Continuing medical education during pandemic waves of COVID-19: Consensus from medical faculties in Asia, Australia and Europe

This article was migrated. The article was marked as recommended. Medical faculties have the responsibility to train tomorrow’s doctors and in a crisis face the challenge of delivering students into the workforce promptly and safely. Worldwide, medical faculties have faced unprecedented disruptions from viral outbreaks and pandemics including SARS, Ebola, H1N1 and COVID-19 which bring unique challenges. Currently there is worldwide disruption to medical faculties and medical education due to COVID-19. Despite close links with clinical medicine and the known risks of pandemics, many medical faculties have been caught off guard without pandemic planning in place, to deal with an exponential rise in infections and deaths, overwhelmed health services and widespread community risk of transmission. Assessing transmission risk of COVID-19 in teaching, clinical and community attachments and continuing medical education is paramount as medical faculties face subsequent pandemics waves. Consensus statements based on best available evidence and international expertise from medical faculties in Asia, Australia and Europe were developed to help guide the protection of staff and students, priorities on teaching activities and further educational development. Infection prevention, infection control, contact tracing and medical surveillance are detailed to minimise transmission and to enhance safety. Recommendations on teaching activities planning can enhance responsiveness of medical faculties to tackle subsequent waves of COVID-19 infection. A global approach and dialogue are encouraged.


Introduction
The initial alert of the novel coronavirus in Wuhan, China on 31 December 2019 and subsequent community transmission (Huang et al., 2020) was initially under the radar of many medical schools across the world.As epidemics erupted in Iran, Italy and transmitted across Europe, United States and globally, medical faculties had to respond rapidly to regional and national containment and mitigation efforts as well as ensuring the safety of medical staff, medical students and patients.The timing of COVID-19 pandemic had varying impacts on teaching and assessment arrangements in different countries and medical faculties.The COVID-19 pandemic is estimated to persist for many more months into 2021 with researchers suggesting episodic quarantine and lockdown as a possible strategy to reduce transmission until a vaccination is available and widespread (Ferguson et al., 2020).
Medical schools are now experiencing the impact of this on their curriculum planning and infection control measures in the longer term as they anticipate further waves of COVID-19 infections in the near future.In Western countries, approximately 10% of health care professionals have been infected with COVID-19 (Remuzzi and Remuzzi, 2020;Ng et al., 2020) health care facilities and intensive care units were overwhelmed, resulting in exponential rise in infection and deaths with a large national and regional diversity (Xie et al., 2020).In addition, clinical staff had to deal with inadequate or insufficient personal protective equipment (PPE), lack of ventilators and make difficult treatment decisions (Truoget al., 2020) resulting in ongoing physical risks and psychological toil with many cases of physical and psychological exhaustion as health care workers became infected, quarantined or unwell (Chen et al., 2020;Cai et al., 2020).This has and will continue to have a direct impact on capacity of medical faculties to provide teaching and assessments as well as the provision of experienced examiners.Many medical schools, noting previous infection risks to students during SARS (Patil and Yan, 2003;Clark, 2003) have suspended face to face clinical and community teaching as the pandemic evolved.Some schools have opted to forgo or postpone the final clinical examinations and graduating students early (Amante and Balmer, 2003;General Medical Council, 2020) and discuss whether to continue online learning into the next academic year.
Current knowledge about COVID-19 includes substantial pre-symptomatic and asymptomatic transmission (Bai et al., 2020;Zhang et al., 2020;Zhou et al., 2020) with an average 3 infections (range of 1.4 -6.5) from a single infection (Liu et al., 2020), although transmission rates can vary depending on the national and regional situation.COVID-19 has been shown to affect all ages but serious illness or death mostly occur in the elderly and those with comorbidities such heart disease, lung disease and diabetes (Emami et al., 2020;Guo et al., 2020).Main transmission routes appear to be by droplets transmission to close contacts or contact with contaminated surfaces, although in some circumstances, there is evidence of aerosol transmission.Emerginig information about infection risk and transmission of COVID-19 allows medical faculties to can make measured responses in optimizing staff, communications and infection control to better provide medical education particularly in clinical settings.As further pandemic waves of COVID -19 looms, a clear and thoughtful policy regarding infection prevention and control, prioritisation of class resumption and planning for further waves of infections will be required.Through the Global Alliance of Medical Excellence (GAME) is an international collaboration of medical faculties, consensus guidance from medical faculties in Asia, Australia and Europe in continuing medical education cover three main topics: 1. How to protect staff and medical students during the COVID-19 viral pandemic?2. What teaching and assessment activities should be prioritised?3. How can medical faculties evolve to enhance medical education for subsequent pandemic waves?

