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IT IS highly likely that 2020 will be the year that everything changed – imperceptible trends in the way doctors learn have accelerated at lightning speed and, for all of us, things will never be quite the same again.
In their recently published systematic review of medical education during the COVID-19 pandemic, a global coalition of medical educators report a startling statistic, “In total, more that 900 million learners in all levels of education, including higher education, have been affected.” The effect on medical education has been particularly severe for a number of important reasons:
“[Clinicians] have responsibilities primarily towards service provision and supporting their health system, particularly in times of crisis. This is exemplified by the shutdown of academic institutions worldwide, reallocation of academic trainees into clinical roles and cessation of mandatory training and teaching. Many trainees have been prevented from rotating into new specialties or training positions and supplementary research and audit work that is not essential has been postponed.”
The effect of this global pandemic on the training and ongoing education of doctors has been felt at all levels and across all countries. Both in Australia and globally, medical students have faced enormous and disproportionate disruption at critical periods of their training. Their medical schools have faced unprecedented challenges in delivering teaching and clinical experience sufficient to allow newly minted doctors to graduate and become interns. In the early stages of the pandemic, most medical schools instituted a rapid and unavoidable transition to entirely online teaching for junior medical students. The clinical training components of medical schools were forced to streamline, and virtually all elements of medical courses changed. These changes imposed major upheaval to “important aspects of university life such as such as friendships, personal identity development, exposure to diversity and self-care skills.”
Vocational training, similarly, was severely disrupted. In contrast to university-based medical education, specialist training is conducted almost exclusively in clinical settings, with registrars making a substantial contribution to patient care in hospital, clinic and other health care settings. Specialist training programs with a major procedural component – orthopaedic surgery, for example – reported reductions in elective surgery caseloads of as much as 93%. At the same time, mandated lockdowns and travel restrictions reduced the volume of emergency surgery as people were not exposed to risk situations such as driving or workplace activities. Providing patient care in other specialties, such as anaesthetics and otolaryngology, presented an extremely high risk to clinicians and prompted severe limitations on training. Attainment of procedural competencies is a key step in vocational training so these limitations were a blow to many registrars.
At the same time, formal assessments such as oral and written examinations were delayed or cancelled by many Colleges. Trainees devote years to examination preparation, and hospitals often adjust rosters and leave arrangements to accommodate exam schedules. Uncertainties about the format and timing of high-stakes examinations not only have a severe emotional impact but postponements often affect the completion of training for registrars and may delay the entry of practitioners to independent clinical roles at a time of workforce shortages in some disciplines.
Medical students and registrars are not the only people learning. Qualified practitioners have to fulfil continuing professional development (CPD) activities to maintain registration and College Fellowship. In recognition of the unique situation, the Royal Australasian College of Surgeons and the Royal Australasian College of Physicians offered extensions for their CPD requirements and advised that, while educational activities are encouraged, no penalties would apply if CPD requirements were not met. These concessions were an obvious and pragmatic response to the restrictions that the COVID-19 pandemic placed on doctors’ capacity to participate in the traditional activities of CPD – travel to conferences, local meetings, and having the time and capacity to perform clinical audits.
That was then, and this is now
The COVID-19 pandemic has exposed four particular vulnerabilities in medical education:
- access to clinical cases related to training, particularly for vocational and specialty registrars;
- staff shortages limiting both availability of supervisors and trainers and causing roster disruptions;
- cancellation of educational conferences; and
- difficulties in conducting workplace assessments and formal examinations and assessments.
Yet our responses to the pandemic suggest it is very likely that we can turn these vulnerabilities into strengths going forward.
For specialty trainees, methods of assessment have been undergoing a steady evolution for some time and the pandemic and its aftermath are likely to accelerate change. The big-ticket items for trainees usually are the high-stakes clinical, oral and written examinations. The pandemic has exposed vulnerabilities in these examination processes and might well enhance a new look at assessments in the workplace. There are well known drawbacks to workplace-based assessments (WBAs) which sometimes see them as either a series of individual high-stakes assessments or, alternatively, box-ticking exercises. New approaches to these assessments and pivoting to tools such as supervised learning events (SLEs) and other robust methods of assessment might benefit trainees, their supervisors and, ultimately, the patients they care for.
