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August 26, 2020

The Transformational Effects of COVID-19 on Medical Education

Author Affiliations
  • 1Department of Medicine, University of California San Francisco School of Medicine
  • 2Dell Medical School, University of Texas at Austin
JAMA. 2020;324(11):1033-1034. doi:10.1001/jama.2020.14136

In 2010, a Global Independent Commission on Education of Health Professionals for the 21st Century, composed of experts in public health and health care from around the world, asserted that the purpose of health professions education was to improve the health of communities.1 The commission called for the educational institutions of health professions to design curricula to address the major causes of morbidity and mortality in their communities. The coronavirus disease 2019 (COVID-19) pandemic brought both clarity and urgency to this purpose and many academic health systems in the US have responded.2

While many will remember the COVID-19 pandemic as a source of disruption, it is likely that it will also be viewed as a catalyst for the transformation of medical education that had been brewing for the past decade. Educators across the country recognized that the physician workforce needed for the 21st century not only must embrace the enduring competencies of professionalism, service to patients, and personal accountability, but also must embrace new competencies that are better suited to addressing today’s health challenges.3 These emerging competencies include the ability to address population and public health issues; design and continuously improve health care systems; incorporate data and technology in service to patient care, research, and education; and eliminate health care disparities and discrimination in medicine.4 Across the country, medical schools have embarked on curricular redesign to ensure that the physician workforce being trained is the workforce needed.5 The pace of change has been steady but slow, constrained by concerns about balancing curricular time among the many important subject areas and legacy support for traditional courses and content.

The onset of the COVID-19 pandemic and the public health response required to minimize the catastrophic spread of the disease required an immediate change in the traditional approach to medical education and clearly amplified the need for expanding the competencies of the US physician workforce. Medical educators responded at the local and national levels to outline concerns and offer guiding principles so that academic health systems could support a robust public health response while ensuring that physician graduates are prepared to contribute to addressing current and future threats to the health of communities. While each school approached their response somewhat differently, several common themes have emerged.

Support a Robust Public Health Response to the Pandemic

Shelter-in-place orders enacted by multiple public health organizations demanded that all educational institutions eliminate large gatherings. With only days to prepare, faculty and staff shifted all didactics, discussion groups, and assessments to remote platforms. Learners were coached to serve as ambassadors for factual information about COVID-19, producing evidence reviews for clinical teams and public health leaders and preparing public service announcements in different languages for diverse communities. Electives were created to allow testing, case characterization, and contact tracing to become learning experiences while supporting the local public health response.

Adapt Curriculum to Current Issues in Real Time

The pandemic provided an opportunity for learners to realize the dynamic nature of medical knowledge and appreciate how mastery of key concepts in human biology, sociology, psychology, and systems science are essential for physicians to respond to a novel threat to human health. Students were immersed in institutional learning experiences, demonstrating the commitment that physicians make to lifelong learning. Town halls led by basic, clinical, and translational scientists; epidemiologists and public health officials; and health systems leaders and frontline clinicians demonstrated to students how physicians with diverse skill sets and different disciplinary lenses come together to solve complex health care problems. Faculty used foundational knowledge in psychology, sociology, and humanities to analyze ethical challenges in rationing care; professionalism challenges of caring for patients during a pandemic; sociologic challenges of homelessness, food insecurity, and poor access to health care for many populations; and policy challenges of restriction of personal autonomy.

Graduate a Class of Well-Prepared Physicians Each Year, on Time and Without Lowering Standards

A particularly challenging aspect of education during the pandemic was the substantial restriction of clinical learning experiences for medical students. Given the shortage of personal protective equipment, limited COVID-19 testing abilities, and uncertainty about how easily the virus could be spread, medical schools were reluctant to engage learners in care of patients with or suspected of having COVID-19. Further complicating the issue was the decline in numbers of patients seeking care for conditions other than COVID-19. Faculty and residents, coping with patient surges and novel care delivery methods such as telemedicine, had limited bandwidth for supervising medical students.

These restrictions on the usual medical education model of clinical workplace learning required medical educators to outline priorities for the limited clinical learning experiences and design different approaches to competency attainment. Guided by their established graduation competencies, schools prioritized clinical learning experiences for those students close to graduation, ensuring adequate preparation of the 2020 intern workforce. Some schools graduated students early so they could join the workforce.6

In the absence of sufficient clinical learning sites, medical educators redesigned core clerkships to allow students to continue to advance their clinical knowledge through faculty-guided, remote learning strategies involving didactics, case conferences, and, in some instances, participation in videoconferences of inpatient and outpatient encounters. The pedagogical principles of competency-based, time variable education were quickly operationalized to enable schools to shorten traditional time-bound block clerkships without lowering performance standards.7

