Impact of the COVID-19 pandemic: The perceptions of health professions educators

This article was migrated. The article was marked as recommended. What are health professions educators doing during the COVID-19 pandemic? A search of articles in MedEdPublish on the topics of COVID-19 revealed 39 articles published in the first 3 months of the pandemic. Topics included curriculum adaptation, guidelines for using technology, assessment adaptation, impact on students, faculty and career development, and conference adaptation. There was significant overlap among articles, particularly those discussing teaching, learning, and assessment practices. Common themes were adaptation, innovation, remote delivery, flexibility in the face of a pandemic, and how to continue to educate and graduate competent health professionals. All articles were descriptive, and none included data describing efficacy, likely due to the short timeline since the pandemic’s inception. Additional study is necessary to produce evidence for the teaching and assessment adaptations described. Some changes are likely to persist longer-term and may outlast the pandemic itself.


Background
The COVID-19 pandemic is a major event that has disrupted almost all aspects of life since January 2020.Health professions education is no exception, because it operates within the healthcare system, universities, and the broader community.Health care has had to switch rapidly to focus on both public health prevention strategies and the acute care of patients with serious COVID-19 infections.Education providers, like all sectors of society, have been subject to community-wide strategies introduced to limit the spread of disease.Additional personal hygiene requirements, social distancing, and restrictions on mobility and travel have resulted in community 'lockdown'.With fewer patients, clinical teachers, students and professional staff at teaching campuses, all teaching, learning and assessment activities are affected.On-line content delivery has increased, clinical placements have been suspended or altered and assessment practices have had to change.
One additional change evident to editors of medical education journals is that academics seem to have had more time to write about their experiences.This journal has received substantially more manuscripts than normal.About 5 months into the pandemic, we have published 38 papers with either 'COVID-19' or 'pandemic' in the title or as the main subject.Contributions have come from a wide range of participants, including those in leadership roles, teachers, examiners and learners, and from many nations.MedEdPublish may be particularly suited to provide a window on what is current, because the journal has a relatively rapid publication cycle and publishes all manuscripts that meet ethical and formatting standards (about 90% of all submissions), allowing the community of practice to decide their value (Hays, 2016).We prioritised the processing of these papers because of the high level of interest in ways of responding to the major disruption.The result is a compilation of early papers that describe how health professions educators managed through the initial stages of this evolving crisis, allowing a synthesis to be made of responses to the disruption.Here we provide a brief summary of strategies reported around the world.

Method
A search for articles on the MedEdPublish website was conducted using 'COVID-19' and 'pandemic' as the primary search terms in the fields of 'title'.The date of the final search was 30 th June, almost exactly 3 months after the first COVID-19 article was published on 23rd March.While the closing date is arbitrary, the period spans the initial outbreak of the pandemic and the rapid responses to the global disruption.A simple descriptive analysis was conducted to categorise articles by type and broad topic content, focusing on strategies for adapting to challenges, rather than simply describing them.All of the articles were set primarily in medical programs, with five including an interprofessional viewpoint across health professions' education programs.Each paper was subjected to a 'light touch' thematic analysis to understand the common topics discussed in the health professions education community as the pandemic unfolded.

