Adapting to COVID-19 Changes, Third-Year Students Return for Clerkships

Getting back to normal. That has been a universal longing ever since the COVID-19 pandemic struck, but how? Figuring out how to shift course when “normal” is no longer a direction possible for medicine students has been the challenge for faculty and curriculum directors at Northeast Ohio Medical University and their hospital partners.

So Susan Nofziger, M.D., clinical associate professor of pediatrics, was ready to celebrate – cautiously – at the beginning of June, when the third-year College of Medicine students were back at their hospital clerkships. “Week One is done!” said Nofziger, taking a breath in what will continue to be a busy process of working with a huge team of people across many institutions. The goal: Find a way for third-year students to complete their normal time in hospitals as part of clinical teams to see patients in the various areas of health care.

It has been a whirlwind.

Back in March, Dr. Nofziger says, “We had all been watching the news about COVID from a clinical perspective and wondering how it would affect our hospitals. What stories we were seeing were dramatic, in other countries – in Italy – and once we started to see it here in Ohio, it started to have a snowball effect. Hospitals were very concerned about safety of the students.

“We were very clear that we didn’t want students seeing any COVID patients. There was a general concern about the hospitals’ ability to provide personal protection equipment (PPE) for their staff, their physicians and the staff in the operating rooms — so that had a trickle-down effect. The displacement of students was really from a hospital standpoint, as a concern about safety. They just didn’t have the PPE available and the structures in place.”

Things moved fast, with nearly continuous meetings among NEOMED leadership. Ultimately, the University decided to pull all students from clinical sites, and soon afterward, the Association of American Medical Colleges issued a recommendation to that effect.

What next?

Students in the internal medicine and surgery rotations only had two weeks left, so online material was designed to supplement what they had already learned clinically. On the other hand, students had only just begun their six-week clerkships in family medicine, OB-GYN, psychiatry and pediatrics.

The clinical experience directors (CEDs) and site directors got busy, fast. They drew on databases of interactive cases for the students to study online and they added Zoom lectures and online curriculum.

Dr. Nofziger pointed to Erik Messamore, M.D., Ph.D., an associate professor of psychiatry, as one especially enthusiastic instructor, who eagerly developed a series of lectures that would capture some of the most important takeaway knowledge of the traditional psychiatric clerkship.

Dr. Messamore says, “I tried, of course, to cover all the important points about recognizing symptoms, formulating diagnosis, and evidence-based treatment. But I also tried to describe how these illnesses play out in real life and how to think logically outside the box in cases where the initial treatments don’t produce the desired outcomes.”

NEOMED also capitalized on its Project ECHO^® model, a regular online forum that connects community providers, such as physicians, with experts in specialties including mental health. The ECHO team, led by Nichole Ammon, clinical assistant professor of psychiatry, included the students in the live videoconferences, which combine presentations with discussions and problem-solving for specific cases.

“Even though students were away from their clinical sites, they were discussing real patients and real clinical care in a way that they would be on the floor. That was a pretty amazing new resource,” says Dr. Nofziger.

Surgeons Drazen Petrenic, M.D., and Noaman Ali, M.D., both clinical faculty at Cleveland Clinic Akron General, added lectures, as did pediatricians like Dr. Nofziger, who serve as NEOMED clinical faculty in addition to their roles as clinicians at Akron Children’s Hospital.

Not only the enthusiasm but the ingenuity impressed Dr. Nofziger.

“One of our new site directors, Steven Haywood, M.D., an assistant professor of emergency medicine at Summa Health, reached out to me and said, ‘I have this amazing residency emergency medicine curriculum that could be adapted to medical students. What do you want me to do?’ (Go ahead, was Dr. Nofziger’s response.) “Dr. Haywood organized individual Friday meetings with the Summa Emergency Medicine staff on his own. I heard really positive feedback about the experience. He adapted it so students have evidence-based learning in emergency medicine on the best curriculum we have available.”

Clinical bias was a topic Dr. Nofziger had long wanted to cover, and a topic that is beginning to be discussed more in medical education, she said.

“We talked about the importance of always having a couple of differentials for a patient so that you can change your thinking clinically when something happens, instead of being stuck in your thinking.

“We discussed the different kinds of biases because I think it’s a different way of thinking about medicine. Diagnostic errors, the way we think about our patients, are some of the most common errors in medicine. We need to be aware of how we think and when we are most likely to have an error and pause.

“There is so much pressure in medicine to be efficient, to see that patient quickly. Some students are going to be in critical settings, like ICU settings,  where you see a huge volume of patients. You really have to force yourself to pause and ask yourself, is this a place where I’d be more likely to make a medical error?”

Coming full circle

After two weeks of online instruction, the directors realized that due to the spread of COVID-19 and safety concerns that online instruction would need to continue longer, so they created a four-week course called the M3 COVID-19 intersession. An expanded version of the Social Determinants of Health elective that many fourth-year students take, it included a COVID-19 curriculum created by instructor Erica Stovsky, M.D. (’07), assistant professor of internal medicine, as well as modules on COVID-19 created by the Project ECHO facilitators.

On April 27, internal medicine and surgery rotators began a  four-week online block of emergency medicine, while six-week rotators advanced to their next online block of instruction. Blocks of instruction were scheduled to allow six-week rotators to begin three-week clinical experiences on June 1 and nine-week rotators to return on June 15.

By August 7, students in all but one of the clerkships will have finished the clinical portions of their rotations. Next January, as fourth-year students, they will need to return to finish the clinical portion of that clerkship. Normally in January, fourth-year students are doing electives and interviewing for residencies, so they’ll need to work this into their schedules. Of course, if travel is still limited then, students will be doing their residency interviews virtually, so that will free up time, notes Dr. Nofziger.

David Sperling, M.D. (’85), the senior director of clinical experiential learning, is focused on the fourth-year students. He has worked to make a smooth transition for this year’s third-year students, who have had to make so many adjustments, says Dr. Nofziger.

“They were used to doing a six -week clinical rotation and a test at the end (called a shelf exam, covering everything learned in that particular clerkship). They were used studying at the end of the day and on weekends. Now we’re giving them this full online curriculum and telling them, instead of finishing your shelf examinations and then you have Step 2, (the state medical licensing test, also known as the boards) I’m going to have you in clinical time and you’re also studying for Step 2,” she explains.

Craig Theissen, director of NEOMED’s Learning Center, has been one of the students’ biggest sources of support, reaching out not just to the students as a whole but also to individual students to talk through their plan of attack for studying for Step 2 and shelf examinations, says Nofziger.

“They say it takes a village, and at all of our sites, the partners we work with have been communicating with us to make things happen. People have been working evenings and weekends. We’re still holding our breath, but I think we will be able to handle the problems. The dedication to our students is the main thing holding us together.”