Ricky Tsang,¹ Bailey Burrell¹

¹Faculty of Medicine, University of British Columbia, British Columbia, Canada

The emergence of COVID-19 has forced medical schools to adapt and re-imagine the delivery of curricular activities. Almost overnight, medical schools transitioned away from traditional, in-person instruction in favour of remote teaching to comply with public health orders. Digital technologies became paramount for the delivery of curricular activities and student assessment was no exception. Virtual Objective Structured Clinical Examinations (vOSCE) were developed and implemented at a rapid pace for the assessment of clinical skills.^1,2 Thus far, they have been met with positive feedback from students and examiners.

Some studies posit that vOSCEs represent the future of clinical skills assessment. Proposed benefits include time and cost savings, adaptability and scalability, and comparability in scores between in-person and virtual examinations.² Others maintain that in-person OSCEs remain the gold standard and should be reinstated once public health orders are lifted.¹ We certainly agree that vOSCEs have merit in assessing history taking, counselling, and associated soft skills – the virtual platform lends itself well to their assessment. Our exposure to virtual care through primary care placements has reinforced the importance of developing these virtual care skills in an era where COVID-19 has catalyzed the growth of telemedicine. During the early stages of the pandemic, telemedicine represented between 38-77% of ambulatory visits in Australia, Canada, and the United States, and while reliance on this modality has declined with the relaxation of public health restrictions, use of telemedicine is projected to remain well above pre-COVID-19 levels.³ If it is the mandate of medical schools to train their students as well-rounded generalists, then developing and assessing their skills to conduct telemedicine-based, virtual patient encounters would appear indispensable as telemedicine is poised to remain integral to primary care in the post-pandemic world. This is also consistent with the eHealth-oriented CanMEDS competencies addendums proposed by the CanMEDS eHealth 2015 Expert Working Group, which suggest that the Medical Expert should be able to, “adopt a variety of information and communication technologies to deliver patient-centred care and provide expert consultation to diverse populations in a variety of settings.”⁴

Conversely, we believe the assessment of physical examination skills is ill-suited for the virtual format. Physical examination requires complex psychomotor skills and sensorimotor integration. Consider, for example, how impractical it would be to examine a baker’s capabilities through a virtual demonstration of their skill, without the opportunity to touch, smell, or taste their craft. Similarly, clinical skills are the “bread and butter” of a physician’s work and rely on aspects of the physical world that cannot currently be conveyed through a screen with any comparable degree of concision. Such an examination is neither practical nor feasible when assessed virtually, save for brief screening manoeuvres. That is why, when conducting telehealth appointments, physicians must recognize the limits of the appointment and arrange for in-person follow-up when necessary.⁵ Simply put, elements of a physical exam are lost when conducted virtually, and you cannot assess that which you have made impossible for students to perform. Likewise, students will be unable to receive feedback on important physical exam manoeuvres, many of which involve sensory feedback and nuance.

In an era where the physical examination is being eschewed in favour of medical technology that is increasingly relied upon for assessment and diagnosis, it becomes imperative to faithfully teach and assess physical examination skills to ensure future clinicians have robust competence in this dying art. The horse must remain in front of the cart – at least until the automobile that is medical technology becomes robust enough to replace it completely. Perhaps the solution in the meantime is one of compromise; the creation of hybrid OSCEs, one where in-person stations are utilized to assess the lion’s share of skills but are thoughtfully supplemented by virtual stations to assess the full spectrum of clinical skills required of the modern physician. It seems vital to us that physical exams remain physical, but that students are taught to incorporate the expanding number of options available to them for patient interaction.

Certainly, we do not mean to disparage the extraordinary efforts of medical schools that have adapted vOSCEs out of necessity and with great haste. The COVID-19 pandemic has affected life in a seemingly endless number of ways and forced the innovation of new paths forward. Perhaps too, it has catalyzed a new dawn in clinical skills assessment, one where physical and virtual skills are treated and examined as independent entities, but considered no less important than one another for the comprehensive education of a physician.