Results
The 38 articles were spread across categories -'Personal view or opinion piece' (15), 'Practical tips and/or guidelines' (13), 'New educational method or tool' (6), 'Letter' (2) and "Case study' (2).None were research papers, probably reflecting the short time frame from action to publication.Many articles covered more than one topic, particularly the more general overview articles.For example, the use of technology was commonly mentioned in adapting most teaching, learning and assessment activities.The most common topics were the use of technology (28), curriculum or assessment adaptation (26), impact on undergraduate and postgraduate teaching (17), faculty and/or career development (7) and conference adaptation (3).The summary data for the articles and letters are presented in Table 1.
There were examples from several schools in different countries that documented how faculty responded quickly and successfully to adapt to the rapidly evolving situation.Approaches were similar, and there has not yet been sufficient time for institutions to evaluate the impact of their interventions.The key to success appeared to be leadership and communication involving all stakeholders (Samarasekera et al., 2020).Lectures are now online, the use of simulation has increased and strategies for reducing the mixing of patients, students and staff for teaching and assessment are being developed.A common view is that health professions' education will continue to use these strategies, at least to a substantial extent, even after 'stability' returns.
Technology use.Several articles addressed the need to scale up technology use, both using existing software and developing new software.Challenges for lower income countries were acknowledged (Cecilio-Fernandes et al., 2020), and the differential access to infrastructure between nations was explored.Faculty and students' access to and proficiency with technology was also noted as being heterogenous.Authors provided practical tips about the use of blended learning with the right balance of synchronous and asynchronous online learning and teaching (Eachempati et al., 2020;Sanders et al., 2020).
Curriculum adaptation.Various degrees of blended learning, with some reliance on virtual learning environments, are now widespread and have probably allowed programs to continue, albeit quite differently.Almost all articles referred to  students having to rely more on online learning methods, which was more socially isolating.This seems to be more straight-forward for more didactic methods, as lectures are relatively easy to broadcast and team-based learning can take place in online 'rooms ' (Wong et al., 2020).Clinical teaching is much harder to adapt due to safety and narrower clinical workload.Placements were cancelled or deferred, except in some cases for more senior students, so innovation became essential.One interesting innovation is the use of simulated patients for communication skills teaching via live streaming (Sudhir et al., 2020).Virtual reality methods, where technology was available, were thought to be a potential growth area as part of a broader vision to extend the use of technology in medical education (Goh and Sandars, 2020:2).
Assessment adaptation.Arguably, assessment, particularly clinical assessment, has suffered the greatest impact.While there were only four papers on adapting assessment, common themes emerged.The strongest message is that the forced change in assessment practices is an opportunity to improve assessment practice into the future.Assessment may become more programmatic, more reliant on many more methods and assessment events, and less reliant on large, high-stakes events (Wadi et al., 2020;Sabzwari, 2020).The recording and monitoring of assessment may become more important, with more sophisticated technology to support e-portfolios (Alrafiae et al., 2020).While OSCEs can be modified to improve safety (Boursicot et al., 2020), will they continue at all, given the potentially high risks of transmission at crowded examination centres where patients, students and examiners from many places are thrown together?
Faculty/career development.Two more attributes seem to have been added to the list of desirable attributes for faculty members.One is a much deeper expertise in education methods, particularly those required to support remote teaching, learning and assessment (Kachra and Ma, 2020).The unrealistic expectation that teachers can be rapidly pushed online without support and training was explored by Fawns et al., 2020.The other is flexibility and a capacity to change education strategies rapidly (Shimizu et al., 2020).How to achieve this on a large scale is not addressed, although specific training in technology and managing disruption may become more frequent.The impact of surrounding community supports, such as childcare arrangements, public transport and the potential to maintain working from home are likely to remain prominent issues.
Impact on learners.Students at one school created an App that tracked rapidly changing information on COVID-19 to both increase knowledge about and protect them from the disease (Niburski and Niburski, 2020).Similar software was developed in many nations for both the professions and the general public.Postgraduate specialty trainees reported that the narrowing of clinical workload may have had a greater effect on their training because some services closed and clinical staff were re-directed (Johnson and Blitzer, 2020).The outcome may be a delay in completion in several speciality programs.There was also a report of volunteering of undergraduate students (and faculty) to assist in managing the heavy workloads (Mendes et al., 2020), and one of early graduation of final year students to support the workforce (Alexander et al., 2020).The 'rite of passage' of graduation ceremonies was maintained through live streaming (Blyth et al., 2020).
Conference adaptation.One article reported the rapid adaptation that had to be made with little warning to the Ottawa 2020 conference that was held at the beginning of March, just as the pandemic was taking hold outside of China (McKimm et al., 2020).Only about 30% of registrants could attend, and social distancing was encouraged.Plenaries and workshops switched to online presentations with international live streaming of questions and discussion.This appeared to work well, particularly for plenaries and some workshops that were discussion based rather than 'hands-on' practical in nature.The heroes were the IT team and participants who connected at very unfriendly hours.Another paper reported the conversion to online methods for an international conference held at the end of March, when the pandemic had progressed further.There were several hundred registrants in 20 countries and the most likely outcome was cancellation.Instead, organisers spread sessions over 4-8 weeks to allow for engagement through local and technology-mediated discussions while registrants continued to work (Margolis et al., 2020).These blended conference delivery approaches may become part of all future conferences.

