IFMSA Report l The Impact of Covid-19 on Medical Education Worldwide

IFMSA Report

The Impact of CoVID-19 on Medical Education worldwide

The Impact of CoVID-19 on Medical Education worldwide: a survey analysis Introduction Methods: Results: •

Students’ attitude towards the pandemic

•

Students’ participation in the fight against CoVID-19

•

Students’ risk exposure during CoVID-19

•

Medical Education during and after the pandemic

Recommendations: •

•

Medical students’ role during the pandemic: o

Competency preparedness

o

Protecting medical students from the risk of infection

E-learning in quarantine and Medical Education: o

Best practices in e-learning

o

How do medical students envision Medical Education beyond the quarantine

Conclusion:

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Introduction As countries across the globe went into quarantine, medical schools and students have been highly affected by CoVID-19: the pandemic has put medical students worldwide away from their classes and clinical training, and are faced with a new reality in regards to their Medical Education. Whether medical students continue their education from home or join forces with the local health workforce to strengthen their healthcare facilities in the fight against CoVID-19, IFMSA aims to collect data from medical students worldwide so as to assess the impact of the CoVID-19 pandemic on Medical Education, through gaining an insight on medical students’ situation in the equation of healthcare during the current pandemic, analyze to which extent the quality of the future health workforce is affected by the pandemic, and what lessons can we learn from our present, so as to strengthen the preparedness of medical students and medical schools for future pandemics, shall they occur.

The purpose of our study was to complete the following objectives:

1. Track the adaptation of medical schools to the requirements of the current pandemic and the alternative measures provided to medical students.

2.

Conduct a global assessment on: •

Students' attitude towards the pandemic

•

Students' involvement in supporting healthcare during the outbreak

•

Students' level of clinical exposure to the risk of CoVID19 infection within healthcare facilities

•

Students' Education during and after the quarantine

Through the following document, you will be able to go through the analysis of the results of both the survey and tracking sheet of the impact on CoVID-19 on Medical Education and medical schools respectively, and as well as the recommendations medical students worldwide voiced so as to shape Medical Education during and beyond the pandemic.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Methods: Type of study: This is a cohort cross-sectional study.

Study period: This study took place between April 1st and April 20th, 2020.

Target population: The instruments were shared on the IFMSA communication channels targeting the National Member Organizations respective representatives.

Instruments: 1. IFMSA Medical Education Tracking Sheet during CoVID-19: A Google spreadsheet was created with 6 items distributed per columns to collect: •

Country or territory: a list of countries and territories was indicated as per the NMOs representation.

•

Total number of medical schools in the country or territory

•

Status of medical education: this column contained a dropdown with 2 options: suspended and ongoing.

•

Level: this column contained a dropdown with 2 options: national and local.

•

Alternative measures: this column contained a dropdown with 5 options: University Online Education, Small Groups Teaching, Non-Formal Education, University Online Education + Small Groups Teaching, and None

•

Duration: referring to the duration of the alternative methods

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

2.

IFMSA Survey on the impact of CoVID-19 on Medical

Education: In compliance with the Global Data Protection Regulations (GDPR), participants were able to identify and share data in relation to : •

Personal information: name and email address.

•

Education: full name of university they are currently enrolled in.

•

IFMSA involvement: National Member Organization (NMO) of affiliation, position in their NMO

Moreover, the survey contained 19 items distributed in 4 sections, each containing a mix of different types of questions, whether checkboxes, multiple choice questions, likert-scale type multiple choice grids, and open questions. The sections were: •

Students’ attitude towards the pandemic

•

Students’ involvement in supporting healthcare during the pandemic

•

Students’ level of exposure to risk of infection within healthcare facilities:

•

Medical Education during and after the quarantine

Additionally, consent was provided to participating in the study before filling the 4 aforementioned sections.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Results: 1. General results: a.

IFMSA Medical Education Tracking Sheet:

A total of 2761 medical schools in 103 countries were tracked between April 1st and April 20th, of which 2614 medical schools in 95 countries suspended the delivery of their curriculum within the conventional physical settings.

