Medical education is not just a program for building knowledge and skills in its recipients… it is also an experience which creates attitudes and expectations.

Abraham Flexner

It’s long been appreciated that medical education must provide much more than academic knowledge about human biology and pathology. It must also provide opportunities to observe and participate in the application of that knowledge to real people with real problems. In fact, the earliest forms consisted entirely of “on the job’ practical experience in apprenticeship-like arrangements with practicing physicians. The contemporary model of medical education incorporates the Clinical Clerkship which, since early in the twentieth century, has provided opportunities for medical students to work alongside fully qualified physicians and make active contributions to clinical care while observing, learning and advancing their skills. It has been modified considerably over the years, extending into a variety of clinical settings and incorporating embedded formal learning activities. It has proven highly effective in preparing students to both develop fundamental skills and better understand their own place in the rapidly expanding world of clinical medicine.

Until, that is, about a month ago.

As a result of the massive disruptions caused by the COVID pandemic and as reported in the last edition of this blog (https://meds.queensu.ca/ugme-blog/archives/4797), it became unavoidably necessary to pull medical students from their clinical placements. This was not because of a lack of perceived value, but because the simple logistics of maintaining safe and educationally viable experiences in the face of the stresses currently being faced by our hospitals and faculty became insurmountable. Since then, students have been undertaking an on-line, remotely delivered curriculum intended to provide learning that would normally have been undertaken in conjunction with their clinical placements. By doing so, it’s hoped they will be in a better position to complete their training within whatever time remains when clinical placements are eventually resumed.

Over the past few weeks, medical schools across the country have been almost continuously engaged in discussions to determine when and under what circumstances students will be able to re-engage this very necessary component of their education.

Why the rush?

Firstly, these clinical placements are essential components of learning and training. To undertake medical education without experiencing clinical application would be like trying to learn to play the piano without ever touching one. One might learn everything about how the instrument is constructed, how it works and the principles of music, but could never become a musician without guided, progressive application of all that knowledge.

Secondly, Clinical Clerks are able to provide useful clinical service. Although their scope of activity is obviously limited, they are able to off-load certain tasks to allow more advanced learners and fully qualified physicians more time to concentrate on more complex patient interactions and procedures, all the time observing and learning through active participation. They will also, and very importantly, learn the value and satisfaction that comes from helping provide useful  service to patients and thus further their growth as professionals.  

Thirdly, and very pragmatically, failure to graduate on time will be very damaging. Our medical schools serve our society and are expected to provide a steady infusion of trained physicians to the Canadian workforce. There will be a point at which insufficient time is available to complete degree requirements. A failure to graduate the 2021 class on time, or close to it, will result in gaps in that supply line, at a time when need is particularly urgent and is likely to continue well into the future.  In addition, overlapping with subsequent classes will put further stresses on already limited clinical training sites and have implications well into the future.

Finally, it must be recognized that the students of today will be the leaders and front-line providers of whatever health care crises face our society in the future. We must not deny them the learning that this crisis provides. There is valuable, perhaps unique, learning available to them that will shape not only their understanding, but their attitudes and personal preparedness. 

For all these reasons, much thought has been given to the “when”. In doing so, a number of principles and practical criteria have been developed.

Principle 1: Patient Safety.

Would the presence of students in the clinical environment jeopardize or promote optimal patient care?

  • Would students be able to provide valuable service by “off-loading” specific aspects of care from other providers?
  • Would students increase the risk of disease transmission?
  • Would students consume valuable PPE?

Principle 2: Student Safety.

Can students be protected from, or excluded from, excessive risk?

  • Although some small risk is inherent in any clinical placement, would students be exposed to risks considered above the “norm”, or without protections and considerations that would be reasonably expected?
  • Will students be provided with the full, minimum PPE that is suggested as required by scientific knowledge with respect to COVID-19?
  • Are there local occupational health processes in place to protect students who may be exposed to COVID-19?
  • If it is deemed essential to exclude students from some clinical situations and not others, can that exclusion be reliably achieved?
  • Do current student liability arrangements cover the current clinical environment?

Principle 3: Safety of clinical teaching faculty and hospital staff.

Would student placements jeopardize the safety or wellness of teaching faculty or other hospital staff?

  • Would students provide valuable service that would be of benefit to faculty or other providers?
  • Would students integrate into care teams as currently constituted during this crisis?

Principle 4: Learning.

Can a valuable learning experience be provided?

  • Are there sufficient roles in which students can engage?
  • Do these roles have educational value?
  • To what extent is any involvement at this time a valuable and possibly unique learning experience?

Principle 5: Supervision.

Are there sufficient clinical teaching faculty available to provide student supervision?

  • Can continuing oversight of learners be provided?
  • Can learners be assessed?
  • Are these available in all areas necessary to provide a full clerkship experience?

In terms of the “how”, criteria such as these will be continuously assessed and the current state of readiness for re-entry evaluated on an ongoing basis. It’s understood that a certain minimum time, at least a month, will be required to “on-board” students to the altered workplace. The earliest possible return is therefore always at least a month displaced from a final decision. At this point, only the most optimistic estimates would suggest a return before July.

In addition, schools are striving very hard to coordinate their efforts and synchronize both entry and graduation dates. Given the differences in curricula and clerkship structures across the country, and the differing regional impacts of COVID, it seems unlikely all schools will reach a state of preparedness at precisely the same time, but there is strong commitment to minimize discrepancies.

There is also a growing recognition that the elements of clerkship and the residency matching process are almost certainly going to be substantially altered. Discussions about the number and type of elective opportunities that will be available, and the implications for residency selection are very much “on the radar” of undergraduate programs, postgraduate programs and CaRMS, but substantive decisions must await more clarity about timing of return and graduation dates. Whatever those dates, schools all recognize the critical importance of ensuring that all graduates are provided equivalent opportunities to achieve graduation requirements and engage residency positions.

It will be important through this process to maintain full transparency and communication between schools and, critically, with our students whose lives and careers are literally “on hold”. This article is an attempt to promote that communication, which will no doubt continue across our country in the weeks and months ahead.

Stay tuned. We will get through this, together.