In mid-March, COVID-19 upended the traditional Yale School of Medicine (YSM) curriculum for MD students. Didactic coursework and clinical skills training had to be rapidly converted to an online format, and clinical rotations and most sub-internships (sub-Is) were suspended in the space of a few days. Decisions quickly had to be made to ensure that during the clinical suspensions students would have meaningful and robust curricular and volunteer activities available, and that they could continue to earn credit toward graduation.
Against this backdrop, students were eager to play a valuable role as the health care field, and society more broadly, confronted this global pandemic.
Within a two-week period, four “pop-up” electives related to COVID-19 were created and launched, enrolling 96 MD students and involving numerous faculty. Two more electives focused on Inpatient and Outpatient Telehealth were soon added, with a total of 39 MD students participating. Michael Schwartz, PhD, associate dean for curriculum, said there were ideas for additional electives, but with so many faculty on the COVID front lines, there was not enough time to formalize their design and find the needed faculty to teach them. Schwartz was pleased with the strong student interest in these electives. Every student who registered for an elective was able to participate, and nearly all received their first choice.
The creation of these electives sprang from an idea rising fourth-year MD student Max Jordan Nguemeni Tiako, MS, raised on March 17, in a Zoom meeting with Dean Nancy J. Brown, MD, Medical Education leadership, and over 100 YSM students.
Schwartz is grateful for the tremendous efforts of students, faculty, and staff in quickly developing and operationalizing these successful electives. He praises the student organizers for their creativity, energy, and ability to make dynamic connections across mentors and preceptors. And he points to the critical role of the Office of Education staff, who already were juggling the demands of converting the didactic curriculum to an online curriculum, noting their strong commitment to ensuring students felt fully-supported by the office in this changing landscape.
While there were a variety of learning opportunities and pedagogies used in these virtual electives, they uniformly were influenced by the pandemic, and all provided students with outstanding learning opportunities, academic credit, and a sense that they were contributing to the effort against COVID. An important ancillary benefit was providing community, during a time of social distancing and uncertainty.
Patients, Populations & Pandemics, Responding to COVID-19
Rising fourth-year YSM student, Fatima Mirza, marvels that it only took one week to develop Patients, Populations & Pandemics, Responding to COVID-19. The elective was a highly interactive opportunity for 30 students to integrate and critically evaluate evolving information about COVID-19.
Mirza was one of three student liaisons for the elective, which ran for six weeks starting on March 30, along with rising third-year MD students Muriel Solberg and Lucy Kohlenberg. Faculty course leader Saad B. Omer, MBBS, MPH, PhD, FIDSA, director, Yale Institute for Global Health, who co-taught the course with Sheela Shenoi MD, MPH, assistant professor of medicine, said “the course would not have happened without the student liaisons.”
Each Monday, students joined a 75-minute lecture on topics ranging from “Introduction to COVID-19: Zoonosis, Epidemiology, and Disease Control” in week one, to “Mental Health of Physicians, Patients, and the Community under Social Distancing” the final week, delivered by faculty directly involved in the COVID-19 response. During the week, as information on COVID was evolving, student teams selected a question based on the Monday lecture, conducted research, and prepared a presentation. Then during a two-hour session each Friday, one student from each team presented, which the remaining students teams critiqued. Each of the groups were paired early in the week to facilitate independent research in order to critically appraise the work of their classmates.
As Omer explains, “pedagogically, we focused on developing the students’ critical thinking capabilities. The course sought to have them assimilate and critically evaluate uncertain and developing information, and not only present to their peers about it, but then to defend against the evidenced-based and collegial critiques and questions their peers raise.” Shenoi believes, “the students wonderfully rose to the challenge.”
While the demands of COVID-19 made it an extremely busy time for Omer and Shenoi, Omer says “listening to the absolutely superb Friday presentations and thoughtful critiques was the best time of the week, and the time commitment was totally worth it.”
