Medical Education continues in face of COVID-19

For more than a week after March 10, when the university asked students to stay home after the spring break, Michael Schwartz, PhD, was working 14-hour days and on weekends, scrambling to adjust medical education to the novel coronavirus pandemic. As associate dean for curriculum, he has been overseeing the training of over a hundred of faculty at the School of Medicine to teach online, as well as dealing with other issues that emerge when students can’t gather on campus.

With the virus accelerating, and schools and businesses shutting down across the country, plans changed almost daily. Students throughout Yale University were first asked to stay away until early April, then through the semester. Access to research labs was initially curtailed, then all non-critical research was suspended, effective March 20, with exceptions for essential maintenance, certain clinical research, and research addressing the coronavirus.

“You have a plan, and the plan changes a day later,” Schwartz said. “You communicate to everybody, this is what they’re going to do, they set it up, the next day we find out something different and it changes everything.”

It’s a rolling target. Yale, along with the entire world, faces a pandemic unseen since the flu of 1918. States and cities are asking people to stay home except to buy groceries, visit their doctors, or perform essential chores, and gatherings of people are limited to 10 or fewer. At Yale, conferences and meetings have been cancelled or postponed. The annual Match Day celebration in the Harkness ballroom became a virtual party, and the university has cancelled Commencement ceremonies. Medical and graduate students have shut down their experiments. Medical and PA students have been pulled from clinical clerkships and are working with faculty online to advance their studies in other ways for eight weeks. First-year students don’t know how they can line up summer research projects. Medical and PA students can no longer travel abroad for foreign clerkships, including a week-long elective in the Dominican Republic during spring break. Programs that bring students to Yale from other medical schools, both foreign and domestic, have also shut down.

On the bright side, said Schwartz, “there’s a community of students and faculty that are looking out for the best interests of all their colleagues.”

The challenge is to maintain some sense of normalcy and keep things moving at a time when things change on a day’s notice and there are few answers. How long must we stay at home? When can we return to work or our studies? Will our research projects be stalled? How can we make up lost lessons? And, for those in the medical community, there’s a growing concern for frontline health care providers who lack adequate protective gear and diagnostic tests.

In crafting plans to deal with the repercussions of the pandemic, the medical school faculty recognizes that, for medical students, no one size fits all. In their three pre-clerkship semesters, students learn largely in classrooms and lecture halls, and during summer research projects. In their clerkship years, students round at hospitals. Students taking a fifth year or studying in the MD-PhD program run experiments in labs. “All require different responses and decision processes that require different groups of administrators,” Schwartz said.

In addition, the medical school is home to hundreds of graduate students and 80 students in the Physician Associate Program, who are also affected by decisions that the university acknowledges can lead to “hardships.”

The task that had Schwartz and his staff working nonstop was working with faculty to develop online alternatives to lessons in the classrooms and lecture halls. Medical students in the three pre-clerkship semesters can now listen to lectures and attend classes online—the Office of Education has posted podcasts of lectures from the previous academic year and is training faculty to hold online workshops and lectures.

Starting on March 16, clinical clerkships had been suspended for eight weeks, except for sub-internships for advanced students. “After eight weeks, we’ll have to reassess. We’re still in a crisis,” said Nancy R. Angoff, MPH ’83, MD ’90, HS ’93, associate dean for student affairs. She and Schwartz are also looking for a way to recoup those eight weeks without adding to the time students spend in medical school. “We would like to do it so that it doesn’t lead to anyone having to extend medical school or be forced into taking a fifth year if they don’t want to,” said Angoff.

Working with Dean Nancy J. Brown, MD, the Jean and David W. Wallace Dean of Medicine, and the C.N.H. Long Professor of Internal Medicine, they suspended the clerkships because the educational objectives of the clerkships could not be met, with students excluded from some practice sites and the people responsible for teaching and supervising pulled elsewhere. In addition, there has not been enough personal protective equipment to go around, and it needed to be conserved for those in critical care positions. “We came to the conclusion that for the safety of the students and to maintain the quality of patient care,” Schwartz said, “we would remove them.”

Students in the clerkships pushed back on a plan to have them use those eight weeks to study for Step 1 of the United States Medical Licensing Examination, commonly known as the boards. They pointed out that many of the national centers that administer the tests have closed and there’d be competition for the remaining slots. And many students have lost their usual places to study, like libraries and coffee shops, as well as places to relieve stress, like gyms.

“With all the anxiety and stress, and while there are other things that we could be doing, such as providing support to our families or our communities, many in the class would not feel prepared to take Step 1 at this time,” said Jack Tang, a co-president of the Class of 2022.

The medical school administration is also offering alternative ways to spend the time. The Office of Education was able to work with faculty to create four new electives focused on case based simulations and COVID-19. This has allowed the clerkship and post clerkship students to utilize the weeks of the suspension to complete elective credits that will be needed to keep their graduation plans on track The Office of Student Affairs has posted an online spreadsheet with volunteering opportunities. So far more than 60 students have offered to baby-sit for clinicians working in Yale New Haven Hospital, said Tang. Other students are scouting out alternative sources of protective face masks, grocery shopping for patients who cannot get out, and making phone calls to patients to find out if they have medical problems that need attention or medications that need refills. Like most students, he said, he’ll be using his time to study and volunteer, but he’s also spending this time reconnecting with loved ones and working on hobbies that are crucial to maintaining wellbeing.