Protect Limited Educational Resources and Treat Learners Equitably

Geographically variable travel and quarantine restrictions along with institutional challenges in identifying sufficient clinical training sites for their own students led many schools to suspend their usual practice of offering visiting rotations for senior students. The inconsistent availability of visiting rotations presented a threat to equity in residency selection because residency programs frequently use these rotations as an element in their selection process. In response, educators from across the country recommended that residency programs forgo the use of visiting rotations to select candidates for this residency cycle. The Coalition for Physician Accountability provided important support for this recommendation.8

Engage in Crisis Communication and Active Change Leadership

Principled decision-making, change leadership, and crisis communication were essential to the educational response to the pandemic. Educational leaders, like their health systems counterparts, opened command centers to bring together experts on a daily basis to respond to the shifting environment, often working in concert with other health professions schools to share learning resources. Many schools held daily learner town halls in the early phase of the pandemic and regularly thereafter, using frameworks such as the Centers for Disease Control and Prevention’s Crisis and Emergency Risk Communication approach to provide up-to-the-minute information (competency and expertise), acknowledge uncertainty (honesty and openness), demonstrate concern for the emotional stress of the situation (empathy and caring), and reassure all that people were working on their behalf (commitment and dedication).9

Professional organizations, accrediting bodies, licensing boards, and government agencies were important partners to medical schools during this pandemic response. Public health departments allowed health care institutions to define senior students as essential so that they could complete their rotations and graduate on time. The Liaison Committee on Medical Education accommodated changes in instructional methods as long as competency standards remained unchanged. State governments used regulatory statutes to enable early medical school graduates to work temporarily in the COVID-19 responses. Specialty societies supported decisions about visiting rotations and virtual interviews. The Association of American Medical Colleges issued national guidance documents reminding schools of the need to protect students from unreasonable personal risk and coercion but supporting deans of medical schools to make decisions based on their understanding of local circumstances and needs.

Despite the disruption of the pandemic, medical students not only continued to learn but, in many circumstances, accelerated their attainment of the types of competencies that 21st-century physicians must master to meet this pandemic and address other complex problems in health and health care. In supporting learning during these times, schools and learners pilot tested new methods of instruction, rethought their approach to assessment, identified different methods to build community, and adopted new strategies for recruitment and admission in a travel-constricted world. All of these new approaches have the potential to catalyze the modernization of US medical education that is underway, with faculty, learners, and staff increasingly recognizing that new approaches may be better than the old (eTable in the Supplement).

Decades from now, a student may ask, “Where were you in the pandemic of 2020? What was it like? What did you learn?” Students today will be able to answer that they were not on the sidelines but rather a part of the response when the medical profession proved its worth to a struggling country and learned so much about how to rise up and reach new levels of caring. These formative lessons are likely to be even more important and influential to today’s medical students than they have been to the rest of the profession. There may be no better time in history to learn what it means to be a physician.

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Article Information

Corresponding Author: Catherine R. Lucey, MD, Department of Medicine, University of California San Francisco School of Medicine, 533 Parnassus Ave, Ste U-80, San Francisco, CA 94118 (Catherine.Lucey@ucsf.edu).

Published Online: August 26, 2020. doi:10.1001/jama.2020.14136

Conflict of Interest Disclosures: Dr Lucey reported serving as the site principal investigator for a Kern Family Foundation grant to the Medical College of Wisconsin for the Transformation of Medical Education. No other disclosures were reported.

References
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Frenk  J, Chen  L, Bhutta  ZA,  et al.  Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.   Lancet. 2010;376(9756):1923-1958. doi:10.1016/S0140-6736(10)61854-5 PubMedGoogle ScholarCrossref
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Berwick  DM, Finkelstein  JA.  Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new “public interest.”   Acad Med. 2010;85(9)(suppl):S56-S65. doi:10.1097/ACM.0b013e3181ead779 PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    Transforming medical education
    Niharika Vinayek, MBBS, MD, DGO | University of Maryland School of Medicine
    I appreciated this very thoughtful article by Dr Lucey and colleagues!

    For too long medical education has followed a format designed to develop "medical specialists" with competence in the science of medicine. The COVID-19 pandemic has provided the ultimate opportunity to disrupt all prior curricula to create a new curriculum that has the adaptive capabilities necessary to become a physician of tomorrow. This curriculum would be delivered in person, online, adapt to future learning formats, and contain science and elements of medicine of the future. As unusual and unexpected biologic emergencies appear, there is a need for a physician
    who can step up to lead public health, and to deliver coordinated care that addresses the very basic needs of a patient- in their homes, via telehealth, in person, or in future formats that are not known yet.