For Mirza, who has a strong interest in health communications, one of her favorite parts of the course was creating COVID-related infographics which she believes have the potential to help front-line providers and patients. (Please see the "Related Links" in the sidebar for the infographics for weeks one through six.)
Omer emphasizes universities have a responsibility to be the guardians of collective memory and courses such as this elective are one part of that effort.
Internal Medicine Outpatient Telehealth Elective
When clerkships were disrupted, several students initiated a volunteer Medical Student Task Force (MSTF), helping Yale clinicians by reaching out to patients whose care had been disrupted by Covid-19 to make sure they did not have any urgent medical or prescription needs and to relay any urgent needs to their providers or on-call faculty members.
As assistant professors Joyce Oen-Hsiao, MD, FACC and Ilana Richman, MD, the course leaders of the Internal Medicine Outpatient Telehealth Elective explain, these students “decided they wanted to learn more about the clinical aspects of telemedicine and reached out to us to start a new elective. So the idea really came from the students, and they have been instrumental in setting up the elective and shaping its content.”
Rising third-year MD student Erin Yeagle, one of the student course leaders said, “I'm very grateful to our administration for supporting us in developing this elective, and glad to have had the chance to learn from experienced telehealth providers and experts in the field about this increasingly important part of medicine.”
Oen-Hsiao and Richman jointly shared “telehealth is likely to remain a part of the health care landscape for the foreseeable future and it will be important for students to gain some skill and comfort managing patients remotely.”
The 15 students in the course learned how to conduct remote patient visits from experienced telehealth providers in online classes, and then had the opportunity to develop these skills through patient calls as part of the MSTF, supervised telehealth visits with clinicians, and simulated telehealth encounters with each other.
Oen-Hsiao and Richman describe how with telehealth, especially if there is no video, there are fewer data points, and medical professionals have to rely on how the patient is subjectively feeling rather than objective data. Yeagle describes how “it was difficult, but I think valuable, to learn how to take a history from a patient over phone or video in a conversational way. I realized just how much I had relied on nonverbal cues. My first preceptor in the elective, Dr. Jaime Gerber, really emphasized the importance of this skill, and gave me plenty of time to practice.”
Rising third-year MD student Muriel Solberg, the other student course director, said was an amazing experience. “I got to work with a cardiologist seeing patients for about four hours per week and she was always willing to debrief with me after seeing patients to give me feedback. It is unusual to get direct feedback regularly from an attending who has really watched you work with patients, so that was also a remarkable feature of the elective.”
IM Inpatient Telehealth Elective
When the COVID-19 crisis hit, Professor Mark Siegel, MD, program director, Internal Medicine (IM) Traditional Residency Program, and Chief Resident Ethan Bernstein, MD, were eager to engage students in supporting their team. They asked for student volunteers to help design a pilot for a possible elective involving remote support. Rising fourth-year MD student Fouad Chouairi and rising fifth-year MD students Lina Vadlamani, Amanda Zhou, and Isaac Freedman, who all were one week into their IM sub-I when COVID interrupted their work, raised their hands. They hoped to continue as much of their sub-i role as they could remotely and were eager to help with patient care in the COVID effort.
After four days, when it was clear the students’ involvement was beneficial to the IM team and to student learning, the pilot was converted to a two-week elective, with fifteen students registering for an initial two-week block, and seven more for a second two-week block. Students followed an intensive four days on/four days off schedule, from 6:30 am – 2:00 pm, with an option to stay on for an hour of infectious disease rounds.
Students were paired with the same resident and intern on COVID teams for the two-weeks, and their roles included writing progress notes, participating in rounds remotely, engaging with patients and their families remotely, and conducting literature reviews based on clinical questions that arose during rounds. The aim was to enable students to learn about the COVID-19 pandemic and gain experience with ICU rounding and documentation, while also reducing the workload on residents.