Tang lives in an apartment near the medical campus, but some 40 medical students and four PA students were living in Harkness Hall, the dormitory on campus. That was cause for concern, said Angoff, because of the shared bathrooms and kitchens that made coronavirus infection a risk.

On the weekend of March 21 and 22, Harkness Hall had its population thinned to reduce the density. Occupancy was reduced from 70 to 24 residents, 15 of whom were medical students (the four PA students had already found alternative accommodations). While many students went home to their families, 80 students from various graduate and professional schools were relocated to Old Campus and other locations at Yale.

First-year medical student Chelesa Fearce is one of those who moved out of the dorm and is home with her family in Atlanta, where she’s studying and taking classes virtually. What she misses most are classes in history-taking and the physical exam. “Not having the physical exam is hard because that’s where you’re learning the skills to be a physician,” she said.

“There are pieces we are not able to do right now,” Schwartz said of the classes in physical exam, anatomy, and dissection. “They have to touch each other or touch a cadaver. For those activities, we are creating videos for students to watch while they’re away, with the notion that we will have to make up some of that hands-on experience when they return.”

For first-year student Hanya Qureshi, at home with her parents, sister, dog, and piano in Princeton, N.J., the biggest loss is studying with classmates and friends.

“Yes, we are still learning, and yes, it is challenging,” she said, “but I have faith that we’ll be able to get through it. The saddest part is the lack of personal interaction. The whole idea of medicine, this career all of us have chosen, centers around being able to interact with people, make people feel comfortable, and assess how people are thinking or feeling. When this interpersonal component goes away you miss a key component of what medical school is all about.”

For first-years, she said, another worry is planning summer research projects. “A lot of people were figuring out what lab they wanted to be in, meeting with principal investigators, picking projects, and applying for research funding. All of that is pretty up in the air now,” she said. “No one knows when we’ll be back. It’s a fluid situation and it has caused a lot of anxiety for a lot of people.”

For graduate students, the issue is less missed classes than lost experiments. Richard Crouse, in his fifth year of neuroscience research, shut down an experiment in brain systems that process memories a few days early to meet the March 20 deadline to shutter labs. Due to the timing, this meant losing two months of work. “It was a real bummer,” he said, “but everyone here understands what’s at stake.”

“Some of the students are very concerned about that,” said Charles A. Greer, PhD, director of the Yale Interdepartmental Neuroscience Graduate Program and professor of neuroscience. “If you lose a few months it can set you back for a year because you have to get everything restarted.”

Greer also wants to ensure, as do other faculty, that the students maintain their emotional and mental well-being while they’re isolated at home and unable to work in the lab. “The highest priority has to be their health, all aspects of their health,” he said. “Mental health has become increasingly a big challenge for graduate and undergraduate students. We want them to be assured that if they need someone to talk to, we are here, and if they need to talk to someone else, resources are available to discuss anything that is disturbing them.”

The Physician Associate Program is providing online lessons for the 40 students in the didactic phase of their education. Forty PA students have also been pulled from clinical rotations—the program has revised the academic schedule so they can work on their theses while they’re off the wards. Program director Alexandria Garino, PhD, PA-C, also wants to be sure that the students are well mentally and emotionally.

“Students went from being together in a small classroom and now they’re dispersed all over the country,” Garino said. “That was such an abrupt change for them, and they no longer have that camaraderie.”

She’s hoping to hold an online open mike night where students can sing, play an instrument, read a poem, or tell a story. “It’s a way for them to come together and socialize,” she said.

Winifred Tung, a first-year PA student, said she’s taking classes via Zoom from her home in Cupertino, Calif. Faculty are recording lectures to post online, and students can also access lectures for medical students on the same topics. Students are attending virtual anatomy labs as well, Tung said.

“Right now,” Tung said. “I'm just trying to get adjusted to online learning, re-plan some of my vacation, and make the most of the time with my family. The plan is to start our summer semester in person on May 4, but just like everything else, that could very well change.”

A separate online PA program that has more than 160 students in 34 states has seen few changes, said director James Van Rhee, MS, PA-C. “We were already online, so we’re functioning as normal,” he said. “For the most part we have been able to keep our students going in the clinical year. If the student doesn’t feel comfortable going out, or they can’t because their kids are home from school, or it’s just not feasible, we put them on hold.”

Among the least affected medical students, at least academically, is Max Jordan Nguemeni Tiako. He’s taking a fifth year for research that doesn’t involve pipetting or running gels in a lab. He’s at the University of Pennsylvania in Philadelphia, crunching numbers on addiction and pregnancy. But he’d rather be in New Haven and is contemplating a return.

“I’m lonely,” he said. “I’m a total extrovert. I would rather be socially distant in a place I’m familiar with and with roommates.”

His thoughts are also with people he knows on hospital wards who are confronting the pandemic. “I’m concerned about my friends who are residents and mentors who are working on the front lines of this. I think that’s probably what worries me the most.”