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ON 16 March 2020, as cases of COVID-19 escalated across the globe, the Victorian government declared a state of emergency, introducing measures to slow viral spread. Health care providers, including Ballarat Health Services (BHS), a major regional health service in Victoria hosting students from three Australian medical schools, prepared to receive an influx of patients. At the time, Australia was thought to be just weeks behind global hotspots, expecting exponentially rising COVID-19 cases and health service demand.
Concurrently, mirroring the need for rapid action, the Chief Medical Officer (CMO) of BHS called leaders of each medical school in Ballarat to discuss risks to students, patients and the community from continuing student placements. Placements were deemed non-essential to critical hospital service delivery; the following day, they were paused with no pre-set resumption date.
Clinical placements for final year medical students are vital to producing a competent intern workforce. Suspending these placements risked producing a 2021 cohort of underprepared interns, placing increased pressure on other members of the clinical team and potentially affecting patient care.
As public health measures initially flattened the curve, the Victorian Department of Health and Human Services (DHHS) recommended continuation of clinical placements where possible. In early April, we — two registrars who had previously been working solely clinically in anaesthesia and internal medicine — were asked by the BHS CMO to formulate plans for the safe reintroduction of medical students in collaboration with the medical school leaders and BHS; we were given 3 weeks to come up with a plan.
Our aim was to furnish final-year medical students with the skills required of safe and competent interns, while balancing COVID-19 associated risks.
We identified key issues and risks both for clinical and educational stakeholders through consultation via online communication platforms. After examining existing arrangements and wide stakeholder engagement, including with medical school leaders, departmental heads and senior clinician teachers, we started an iterative process of successive drafts and formulated several plans aligning with various potential COVID-19 situations.
The plan we proposed was employing a “near peer” model, with final-year students working closely with an intern or House Medical Officer and performing the tasks of junior doctors under supervision, to recover rapidly any clinical attachment time lost and maximise training opportunities available. Rotations included medicine, surgery and emergency medicine to align with core Postgraduate Medical Council of Victoria intern requirements. Prioritising final-year medical students’ placements, given the need for training of future doctors, allowed for completion of pre-internships for all 49 final-year students simultaneously and early in the clinical year. Plans also integrated students from all universities. Consideration was given to employment of students in clinical or non-clinical roles; however, at the time surge workforce was not required. We encouraged university autonomy to place their students to meet individual requirements. We mandated appropriate personal protective equipment (PPE) training and early influenza vaccination to prepare students and offered additional support to prepare junior doctor educators involved.
Two clinical registrars, one non-clinical problem
As registrars who met for the first time to collaborate on this project, we integrated our two different skill sets and perspectives to problem solve effectively. Although working autonomously can feel more time-efficient, working together broadened our views and problem solving in partnership gave us a sounding board for ideas.
Compared with clinical work, this was much more self-directed; we got out what we put in. The working relationship between we registrars and our CMO supervisor felt more like mentorship and facilitation rather than the traditional hierarchical “clinical supervision” of registrar by consultant, which was a positive experience. We were given freedom to plan time suiting our optimal working styles. We felt trusted to bring our own perspectives to solutions centred around the junior doctors asked to take on medical student teaching. Nevertheless, routine check-ins and feedback remained essential.
Virtual leaps and bounds
Knowing where to start was not easy. Neither of us knew key stakeholder groups: neither medical school nor clinical department leaders, all of whom have many demands on their time. At this point, online communication platforms were relatively unfamiliar – as clinicians, we almost exclusively communicate face-to-face. Six months later, use of video conferencing software is commonplace and telehealth is the norm. This illustrates necessity rapidly altering common practice in health care systems often resistant to change.
Juggling stakeholders
Our plan needed to address diverse stakeholder interests and be feasible across our public health service, the neighbouring private hospital, and three medical schools. Each medical school had different pre-existing curricula, including specialties, rotation timing, research placements and formalised pre-internships. The landscape of clinical placements for each university varied, with one having withdrawn all student placements, another only permitted to continue at certain sites, the third with some students volunteering as “clinical assistants”.