The tracking sheet was able to follow the situation of medical schools from all IFMSA regions, more specifically 175 medical schools from 14 countries and/or territories in Africa, 753 medical schools from 18 countries and/or territories in the Americas, 1072 medical schools from 15 countries and/or territories in Asia-Pacific, 178 medical schools from 11 countries and/or territories in the Eastern Mediterranean Region, and 583 medical schools from 45 countries and/or territories in Europe.

b. IFMSA Survey on the impact of CoVID-19 on Medical Education 411 medical students responded to the survey, representing 248 medical schools worldwide from 68 countries, of which 28 medical schools are in 7 countries and/or territories in the African region, .64 medical schools are in 15 countries and/or territories in the Americas region, 86 medical schools are in 13 countries and/or territories in the Asia-Pacific region, 47 medical schools are in 9 countries and/or territories in the Eastern Mediterranean region (EMR), and 59 medical schools are in 24 countries and/or territories in the European region.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Responses

Medical schools

Countries

Region

411

248

68

All

34

28

7

Africa

149

64

15

Americas

114

86

13

Asia-Pacific

50

47

9

EMR

68

59

24

Europe

Table: Responses distribution and representation across regions.

Map: countries represented in the IFMSA Survey of the impact of CoVID-19 on Medical Education

2.

Students’ attitude towards the pandemic:

In this section, we wanted to understand the attitude of medical students towards the pandemic. In order to assess it, we have asked 2 questions related to their opinion regarding their national response to the pandemic and their curricula preparedness.

First, regarding students' attitudes regarding their respective national responses, we received 411 responses. The answers were mostly divided into two halves. On one side,

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

199 students (48.4%) thought that the national response was insufficient to control the virus.

On the other side, 193 students (47%) thought it was adequate and it was necessary to take measures regarding the pandemic. Only a minority (10 students) estimated that their national answer was excessive regarding the nature of the virus.

The second question was related to the level of confidence of medical students regarding their competence and involvement as future health professionals in the pandemic control.

We asked the participants to rate this aspect of their medical education preparedness from a scale to 1 to 5, and the global average was 2.74/5

IFMSA International Secretariat, c/o IMCC, NørreAllÊ 14, 2200 København N., Denmark

3.

Students’ participation in the fight against CoVID-19

Answers were collected from students of 284 medical schools around the world. Only 36 of them were reported not to have involved their medical students in healthcare during the pandemic.

In 122 of the medical schools, only the students in the clinical stage of their studies and/or in internships were involved while 47 medical schools involved preclinical and clinical students or interns. It was unknown in 68 medical schools.

112 medical schools allowed students to get involved on a voluntary basis only, while it was mandatory in 52 medical schools, mostly as a part of their clinical rotations or internships. 8 of the medical schools that made student participation mandatory also proposed a voluntary involvement in some cases. The fast-tracking of final year medical students was confirmed in 7 of the responding countries and/or territories (Brazil, Catalonia, Chile, Colombia, Egypt, Singapore and Thailand). The mandatory or voluntary basis of involvement was unknown/not reported in 69 of the surveyed medical schools.

In 91 (37%) of the medical schools that involved their students, the students were not directly exposed to patients, but rather engaging in activities related to promoting awareness, call centers & helplines, and logistical assistance. While in 154 (62%) schools, the involvement included an exposure or possible exposure of students to any patient (medical assistance, testing, triage).

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

In terms of regional distribution, we noted that more than half of the medical schools from Asia-Pacific (67,4%), Eastern Mediterranean (65,96%) and European (77,96%) regions respectively involve medical students in the response plan against CoVID-19, regardless of the format. While 46,88% of medical schools from the Americas region reported an involvement of medical students, only 28,57% of the medical schools who participated from the African region report students’ participation in the fight against CoVID-19.

4.

Students’ risk exposure during CoVID-19

From the former results of our report, we have seen that students are/were participating in the fight against CoVID-19. In this section, we are going to look at the risks for those who have encountered, by questioning their involvement in healthcare facilities, awareness and providence of protective measures.

Starting with our first question, we wanted to know In which of these types of healthcare facilities medical students are involved?

Out of 411 responses, 221 are stated as they are actively involved in some levels for the fight against CoVID-19. 67.8% of the students were in the medical units, while %58,3 of

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

them were helping in the outpatient clinics. We see that nearly half of the students (48.4%) worked in the Emergency level, including triage, first examination and interaction with patients however, 44 of them worked in the Laboratories which have no interaction with the patients. 13,5% of the students stated that they are working either in call centers, public health facilities or homecare services.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Second question was asked to understand how students are aware of the personal protective measures that need to be taken by them. In order for that, they were asked to give points to some of the example measures and use of equipment. * (1= I’m not aware of any hygiene protocol nor how to use the personal protective equipment - 5= I feel confident following the hygiene protocols and using the PPE)

From the points that were given to the first question, we can see that 174 out of 411 feel confident following the hygiene protocols and using the PPE. Also for the last question, 47 of the respondents have given 1 point for their awareness of disposable gowns which meant they are not aware of their usage or their involvement in hygiene protocols.

