It’s science, not speculation, that will get us through this.

Why do COVID patients experience such profound hypoxia without feeling dyspneic?

Why is there such heterogeneity in clinical severity among young, previously healthy patients?

Are asymptomatic people able to carry and transmit the virus, and for how long?

Does immunity develop after infection, and how long does it persist?

Does antibody status indicate complete protection from re-infection?

Do currently available anti-viral agents have effect?

Will previous approaches to vaccine development be effective?

These are some of key questions still under investigation as we now pass 6 months since this infection originally came to attention. The answers to these questions are the keys to resolving the greatest heath and economic catastrophe the world has faced. The answers will not be provided by scientists or politicians working in isolation, but rather by the application of scientific approaches, supported by political and economic action.

This past week, we’ve seen examples of how this can work well, and how a lack of synergy will impede progress.

In Canada, our government has announced a billion dollar investment in COVID-19 medical research, and support for a Task Force to determine the extent of the disease.

In Germany, a nation-wide public health investigation has begun to carry out widespread serologic testing intended to define the true extent of disease and implications of prior infection.

(New York Times Photo from story link)

In the United Kingdom, vaccine development is well underway with massive investments already in place.

All these have come about through effective collaborations between government, funding agencies and scientific and medical communities. We’ve also seen examples of what can transpire when those collaborations are not effective. We’ve seen that, even if well intentioned, speculative assertions by a political leader can be assumed by the public to be scientifically informed and thereby lead to dangerous actions.

There has been much debate in recent years within the medical education community regarding the relevance of research and critical appraisal in undergraduate medical education. These topics have been gradually and rather insidiously receiving  decreased attention in favour of the many other competencies and “hot items” that have been emerging, all with justification. I would suggest that recent events have resolved that debate. The questions posed at the beginning of this article were not posed exclusively by basic scientists and epidemiologists, but also by clinicians trained to accurately observe patient responses, critically assess current understanding and pose valid, useful hypotheses for testing. Clinicians will also be very much involved in developing protocols and executing investigations to find answers. Medical schools have a responsibility to ensure that fundamental training continues to be a core component of their programs, now more than ever.

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“Meducators” aim to help healthcare and other essential workers’ children with 1:1 online tutoring

Editor’s Note: Medical students (and many other Queen’s Faculty of Health Sciences students) are volunteering their time during the COVID-19 pandemic in a number of different capacities. This is in addition to continuing with course work responsibilities, as much of the UGME curriculum is now being delivered online. This post highlights one of these student-led volunteer initiatives.

By Angie Salomon and Kiera Liblik (Meds 2023)

Image is logo for the project. It's a cartoon teddy bear wearing a graduation cap. Text reads Queen's U Meducators: a medical student initiative to support healthcare providers and their children during COVID-19

To hardworking healthcare professionals, and all others providing essential services to our community during COVID-19: WE WANT TO HELP!
Queen’s “Meducators” are a group of Health Sciences students at Queen’s University who want to support the educational success of students of healthcare (and other essential) workers in our community through a free, one-on-one tutor program via on-line video conferencing. Our tutors can provide informal tutoring services for children of all ages and grades (K-12) across core subjects (math, science, English, French). The service may range from simply supporting the student virtually while they complete their homework, to creating full-on lesson plans to aid their learning. If this is of interest to you or your family, please submit a request using the following link: https://forms.gle/k3mdo6cLYZtULmYF6

If you are a Health Sciences student (Medicine, Nursing or Rehabilitation Therapy) who would like to volunteer as a tutor, please sign up here: https://forms.gle/Ly8d2xmXax47iGDM7

If you have any questions, please don’t hesitate to contact Angie Salomon (asalomon@qmed.ca) or Kiera Liblik (kliblik@qmed.ca).

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Getting students back into the clinical workplace. Why? When? How?

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.