Method
A Pubmed/MEDLINE search was performed using 'severe acute respiratory distress syndrome' 'SARS' 'COVID-19' 'pandemic' 'pandemic planning' 'medical education' 'medical schools' 'medical students' as MeSH terms.Statements from the international Medical Associations (e.g.American Medical Association, British Medical Association etc.), Medical College Associations e.g.Association of American Medical Colleges etc.) and international medical bodies such as the World Health Organization and Centers' for Disease Prevention and Control were prioritized.In addition, opinion and perspectives articles of medical journals were also discussed to stimulate consensus.
Guidance was grouped according to WHO pandemic phase descriptions: Phase 4 -6, post peak and containment, delay and mitigation (World Health Organisation, 2020a).Phase 4 is sustained human to human transmission, Phase 5 and 6 are peak of the pandemic where there is widespread transmission.
Containment phase aims to prevent disease transmission by early detection, isolation, medical surveillance with contact tracing and screening e.g. in Hong Kong, Australia.Delay phase aims to slow the spread and lower and delay the peak of infected cases.Measures include social distancing, closure of schools and cancellation of mass gatherings e.g. in United Kingdom, The Netherlands and United States.The mitigation phase occurs once infection is widespread and optimises medical health care personnel and facilities to optimise care e.g. in China, Iran, Italy (World Health Organisation, 2020a).
All member institutes were invited to contribute and respond to statements and consensus was reached when agreement was reached in ≥ 75 % of all member institutions.Member institutions were asked to state the degree of agreement (strongly agree, agree with minor reservations, agree with major reservations, disagree with major reservations, strongly disagree).Statements, tables and figures which reached ≥ 75 % agreement (strongly agree, agree) were retained and a second round of revisions were made similarly by consensus.Details of member institutions who responded are detailed in Appendix 1. 3. Staff should triage their symptoms daily and only enter office areas if they are symptom free and use appropriate respiratory protective equipment such as the use of facial masks.The use of FFP1 or cloth masks should be used if available (World Health Organisation, 2020b;Department of Health, 2020;Feng et al., 2020).FFP2 /3 masks should be used in higher risk clinical contact areas, provided there is ample sample and hospital use has been prioritised.The wearing of facial masks will be influenced by state and national guidelines.

Recommendations
4. Regular updates regarding step up and step-down pandemic work arrangements should be communicated as far ahead as possible (Centers for Disease Control and Prevention, 2020a).
5. Medical schools should be aware of staff working in separate hospitals or units taking care of infected patients or patients with high suspicion of infection and minimise contact with other faculty staff and students to reduce the risk of infection to medical students.

Medical students
1. Effective communication is vital.Utilise effective modes of communication and connection with students e.g.regular liaison with class representatives and regular communications should be made to manage expectations as the pandemic evolves.Timely communication about surveillance, infection control and prevention can lessen anxiety.A named contact person or unit should be made available for student queries and assistance (Centers for Disease Control and Prevention, 2020a).
2. Low risk teaching areas e.g.off-site non-clinical facilities such as simulation teaching areas can be identified in advance as reserve facilities for use when there is limited community transmission and satisfactory containment measures.Additional infection control and prevention measures such disinfection, social distancing, small groups may be used to further reduce infection risk (Centers for Disease Control and Prevention, 2020a).
3. Careful consideration regarding which examinations are deemed essential is critical and the option of and feasibility for online assessment and should be encouraged e.g.remote testing using open book format to test critical thinking.If essential examinations are conducted on site during low risk periods of the pandemic strict measures including surveillance of examiners, supporting staff and students, triage, social distancing and regular disinfection are required (See Table 1).Resources for onsite examination will become limited in the mitigation phase.In this phase staff resources may be low and there is increased infection risk in patients and simulated patients and asymptomatic COVID-19 carriers.In this phase may need to be delayed or alternative/ online arrangements should be sought.As the pandemic evolves, there is a need to step-up and step-down infection control measures.3. Sufficient time should be given for online curriculum planning and team meetings, which can enhance a collaborative approach and efficient use of strengths and skills within the team.4. Online modalities can be effective for lectures, case based, problem based and team-based learning (Abrahamson, 2006;Augestad and Lindsetmo, 2009;Barrows, 1996;Joyce et al., 2017;Lim et al., 2006;Lim et al., 2009;Wong et al., 2005) Interactive sessions can be enhanced by using small groups and multimodal teaching including patient and virtual simulation (see Table 3).
5. As COVID-19 pandemic evolves and with the likelihood of recurrent community transmission, the strategy should prioritise key tasks which require face to face teaching during the period of no or low transmission with capacity in delivery (see Table 4.) Part 3: Enhancing medical education 1.The mass adoption of online teaching and learning brings opportunities for collaborative efforts in content development e.g.clinical case and clinical signs/ photos library, patient narratives.This is particularly useful for countries in which medical schools share curriculum or qualifying examinations e.g.United State, Canada, Germany.Further discussion is necessary on minimal competency frameworks and the feasibility and adaptation of national clinical exams in further waves of COVID-19 infection.Meanwhile, there is potential for international collaboration to expand the cultural and diversity and development of global resources for medical education.
2. Pandemic preparedness is particularly pertinent for final year students as they prepare to work during COVID-19 pandemic.Evidence of pandemic preparedness teaching in medical schools have largely been theoretical,  Change written examination format to viva or computerised adaptive testing which can be done online or opportunistic delivery using multiple venues.
Opportunistic clinical examination delivery with strict infection control measures Change clinics to virtual clinics (See Table .3) with real case scenarios of that clinic session and incorporate clinical tasks e.g.history taking, clinical assessment and counselling.