In median: 34,5% - 5 points, 31,1% - 4 points, 19,5% - 3 points, 8,9% - 2 points, and 6% 1 point

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Finally, we wanted to see how these protective equipments were provided from the respective healthcare facilities, which are supposed to limit the risk exposure of CoVID-19 to the students.

*(1= Unprovided for medical students 5= provided in sufficient quantities N/A= not applicable)

As we scroll right to the chart, we can see that the more complicated, expensive the equipment gets, the less they are provided to the students. 102 of the responders pointed as their hygiene protocol was provided in sufficient quantity while 36 of them pointed as the same for disposable gowns. It is not very different for the gloves, masks and the glasses too.

39 of them pointed as the single-use gloves are not provided for medical students however the number increases 2 times with the unavailability of the protective glasses.

IFMSA International Secretariat, c/o IMCC, NørreAllÊ 14, 2200 København N., Denmark

Our respondents were asked whether there is an official protocol/statement or policy that outlines medical students’ involvement in the outbreak? Nearly half of them (47.9%) are not ‘protected’ by an official document, while 19.7% are not aware of this issue.

Merely ⅓ (32.4%) of them have clear directions on their role during the pandemic.

As highlighted in the previous answer, half (55.9%) of the medical students who answered the survey don’t benefit from a protocol/statement which should guide them during the outbreak. However, for the others, this ‘opportunity’ came mostly from their governments (20.4%) or medical schools (13.6%). Less than 5% had those roles outlined by their NMOs (3.9%) or other students’ organizations (3.1%). In the remaining 2.6% cases we are talking about a mix effort of those aforementioned; sometimes, hospitals or student councils were also involved.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

In terms of compensation for their services, the majority of students (44.2%) don’t have any benefits. Only 15.3% of the students receive monetary support, while half of the later (7.1%) have some extra credits added to their GPAs. 3.8% are not aware of their incentives. 0.9% of the cases have some different experiences: either the number of mandatory shifts is reduced by half, either the involvement is counted as internship or as some practical hours.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

5.

Medical Education during and after the pandemic

In this section, results were provided from the responses both to the IFMSA Survey about the Impact of CoVID-19 on Medical Education and The IFMSA Medical Education Tracking Sheet during the CoVID-19 Pandemic.

2761 medical schools from 103 countries were analyzed based on the tracking sheet, and 2614 medical schools from 95 countries have reported a complete suspension of the delivery of the educational program of the year in physical settings, out of which 1120 medical schools in 66 countries were reported to switch to the use of an online platform for delivering the curriculum.

If the previous question was responded YES, what was the methodology they’ve used?,

The options for this question involve, online lectures, small group teachings, clinical case discussions, tutorials, online simulations.

The vast majority with 275 out of 391 responses, were online lectures, followed up by clinical case discussions (141) and small group teachings (124). 64 students responded as none, which resulted as 16.4% of the students.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Aiming to see online platforms used in the quarantine, What kind of platforms are used in your universities?

While more than half (55,7%) of the universities are having their education in their Private Platforms, Publicly Available Platforms and Other platforms are also used frequently. Google Classroom, Zoom, Microsoft Teams, Skype were given as an example for the “others” section with 13.8%, respectively.

To follow up on that, , we asked them to rate the quality of the teaching methodologies used online from one to five. (1: very poor - 5: perfect - N/A: Not applicable) Looking at the chart, the first thing we noticed was that the response “N/As” were quite predominant in 4 teaching methodologies, namely Small Groups Teaching, Online Simulations, Clinical Cases Discussions, and Tutorials, which is due to the fact that lectures were predominantly used as the main teaching methodology online. Moreover, the level of satisfaction in relation to each teaching methodology was above average, as the quality for online lectures was averagely rated 3.4 out of 5 points, followed by small groups teaching rated 3.03 out of 5 points and clinical cases discussions 3.02 out of 5, and lastly tutorials rated

2.95

out

of

5

and

online

simulations

rated

2.7

out

of

5.

Our last question was, regarding assessment, how has it been adapted?

This was the most diverse response we got for this section. Although 45% of the stated no plan for exams has been shared yet by the time of this survey, 127 students out of 411 responded as their exams will take place online. 88 students responded as their exams will be held physically after the quarantine while 31 selected that their exams will also be physical but within an adaptation to social distance rules.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

Recommendations: 1. Medical students role during the pandemic: •

Competency preparedness :

According to AAMC (Association for American Medical Colleges), “clinical skills education in the undergraduate medical curriculum is fundamental to the development of basic clinical methods and the lifelong achievement of excellence in clinical practice.” In simpler words, in our medical curriculum we are supposed to be taught a series of competencies or “the ability to do something successfully and efficiently”.

