The COVID-19 pandemic was—and remains—a source of disruption to healthcare delivery and education. But this wide-spread disruption, which has affected students in classrooms and on clerkships alike, will likely become the catalyst to accelerate the transformation of medical education. To find out more about the impact of COVID-19 on medical education, healthcare delivery and the doctor-patient relationship, MEDICUS spoke with two experts—Professor Trudie Roberts, Professor of Medical Education at the University of Leeds and past President of the Associate of Medical Educators in Europe, and Professor Ian Curran, Vice-Dean for Education at Duke-NUS and Fellow of the Academy of the US Society for Simulation in Healthcare.
MEDICUS: Last year saw an unprecedented disruption to medical education. What challenges and opportunities emerged from this period of disruption?
Trudie Roberts: The biggest impact has been on the clinical experience and how to cope with that because, suddenly [in the UK], we were faced with a government lockdown and increased pressure on clinicians. It took innovation and ingenuity to get the balance right between keeping students safe, enabling them to do the best they can on the wards and making sure they—especially the more junior ones—didn’t get in the way of other healthcare professionals who were very busy.
Also, of course, medical students faced what all students faced—no on-campus teaching. We all had to move online, which presented another learning curve for both students and staff.
Ian Curran: Our teaching faculty were very creative and innovative. We tried to do just about everything virtually, including e-tutorials and e-ward rounds. Some things worked, like e-ward rounds. We even tried e-clerking, whereby clinicians would give patients iPads and then the patients would be clerked through the iPad by the students remotely on another iPad. But because of various practical, educational and professional challenges—not everything we tried worked out as we had hoped.
We found that TeamLEAD, our team-based learning method, which is a very interactive, small group-based educational pedagogy, converted well to a Zoom-based format.
Ultimately, however, healthcare professionals learn by doing. They need contact with real patients and supervision and support by other real professionals. Our challenge was how to do that safely. By mitigating the risks carefully, we, cautiously and safely, reintroduced final-year students into clinical practice just over two months after clinical training was suspended in Singapore due to the pandemic restrictions.
During that difficult time, we also conducted our ‘Finals’ in a safe, effective and robust way. I am grateful that our clinical colleagues (from the SingHealth Duke-NUS Academic Medical Centre or AMC) prioritised this important event, even amidst the height of the pandemic, with support and guidance from the Ministry of Health. As a School, we felt it was important to demonstrate that our students had met the required standards to graduate and join the medical workforce. It was, therefore, very important that we retained the reliability and validity of these high-stakes assessments and honour our students, achievements in this unique rite of passage into the medical profession.
Trudie Roberts: I don’t give out praise very easily, but I do think that Ian and his team have done an absolutely wonderful job with the assessments at Duke-NUS. It’s very influential work, and I don’t underestimate the amount of work that was needed to pull that off. What they have managed to do not only benefits patients in the first instance, employers and the School’s reputation, but also students themselves because it gives them the confidence in performing those clinical skills.
MEDICUS: Technology has played a big role during this pandemic. How would you assess its future potential?
Trudie Roberts: We saw some amazing innovation. Now, it will be important to see which bits of these innovations can continue to be additional resources rather than replace face-to-face teaching. Something like an e-ward round, for example, will never take the place of actually seeing that, but it could help prepare students so that before they go, they’ve got an idea of what to expect and can, therefore, take part better because clinical interactions are such precious learning opportunities.
The pandemic has also forced us to use more technology and at a much faster rate than perhaps we would have otherwise. But maybe in the future, there should be a mixture of online and in-person teaching so that we can retain face-to-face interaction and contact, which is so important.
Ian Curran: With this pandemic, large parts of the healthcare system moved almost overnight to teleconsulting. We’ve had to develop packages of learning around [this skill] very quickly over the last year. Some unique and technical challenges needed to be aired and discussed, including the fact that you won’t see the full patient in front of you—in the end, there is no real substitute for real patient contact.
We should be very clear that we should use technology to save time, so that we can spend more time [with patients]. That’s the challenge because, often, you’ll get people in the vanguard who seek to convert everything and one of the dangers is that you lose the things that are important without properly understanding the value of what you are losing until it is too late or gone.
MEDICUS: The pandemic has accelerated change in many sectors, including in healthcare. How will the relationship between doctor and patient change as a result of this?
Trudie Roberts: I think it has to evolve into a partnership between doctors, nurses, therapists and the patient because we’ve got to get away from patients waiting until they get ill. We do need to help patients help themselves. Some people who are in the biggest need have challenging lives, so it is much more about advocating for patients to be partners. We have to also recognise that when patients are very vulnerable, then that partnership will be difficult but we still need to support them through that.
You can also see doctors’ changing role in new groups like doctors for climate change, doctors for social change. Medicine is becoming a much bigger discipline. It’s not just when I go into work that I see the disease and I teach the disease. It’s about how can I play a responsible role to help to improve society in general.