Chouairi, Vadlamani, Zhou, and Freedman, the student coordinators for the elective, initially were concerned how they would integrate themselves into the work flow in a way that was helpful, and not a burden, but speaker phones, Zoom, and Facetime all enabled them to integrate quite easily. “We definitely felt like we were able to help the team, for example saving a few hours a day for the residents, while at the same time having a positive educational experience,” notes Chouairi. The students were grateful to the residents who, despite being extremely busy, took time to mentor students. Chouairi describes how “the residents were so welcoming. We as students became part of the team, versus being a student who was a burden.” They specifically point to Siegel, Bernstein, Resident Sumit Kumar, MD, MPA, who helped the students establish the elective at Yale New Haven Hospital’s Saint Raphael campus, and Associate Professor Dana Dunne, MD, the course director, for their strong support.
Freedman “found the most personally impactful part of the elective was connecting with families and patients. We were a conduit for questions to the medical team and a source of comfort” when patients were isolated. Zhou echoes this: “It was such a privilege that the patients and families let us into their lives at such a critical time when the patients were very sick, and the families were so worried.”
The evolving nature of COVID-19 was both a challenge, and provided a fascinating learning experience, making the students’ research on issues critical. Vadlamani adds, “we had a unique opportunity to be engaged in a clinical setting as COVID unfolded as a pandemic. We witnessed as the understanding of how to treat COVID patients was developing and care was changing as a result.”
Emergency Management of Acute Disease Processes through Virtual Simulation
Leigh Evans, MD, associate professor of emergency medicine and executive director, Yale Center for Medical Simulation (Sim Center), explains that when YSM students suddenly could not participate in clinical rotations and most sub-Is, her team at the Sim Center felt it was important “to create an environment for them as close as possible to seeing patients,” and quickly developed this elective. The Sim Center had never offered a virtual simulation course to MD students, but it was the students picked it up quickly and the course received favorable reviews.
The Emergency Management of Acute Disease Processes through Virtual Simulation elective ran for six weeks, beginning March 30. While each student only spent 90 minutes a week at the Sim Center, this was a significant undertaking for the Center, which offered eight 90-minute blocks each week, to enable eight groups, of six students each, to participate. (The Sim Center had determined the learning experience was most effective with groups of this size.)
In the elective, students practiced management of acute disease processes through virtual case scenario simulation. Using Zoom, they engaged with Sim Center Supervisor Joy Grabow, acting as a patient, and had access to data such as CT scans, x-rays, and labs, as well as physical exam findings. Groups of three students worked together to actively manage the patient, while three other students observed and provided feedback, before switching roles. The faculty were on Zoom with the students, but simultaneously used Google Hangout among themselves, to privately discuss the scenarios. At the end of each session, an attending faculty or senior resident provided formative feedback.
Evans originally had thought the Sim Center would pull in faculty with an expertise on specific topics, but with so many faculty in the COVID-19 wards, they mostly relied on their own team, including simulation fellow Thomas Yang, MD, emergency medicine resident Samuel Buck, MD, Jessica Ray, PhD, Luis Cruz and Jeff Hoffman (simulation operations specialists) and Grabow, who beyond playing the role of the patient, coordinated the complex logistics.
The course scenarios complemented what the students would have been seeing on their clinical rotations, for example, Sepsis, Pulmonary Embolism, Diverticulitis, Burn/CO/Cyanide Toxicity, and Guillain-Barre Syndrome.
Samer Hassan, a rising third-year MD student, “found the experience very educational because a lot of the skills that made in person ED sim cases successful were also valuable in the virtual experience—clear delineation of roles, communication, and collaboration are all essential in the course of a case.” And while they could not actually practice physical examination, Hassan explains, “we were still able to demonstrate our understanding of which physical exam maneuvers were appropriate in the setting by dictating them to the acting nurse.” The Sim Center conducted a virtual presentation on the course for a 13-school consortium of peer schools, so this elective may influence curricula beyond YSM.