Normal priority
Active adaptation to online learning, resume face to face when able (subject to national policy, community activity restriction and infection risk).Schedule courses most amenable to online learning e.g.anatomy, biochemistry, radiology etc. first over clinical courses in peak and post peak pandemic periodContinue simulated patient teaching and preclinical teaching and use of cadavers in small groups with infection control and social distancing when amenable

Low priority
Asynchronous courses with established online format Community/ service learning e.g.attachment with community nongovernmental organisations, home visits.
Use programmatic approach and self-directed learning for established asynchronous online courses Postpone community visits.When visits can resume, distribute experiences between student groups and use presentations and sharing to enhance learning and reflection.Build a library of online interviews with non-governmental organisations and patient interviews 3.During COVID-19, suggested roles for medical students include assisting with childcare for health professionals, assisting the elderly to participating in low risk clinical tasks (Lee, 2020;Miller et al., 2020), whilst there are evident needs where additional help is required e.g. in nursing homes (Orrechio-Egrestiz, 2020).Much less is known about the medical students' attitudes and willingness to volunteer.Further research and discussion are needed to explore opportunities for learning and how medical schools can facilitate learning roles in placements or alternatives e.g.telemedicine, protect students in at-risk areas and enhance social responsibility efforts and roles in the community.

Conclusion
In this evolving COVID-19 pandemic, medical training must continue to ensure an uninterrupted competent workforce and the recommendations set out this consensus guidance can help medical schools prepare and facilitate teaching and assessment with guidance on infection control for staff and students, enhancing online teaching and prioritising teaching activities as well the need for research and development to enhance medical education to withstand future pandemic waves of COVID-19.

Take Home Messages
As COVID-19 pandemic evolves, medical faculties must continue medical education to ensure an uninterrupted competent workforce.
This consensus guidance developed from medical faculties in Asia, Australia and Europe of current best evidence and expertise can help medical schools prepare and facilitate teaching and assessment in subsequent pandemic waves of COVID-19.
Guidance covers infection control measures for faculty staff and students, recommendations in teaching modalities and planning as well as suggestions for further faculty and educational development.
A global approach and dialogue in tackling subsequent waves of COVID-19 is encouraged.Faculty members and staffs of university hospitals and medical college have worked on-site, not at home for all periods of COVID-19.However the entire curriculum has transformed to online format since Feb. 25th.Clinical rotations were suspended for three weeks and recommenced from March 16 th .The face to face cadaveric dissection recommenced on April 21.Anatomy and Physiology mid-term examinations were conducted face to face on April 16 th , and 20th, respectively.All deferred examination and simulation sessions are planned to conduct by face to face around early July.At the entire university level, KU recommended online lecture for the semester, but small group sessions less than 30 students was allowed form May 4 th , only if students agree with their attendance.