In this section, we will summarize 411 international medical students’ opinions on how they should be better prepared if similar situations occur, either pandemic or remote education.

Regarding “What measures would you want your medical school to take to restore/supplement the missed period?”, our respondents tackled a wide range of aspects, from financial issues, to administrative management of medical schools and online teaching & learning. The majority of students (59%) are satisfied and agree with the remote education practices they undergo, seeing them as an optimal solution for the time being. Approximately 24% of the students are willing to give up their vacations or weekend days to recover the missing classes, while some of them believe extra weeks or extra hours before resuming their physical attendance should be a good alternative. A solution proposed by few of them is to completely freeze the remaining school year and resume it once the situation permits. 3% of the students experienced some resourcefulness distress, and they requested for free access to online materials or better internet connection. 14% of those who answered the aforementioned question offered their aftermath options, stressing on the importance of clinical practice, maybe more intensively done, for after quarantine/restrictions end. However, the most predominant problems raised here are the lack of teachers’ expertise in offering online teaching or not enough materials offered.

220 students answered the question “Does your medical school have any good approach to education during the pandemic that you would like to share?”.

Unfortunately, almost half of them (48%) believe their faculties don’t offer the required support, while other 4% are not aware whether some models of good practice exist or

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

not. Approximately 40% of the students receive appropriate online education, with more attention given to epidemiological, infectious diseases or respiratory studies. 8% of the respondents share some particularities of their stories- some of them are in constant communication with their teachers for solving the issue of ‘education put on hold’, whereas some faculties eased the financial burden of their students. In some cases students are fully responsible for an awareness campaign on COVID-19, while in others, faculties are in charge. Mental health is also approached differently between medical schools, for some of them being a focus, while students from the others experience increased issues in this area.

Exams are either completely shifted to an online setting or they will be held in the classical format once this will be allowed. In some cases, final year students are frontline workers.

About “How do you think your medical school should be better prepared, should another pandemic occur?”, we received plenty of ideas from our respondents, which proves again the accountability of medical students. More than half of the students (54%) wish for better implemented online platforms for teaching and learning, emphasizing again on how valuable is teachers’ training in an online setting. Resources (materials, recorded videos, simulations) should be made available and easy to access at any time given, and finer teacher-student interaction is recommended.

21% of respondents believe education should be focused on how to manage a pandemic, whether it is about theoretical (in the form of books, lectures, manuals, guidelines) or practical (on-site experience) knowledge. Some of them raise the point of insufficient PPE in the medical setting and call for medical schools’ laboratories to be accordingly equipped and used in similar situations. Last but not least, they reiterated the significance of population’s well-being, following official safety measures and protocols and increasing awareness about public health.

18% had wider perspectives, such as - how a faster administrative response reduces the mental distress of medical students, and how substantial is the communication between medical faculties - students vs governments - general population, calling out for support for medical students’ organizations which take action in disseminating information, elaborated contingency plans and collaboration between medical faculties. Only 5% of the students were satisfied with the level of preparedness of their medical schools and 2% are still unsure on what can work better in a similar situation.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

•

Protecting medical students from the risk of infection

As stated in the survey responses, medical students showed different patterns of involvement in the fight against COViD19 with variations in involvement rates and fields of involvement.

Due to that, students were exposed to risks according to the healthcare facilities they are involved with.

Each of those domains has its own risks of exposure that could lead to infection cases among the medical students present in that facility for both voluntary or mandatory reasons as well as the initial health workforce in the facility.

As a result of their high-risk working conditions, students must be protected and compensated

for

their

service,

regarding

the

Personal

Protective

Equipments

(PPEs), students’ showed good levels of awareness in terms of usage, safety and disposability as the figure displays.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

On the other side, healthcare facilities and institutes showed dissimilar patterns for their measurements and procedures to limit students4 exposure to CoVID-19 during their education and service as reported by the students.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

2.

E-learning in quarantine and Medical Education: •

Achievements and feedback on e-learning:

E-learning is the act of including technology in educational processes. It differs, for example, from distance learning, which means that the educational process is happening remotely.

The use of technology has been widely debated for decades, but, currently, it is more debated than ever. It brings different approaches to education and has come to show many positive sides.

•

It allows uniformity in the process, once the available information is the same for all students;

•

Students are able to pick the best place to use technology and the most suitable time of the day, which also fits well the principles of andragogy (which is how adults learn), by giving students independence.

