Reflection on the effect of COVID-19 on medical education as we hit a second wave

The COVID-19 pandemic was declared in March 2020, following the report that the world has breached the 100 000 bar of new cases. The news has caused world-wide havoc leading to spontaneous, rigid measures to contain the infection and reduce the impending burden. The impact of the COVID-19 on the health and economy has been significant, leaving deep scars in the lives of many people. However, medical education has faced the brunt of the outbreak in similar ways. Although the immediate effect appears negligible, it is bound to impart important implications on students, teachers, the health system and community. While some countries seem to be coming down the peak, the global infection rates and mortality rates are creeping up. However, there is a lack of global consensus on what lies best for students and communities. Each country will have to propose their authentic strategies to continue high standard medical training. The recovery phase takes time and effort, re-structuring education and catching up with lost time might need to be prioritised. In this review, we discuss in-depth the implications and potential outcome of the pandemic on medical education globally, and analyse the impact on COVID-19 infection on medical education.


Introduction
COVID-19 has been in the limelight over the last few months, dominating all the headlines.The outbreak which started as a mere epidemic in the Wuhan City, Wuhei Province of China, has progressed into a major pandemic contributing to millions of cases and hundred thousands of death across the globe (WHO, 2020).By August 2020, the number of people affected by the novel coronavirus (SARS-CoV-2) has exceeded 23 million people, with more than 800 000 deaths across the globe.The pandemic has imposed an unprecedented global burden.While the impact on the health system and economy (Ozili and Arun, 2020) are deeply felt, lateral implications cannot be ignored.For instance, the burden of psychological distress (Wang et al., 2020) (Kontoangelos, Economou and Papageorgiou, 2020) and bearings on education are already the competing themes.Hence, it is crucial that education providers scrutinise the immediate and long term implications in their respective domains and design policies to minimise the detrimental effects that this pandemic might have on students.
Primary and secondary education have deviated abruptly to online and distance learning to facilitate continuity of the curriculum (UNESCO, 2020b).Higher education has also followed the trend and all full time courses have been transformed into online classes through platforms such as google meet and zoom.While the short term solution has proved to be effective in completing course content and delivery of classes, the long term outcomes might remain questionable.Consequences can be worse than currently envisaged as students missing school have worse performance compared to students who have not missed schools (Gottfried, 2011).The detrimental effects can further accentuate the disparities related to poverty in some countries, where access to technology remains a luxury.In the United States, it is that at least 14% of children still do not have access to internet.
While the stakes of primary and secondary education are looking grim, higher education is at higher risk, especially for medical education.In several countries such as the United Kingdom, United States and Italy, final year medical students have been promoted directly to work places to support the front line workers.Newly qualified doctors need constant shadowing and supervision, which might be limited in the current state.On the other hand, start line prospective medical students are being diverted to different fields such as public health for a year in the same optic of enforcing the capacity of the health system (Bauchner and Sharfstein, 2020).Countries are constantly innovating their approach to consolidate the medical workforce.These decisions are being welcomed by health care providers in this predicament, but pedagogical experts might be sceptical about the benefits conferred through such an abrupt transition to medical education.

