Abstract
When COVID-19 curtailed elective surgeries, our college transitioned to a virtual platform. “Benched” surgeons statewide engaged students online. Third-year students who had completed 2/3 of a longitudinal integrated clerkship (LIC) studied online modules on topics germane to surgery for 1 week. Core entrustable professional activities (EPAs) for entering residency were the backbone of lessons/assignments/assessments. Surgeons coached students around EPAs. Fifty-eight students in consistent small groups, spent 2 hours/day for 4 days with the same pair of surgeon coaches. Off-line, students created a unique hypothetical case/day, practiced and peer-reviewed EPAs. Online, coaches posed scenarios to drill EPAs. Pre/during/post assessments demonstrated progressive proficiency. High level of engagement resulted in 100% attendance and ease of recruitment/retention of faculty. Although variability in students’ clinical settings was high, a virtual week had aided in leveling the learning environment. Prior experience with 2/3 of their total surgery exposure in the LIC allowed for a smooth transition to virtual.
Keywords: surgical education, resident education
Introduction
Washington State University (WSU) is the country’s first with 100% of students in a longitudinal integrated clerkship (LIC) in a distributive geographic model1 for their third year of medical education.
Longitudinal integrated clerkships (LICs) represent a model clinical education that is growing in adoption in the United States, Canada, Australia, and South Africa.2 As opposed to delivering specialty-specific education within time-limited block rotations, medical students in LICs are afforded an opportunity to observe the comprehensive care of patients and populations over a longer period (in our college’s case, it was a 10-month academic year). In our LIC, because the traditional “silos” of specialties-within-time-blocks is turned on its side Figure 1, our third-year students are afforded opportunities to invest in relationships over a 10-month period and across disciplines and venues. This model of continuous learning has afforded our students longitudinal relationships with three important aspects of care and medical education: (1) the patient, (2) the preceptor, and (3) the specialty.
Figure 1.
COVID-19 interrupted third-year educational experiences differently for traditional sequential block rotation vs longitudinal integrated clerkship.
When the COVID pandemic devastated global health in March 2020, medical students in the United States were immediately removed from clinical environments. This was done out of safety concerns for the students themselves, as well as (1) a concern for shortage of hospital beds and ventilators for those who could become infected and (2) serious concerns in the realm of personal protective equipment shortages for caregivers.
The leadership of our medical college met rapidly to understand whether we could pivot to a virtual platform for delivery of our medical education. Simultaneously, elective surgeries in the state were also curtailed overnight. This allowed “benched” surgeons statewide (who served as members of our community-based faculty) ample time to engage our students online. Our college called this period when clinical education was delivered online “The LIC Virtual Clerkship.”
Methods
Core entrustable professional activities (EPAs) for entering residency have been adapted by our college leadership from the AAMC.3 These EPAs served as the backbone of lessons, assignments, and assessments.
Third-year medical students who had completed 2/3 of their longitudinal integrated clerkship were asked to study online modules on topics germane to surgery for 1 week. Students were asked to create hypothetical scenarios from online modules which they watched on the Aquifer WISE-MD asynchronous delivery platform created by NYU Langone School of Medicine.4 Gratefully, this platform was offered at no cost to medical schools during the peak initial months of the pandemic.
The content was standardized in several ways: First, we divided the 30 students into student-coach teams which focused on particular themes (general surgery, oncology and endocrine, vascular, and critical care). Selected modules from the Aquifer WISE-MD curriculum were assigned to each theme. We matched the students to the teams which would cover those themes according to a survey of their learning gaps. We matched the faculty coaches into their subject matter expertise area. Standardization was attempted within these themes and these student-coach teams in this way.
Second, the Course Director was able to float in and out of virtual meeting rooms to observe and redirect for standardization. During the Wednesday when the students had a break from meetings with the faculty coaches (see below), the Course Director met with faculty coaches for faculty development. This also aided with standardization.
Surgeon faculty used the student-created scenarios as a starting point to coach students around five EPAs: (1) oral presentation, (2) transitions/handoffs of care, (3) recognition of urgency/instability, (4) calling for a consultation, and (5) informed consent. Surgeon faculty assessed the students via a standardized form which captured each of these EPAs, as well as medical knowledge, professionalism, and receptivity to feedback [Supplement].