Discussion
What has emerged from this experience of the most severe global disruption in about 80 years (the second World War may have been a similar scale) may best be described as shared experiences and similar responses, with some genuine innovations and a need for further educational development, evaluation and research.What lessons can be learned?Some changes to health care and health professions education may remain for some time, perhaps becoming permanent.Further global disruptions, although rare in terms of human lifespans, are likely at some stage.Other, less severe disruptions may be more common.Telehealth and telehealth professional education may become more common and important.
As interesting as this collection of papers is, we are left with a series of questions that need to be answered for the community of practice to thrive.Should all lectures be recorded without audiences and be available as podcasts and videos?Will some students demand seated classes as part of their educational experience?Will medical educators embrace the tools in their virtual learning environments to enhance the design and effectiveness of their online lessons?How sustainable are large, high stakes written and clinical examinations?Should we move to more frequent, smaller assessment activities of greater breadth?Although simulation and virtual reality will develop further, how can immersion in real health care be maintained?How can we remain in a state of preparedness and ability to respond rapidly to future disruptions?How will faculty development evolve?Will working patterns remain more flexible and, if so, how will this affect career development?Will large international conferences survive?How will professional networks develop and thrive if 'corridor' conversations and debates over tea or coffee cannot take place?An issue that pervades most of these questions is: what is the value of social interaction in medical education?
These questions form a substantial agenda for research and debate as health professions' education evolves.A quote from the business literature is apposite: 'Vision without action is merely a dream.Action without vision just passes the time.Vision with action can change the world' (Barker, 1993).

Limitations
This is a limited review of papers submitted to only one health professions education journal.All are self-report articles with no data or evaluation to guide judgments of effectiveness.The article therefore represents the thinking and responses formed on the run during a major global disruption, not a definitive review of how best to respond.

Conclusion
Health professions educators had to respond quickly to the re-focusing of health care and healthcare staff to a narrower clinical caseload with tight infection control measures in highly stressed health care systems.The surrounding, community-wide measures such as enhanced personal hygiene measures, social distancing and travel restrictions, made campus attendance almost impossible.Programs switched rapidly to online methods where the technology was available.Clinical learning was cancelled or deferred, and where possible replaced by simulation, with the assistance of virtual reality.Learning and assessment were disrupted, most severely for those nearing graduation and in postgraduate specialty training.Amidst this turmoil, some interesting innovations have emerged.There is need for evaluation and research to produce evidence that guides the adoption of innovation in future teaching, learning and assessment practices.The recent disruption is an opportunity to improve health profession education beyond the duration of the pandemic.This article has focused on questions that need answers, so the focus should now be on evaluation of adaptation strategies.

Take Home Messages
Health professions' education had to respond quickly to the rapidly unfolding COVID-19 pandemic

Normal business was not possible
Globally, responses appear to be similar The disruption has resulted in innovations that need evaluation Some of the changes are likely to persist as better ways are found Thank you very much for this timely article.This paper is extremely well written with a very high standard of English language.The paper provides a very valuable table with a collection of references of medical education experiences during the COVID-19 pandemic in medical education.The main themes of common findings that arise in the reference papers are well defined and described, giving an insight into some of the issues that have arisen during the pandemic crisis.There are a number of questions arise in the conclusion that could inform other medical educationalist researchers to initiate new investigations, researching into the future of medical education, including the evaluation of student experiences.Readers who are interested in viewing different medical education experiences and alternative methods of delivery will be able to search the table of references in this publication as a useful repository to seek new ideas.A small selection of examples of individual experience to highlight some of the generalized themes would be interesting to read.The addition of some educational theory background into curriculum design, assessment and the use of technology in medical education would have given a better contextual introduction to the paper.A table of the examples of technology and software used by the reference papers would be an extremely helpful addition to the paper.An example that highlights the most interesting practical tips that the author appreciated would be most appreciated.A description of a small sample of suggestions and examples of assessment methods that aim to improve or innovate the This review has been migrated.The reviewer awarded 4 stars out of 5 Thank you for summarising recent articles related to the COVID-19 pandemic in MedEdPublish.To help the reader, the authors may wish to put the methods section after the background section so the warrant for the review is clearly established before the methods are described.The sample of 39 articles produced six themes reported in the results.I noted that they reflect the challenges and opportunities that my colleagues and I have experienced at our medical school in New Zealand.The questions raised in the discussion will be useful to stimulate conversations with colleagues and help us to think about how we might design research study that evaluates the strategies we have adopted during the disruption to our educational programmes.
Competing Interests: No conflicts of interest were disclosed.

