Salient lessons: How medical schools are adapting to the ‘new normal’

Catherine Reilly reports on medical schools’ preparations in resuming their degree programmes amid Covid-19

The safe return of education has been a major national talking point over recent weeks and months.

Within this sector, Ireland’s six medical schools are facing unique challenges in resuming their degree programmes. Clinical placements, group-based learning, and close observation of professional formation are all imperative to medical training and future safe practice, with much of this required in-person.

In spring, clinical placements on HSE sites were suspended as part of the Covid-19 crisis response. According to a HSE document last updated on 17 August, the Executive will facilitate “essential clinical placements” for all healthcare students once specific infection prevention and control guidance is followed.

The range of requirements on educational institutions include, but are not limited to: Providing an assurance that the unsupervised presence of students in clinical areas is avoided or limited and very carefully controlled; that all students have had appropriate infection prevention and control training in advance of clinical placement; and that a process is in place for students to make a declaration they are free of key symptoms of Covid-19 each day immediately before or when they present for placement
Generally, the number of people present at a bedside teaching session should be no more than five, excluding the patient and any accompanying person (four students with one teacher/educator).

Routine testing of asymptomatic students for Covid-19 before moving from one clinical placement to another is not currently recommended, but a Covid-19 healthcare worker relocation self-risk assessment does apply in cases where the student is reassigned from one institution/service to another on completion of the placement.

Preparations

Prof Deirdre McGrath, Head of the University of Limerick (UL) School of Medicine, told the Medical Independent (MI) its staff have been working assiduously for months to ensure students are prepared to return safely to the campus and clinical sites. This has included the development by UL of tailored online modules. The graduate entry medicine programme at UL is four years in duration, with the first two years campus-focused.

The curriculum retains the same learning outcomes and maintains the standards required by the Medical Council, emphasised Prof McGrath. But the mode and nature of delivery must change in some instances.

Separately, the Medical Council said it has been exploring the feasibility of running online accreditations of medical schools during Covid-19 restrictions, with a view to conducting physical, on-site inspections at a later date, when safe to do so, in accordance with Government guidelines.

“Any teaching that can be done online is being done online and it is being done in block for the clinical training years,” said Prof McGrath, who confirmed third and fourth years commenced on 17 August. “So what will happen is the students essentially will go into their clinical placement in the morning, they will do their supervised sessions with their clinical team, they will have their bedside teaching if that needs to be done… and then they will leave the hospital site and do their online teaching in the afternoon.

“We are very much focused on simulation as well, as that can allow us maybe to move some of that clinical teaching into a more sheltered and protected environment within a clinical teaching site, but away from patients.”

Clinical exposure

However, Prof McGrath emphasised that clinical exposure to patients is absolutely essential for medical students. “There is still a need for students to have that experience of putting a hand on a patient, feeling an abdomen. You can listen to sounds on an audiolink, but it really isn’t the same as listening to a real patient…They have to listen to normal chests or have to examine normal abdomens in order to be able to appreciate what is abnormal as well.”

She continued: “It is very much a structured learning environment with an emphasis on optimising their time with patients, and then obviously, any teaching that can be done online is done in an online setting. To be honest, we have been very fortunate – we are a young medical school, we have a very dynamic team, and even people who might traditionally have been ‘diehards’ and very unsure about moving into an online setting have done so, because of the nature of the crisis we have been faced with.”

Most UL degree programmes are resuming from late September, but the medical programme has started earlier. “Medicine is a bit different in the sense it is a professional degree programme and because of that we are required by the regulator, the Medical Council, to ensure not only do they have the knowledge, but they have the attitudes and behaviours that are necessary to function safely and competently in clinical practice,” explained Prof McGrath, who is a Consultant in Respiratory Medicine.

“So in that respect, we were very aware of the need to observe our students on a regular basis and bringing them in one week out of every few weeks wasn’t really going to be sufficient. So we actually put a proposal to our university with schedules based on social distancing requirements and the public health guidance to ensure the safe return of students and to bring them back on a more regular basis on campus.