Further Detail
The LIC Virtual Clerkship lasted 6 weeks, with the surgery portion of the course lasting 1 week. The COVID distancing mandates took effect on March 15, 2020. Our college leadership spent 2 weeks collaborating to pivot to virtual. The LIC Virtual Clerkship started on April 1, 2020 and ended 6 weeks later, which coincided with the MD-program students end of their scheduled third year. Luckily, prior to the pandemic outbreak, our students had completed two-thirds of all of their clinical clerkships in 6 different specialty areas (psychiatry, ob/gyn, surgery, pediatrics, family medicine, and internal medicine) because clerks weave in and out of all 6 disciplines over the 10 months of their third year of schooling. As a result, each of the Clinical Education Directors (one in each of the 6 disciplines) took the role of Course Director for 1 week of the LIC Virtual Clerkship.
We lessened the student load by offering the same week-long course twice during these 6 weeks. Surgeons jumped at the opportunity for surgery to take the first 2 weeks of the 6-week Virtual Clerkship. This was to our advantage in faculty recruitment. It synchronized perfectly with operating room shut downs. The class size was approximately 60 students for the year. Week 1 of the course had approximately 30 students. Week 2 of the course had a different 30 students. The faculty were the same for both weeks, which helped standardize the course. Students spent about 6-8 hours a day on the course. While much of that time was self-study and prepping assignments, their faculty coaches met with them for 2 hours each day x 4 days of the course week (MTThF). The Course Director held office hours for student participants on W of the week.
Results
Fifty-eight students participated in consistent small groups. The small groups were continuous in that they were the same each day. The teams collaborated during their self-study time to ensure each team member picked a different topic within the module list to cover. In addition, the partners within the teams also met for peer review on oral presentations. These peer-review-partner relationships were continuous for the whole week.
Off-line, students created a unique hypothetical case/day, practiced and peer-reviewed 5 EPAs.
Online, coaches posed scenarios to drill EPAs. Students spent 2 hours/day for 4 days with the same pair of surgeon coaches. The cases served as a springboard, and the height of the springboard increased as time over the week ensued. Students were coached to increase their case complexity each day (for example, add a patient co-morbidity). Surgeons were coached to expect that higher entrustment skills can be demonstrated over time (for example, add a post-op complication which allows the student to recognize a change in the patient’s status requiring urgent or emergent care).
Pre/during/post assessments demonstrated progressive proficiency of skills. Our college collected EPA data from students prior to the COVID shutdown and also when they returned to the clinical setting. In addition, we also have assessment data from the course itself. At the time of this publication, the pre/during/post assessment data has been viewed by the Course Director who made the observation of progressive proficiency. Unfortunately, the granular data has not yet been released by our Assessment Unit for the purposes of publication.
High level of engagement resulted in nearly 100% attendance. Engagement was ascertained by observing that all students attended the sessions with the coaches with their videos enabled. Each student and faculty had equal time to speak, present and ask questions. The pairing of 2 faculty coaches with five students allowed for a high teacher-to-faculty ratio, which also aided in engagement. Pre-session assignments were completed. Coaches commented to the Course Director that arrived to their sessions prepared.
For surgery, the LIC Virtual Clerkship aided in recruitment and retention of faculty. We are a new school, and therefore preceptor recruitment was especially important during this inaugural class' year. By engaging surgeon faculty in this virtual format, surgeons strengthened their relationship with the college, with the students and with the Course Director. All of the surgical faculty who taught in the virtual clerkship are still precepting students today. In addition, most of the surgical faculty who taught in the virtual clerkship volunteer to serve as oral examiners for our fourth-year curriculum, as well as for our surgery transition to residency course (based off of the ACS/APDS/ASE Surgical Residency Prep curriculum).
Twenty (35%) in our first class of medical students forecasted for careers in surgery and anesthesiology. Ultimately 15 of 58 (26%) students who participated in this virtual clerkship clinched surgery or anesthesiology positions at graduate medical education training programs in the 2021 Match. Three students changed specialty and 2 remain unmatched. The authors realize that the real proof of effectiveness of this Virtual Clerkship is performance on end of rotation exams and/or USMLE compared to historical, non-COVID students. Unfortunately, because we are a new school, we do not yet have this data. Additionally, we are keenly following how these students perform in residency. For the students who matched into surgery, we are attempting to keep in touch with their program directors.