•

Students can be anywhere in the world, as long as they have internet;

•

It's a time saver for teachers, since the recorded content can be available for more than one class.

It is also important to use a learning management system (LMS), which allows both students and teachers to improve their organizational skills. The teacher can also upload various different links in the learning content area, allowing students to seek for further information immediately after the class, if they please. Learning management systems can also ease communication, with the use of chat rooms and discussion boards. Assessment tools can also be built up on these systems.

Nevertheless, since there are also difficulties with e-learning and distance learning, it is necessary to state some good practices.

•

Students and teachers pick and test different systems together, making a final choice together as well.

•

The course plan has goals to be achieved and it is clear for students what outcomes are expected of them. Unclear instructions will be very harmful to the motivation of students, and it can also generate confusion, which will be a stressful factor for both teachers and students.

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark

•

Videos are often more attractive than texts and also help diminish distraction.

•

Participants’ feedback is very important, once it helps enhance the weak spots of the educational process.

•

Drip-feeding content is also a good practice: it means scheduling the content delivery for modules or lessons. When students be are granted content in segments, it helps assure the clarity and structure of the content being taught.

•

E-learning is different from distance learning, and everything is different from trying to teach and learn in the middle of the pandemic. Therefore, the strongest recommendation is that it is acceptable to not do things 100% perfectly; after all, quarantine is about a world crisis. Caring for students' and teachers' mental health and the constant reminder that everyone is going through this together and on the same side are vital practices during these hard times.

•

How do medical students envision Medical Education beyond the quarantine?

This pandemic has turned the world of medical education around, and has forced the system to adapt, innovate and deliver. As our previous discussion highlighted the strategies that have been adopted globally, we must not forget to address the efficacy, acceptability and sustainability of such learning solutions. The most pressing question is, what happens when all of this is over? How sustainable is this adaptation, can these solutions survive the test of time, how will they be accepted when “routine” life resumes?

Through our survey, we were able to elicit the commonalities, while appreciating the diversity of the vision students have globally. The common end goal remains to be the same - to become good quality doctors, with adequate and appropriate training. Another commonality is that students globally want adequate clinical training and patient interaction before graduation. We can all appreciate the relevance of these statements as we know that the true outcome of any medical education system is the quality of doctors it produces, and in order to maintain the highest quality of professionals, we cannot compromise on the training.

Students, however, face different challenges globally, which affect their approach towards

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their medical education. In some parts of the world we have students wishing for an extended year, a repeated semester to ensure desired outcomes from the academic year, while in some parts we have students wishing for an accelerated graduation in order to be able to serve the communities quicker. Prioritizing topics, re-enforcing the imminent health needs of the communities, the need for newer interns and doctors being introduced into service,

are

a

few

areas

which

the

students,

again

have

consensus

on.

Online lectures, demonstrations and e-learning resources have taken precedence over any other learning methodologies, and are being well accepted by students, provided that the para-educational technicalities, including internet access, fee for the curricula, technological training of professors are being catered to as well. What we have assessed from this situation is that we have plenty of existing resources, and thanks to technological advancements we can adopt such innovations to supplement our routine medical teaching. While there is no substitute to patient interaction, real life practice and on ground clinical teaching, we can always supplement and strengthen our training by maximally utilising these online tools. They save time, effort, and are increasingly innovative, thus ensuring increased interest and motivation amongst students. These solutions also help reduce costs of medical education while providing an added dimension to medical training!

The system definitely needs to be revamped, needs to become more flexible, and will probably face the ripples of this pandemic for years to come, we however can benefit from this if we come together to realise and act upon our vision of medical education.

Conclusion: As a conclusion, the resilience of any system is defined by its ability to adapt to the needs of those within the system and the environment we coexist in. Students forming a crucial component of medical education systems, become increasingly important stakeholders while the system is revamped and redesigned. As student leaders, we recognise the imminent need to inculcate a student perspective while developing learning solutions, to ensure that systems

remain

accountable

while

maintaining

good

outcomes.

A transformation of the medical education system has been long due, and there is no better time than now to strategize, innovate and work together to build a system that achieves a middle ground in terms of innovation and hands on medical training, that not only helps us

IFMSA International Secretariat, c/o IMCC, NørreAllÊ 14, 2200 København N., Denmark

during,

but

also

improves

our

training

beyond

the

pandemic.

“Education is what survives when what has been learned has been forgotten - BF Skinner”

IFMSA International Secretariat, c/o IMCC, NørreAllé 14, 2200 København N., Denmark