BALAJI ARUMUGAM TAGORE MEDICAL COLLEGE AND HOSPITAL
This review has been migrated.The reviewer awarded 4 stars out of 5 It's a great pleasure to read the commentary on the perceptions of health professions educators with the review of 39 articles published under Mededpublish.Authors are appreciated for publishing such a wonderful work.The technology use with adaptation towards curriculum and assessment to impact the learners is a great task for the past three to four months.Lock down periods were initially taken as a relaxation time for many of us but as gradually the days went on, we were forced physically/mentally to get adapted for the situation.The colleges/medical schools were closed for almost more than 2 months without regular personal classes and were transformed into virtual classes.The syllabus can be covered but how to ensure that the students have become competent.Online / Virtual classes can be taught but the assessment has become a bigger task especially after the implementation CBME from 2019 onwards under medical council of India.
& UAEThe assessment clock: A model to prioritize the principles of the utility of assessment formula in emergency situations, such as the COVID-More than adaptation: why we carried out faculty development on assessment in the middle of a pandemic X X MEP=MedEdPublish, TEL=Technology Enhanced Learning, UGT=undergraduate teaching and training, PGT=postgraduate teaching and training

Table 1 .
A summary of 38 articles published in MedEdPublish during the first wave of the COVID-19 pandemic.
Dr Julie Hunt, DVM, MS, AFAMEE is Medical Director of the DeBusk Veterinary Teaching Center, College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, USA.ORCiD: https://orcid.org/0000-0003-1927-432XKerrieMcKay,BA(Hons)joined the Association for Medical Education in Europe in 2015 as part of the AMEE Secretariat Team based in Dundee, Scotland.Her primary role, as the MedEdPublish Administrator, is to support all aspects of the journal, including the Editorial Team, Editorial Board, Reviewing community and Authors.Kerrie was specifically involved in the processing of COVID-19 related manuscripts for this article from submission through to publication.Reference Source Mendes Chiloff, D., Muniz de Freitas, V., BorgesCardin, N., Bianchi  Matiuzzi, C., et al. (2020).Volunteering in medical school during the pandemic: a solution for teaching.MedEdPublish.9, [1], 114.Reference SourceMohammed Sami Hamad, S.,Iqbal, S., Mohammed Alothri, A., Abdullah Ali  Alghamadi, M., et al. (2020)."Toteach is to learn twice" Added value of peer learning among medical students during COVID-19 Pandemic.Goh, D. L. M., Yeo, S. P., Ngiam, N. S.P., et al. (2020).Response and Lessons Learnt Managing the COVID-19 Crisis by School of Medicine, National University of Singapore.MedEdPublish.9, [1], 92.Reference Source Sandars, J., Correia, R., Dankbaar, M.,de Jong, P., et al. (2020).Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic.MedEdPublish.9, [1], 82.Reference Source Shimizu, I.,Mori, J. and Kanno, H., (2020).More than adaptation: why we carried out faculty development on assessment in the middle of a pandemic.MedEdPublish.9, [1], 105.Reference Source I liked very much this article.Thanks for great summary of 39 articles about covid impact.The article is very well written with a good English.It provides excellent summary points with detailed tables and collection of references of medical education experiences during the COVID-19 pandemic in medical education.Conclusion part arises new questions and directs the readers to new researches.For example, the situation of medical education specifically poses an additional challenge during the pandemic, as this is a curriculum that is greatly based on clinical practice in many faculties.The question arises in my mind to what degree this situation affected medical students in clinical training as future physicians, as essential components of practical knowledge will not be available to learn via distance learning.Thanks for great job!
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Good work by the authors.It's worth reading this commentary.Thanks Competing Interests: No conflicts of interest were disclosed. https://doi.org/10.21956/mep.19140.r27662