Discussion
From a learning gap2 analysis, we saw high variability in students’ clinical experiences. We suspect this is due to several factors, including but not limited to (1) inaugural class, (2) community faculty, and (3) distributive model. The virtual week aided in leveling the learning environment. For me, as Course Director, I viewed this as a silver lining. Our course team was afforded an unexpected opportunity to have direct ownership over what skills students were practicing and being assessed on.
Now that our course team and I have a taste of what that is like, we welcome the chance to integrate a hybrid-virtual platform to future surgical rotations, regardless of whether pandemic restrictions are in place or not. There are several ways which we have kept the momentum which we gained in the virtual clerkship in motion at present: (1) fourth year medical students who enroll in a 4-week elective in surgery sit for an oral exam which is delivered at the end of their rotation on a video conferencing platform by 2 faculty members. On the faculty-side, the same assessment form which we used for the Virtual Clerkship is used for our oral exam. On the student-side, a similar format of preparing a case presentation and walking through a hypothetical development pitched by the faculty member is undertaken. (2) We are currently modifying an academic half day curriculum for our third-year clerkship students which could incorporate this same format. (3) For students in the academic year which was subsequent to the March 2020 COVID outbreak in the United States, the virtual clerkship construct was implemented for students whose COVID illness or exposure caused a week of excused absence during scheduled surgery educational experiences.
The students and faculty who participated in this course completed course evaluations [Supplement].
Most definitely, prior experience with 2/3 of their total surgery exposure in the longitudinal integrated clerkship allowed for an extremely smooth transition to the virtual surgical skills platform. I cannot imagine how challenging this must have been for educators who were trying to deliver a standard surgical block rotation to those students who had never been in the operating room, or had never functioned as a member of the surgical team. The lived experience is irreplaceable. Fortunately, in our experience it was supplemented, augmented, and enhanced, not replaced.
In summary, the challenges of delivering medical education during the COVID-19 was the mother of invention of a hybrid-virtual format for both third- and fourth-year clerkships, which has segued nicely into our future programming planning.
Supplemental Material
Supplemental Material for Homeschooling Surgery Students: Washington State University’s Longitudinal Integrated Clerkship Transitioned to a Hybrid-Virtual Platform Triggered by the COVID-19 Pandemic by Anjali S. Kumar in The American Surgeon
ORCID iD
Anjali S. Kumar https://orcid.org/0000-0002-2312-8512
Notes
The distributive model is described as follows: WSU has divided the state into four quadrants. Each quadrant has a central campus at an existing WSU facility. The first 2 years of the MD-program are called “pre-clerkship years.” Those 2 years are delivered at a singular location for all enrolled MD-program students at one of the four campuses (the one equipped with an anatomy lab). The second 2 years are called the “clerkship years.” The educational experiences of those years are delivered at one of the four campuses. The partnering health systems in that campus catchment area plays host to enrolled students. When students matriculate, they are assigned to one of the four campuses. There are an equal or near-equal number of students assigned to each campus.
To assess learning gaps, we formed a Qualtrics survey which every student in the third year completed prior to learning group assignment. The students were given a list of the Aquifer / WISE-MD modules and were asked to identify which subject areas they had not yet seen in the 2/3 of their surgery clerkship experience which they had already completed. Based on those gaps, we assigned students to a particular learning group.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
References
- 1.https://www.aamc.org/data-reports/workforce/report/state-physician-workforce-data-report
- 2.Worley P, Couper I, Strasser R, et al. Consortium of longitudinal integrated clerkships (CLIC) research collaborative. A typology of longitudinal integrated clerkships. Med Educ. 2016;50(9):922-932. doi: 10.1111/medu.13084 [DOI] [PubMed] [Google Scholar]
- 3.https://www.aamc.org/what-we-do/mission-areas/medical-education/cbme/core-epas
- 4.https://aquifer.org/courses/wise-md/
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Material for Homeschooling Surgery Students: Washington State University’s Longitudinal Integrated Clerkship Transitioned to a Hybrid-Virtual Platform Triggered by the COVID-19 Pandemic by Anjali S. Kumar in The American Surgeon