“Our [first and second year] students are due to start on 31 August and that was approved by the university and by our health and safety team and space management committee within the university.

“Obviously space is an issue for all universities, not only within the campus but on clinical sites. Because again, tutorial rooms that might traditionally have housed nine or 10 students now can only take three, with a tutor. So we have to do that very carefully, but we have managed to schedule it, thanks to a fantastic team.”

Looking ahead

While there are contingency plans, Prof McGrath anticipates challenges ahead. She said all universities face issues around resources, while teaching space will be at a premium in clinical sites. In autumn/winter there will likely be increased staff absences due to illnesses suspected as Covid-19. “I think this is going to be a problem because we have been told to redeploy staff into those spaces, but in medicine it is somewhat different because specific areas require specific expertise. So if someone is missing in paediatrics, someone from medicine or surgery can’t necessarily cover the teaching.”

Meanwhile, Prof McGrath said the increase in intern places in 2020 due to the Covid-19 crisis had greatly benefited students and the regional healthcare system. “We were delighted with the uplift,” she said, “what we would love to see is that uplift maintained.”

Students’ view

Speaking to MI on 24 August, Mr Derry O’Flynn of the Association of Medical Students Ireland said there was concern among medical students that clinical exposure may be significantly reduced. There were also mixed experiences of communications from the medical schools, according to Mr O’Flynn, with some students reporting a lack of clarity about what lay ahead in terms of placements, online teaching, and assessment.

Some students felt they were going into final year “at a disadvantage” due to the disruption caused by Covid-19 in the spring and cancellation of overseas summer electives. Students have faced the demands of catching up, while preparing for the new year.

For final-year students like Mr O’Flynn, there was an acute awareness that they will be entering clinical practice by July 2021, if not earlier. “There is no ‘plan B’ for next July, we have to be ready by then,” he said. “And I think that is what the colleges are focusing on – what is the best way to get us to that position where we can start in July or before July.”

The journey through medical school is not easy at the best of times, said Mr O’Flynn, and the circumstances around Covid-19 represent another “hurdle” that he feels medical students will rise to.

“The colleges’ communication must be, and will be I am sure, up front and very quick; that will aid in our year ahead.”

Ms Claire Stenson is an IMO member and a class rep for final-year medicine at the RCSI. Over recent months, students have voiced a number of concerns, such as whether there will be a compromise on clinical teaching and less access to a full range of placements. There has also been anxiety about how effective online teaching will be compared to in-person tuition.
“We actually have already started with online teaching and that was brought forward a month. So far… we have not found a compromise at all in our teaching, our small group tutorials,” said Ms Stenson.

“More so than ever I think we feel a part of the team – we have clinical lectures and we have consultants emailing us about different things, which we might not have got before [although] we don’t know as we have never been in final year before. That was one of our biggest concerns, but so far, so good. We have been reassured that we won’t be compromised on placements as well.”

There are also particular protocols in place for students who are considered high-risk in regard to Covid-19, she confirmed. In addition, Ms Stenson said the students themselves have discussed the importance of complying with national guidance and this has also been communicated by the RCSI.

Nevertheless, there is still a degree of worry among students about the potential for unexpected developments that may affect placements and exams. “I am hopeful the contingency plan will cover every possible outcome and we have been given some insight into what those plans are if things were going to change. But because we are going into final year, we are going to be working as doctors in a matter of months so the closer we get to graduating the more concerned [we are] that you might not get the skills or might not get the exposure… but we have been reassured those things won’t happen.”

Last spring, the class above Ms Stenson’s graduated early in extraordinary circumstances as the Covid-19 crisis rapidly unfolded. “That was, in a way, scary and I remember them saying to us, ‘you might think this has really affected us, but it will actually affect you guys coming up next after us the most’. I am seeing that now, because obviously we have online teaching, we had to do our exams online and things like that, and it worked, it was just a case of adapting to that.”

Adapting to evolving circumstances will be part of life as a doctor, noted Ms Stenson. “Not many doctors can say they were on placement during a global pandemic… as students we feel we can learn a lot and go out and be better doctors hopefully.”