Teaching in medical education
Medical education is a complex system integrating informative sessions with clinical training to prepare next generation of medical practitioners with the prime motive of delivering high standards of care to patients, meeting the evolving societal needs (AAMC, 1998).Improving patient satisfaction through high level communication skills and up to date treatment has become the norm in most countries (Prakash, 2010).The society expects high levels of professionalism from doctors (Kirk, 2007).While the definition of professionalism differs widely, one of the key facets is clinical excellence.We seem to be breaching this norm by shunting students prematurely ahead without the same high level of teaching that takes years to be drawn, designed and implemented.The rapid transition to online education has not been adequately tested.Online teaching takes a minimum of nine months to prepare and implement.Conversely, the COVID-19 outbreak led to the migration of face to face classes to a different medium that is aligned with the social distancing policy and confinement (Hodges et al., 2020).This strategy has enabled the continuity of most educational sessions, while reducing the risk of the coronavirus transmission.However, the teaching of professionalism takes place in the clinical setting basis, where students learn by doing and through reflection and feedback.However, the absence of this particular intervention for even a few months might be taxing on medical education.Although remote learning is enabling course continuation, it is far from ideal when learning soft skills such as professionalism, time management and inter-personal skills.Unfortunately, even virtual reality and simulation is unable to cater for these skills.
The lock down has led to major disturbance to the educational system globally with a knock on effect on the future academic years (Burgess and Sievertsen, 2020).Several implications have been noted including disruption of the admissions procedures, interference in the running of classes and the conduction of summative assessments.While most institutions have promptly adapted to the demands of the situation by converting to online classes and assessment, there remains the dilemma of uncertainty when it comes to long term arrangements in medical education.Experienced and resourceful schools are treading through relatively much ease compared to schools from resource limited countries.The priorities of the healthcare system have temporarily shifted to primarily saving lives and prevent infection life during the crisis.Saving lives have been negotiated against quality of care in several countries, due to extreme load of casualties impinging on the demands, neglecting the educational needs of medical students, who are already baffled about future prospects and the temporary intervention applied to bridge the gap.Although digital learning has been present for a while and is infiltrating all domains of education including medicine, its application in medical education is fairly sparse and optimised by few resourceful colleges who can afford state of art technology.
Containment has forced medical students to learn from their homes.Educationalists have devised remote learning approach even in clinical surgery and anatomy by providing daily video conferences through case discussion (Moszkowicz et al., 2020).Clifton et al., (2020) on the other hand encourage the use of simulation based learning to promote anatomy and surgical teaching during confinement, as a cost-effective method.However, a large number of medical institutions still have no access to simulation labs.But, Khalil, Abdel Meguid and Elkhider (2018) have previously reported the multiple benefits of blended learning that counteracts the limitations of setting up expensive, high tech labs.Longhurst et al., (2020) discussed the urge to adapt the curriculum for anatomy teaching that will spontaneously switch to remote mode during times of confinement and lock down, with the impending second waves in various countries.A preparedness plan for higher education need to be considered in view of similar future events, limiting the disturbances imposed on medical education.

Medical curriculum
The series of events that have prevailed over the last few months make us ponder as to whether our medical curriculum has rightly prepared the medical force for such an event.Due to stability in the health sector over the last century, with recurrent small epidemics being successfully conquered through simple strategies, the medical curriculum has focussed on chronic care, while acute care remains embedded in the curriculum (Mishra, 2015).Emphasis has been laid importantly on chronic disease management, communication skills and patient centred care.We thus query whether the medical curriculum has been geared to address major public health emergencies such as pandemics or outbreaks.Over the last two decades, the world has witnessed three major epidemics including the Severe Acute Respiratory Syndrome (SARS), MERS (Middle East Respiratory Syndrome) and COVID-19, which have claimed many lives.However, the emergency response remains slow, erratic and without consensus.It warrants reflection if the devastating effects of these outbreaks could have been prevented with early intervention and ample preparedness.Global health organisations such as the WHO and International Health Regulations have published several guidelines and protocols which have proved to be futile to avert such a crisis.It is high time that medical educationalists analyse the evidence and propose essential change to the medical curriculum that gears doctors with essential public health skills at all levels to organise early interventions in response to outbreaks.It suffices to reiterate the degree of public health in medical and paramedical curriculum might not be enough.