    There is a need to recognize and to reward primary care as an essential building block of our medical system, a natural fit in the public health-primary care partnership, a leader in population health, to drive the solutions that elevate the health of the public. There is a need to recognize and temper the hospital-centric educational model, to embrace the community as a driver in the health care spectrum, and a consumer of health care professionals, specifically physicians. The hospital-centric model is fundamentally flawed with its focus on the ill patient, and the lack of focus on the well patient where there are a multitude of opportunities to improve health. There is a fundamental need to recognize that educators such as myself who have taught generations of medical students are stewards of the past, with limited expertise in sheperding the future medical curriculum to its final adaptive form. The transformed curriculum must be driven not only by the needs of today, and be shaped by the old stewards and the new generation, but contain the adaptive reserve for challenges that tomorrow will bring.

    A vision of such a student may be one who is a master of adaptive learning, a competent physician who specialises in the patient, and knows how to engage and lead diverse entities in the Communities of Care of the future. I look forward to a future new curriculum that is formatted by physicians, students and patients to truly transform medical education as we know it, to create the physician of tomorrow who is a life-saving 'hero', and a leader in the Communities of Care.

    Niharika Khanna, MBBS, MD, DGO
    Professor Family and Community Medicine
    University of Maryland School of Medicine
    CONFLICT OF INTEREST: None Reported
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    "Better Prepared to Serve the Needs of the Population"
    Peter Plantes, M.D. | hc1 - Physician Executive
    My compliments on your JAMA article about the impact of COVID-19 pandemic on medical education. This article will be referenced in the history books a hundred years from now when they are trying to understand, "What was it like during the COVID-19 pandemic?"

    For a senior physician like myself, I wonder how medical schools can mix the new ways of learning via technology with enough of the traditional "apprenticeship" approach to create the magic of an effective medical education. I was trained at University of Pennsylvania (MD '82) where we were on clinical rotations by the 3rd
    month of our 2nd year and personal computers were the size of a large suitcase.

    All of society has been asked to learn a lot about epidemiology and population management. It is good to know this Pandemic has had at least one positive side effect, which is to motivate more relevant education of those in medical training to the needs of the population they will serve throughout their careers.

    Peter J Plantes, MD
    (817) 946.3751
    Physician Executive @ hc1
    PeterPlantesMD@Gmail.com

    https://www.linkedin.com/in/peterplantesmd
    CONFLICT OF INTEREST: None Reported
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    Where have all the internists gone?
    Charles Beauchamp, MD | Private Practice
    During the pandemic, we have been bedazzled by epidemiologists whose brightness blinds us and whose voice chanting "lockdown" "lockdown" "lockdown" deafens our pathophysiological understandings.

    Three major deficits in medical education must be resuscitated:

    1) Pathophysiological reasoning
    2) Clinical diagnosis to facilitate early diagnosis and treatment in course of disease
    3) Empirical, cost-beneficial therapy based, in part, on extensive review of the peer reviewed literature and extrapolation from astute awareness of pathophysiology

    We general internists have blown the opportunity to take a lead in caring astutely for pandemic-stricken patients early in their course, thereby causing unnecessary hospitalizations and
    intubations. We do not need one million ventilators. We need to act with warp speed early in the course. And we will need much more than a vaccine that prevents but does not affect transmission to get ourselves out of the horrible predicament we now find ourselves in the USA.

    Medical schools should not pander to a poorly managed pandemic. They should enhance the means of doing national comparative effectiveness studies in primary care with general internist leadership so we are much better prepared for this and the next pandemic. We should have learned from SARS, but did not. We should have understood what unites the unholy three: diabetes, obesity, cardiovascular disease, but did not. We should have understood pathophysiology from past studies of acute lung injury in humans and animals, but did not. We should have eschewed simplistic explanations like "cytokine storm", but did not. Is our motto, "Yes, we can" or "No, we can't"?

    In poor rural areas where I practice, only Direct Primary Care with profiteers and bureaucrats kicked to the curb, community-up control of care monitoring and subscription-financed and value-focused care devoid of outsider "uber-management" will ensure economically viable, universal, excellent care.

    There are provisions for activation of Direct Primary Care in the ACA with "wrap-around" catastrophic care insurance coverage by competing, multi-state MUTUAL Insurance Companies, financed by progressively subsidized HSAs with tax free in and tax free out potential of savings (via association with a well run HSA Bank) given a pro-health consciousness born at birth out of self, family and community economic joint-interest and "disimpaction" of partisan politics obstipation.

    The battle cry should be: ACTIVATE the DPC provisions of the ACA, NOW!

    Then recruit medical students from the community to which they want to go and practice. Teach them how to adhere to the maxim: "What this patient needs is a doctor who is also a scientist!" Support them in practice with a national policy of HIT-supported comparative effectiveness studies in primary care with medical school coordination.
    CONFLICT OF INTEREST: None Reported
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