Not an academic question

When 100 first-year students arrived on Harkness Lawn for the White Coat Ceremony on August 28, 2020, they came in small groups. They wore masks and took socially distanced seats. They donned their white coats on their own without the symbolic assistance of faculty. And no friends or family were in the audience to cheer their welcome into the medical profession.

Before the ceremony, Yale health and safety staff had reviewed plans for the event. The tent on the lawn, even though it had no walls, posed more of a risk than open air, so the staff conducted smoke tests to map air flow.

The impact of COVID-19 was felt throughout the first-years’ two-week course titled “Introduction to the Profession.” The course, co-directed by Nancy Angoff, MD ’90, MPH ’81, MEd, and David Rosenthal, MD, assistant professor of medicine, with student directors Melanie Zheng ’22, and Nensi Ruzgar ’22, ordinarily takes first-year students into the hospital to allow them a glimpse of their future roles in medicine as well as an introduction to the New Haven community. But this year, the course was completely virtual. It focused on two simultaneous public health crises: the coronavirus itself and structural racism exposed by the inequitably distributed effects of the virus among Blacks and Hispanics.

Every incoming first-year student was sent a copy of the book Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-first Century. One of the benefits of Zoom is that the videoconferencing software enabled a visit with the book’s author, Dorothy Roberts, JD. A morning devoted to discussion of the book was organized by second-year students Autumn Nobles, Ellelan Degife, Muzz Muhammad, Chelesa Fearce, and Chinye Ijeli.

Since the spring of 2020, when faculty had just days to adjust the curriculum, the coronavirus has affected just about every aspect of the medical school. At that time, students had to abandon their clinical clerkships and attend lectures online, while many who lived in the dorms had to go home. Faculty began planning for the fall semester, finding ways to bring students back to New Haven.

“The biggest challenge was doing in-person activities in a way that was cognizant of and responsive to the restrictions that are in place,” said Michael Schwartz, PhD, associate dean for curriculum. Students, he said, had been clamoring for such activities. Otherwise, they asked, what is the point of being in New Haven?

This balancing act remains a work in progress, and one expression keeps coming up. “It was very much building the plane as it was flying,” said Dana Dunne, MD, HS ’90, FW ’92, MHS ’20, associate professor of medicine (infectious diseases), and director of the internal medicine clerkships.

To keep students safe, lectures were kept online and activities outside of class had become virtual. Libraries across Yale were closed. Labs were open in staggered shifts. Students living in dormitories were tested for COVID-19 twice a week. Students living off campus had the option to be tested once a week. Any students who venture on campus in 2021 must fill out an online survey to ensure they have no symptoms associated with COVID-19.

How students are affected by the restrictions depends in large part on where they are in their training. Students in their clinical years had to make up for time lost when they were pulled out of their clerkships. There wasn’t enough personal protective equipment (PPE) to go around, and health care providers in the early days of the pandemic were stretched thin. “The preceptors that were going to be responsible for mentoring, teaching, and training our students were being overwhelmed themselves,” said David Hersh, MD/PhD, assistant professor of pediatrics and director of all clerkships.

Clerkship blocks were shortened from 12 weeks to 10 by moving didactic sessions online. To avoid crowding in break rooms at lunch time, when masks would come off, unused auditoriums where people can maintain social distancing have become lunchrooms. On rounds, teams try to limit how many people can enter a patient’s room.

The experience, Hersh said, will likely stay with students throughout their careers. “It's pretty rare that you get to live through a pandemic and see the impact on patients, on families, on providers, and see what it’s like for clinicians to go through this,” he said.

Lectures in the pre-clerkship semesters, said Peter Takizawa, PhD, assistant professor of cell biology and co-director of the pre-clerkship curriculum, are offered in three formats: podcasts; live online lectures; or hybrid classes that allow up to 35 students chosen by lottery into a lecture hall while others attend via Zoom. Teaching on Zoom is a very different experience, he said.

“When I’m giving a lecture on Zoom, all I see are my slides, so it’s hard to judge how what you’re saying is landing with the students. If you’re in the room, you can see if the students look confused,” he said. Takizawa stays on Zoom after the lecture in case students have questions; he is also available during office hours.

Second-year student Degife noted that even before the pandemic, many students chose to watch lectures online rather than attend in person. Workshops also went online, she said, adding, “I do miss that small-group learning in person.”

Her classmate Nobles said that she resists the urge to mute herself to avoid creating background noise. “At the same time, it stifles the natural reactions you might have like agreeing with someone or chiming in with an opinion,” she said.

Some classes, like anatomy and physical examination skills, require students to be present, and precautions are in place. In the anatomy lab, students study in two shifts so that only half the class is present at any one time. Students wear extra levels of PPE, including face shields, and the rate of air exchange in the lab has been increased. Instead of roaming the room to work with students, faculty teach via Zoom from a dissection table.

Classes in physical examination remain in person, but interviews with standardized patients are remote. Students perform the physical exam on a manikin while interviewing their standardized patients via Zoom. Degife said this arrangement presented an unforeseen problem, however. “The manikin was heavy, so it was falling off the table. It was difficult to keep it in place while you’re listening,” she said.

Graduating students are the first ever to have their residency interviews online. Virtual visits eliminate the cost of travel, but they make it harder to get a sense of a program. “They’ll have resident meetings virtually, but it’s not the same as having a dinner the night before and getting a feel for their personalities,” said Nancy R. Angoff, MD ’90, MPH ’81, MEd, HS ’93, associate dean for student affairs. The med school has offered training in how to interview online, she said.

Another change is the National Board of Medical Examiners’ cancellation of Step 2 CS, an exam that requires graduating students to travel to one of five centers to assess their physical examination and history-taking skills with standardized patients.

On campus, students have organized virtual social activities, like online pumpkin carving for Halloween and a virtual Day of the Dead in November. At Thanksgiving, students gathered online in small groups over meals from DoorDash with vouchers provided by the university. “Some students set up random events where they meet three other people to get to know people you might not feel comfortable reaching out to,” said first-year student Victoria Marks.

“Socially, the part I struggle the most with is the more peripheral friendships,” said one of her roommates, Jacqueline Ihnat. “Every time I hang out with people it has to be so intentional, so you only hang out with people you have shared interests with.”

Despite precautions, some students tested positive for COVID-19 in 2021—not from hospital exposures but from small social events. Angoff and Schwartz, the medical school’s designated health and safety officers, said that another dozen have had to quarantine because of exposures to others who tested positive, mostly domestic partners or roommates. Those who do test positive get regular phone check-ins from Angoff. “That way they just don’t feel as alone,” she said.

While the fall semester neared its end, faculty were planning for the spring of 2021. They know that things can change quickly during the pandemic. They anticipated a surge in infections, illness, and hospitalizations even as the nation embarked on a vaccination program. Lessons learned from the spring of 2020, which required a quick reaction with so much unknown about the virus, have informed the school’s plans.

“As opposed to then, when things happened in a matter of days and weeks, there have been a lot of planning meetings in recent months, to think about if things get worse, what precautions do we need to take and how to best reorganize what we are doing?” said Schwartz. “We are also in continuous and active conversations with the health system, to make sure that the experience of our learners in the clinical environment is being considered and addressed.”