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Five tips for working and learning from home

We’re now into Week 3 of delivering our UGME curriculum (as much of it as possible, at least) via online teaching and learning as part of Queen’s response to the COVID-19 pandemic response mandates. As well, most staff are also working from home. You may still be trying to find your groove in this new configuration of teaching, learning and working without direct in-person contact with colleagues. With this in mind, I’ve begun making notes on tips for working and learning from home. Here are my initial five:

1. Negotiate your space carefully.

A view of my basement bunker office…

This is especially important if you have housemates. In some households, working-from-home space may be at a premium. In my home, there are four of us working and learning from home – my husband, my Grade 10 son, my graduate student daughter who has de-camped from McMaster, and I are competing for space in our townhouse. I’m in what I call the “basement bunker” – it’s a corner of the basement, near the foot of the stairs. It’s windowless but has everything I need: my desk, electrical outlets, and my three computers I’m using to check-in on multiple learning events. My daughter is at the opposite end of the basement, near a teeny-tiny window.

My husband got the kitchen table—he has a window and is closer to the tea kettle—but I don’t have to pack everything away for lunch and supper. My son is migrating from place to place.

2. Make friends with Zoom.

While there are multiple on-line options for course delivery and meetings, for UGME we’ve been using Zoom predominantly for courses and meetings. Like any other online platform, it has its quirks and protocols. It helps to become familiar with the key commands, like “raise hand”, share screen, chat, and how to “unmute” yourself. Remembering to use these things in a timely way is another story.

At least once per meeting, as this screen shot illustrates, I forget to “unmute” myself.

What we’ve all discovered over the last two weeks is that online is more exhausting than face-to-face. My Education team colleagues and I coined a new term – “zammed” as in “I’m zammed” meaning fatigued from back-to-back-to-back zoom session as in: “I’m zammed” in place of “I’ve done six hours of zoom today and I am SOOOO done.”) And, yes, we’ve all voiced the Brady Bunch and Hollywood Squares comparisons.

3. Look away!

In regular office work (and classrooms, too), we naturally change from focusing on “up close” versus mid and far. With so much of our work and learning lives moved online, we’ve upset this balance. To help combat screen fatigue, use the 20-20-20 rule: Every 20 minutes, take 20 seconds to look (out the window, across the room) and focus on something about 20 feet away. (To avoid looking disinterested in a Zoom meeting, turn off video before attempting the 20-20-20 exercise (see #2, above). (For more on the 20-20-20 rule, click here: https://www.healthline.com/health/eye-health/20-20-20-rule#definition)

4. Be flexible and patient with each other and with yourself.

We’re all on a pretty steep learning curve and lots of people are juggling extra responsibilities in an environment that isn’t as conducive to learning and working as our on-campus spaces are. (Not to mention our faculty who continue with clinical responsibilities, some of the front-lines with the COVID-19 response). Meetings and classes may start a couple of minutes late; somebody will have lost a link or have an old one; sharing screens may not launch exactly how we want. And everyone has forgotten that mute/unmute button at least once so far (Again, see #2). As much as possible, take things in stride. If you’re caring for children or sharing tech, you may need to reschedule how/when you do certain tasks. Our recording and posting of all learning events (as quickly as possible) is one tool we have to help with any learners who need to “time shift”.

5. Remember working from home isn’t working 24/7.  

With the line blurred between home and school/work, it can be easy to lose track of any boundaries. Make time for something besides your work/studying. I don’t mean you have to be super-productive at something like some of the memes going around—just get away from your computer and thinking about work/school at intervals. (In the first week, some nights I dreamt about zoom meetings. I woke up feeling like I’d put in overtime). Turn off your brain. Whether that’s some fluff television (insert your poison of choice here… I hear there’s something on Netflix about a tiger?), an online Zumba class, knitting, meditation, or a vicious game of Bears-versus-babies with your housemates….

What are your best tips for our new home-based curriculum? Feel free to share in the comments below.

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