References

1. Boyle JG, Colquhoun I, Noonan Z, McDowall S, Walters MR, Leach J. Viva la VOSCE? BMC Medical Educ, 2020; 20. https://doi.org/10.1186/s12909-020-02444-3
2. Lara S, Foster CW, Hawks M, Montgomery M. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. Acad Pediatr, 2020; 20(6): 760–761. https://doi.org/10.1016/j.acap.2020.05.029
3. Mehrotra A, Bhatia RS, Snoswell CL. Paying for telemedicine after the pandemic. JAMA, 2021: 325(5): 431-432. https://doi:10.1001/jama.2020.25706
4. Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth expert working group report [Internet]. 2014. Available from: https://www.royalcollege.ca/rcsite/documents/canmeds/health-advocate-ewg-report-e.pdf [Accessed May 13, 2021].
5. College of Physicians and Surgeons of British Columbia. Practice standard: telemedicine. 2020. Available from: https://www.cpsbc.ca/files/pdf/PSG-Telemedicine.pdf [Accessed May 13, 2021].

Aman Dhaliwal,¹ Karlee Searle,¹ Danielle Martin^1,2

¹Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; ²Department of Family and Community Medicine, Women’s College Hospital. Ontario Canada

Globally, the COVID-19 pandemic has overwhelmed health care systems in an unprecedented way. There are far-reaching impacts, including in medical education.

In Canada, the increase in clinical demands led to changes in health care infrastructure, requiring physicians, residents, and senior medical students to step into new roles. This “all-hands-on-deck” approach was essential to pandemic response but has tended not to include junior (pre-clerk) medical students. How do we best utilize the skills of junior medical students in a pandemic or emergency situation when the existing frameworks do not accommodate this?

Junior medical students face a dilemma: they are well-equipped with the key attributes to become successful physicians but lack the necessary clinical skills to serve a meaningful role on the frontlines. In response, and despite a lack of official guidance, many junior medical students have forged their own role in supporting the community through various student-led initiatives. This experience has lessons to teach about how the medical student community can be marshalled in future emergency response initiatives.

As the COVID-19 pandemic progressed, it became evident that junior medical students had a strong desire to participate in pandemic relief measures. Despite the limited scope of their clinical abilities, Canadian medical students rapidly began uniting to establish community supports on a voluntary basis. Across Canada, over 150 student-led initiatives were started to assist the community and support frontline workers through the pandemic.¹ Many of these initiatives shed light on the inequities faced by marginalized individuals in the pandemic and worked to mobilize community resources to better support these groups. For example, the COVID-19 Women’s Initiative focused on supporting women and gender minorities who experienced an increase in intimate partner violence during lockdown conditions in Canada. This group raised $30,000 and collected over 22,000 items for 35 women’s shelters across Canada in six months.² Other junior medical student initiatives focused on partnering with seniors to address senior isolation, sourcing personal protective equipment, and assisting frontline workers with life tasks such as grocery shopping and child care.³ Undeterred by their inability to help on the frontlines, these students banded together to make a powerful impact in their communities. 

These medical student-led initiatives required students to augment and practise the CanMEDs competencies of advocacy, communication, collaboration, and leadership.⁴ Although the health advocate role is a core role of the CanMEDs competency framework, integrating health advocacy into medical school curricula has been challenging.⁵ One of many reasons for this may be time constraints with respect to teaching, illustrating, and responding to the social determinants of health.⁶ During the COVID-19 pandemic, time constraints for many pre-clerkship medical students were eased as curriculum requirements were either cancelled or moved to an online format. This may have opened up space for students to, in essence, build their own advocacy curriculum.

Medical programs that provide voluntary learning opportunities to work with underserved and marginalized groups allow students to better understand the social determinants that result in health disparities, as well as the ways in which health advocacy can be practically applied.⁷ These skills turned out to be important for short-term relief during a pandemic, and likely also for the long-term development of these future physicians.

