For the better part of four months, most medical students were removed from direct patient interaction. The hiatus was caused by the COVID-19 pandemic and forced medical schools to consider innovative alternatives. Still, there’s no substitute for walking the wards.
As a new school year begins, many medical schools have plans in place that have led to students returning to clinical rotations, a milestone of particular import to third-year medical students. Others have plans in place that will lead to that development in the near future.
AMA guidance on a return to clinical training calls on institutions to consider several factors, including risk of exposure.
“Schools have taken a step back, and they are looking at each situation and evaluating if it is safe,” said Kimberly Lomis, MD, the AMA’s vice president for undergraduate medical education innovations. “In this clinical environment, you have to ask what’s the risk of COVID-19 exposure. Is it changing on a day-to-day basis? And then there’s the educational component. If you’re overloaded with [COVID-19 patients], what kind of bandwidth do you have?”
Factors at play for clinical training
At Oregon Health & Science University in Portland (OHSU)—students resumed clinicals in late June. With the pandemic’s spread ebbing and flowing, however, it remains uncertain if that will last throughout the school year. Whether or not students remain on the wards is a complex question. According to George Mejicano, MD, OHSU’s senior associate dean for education, OHSU is evaluating that decision on six criteria.
Clinical volume: If there aren’t enough patients to treat, there isn’t enough clinical material to cover. At OHSU, they will consider pulling students from clinicals if patient volume dips below 50% of pre-COVID-19 numbers.
Ability to meet learning objectives: The key question that educators will be asking is if conditions in the clinical environment allow students to meet the educational objectives that are the goal of clinical training.
Adequate bandwidth to supervise learners: “If all of a sudden all the cardiac surgeons are out because they contracted COVID and students were on a cardiac surgery rotation they couldn’t do it,” said Dr. Mejicano, an AMA member. “We’d have to close it down.”
Lack of available personal protective equipment (PPE): OHSU has a dashboard to monitor the availability of PPE. If certain benchmarks are not maintained there is a very limited window for the PPE supply to be replenished. If that doesn’t happen, learners will be called off clinical rotations.
Conditions at a facility: About 60% of OHSU medical students conduct clinical and elective rotations at facilities that are not on the OHSU campus, this includes venues such as the VA. “The philosophy is that we are guests in their home, Dr. Mejicano said. “So, if the homeowner basically says, ‘I can’t take you,’ out we go.”
Signs that an outbreak could overwhelm health systems: These signs include the percentage of positive tests and the number of emergency department visits by patients with COVID-19-like symptoms. If several indicators are high, an order from the state’s governor could be issued that might include restrictions on trainees.
If any of the above situations arise, they may apply to all trainees or a limited number in certain situations.
“It might be very specific,” Dr. Mejicano said. “Removal or closure could occur on a specific ward, like a cluster outbreak on a specific unit, or a specific site, like a specific clinical or hospital, or all home program or for all clinical learners. It could be any of those.”
The AMA has curated a selection of resources to assist residents, medical students and faculty during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time.