It seems unlikely that any workplace assessments will completely replace high-stakes exams, pandemic or not, so moving from the traditional approach of examiner (or invigilator or proctor) being in physical proximity to the candidate must change. The economic consequences of getting high-stakes exams into a reliable online format is so important that even bodies such as the World Bank have weighed in.
To ensure that online examinations produce valid, reliable and fair results is no easy task. Candidates must have access to a suitable device – desktop, laptop or tablet – compatible with the exam delivery software. They must also have a stable and secure internet connection. The format and content of the test must be conducive to online delivery, which is not necessarily easy if either interpretation or drawing images and figures is required. Indeed, format issues can lead to the candidate being assessed on their familiarity with the testing software rather than the knowledge content.
Systems to ensure fidelity of examination behaviour – much easier with in-person invigilation – need to be in place and reliable. Suspicious behaviour might be detected by purpose-developed “proctoring software”’ that can access a candidate’s webcam, browser activity, or keystrokes, with suspicious activity reported to administrators. Even with the highest quality infrastructure, program malfunctions occur and these can prove devastating. The availability of real-time technical support is crucial to successful online examination conduct. These systems also need to ensure equity for candidates with a disability, for example, with the use of appropriate assistive technologies or extended time.
Up close and personal
Careful analysis has taught us that health care carries with it a substantial environmental cost: about 7% of Australia’s carbon emissions are directly attributable to hospitals and medical care. What isn’t recognised in such an analysis is that the learning required to become a doctor and to continue in practice also has a substantial carbon footprint. As pointed out in an article in The Lancet:
“Medical conferences aim to improve health outcomes worldwide yet contribute substantially to global warming and climate breakdown. This is a paradox which cannot continue.”
In that article, Zotova and colleagues point out that:
“Between 2–5 tonnes of CO2 are emitted by every attendee flying intercontinentally to attend a conference. These emissions are above the annual yearly limit of 2.3 tonnes per person necessary to curb climate change. Hotels and conference venues are substantial emitters because of the intensive energy use of their buildings and operations. Food service usually has generous portions of carbon-intensive foods such as meat and cheese, and often as much as 50% of catered food ends up in landfill. Plastic bottles, single-use coffee cups, and event merchandise with short lifespans are widely available despite their substantial contributions to pollution.”
Despite vocal scepticism from some individuals, the data confirm that continuing professional development activities are associated with improved clinical performance and better patient outcomes. As those of us who trained long ago can attest, there has been change in the nature and intent of CPD. Conferences, as we know them, are very popular ways of participating in CPD and for good reason. Yet for most doctors it won’t be the important environmental concerns that lead to their decline.
Health budgets have been affected severely by the COVID-19 response and money that might formerly have been available for CPD activities such as interstate and overseas meetings will be curtailed. Even for individuals with their own practices, not relying on hospital funding of CPD, the pandemic has had a major financial impact for many. All predictions are that travel, most likely, will be more expensive. The number of registrants for meetings, taking into account venue restrictions dictated by social distancing, are likely to be much smaller for some time yet.
Learning through hybrid and fully virtual meetings has advantages, but drawbacks too: most of us now are familiar with “Zoom fatigue”. How long it will be possible to maintain interest sitting in front of a screen seems like a key factor. Without the physical stimulation of being at a venue, strolling around trade displays and having coffee with colleagues, how enticing will large meetings be in the future? Yet there are major advantages: avoidance of jet lag, paying only registration fees and not travel and accommodation costs. These factors might increase virtual attendances, a phenomenon already noticed at large international meetings held during the pandemic. The downside is the challenge to informal meetings, breakouts and networking. Overcoming this is not impossible but will be challenging. Another challenge will be delivering “hands-on workshop” events, often run as part of large meetings. However, virtual-reality technical solutions are already available and might well be ripe for adoption in these settings.