While there are guidelines for ways that senior medical students can contribute to reducing the effects of the pandemic directly, there is a lack of guidance around the contributions of junior medical students. We propose three ways by which Canadian medical schools can facilitate junior medical student community involvement in pandemic and emergency situations.

First, medical schools can provide education and training to students regarding the wide range of non-clinical needs of a population during pandemics and other emergencies. Integrating disaster training into medical school curricula will increase student preparedness and improve knowledge and skills prior to a disaster.⁸ This training could point out the capabilities of junior medical students (as well as other junior trainees across nursing and health disciplines), to increase their sense of agency in disaster response.

Second, medical schools could provide curriculum flexibility in a pandemic or other emergency situation to allow students to engage in voluntary community support initiatives. Junior medical students who have been given the time and flexibility to pursue professional endeavours outside of the core curriculum exhibit increased productivity and sustained interest in their topic of choice.⁹ Furthermore, this flexibility alleviates the time constraints, which frequently act as a barrier to medical student engagement in advocacy work.

Lastly, a unified approach to the role of the junior medical student as part of “whole system response” can promote community engagement to all Canadian junior medical students. Current CFMS guidelines include a role for a pandemic response for senior medical students but neglect to provide a role for junior medical students. Further statements and guidance from national medical education bodies on Disaster Management Plans should expand their guidelines so that Canadian medical schools can prepare junior medical students to be active participants, living up to their full potential as people with time, energy, and a commitment to the health of their communities.¹⁰

Junior medical students are an untapped resource during emergencies like pandemics when the societal need for effectively diverting resources is at its greatest. We have a shared opportunity to further explore the ways in which junior medical students’ skills can be translated into meaningful community engagement during an emergency situation, and to accommodate this into established medical education frameworks. 

References

1. Lu K, Schellenberg J. COVID-19 updates [Internet]. Canadian Federation of Medical Students. Available from: https://www.cfms.org/who-we-are/covid-19
2. Parsons C. U of T med students assist women’s shelters during COVID-19 [Internet]. Faculty of Medicine. 2020. Available from: https://md.utoronto.ca/news/u-t-med-students-assist-womens-shelters-during-covid-19
3. Bowden, S. COVID-19: Canadian medical students ready to step up. Univ Tor Med J. 2020;97(3):e8-e11.
4. CanMEDS: Better standards, better physicians, better care. CanMEDS Framework. The Royal College of Physicians and Surgeons of Canada. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
5. Hubinette M, Ajjawi R, Dharamsi S. Family Physician Preceptors’ Conceptualizations of Health Advocacy, Implications for Medical Education. Acad Med. 2014;89(11):e1502-e1509. https://doi.org/10.1097/ACM.0000000000000479
6. Hancher-Rauch H, Gebru Y, Carson A. Health advocacy for busy professionals: effective advocacy with little time. Health Promot. 2019;20(4):489-493. https://doi.org/10.1177/1524839919830927
7. Borouman S, Stein M, Jay M, Shen J, Hirsh M, Dharamsi S. Addressing the health advocate role in medical education. BMC Med Ed. 2020;20(1). http://doi.org/10.1186/s12909-020-1938-7
8. Earnest M, Wong S, Frederico S. Perspective: Physician advocacy: what is it and how do we do It? Acad Med. 2010;85(1):63-67. https://doi.org/10.1097/ACM.0b013e3181c40d40
9. Peacock J, Grande J. A flexible, preclinical, medical school curriculum increases student academic productivity and the desire to conduct future research. Biochem Mol Biol Educ. 2015;43(5):384-390. http://doi.org.10.1002/bmb.20875
10. Cfms.org. 2021. [Internet] Available from: https://www.cfms.org/files/position-papers/2015%20CFMS%20Disaster%20Management.pdf