Medical placement
The whole world has come to a standstill with this high raging infection that has appeared with no warning and a force that is gobbling away the global population and world economy with potential lingering psychological burden.In this battling moment, it is urged the forces be combined to fight the powerful enemy.Public health authorities are fighting hard to consolidate the capacity of health workers confronting this outbreak, but medical student have been left behind.Their medical placements have come to an abrupt halt in many countries, leaving students and educators confused as to what is the best approach to minimise the harm of being deprived from clinical placement (Hjiej and Fourtassi, 2020).Australia has taken a different stance by ensuring students continue their clinical placement and use the outbreak as an experiential learning process.All necessary precautions have been taken to ensure the safety of both the students and the patients.The exposure does not only shape the learning process but also prepares the students as prospective health workers in case the situation deteriorates further (Halbert, Jones and Ramsey, 2020).It is anticipated that with the re-opening in many countries, clinical placement will take over.However, some colleges will struggle to re-instate students in placements due to other upcoming cohorts.Additional resources will be required to fill this growing gap in the training and career lives of medical students.
The outbreak of SARS presented with a similar calibre, but with a lower fatality rate (World Health Organization, 2003).However, the SARS epidemic was conquered quicker, leading to the mere suspension of a number of activities, including trade and education.Patil and Chan Ho Yan (2003) narrate the journey of medical education during the outbreak of SARS.The contingency plans undertaken to enable continuity of medical education included the provision of protective personal equipment (PPE), tele-conferencing, and hand hygiene.Centuries have shown the importance of clinical placement in medical education and it has made a firm place in the medical curriculum (Alhaqwi and Taha, 2015).Interestingly, a medical student recovering from SARS, describes how thrilling the whole experience of living the outbreak has been for him.Canada was however very strict during the SARS outbreak enabling limited access to unnecessary staff and students in teaching hospitals (Clark, 2003).The reasons for such a decision beckon the safety of students and patients, but also other issues such as cover and insurances.It was deemed that the risks of contamination outweighed the benefits of clinical placements.Lim et al. (2009) concur that it is imperative to balance the risks versus benefits during students' placement.The advent and integration of technology in medical education has facilitated the replacement of live education by simulations, which have been found to be equally effective, more so in times of outbreaks and pandemics.
Rose, (2020) argues that asymptomatic students might become carriers and propagate the infection posing a risk to patient safety.While basic medical science teaching has been promptly transitioned to virtual classes, including group discussion and case based learning, the options for clinical learning is somewhat limited.There has been reported geographical disparity in the decision making with regards to clinical training of medical students.Lack of PPE and the potential risk of infection contraction and transmission have contributed to pausing the clinical training in several countries, while some medical schools have adopted the stance of delivering clinical training through virtual systems.However, the efficacy of such a system remains to be proven.
The short term impact of medical practice might seem grim, if a year or even less of medical education has been altered and students are provided sub-standard training affecting the clinical practice in later years.The suggestions are thus pointing towards the integration of medical students in the current force to provide support to skeletal staff as well as perpetuate learning motives.Educators across the world have diverse opinions as the best stake in such a circumstance, due the ethical dilemma that such a situation has conferred.
The Association of the American Medical Colleges are supporting medical trainees and trainers through an array of useful virtual resources such as links, repository, advice and webinars on COVID-19.Johnson and Blitzer, (2020) meanwhile present their perspectives on the negative implications of COVID-19 on graduate medical education.They show deep concerns regarding the effect of halting the training of medical graduates in the United States on future provision of a healthy medical workforce and discuss the same dilemma of stopping production of high demand products, which is likely to leave a scar on the health system.They also discuss the running of medical training in other situations of crisis such as the major hurricanes that had attacked the country.The authors have compiled a list of innovative approach to mediate the prompt resumption of graduate medical training such as virtual patient interaction, simulation for procedural domains as well as virtual reality options.Similar approach has been advocated by UK educators with the implementation of online classes through telemedicine as well as opening access to virtual patient cases, that might be an alternative for clinical placement (Mian and Khan, 2020).While developed countries might be well equipped to put in place such innovative technology based systems, developing countries get wound up between resource limitation and political decision making before any progress could be made.
Similar concerns have been portrayed by Ahmed, Allaf and Elghazaly, (2020), where authors report rising incidence of COVID-19 in teaching hospitals, putting at risks patients and medical students.While the medical force has an obligation to continue the delivery of the services despite major crisis, this does not apply to medical students, who are still shielded and not contracted to maintain clinical activity.They have been reported to be at risk as well as pose risk to others.Further, with intense competition to get PPEs, medical students remain at the bottom of the list again as they are not providing any services, and require constant supervision.In this demanding situation, where time has become vital, there might not be flexibility to include students in discussions and teaching.But at the same time, we have to think about behavioural learning stipulating that students could learn through the role models and observation.Miller, Pierson and Doernberg (2020) are refuting the decision that medical students should not be allowed in the hospital premised during the covid-19 outbreak.While students need shadowing and supervision, senior students have proven to be valuable in instances where the capacity of the workforce is being threatened.The several roles of the student include clerking of low risk patients, administrative low risk work, relaying of results and phone calls to patients.Some countries have welcomed the use of senior medical students through pre-poned graduation; however other countries have felt less confident to apply such measures despite workforce challenges.Multiple causes have been highlighted including lack of PPE, students being vectors of infections and liabilities.