Monash
Prof. John Atherton is Pro Vice Chancellor and Dean of Faculty of Medicine and Health Sciences at the University of Nottingham in United Kingdom.Prof. Francis Chan is Dean of Faculty of Medicine at the Chinese University of Hong Kong in Hong Kong SAR China.Appendices Appendix 1: Medical institutions: student intake and initial faculty pandemic by 1 February 2020.Staff work at home arrangements.Essential staff arrangements in office.All clinical examinations successfully conducted March -April 2020 (Medical years 4-6) during second wave of infection.Staff resume normal office hours May 4 th 2020.started April 20 th , selected exams on a voluntary basis on Campus allowed when hygiene rules can be secured, stay in home office whenever possible.
fully online and faculty deliver teaching from home.Hospital based staff work from in situ clinical school facilities.Senior students continue in hospital placements.remote teaching for bachelor students.Last year of master has restarted their clerkships University of Bologna, Bologna, Italy 350 students for each of the 6 years (Italian stream) Approx.. 60 students for each year (English stream) Lockdown Medical education: fully remote teaching started in March (lessons; oral and written exams; graduation].Staff allowed to work from home whenever possible; apart from clinical activities, staff must justify circumstances requiring their presence in the University premises. Guo, T., Fan, Y.,Chen, M., Wu, X., et al. (2020)  Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19).JAMA Cardiology.5(7), pp.811-818.Reference Source Harvey, A. (2020) Covid-19: medical students should not work outside their competency, says BMA. BMJ (Clinical Research Ed.).368, m1197.Reference Source Huang, C., Wang, Y., Li, X., Ren, L. , et al. (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.The Lancet.395(10223), pp.497-506.Reference Source Joyce, M. F., Berg, S. and Bittner, E. A. (2017) Practical strategies for increasing efficiency and effectiveness in critical care education.World Journal of Critical Care Medicine.6(1), pp.1-12.Reference Source Larsen, D., Dinero, R. E., Asiago-Reddy, E., Green, H., et al. (2020) A review of infectious disease surveillance to inform public health action against the novel coronavirus SARS-CoV-2.Reference Source Lee, Y. J. (2020) Medical Students Around the US Are Offering to Babysit for Hospital Workers on the Frontlines of the Coronavirus Pandemic.New York, NY: Business Insider.Available at: Reference Source (Accessed: 1 August 2020).Li, Li, Lin, M., Wang, X., Bao, P. and Li, Y. (2020) Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China.BMJ Simulation & Technology Enhanced Learning.6(4), pp.196-198.Reference Source Lim, E. C. H., Oh, V. M. S., Koh, D.-R. and Seet, R. C. S. (2009) The challenges of "continuing medical education" in a pandemic era.Annals of the Academy of Medicine, Singapore.38(8), pp.724-726.Lim, E. C. H., Ong, B. K. C. and Seet, R. C. S. (2006) Using videotaped vignettes to teach medical students to perform the neurologic examination.Journal of General Internal Medicine.21(1), p. 101.Reference Source Liu, Y., Gayle, A. A., Wilder-Smith, A. and Rocklöv, J. (2020) The reproductive number of COVID-19 is higher compared to SARS coronavirus.Journal of Travel Medicine.27(2).Reference Source Medical Schools Council (2020a) Advice from Medical Schools Council to UK Medical Schools on actions surrounding Covid 19.Available at: Reference Source (Accessed: 1 August 2020).Medical Schools Council (2020b) Statement of expectation.Medical student volunteers in the NHS.Available at Reference Source (Accessed: 1 August 2020).Miller, D. G., Pierson, L. and Doernberg, S. (2020) The Role of Medical Students During the COVID-19 Pandemic.Annals of Internal Medicine.173(2), pp.145-146.Reference Source Ng, K., Poon, B. H., Kiat Puar, T. H., Li Shan Quah, J., et al. (2020) COVID-19 and the Risk to Health Care Workers: A Case Report.Annals of Internal Medicine.172(11), pp.766-767.Reference Source World Health Organisation.(2014) Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care: WHO guidelines.Available at: Reference Source (Accessed: 1 August 2020).Orrechio-Egrestiz, H. (2020) As many as half of Europe's COVID-19 deaths were people in long term facilities, Business Insider.Available at: This review has been migrated.The reviewer awarded 4 stars out of 5 This is a well thought out and researched article on how to continue undergraduate medical education in the face of the current pandemic.The authors are very senior academics and the lead many medical education programs.The article can guide others to manage medical education programs when faced with such emergencies.This gave us an opportunity to reflect on what we have done and what else we could have done during this crisis .The title can be misleading ."Continuing Medial Education " usually means CME and implies continuing professional development for practising physicians.May be "Maintaining Undergraduate Medical Education ----" or similar would have been more accurate Competing Interests: No conflicts of interest were disclosed.
Chen et al., 2020).Adequate counselling support should be available e.g.dedicated mental health team or counsellor and capacity for student support can be enhanced with extending the roles of mentors, academic advisors and teachers..COVID-19 (SARS -CoV-2) can persist on paper for 2 days and hard surfaces e.g.glass, stainless steel for 4-7 days(Chin et al., 2020)and can be inactivated by bleach and common disinfectants (World Health Organisation, 2020b).Routine disinfection in medical schools may be guided by state or national regulations.In the absence of guidance and if resources are available, it is recommended that common spaces and facilities and areas of high use e.g.handrails, lift buttons and door handles should be rroutinely cleaned and disinfected (U.S.Department of Health & Human Services, 2020).
Faculty staff and facilities1.Delineate essential work staff and roles and initiate work at home policies.Work at home policies will be influenced by state and national guidelines e.g. during lockdown.For essential workers ensure social distancing for those who return to office e.g.stagger start and finish times to avoid crowding at public transport and distancing of office space.Offer technical support and guidance for those working at home (Centers for Disease Control and Prevention, 2020a).2 4. Medical schools are responsible for students' safety in campus, community or clinic/ hospital-based activities and should maintain close liaison with teaching hospitals and clinic.Medical schools have an ethical responsibility to provide adequate guidance for students who volunteer e.g.competencies, safety, infection control(Harvey, 2020; Medical Schools Council, 2020b; Whelan et al.,2020a; Whelan et al.,2020b).Health or community partners should provide indemnification for volunteer placements and early employment.
Table 2 details recommendations based on the current updates about COVID-19.
Part 2: Prioritising teaching and assessment activities during COVID-19 1.When face to face teaching in community and clinical attachments is suspended, course coordinators should review and revise teaching activities and assessments in line with learning outcomes.2. Medical faculties should support rapid staff development in online teaching and learning for teachers and students.Support may be technological e.g.internet access, provision of notebooks, webcams, microphones, technical assistance for online learning and video conferencing platforms e.g.use of platform features, setting up video communications as well as educational support e.g.use of enhanced program features, exploring different teaching models.The capacity for individual support and guidance require need sufficient resources.Training and use of department support staff can also help problem solve common issues.