COVID-19 Pandemic “History of the Present”
When medical education leadership agreed with the idea of rising fourth-year MD student Max Jordan Nguemeni Tiako, MS, that YSM should create COVID-related electives, Tiako wondered if it would be possible to create an elective that contextualized the moment through studying the social sciences and history. He reached out to Joanna Radin, PhD, associate professor of history of medicine and history, and Psychiatry Resident Marco Ramos Jr., MD, PhD, whom he had worked with before, for their thoughts. Radin and Ramos were enthusiastic, and the group then reached out to professor Anna Reisman, MD, director, Program for Humanities in Medicine, and Maya Sandler, a PhD student in History of Science and History of Medicine, to form a course leadership team.
The course leaders described the COVID-19 Pandemic “History of the Present” elective as “an opportunity to engage in a ‘history of the present’ of the COVID-19 epidemic, while learning about previous epidemics and pandemics through a social science and humanistic lens.” Sixty-five students registered for the six-week course, including 16 MD students, with 24 additional auditors, drawing from the Yale Schools of Nursing and Public Health, and Yale College.
Reisman explains the course content and structure was “very organic,” with the course leaders meeting each Sunday to form their plans for the week ahead. Many of the suggested readings came from a COVID-19 open-source resource, “teach the virus,” which medical sociologist Alondra Nelson manages.
Students were required to complete a capstone project in the media of their choice reflecting on their time during COVID-19, with submissions ranging from daily TikToK videos, to a graphic novel. Students were to write and submit weekly updates about their project, but Reisman emphasizes there was no required structure for these updates, it was more a way to stay connected with the students. Reisman found the updates poignant, providing an honest record of lived experiences, such as when a nursing student working on the COVID-19 wards stated one week that she was unable to work on her project because coping with COVID-19 was all consuming.
Reisman adds that for students who are trained to always have a research question, it was an adjustment to be asked to compile personal data to document what it is like to live through the early part of a global pandemic.
Tiako states “the world felt like it was burning, and so it was really helpful to feel like I was contributing to medical education.” He appreciated both receiving positive feedback from students in the course and providing an avenue for students to receive academic credit. Moreover, coordinating the course required him to be in close contact with his co-leaders, which was “a helpful form of community.”
COVID-19 Elective on Evidence-Based Clinical Information Skills
With information about COVID-19 rapidly entering the public discourse, usually without peer review, YSM Cushing/Whitney Medical Library research and education librarians Judy Spak, MLS, Caitlin Meyer, MLS, and Courtney Brombosz, MLS, thought it was important to offer a course that, among other goals, helped students learn to critically appraise literature and exposed them to a wide set of interdisciplinary resources.
Spak, Meyer, and Brombosz pulled together the elective, COVID-19 Elective on Evidence-Based Clinical Information Skills, in just two days, but Spak explains the course content was fluid – she and her colleagues adapted the topics covered to the students' needs and projects.
The course, which began on March 30, was structured to meet for three hours a day for two weeks, with an assignment every evening. A key focus on the course was the “Four As” of evidence-based medicine: Ask, Acquire, Appraise, Apply.
Two students signed up for the course, enabling close collaboration with the librarians and a bond to form between the students, who had not met before the elective.
On the first day, the students were asked to write a narrative of why they took the course and what topic they hoped to research. Both student’s ideas changed as they dug into the research. One student planned to investigate if the rate of child abuse increased during the pandemic, but because the pandemic was just evolving, there was little literature on this topic. Recognizing that the pandemic was creating financial insecurity, the student broadened the scope to seeing if there is an increase in child abuse during difficult financial times. The second student started looking at evaluating the scientific accuracy of COVID-19 information. When she discovered there was not yet enough scientific information to answer this question, she shifted her project to whether it made sense for researchers to conduct studies on the effectiveness of Chloroquine.
Spak described the growth of the students as “phenomenal – they evolved over two weeks into much better researchers.”