Assessment in Medical Education
The ubiquitous nature of assessment makes the latter more complex during the pandemic of COVID -19.Students and educators have negotiated their way to the medical lectures, classes and placements.However, assessments have remained an unresolved dilemma.Some countries have cancelled examinations and relying on other less validated modes of assessment.Major examinations such as A-levels have also been cancelled or deferred.Medical education relies heavily on summative assessments, which account for performance assessment at the end of the semester or year.Multiple choice questions, extended matching questions, short structured questions are appropriate and reliable instruments in the testing of knowledge, synthesis and analysis.Observed Structured Clinical Examinations (OSCEs) on the other hand serve at assessing the clinical skills, attitudes as well as technical skills of the learner through simulation based interactions.Some examination bodies also use viva-voce to assess the communication skills and case based competencies (Norcini and McKinley, 2007).The COVID 19 crisis has averted the need to undertake clinical examination due to social distancing policies, which has made the conduction of examinations tricky.Most universities have thus deferred their examination till the end of lock down.
The American Board of Medical Specialities has suspended all the written examination during the outbreak and confinement.The implication of this decision is cutting down the resource that is most importantly required in times of predicament.While this option might be the only possibility at the moment, it will impact heavily on the medical workforce as well as contribute to unnecessary psychological distress.We, therefore again question whether summative assessments can be undertaken in a fair and equitable manner to reduce bias and ascertain continuation of training.Sabzwari, (2020) discusses the replacement of the conventional assessments with innovative assessments that can be embedded into formative assessments.The author focuses on competency based assessment, which is a deviation from the assessment of knowledge, skills and attitudes that have become contemporary.She elaborates on the use of virtual patients, log books and Mini-CEX to gather information on a learner's performance.Further, tools like videos and reflections can demonstrate the skills acquired by learners.All these forms of assessments are currently existent, but we are obliged to adapt to suit to their multi-purpose use.While the author discussed authentic ways to undertake assessment, this might not be feasible for resource limited countries.Virtual patient is a concept that has been used but not optimised till date, and there are still a number of reservations of its application especially among advocates of the conventional modes of assessment.However, admiringly Singapore managed to undertake their usual OSCE examination with administrative modification to adapt to the requirement of the current pandemic, meeting the social distancing standards (Boursicot et al., 2020).Several other institutions have adopted novel strategies to undertake summative assessments.Imperial college and King's college have pursued open book assessments migrated online to meet the assessment needs of students and colleges (Birch and de Wolf, 2020).
Knowledge based summative assessments are being considered through remote testing, where students are writing their examination under supervision, very similar to normal conditions.Students have reported that get used to takes around ten minutes, following which the environment feels normal (Murphy, 2020).Likewise the US National Board of Medical Examiners (NBME) have devised remote proctors to facilitate medical assessments in a fair and justified manner (NBME, 2020).While it remains important that assessments are undertaken, so students are not penalised and the medical force is not compromised, the ethics of conducting high quality examinations are still being debated.Students have moved back to their home country, which makes conventional oral assessments such as OSCEs very challenging despite the fact the all necessary arrangements and hygiene precautions are taken.Accreditation boards are regularly meeting and monitoring the evolving situation.But, fluctuating situations make decision making very tricky, as some countries are now facing second waves of COVID-19 outbreaks.
UNESCO on the other hand has not been able to produce a consensual guidance on the conduction of high stake examination (UNESCO, 2020a).While it was agreed that final year students need to graduate on time through the use of credible online assessments, it recommends that all non-final year students undertake formative assessments and online schooling.However, the UNESCO admits that students from poorer communities might be penalised due to poor access to essential teaching tools such as tablets and internet.

Discussion and conclusion
The COVID-19 crisis has been a race against time where efforts have been diverted to saving lives, putting a halt to everything else in the background.Among the different agendas that slipped in the background was medical education and assessments.Various opinions and experiences have emerged to help countries decide on the best course of action for their students.It seems that that there is not one size that fits all when coming to end of year assessments, but with the crisis of COVID-19 adaptations have been made to the detriments of several.
Teaching and clinical placements have been transformed in many countries into online.Virtual reality, medical simulations and video conferences have revolutionised medical education over the last few months.However, these teaching strategies need to be evaluated to draw robust conclusions on their effectiveness.While it helped continuity of curriculum, there is lack of evidence to demonstrate that the patient outcomes and health outcomes are maintained.However, situational analysis is bound to skew all outcome measurements with COVID-19.It is further established that assessments need to take place with minimum disturbance to the design, structure and assessment methods.While some assessments can be easily converted to online formats, others such as the OSCEs and oral examinations can be more challenging, especially for resource limited countries.Although a consensus cannot be yet anticipated, a most suitable alternative is recommended based on the availability of funds.The economic crisis following the outbreak is likely to affect future policies and strategic planning in education.Medical education is a costly entity and might feel the brunt of the economic downpour.

Take Home Messages
The impact of pandemics on medical education is consequent urging governing bodies to devise solutions and contingency plans to limit the impact of future outbreaks and pandemics on medical education.Medical education remains an important supply -chain industry to provide man power to the health system.Weak health systems need to have support and guidance from stronger systems to ensure delivery of care and medical education.
Clinical placement needs to be customised based on each country's requirement, but remains a necessity.
Assessments are important facets of education and need to improvised and included even in high times of crisis.

Notes On Contributors
Dr Abha Jodheea-Jutton is a primary care physician and lecturer at the University of Mauritius.As the coordinator and contributor in two major programmes at the University of Mauritius, she has experienced the impact of COVID-19 on the health system and medical education.