Table 1 .
Infection control and prevention for on-site essential examinations

Table 2 .
Infection control: Pandemic phases and key actions for medical faculties for COVID-19 Phase 4 Sustained human to human transmission (Li et al., 2020) learning during COVID-19 pandemic logistically and technically challenging(Li et al., 2020).There is a role for medical schools to liaise with local hospital and primary care networks to establish key areas and tasks in which medical schools can assist to train students.This can include opportunities for clinical case studies, medical ethics as well as infection control and PPE training.

Table 3 .
Enhancing online teaching

Table 4 .
Priorities and adaptations in medical education during COVID-19 Prof. Walter van den Broek is Director of Medical Education at Erasmus Medical Centre in Rotterdam, The Netherlands.Prof.Gillian Doody is Dean of Medical Education at University of Nottingham in the United Kingdom.Prof.Martin Fischer is Associate Dean for Students at Ludwig Maximilian University of Munich in Germany.Prof.Michelle Leech is Deputy Dean of the Medicine Nursing and Health Sciences Faculty at Monash University in Australia.Prof.Fabrizio De Ponti is Professor at the Department of Medical and Surgical Sciences, University of Bologna in Italy.Prof.Alexander Gerbes is Professor at the Faculty of Medicine at the Ludwig Maximilian, University of Munich in Germany.Prof.Hiroshi Nishigori is Associate Professor at the Center for medical education at Nagoya University in Japan.Prof.Young Mee Lee is Professor at the Department of Medical Education in Korea University in Korea.Prof.Maarten Frens is Professor at Erasmus University Medical Center in the Netherlands.Prof.Hideki Kasuya is Associate Dean of International Affairs at Nagoya University in Japan.Prof.Franco Bazzoli is Professor of Gastroenterology at the University of Bologna in Italy.Prof.Reinhard Hickel is Professor and Dean at Ludwig Maximilian University of Munich in Germany.Prof.Hong Sik Lee is Professor at the Department of Medical Education in Korea University in Korea.Prof.J.P.T.M van Leeuwen is Dean and vice-chairman Executive Board Erasmus Medical Centre in the Netherlands.Prof.Christina Mitchell is Dean of Faculty of Medicine Nursing and Healthcare sciences at Monash University in Australia.Prof.Kenji Kadomatsu is Professor at Nagoya University Graduate School of Medicine in Japan.