A recent commentary published by the Journal of the Royal Society of Medicine* discusses the challenges and opportunities for undergraduate clinical teaching during and beyond the COVID-19 pandemic. Here the authors (1), all medical educators working across both undergraduate and postgraduate education, compare the experiences of medical students and trainee doctors and write of the urgent need to make up for lost time in teaching and training.
COVID-19 has had a huge impact on medical students. Now, a year on from the start of the pandemic and the temporary shutdown of UK medical schools, it has become very clear that disruption to undergraduate education will continue for years to come. Rapid adaptation is essential as the goalposts – dates and standards for professional qualification – cannot be moved.
The challenges in achieving this are numerous. Medical educators must first make up for lost time and ensure that students reach graduation with the knowledge and skills necessary to become safe doctors. This becomes more difficult when taking into account new limitations on student (and clinician) numbers and social distancing in clinical environments. In some cases, this has required splitting cohorts to alternate between clinical and remote learning, reducing clinical exposure. Training was cut short for final year students, allowing some to start work early as interim foundation doctors.
Traditional learning opportunities have been further reduced through restrictions on rotation between specialties, changes to clinical service provision, and the overwhelming predominance of COVID-related presentations throughout the NHS. While some students were able to undertake clinical duties as healthcare support workers, teaching and training was sidelined. New learning technology can help to improve access to limited learning resources and supplement direct experience but will require significant improvement in infrastructure and technological up-skilling for clinical teachers.
We have suggested that, beyond technology, these challenges may in fact be an opportunity for a more radical ‘shake up’ than is usually possible in curriculum development, allowing us to modernise undergraduate training. Placements must be made more efficient, particularly if clinical time is to be reduced in the short-term to comply with infection control and social distancing requirements. Broadening learning outcomes and moving away from a specialty focus could help to achieve this whilst also helping to mitigate the effects of rotation restrictions.
We suggest that undergraduate curricula could better reflect newer ways of working, including virtual consultation in primary care and outpatient clinics, which are set to become even more widespread post-pandemic. E-portfolios have already been introduced for students, allowing earlier familiarisation with postgraduate progression records. Students and clinicians have also called for wider adoption of an apprenticeship model for final year students following the positive experience of those undertaking interim foundation jobs last summer.
Although in our JRSM paper we discuss the challenges and opportunities that the pandemic has presented for medical undergraduates, many of these also hold true for postgraduate training. Necessarily, the pandemic has caused a shift in focus from teaching and training to service provision with some training programmes worse affected than others. Undifferentiated juniors have been differently affected to specialty trainees, however there will have been an impact of some sort on all postgraduates. As for undergraduate education, disruption to ‘normal working’ will be ongoing for some time and the full impact is yet to be seen.
Again, the first challenge is making up for lost time. Junior doctors have faced severe disruption to their expected roles and usual work as a result of redeployment, disrupted or abandoned rotations, teaching cancellation, frequent rota changes and reduced clinical case variety. Particularly for those early in their training, such as foundation doctors, delaying progression is not really feasible. Relatively broad aims and requirements for progression make this less problematic, as these programmes are designed so that competencies can be achieved in a wide range of settings. That said, foundation programme ARCP requirements were altered during the first wave and to a lesser extent during this second wave, reflecting some of the extent of training disruption even before specialisation. The consequences of this remain unclear, but one has to question what the impact will be on the workforce skills base, recruitment to certain specialties, rates of progression to post-foundation training, and even retention.
Compensating for ‘missed’ experience is more difficult for specialty trainees. Given reductions in patient exposure, case variety and opportunities to observe and practice procedural skills, extensions to some programmes may be required. Some specialty societies have suggested extending post-fellowship/-CCT transition periods, particularly for those in subspecialty training. The cancellation or postponement of many postgraduate examinations have caused further difficulties for specialty recruitment processes and junior doctors’ career progression.
Remote learning and technology may offer some solutions. As for undergraduates, didactic teaching was quickly adapted for remote delivery, largely to allow compliance with infection control regulations. Virtual teaching could and should be used at every stage of training, but may offer particular value for specialty trainees, allowing access to scarce resources for a greater number regardless of geography. However, remote delivery does not address issues of access to teaching relating to changes in rotas and workload, and inadequate infrastructure remains a problem. Improvement is urgently needed in many NHS sites and is vital to ensure equity among trainees.
Similarly, as greater use of virtual consultation services is likely to continue well beyond the pandemic, these must be quickly adapted for use as training opportunities. It is important for trainees not only to catch up on outpatient experience and develop their consultation skills, but also to become confident in the use of these newer modalities.
Modernising training is perhaps less relevant for junior doctors given more recent changes to postgraduate programmes, including Modernising Medical Careers and the Shape of Training review. There have already been moves towards generalisation, for example with greater numbers of medical specialists set to dual-certify in General Internal Medicine. It is likely, however, that further review of training programmes and specialty competencies will be arranged in the coming years, as the full effects of the pandemic become apparent.
Perhaps the most important area for attention in the immediate future is trainee wellbeing and support. Various efforts to try and address this are already underway, but their beneficial impact will need to be reviewed and iterative improvements made over time. Whilst medical students have been personally affected by their pandemic experiences and educational disruption, the impact on postgraduate trainees will undoubtedly be far greater. The effect of loss of team structures and rotation goes beyond training, and the emotional burden of the last 12 months has been significant. Several studies have reported increases in low mood, anxiety and sleep disturbance among trainee doctors. Concerns around training quality, busy rotas, risk to loved ones, constant change and uncertainty, combined with the stress of looking after large numbers of very unwell patients, for many, have had significant effects on mental health. The full extent of this is unlikely to be evident until at least the next recovery stage, if not much later.
Postgraduate trainees face many of the same challenges as medical students as a result of the COVID-19 pandemic. Although inpatient numbers in many parts of the country are still well above those in the first wave and focus remains on managing the immediate burden of COVID-19, consideration must be given to addressing these longer-term issues and recognising the opportunities for improvement presented.
*Download the original JRSM paper: Challenges and opportunities for undergraduate clinical teaching during and beyond the COVID-19 pandemic.