The times they are a changing
Beyond meeting-based learning, for the acquisition and maintenance of “hands-on” clinical skills simulation is likely to play a much greater role after COVID-19. A recent review of the role of simulation during the pandemic makes the point that, “the COVID-19 outbreak is a textbook case for the use of simulation and an opportunity for simulation to play to its strengths”. The authors’ review outlines the important potential functions of simulation. These include the educational aspect in allowing rapid and safe (re-)qualification of personnel to function quickly in a variety of clinical and other positions. Secondly, systems can be improved by use of simulation to optimise workflows, bottlenecks and dependencies. Additionally, simulation, and simulation facilitators, can help in supporting health care professionals in dealing with the emotional strain of the situation – a personal focus. All of these aspects are of relevance to other clinical situations unrelated to the COVID-19 pandemic. All of these factors are likely to lead to the establishment of virtual practical examination centres, where simulated patients are used and examiners conduct their assessments remotely.
It is important that the changes in the way doctors learn are fully assessed and fit for their primary purpose, making sure that we provide the highest quality of patient care. To do this will require rigorous assessment and evaluation. The initial signs are encouraging, though. For example, systems for remote assessment and feedback introduced rapidly during the pandemic have already shown high levels of both examiner and candidate satisfaction.
We all are faced with a “new normal”, leading “many educators … ruminating on how best to ensure rigorous medical training that produces a steady stream of competent physicians”. Clinical placement had been the cornerstone of medical training since the early foundations of the medical profession, but things have had to change rapidly. The COVID-19 pandemic has generated unprecedented challenges for the delivery of medical education. Hospitals are limiting students’ attendance at ward rounds, clinics, and in operating theatres; this is a fundamental shift in clinical education from the bedside to the computer screen.
As the pandemic has exposed, community health is the key to economic prosperity. For this reason, the need to prepare our current and future medical workforce has never been as focused as it is now in this setting of a global emergency. The profound effects of COVID-19 are likely forever to change how future physicians are educated. Whereas in the past many of us had a strong preference for in-person learning activities, that has changed both through necessity and choice: surveys already suggest that online platforms are now the preferred option by a large margin. It is highly likely that 2020 will be the year that everything changed – imperceptible trends in the way doctors learn have accelerated at lightning speed and, for all of us, things will never be quite the same again.
Steve Robson is Professor in Obstetrics and Gynaecology at the Australian National University Medical School, and is immediate past-President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
Brendan Grabau is a change management consultant working in the postgraduate medical education and training sector.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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One issue that has been exposed by this is that we have traditionally failed to track learning exposure.
There have always been a limited number of clinical opportunities for students and trainees, and this will likely be exacerbated for at least the next few years. Ensuring we make the most of these opportunities requires us to equitably distribute them, and this cannot be done without understanding who is exposed to what.
It furthers the calls for medical students and junior doctors (as an example) to maintain a clinical learning portfolio. This has been recommended by the COAG Health Council for years, though little or no progress has been made on introducing them. They offer benefit to both the learner and those responsible for supporting their education.
These portfolios are already available – we simply need to start using them.
The Colleges, Medical Schools and regulatory authorities have, by and large, been slow to adapt to the new norm, responding by simply postponing exams and accreditation visits. Yet, as the Australian College of Rural & Remote Medicine has demonstrated, excellent methods for remote supervision and assessment are already in place.
Thank you for pointing out all these opportunities. I really hope that the adaptations we eventually make to Medical Education and postgraduate training remain as permanent fixtures. At the very least, they will further break down the ‘ivory tower’ prejudices which have so disadvantaged rural communities in the past. It will be seen that good doctors have the opportunity to receive excellent training in regional and rural Australia: a fact already known but not voiced abroad by many.