All were eager for student placements to resume, with varying ideas of how to structure the experiential opportunity. This required recognising a variety of priorities to reach consensus within the timeframe.
As registrars relatively new to BHS, consulting each expert, collating information and relaying results was educational. Experiencing this process and the eventual outcome taught us about multistakeholder engagement and challenges involved in developing common resolutions. Although this process required persistence, the organic formulation of solutions born from stakeholders’ own goals was ultimately the key to success.
The face of uncertainty
Only one thing was certain: when it came to COVID-19, nothing was certain. The ability to scale up and down quickly helps nimble responses to rapidly evolving situations. Therefore, numerous options were developed, including full reintroduction of students, reintroduction of final-year students only and complete withdrawal of students. We reaped the benefit from this flexible approach when the risk of community transmission fell enough to initially reintroduce students from all year groups, only to rise dramatically approximately 2 months later as part of Victoria’s “second wave”; clinical placements have consequently been scaled up and down according to the local risk profile. Previously formulating three separate plans when COVID-19 impacts were still unclear eased the planning processes when background risk increased from July to September 2020.
Balancing risks
We needed to weigh COVID-19-associated risks against those of intern underpreparation. If medical students were to contract COVID-19 on placement, consequences to students, their families and the hospital could be significant. Furthermore, certain clinical areas, such as the COVID-19 ward, carry a higher risk. Interestingly, opinions differed among our stakeholders about whether medical students should participate there. Pandemics are a once-in-a-lifetime learning opportunity for students preparing for internship and potentially caring for these patients in 2021. With the adequate PPE and training now available, involving students should carry negligible risk. Overall, we erred on the side of caution, allowing students to learn in lower risk environments, with PPE as appropriate (as per DHHS recommendations to avoid non-essential staff involvement in COVID-19 patient care). At the time of writing, students have continued to attend placements in lower risk areas only.
Mentorship for trainees
Doctors spend years learning how to be expert clinicians in specialist training programs but can be thrust into management and leadership roles with no formal training. All too often, it falls to us to learn management skills. Perhaps medical culture can learn from other industries that have shown the value of formal leadership training. Personally, mentorship from passionate and highly competent clinical leaders allowed us to develop problem-solving skills transferable from our approach to diagnostic challenges in clinical practice. Engaging with project work afforded us the chance to learn skills otherwise rarely nurtured in clinical environments, which will accompany us throughout our careers.
Conclusions and practice recommendations
As clinicians new to medical management and leadership, we offer reflections and lessons that may be helpful for other clinicians in the same boat.
- Prepare and propose flexible plans: these lend themselves to easy scale up and down in response to evolving situations.
- Engage stakeholders: this process can be time-consuming but is the best way to develop a sustainable solution.
- Embrace new experiences as opportunities for learning and innovation: focusing on the health, social and economic consequences of the pandemic, it can be easy to ignore the opportunity to harness this catalyst for change and learn from it.
- Find mentors: clinical training programs tend to focus on vocational skills rather than other contributions clinicians make to departments or wider hospital communities. New consultants are often given responsibilities requiring skills that they never had a chance to develop as registrars. Mentorship in this area is incredibly helpful (important for mentors and mentees in clinical and non-clinical contexts to remember). Seeking formal training in these skills may also add value.
- Get even more comfortable with not knowing everything: Although working with ambiguity is familiar to clinicians, the scale of uncertainty due to COVID-19 has been intimidating. We learnt to be comfortable accepting some uncertainty rather than searching for absolutes.
Dr Serin Cooper Maidlow has worked clinically in the UK, New Zealand and Australia; and is a Royal Australasian College of Medical Administration trainee based in Victoria.
Dr Tanji Lamba is an anaesthetics and public health physician trainee, currently participating in the World Health Organization leadership development program with the Alliance for Health Policy and Systems Research.
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.