acting on students' suggestions. In doing so, we must not lose sight of the fact that it is not the technology itself that will yield the benefits of medical education, but it is the extent to which the technologies can be implemented in a way that leads our learners and faculty towards practices that most engage learners with content, peers, faculty, and patients. Becoming a physician requires a strong dedication to helping, healing, and supporting others, especially during times of crisis, which can seem difficult to complete online while not at the bedside. We must not forget that medical students, as future physicians, will work as our future colleagues, side by side with us and for our patients. Their professional identity cannot solely evolve virtually, forcing educators to provide opportunities to teach and role model in real clinical settings. This is one of the reasons that continuing to create the best conditions for volunteer and frontline services has the potential to benefit the health care system long beyond the direct impact of the work done in the current moment. Overall, we might expect to see more medical students in teaching hospitals or TTCs during a second or even third wave of COVID-19 because this is where these students belong. We dare hope for that, however, only to the extent that we can support medical students’ mental health and resilience to ensure psychological safety during all learning activities, whether online or at the bedside.