Ian Curran: Absolutely. Doctors have evolved from someone who diagnoses diseases to a disease manager and now we’re talking ever more about becoming disease preventers. Our students will not only be the clinician, they will be the health coach, they’ll be the clinical system navigator. And the best way to equip our students to do that is to give them the flexibility and the adaptive capabilities that will enable them to keep reinventing themselves as healthcare advances.
There's another upstream aspect, which Trudie touched upon earlier, which is the increasing role of doctors as change agents, so health activists, health journalists, politicians and policymakers. Some of our graduates are already going into this space. Further, if you look at the modern phenomenon of ‘fake news’ and internet disinformation, having the ability of doctors to communicate effectively in the media to the broader public in ways that are accessible is going to be vital for landing public health messages.
MEDICUS: What is your biggest concern as we look to move beyond this pandemic?
Ian Curran: We’re seeing significant challenges in terms of wellbeing and mental health among students as well as staff and others. We’ve ramped up our student and staff support significantly and we still think it is probably not enough. So, I do worry about the longer-term impact of the pandemic on our wellbeing. We’ve weathered the acute crisis reasonably well as a School. We’ve flexed, adapted, pioneered and innovated. But going forward, I think we have to be mindful that there’s going to be a significant ongoing challenge around ensuring student wellbeing, support for faculty and generally, fostering support and wellbeing throughout healthcare and society as a whole. We have to acknowledge that we have all been through a very difficult and exceptionally challenging time.
Trudie Roberts: We need to be careful that this group of graduates and beyond won’t become known as the lost COVID tribe. It brings into sharp focus that, in medicine, you don’t stop learning after you graduate. Colleagues in the workplace and postgraduate education need to be sensitive to and aware of, the fact that some of these students might feel less confident about certain areas. We have to acknowledge that this has happened and, now, we need to put things in place to support them for the long term.
MEDICUS: So, how will medical education evolve from here?
Trudie Roberts: I’d be very happy if I were 20 years younger and setting out again because I think there’s going to be a revolution in education and it will be about personalisation. Even in normal times, we learn at different rates, different levels. With technology, we can look at actual personalised education. In Leeds, we’ve been wanting to give each student a comprehensive learner profile to help them track their progress. If we can give them that data to show their trajectory, then this will help them enjoy learning much more. It will also help us spot those people who are plateauing off. Often this can be because of a personal crisis. Then we can intervene much earlier on rather than see these individuals crash and burn in an exam.
And healthcare delivery, too, is going to change dramatically. For example, how should we teach, say, anatomy in the future, should we be teaching surgical anatomy and robotics? In Leeds, we’re now looking at how to integrate patients’ wearable technology into the clinical consultation without staring at the screen the whole time. But if you've got a lot of information, how do you integrate all that data? And getting students to understand that the data is not the truth necessarily. If an 83-year-old lady who has had a hip replacement walks 10,000 steps, that’s fantastic. But if that’s a top-level athlete who’s had Epstein-Barr virus, that’s not good. You’ve got to see the data in the context of the patient.
As described by Andreas Schleicher at the OECD (Organisation for Economic Co-operation and Development), our challenge is that we’re trying to produce students for conditions that we don’t know yet, for jobs that are not yet defined and to use technologies that have not yet been invented. And that’s difficult but exciting. So, the challenge for us is to look at what new things need to come in or out of the curriculum.
Ian Curran: I do think it’s going to require some brave decisions in terms of refocusing on what we prioritise in our curricula. It’s about getting that balance right between imparting knowledge, developing technical and clinical skills and capabilities whilst also developing and maturing [the students’] personal and professional identity. If students can drive their own learning, work within their capabilities and understand how to seek additional information so that they’re always current and safe in their practice, then that is a beautifully, inherently safe, high-performing professional you’ve created. To achieve this, we have to focus on the important adaptive and flexible generic capabilities that allow professionals to constantly learn, relearn and unlearn and so be able to keep themselves up to date and current.
With technology, we can present learning in a range of ways. We have to chart and monitor that learning, something that we’ve tried with our new portfolio and learning management systems, introduced last year. This has allowed us to better monitor the progress of our students in their knowledge or clinical skills, but also other aspects of their personal and professional journey.
If you look at other high-performing, safety-critical industries, like aviation: flight crews come and work together effectively (even if they have never worked together before) because of a set of common, consistent rules. We’re importing a lot of this into healthcare, but we need to do more. Situational awareness, the ability to make decisions in a time-sensitive and time-pressured way, the ability to communicate and negotiate effectively—all of these high-level, high-value, generic professional capabilities are really what should be front and centre when considering how we produce safe, competent and capable doctors.
MEDICUS: How do you feel about the future?
Trudie Roberts: I think that when we look at [this pandemic] decades later, it’ll stand out as a very exciting time, a moment when we were pushed into doing things that perhaps would have taken much longer. I hope that coming out of this pandemic, people become kinder to each other, and for my younger colleagues who will shape the future of medical education, it’s a really, really exciting time and I’m envious of them.
Ian Curran: I’m an eternal optimist, so I’m going to say that COVID-19 has been a unique and distinct challenge, perhaps a generational challenge for us, and as with most challenges, they make you stronger as you move forward.
MEDICUS: Thank you both for your time.