By Ecler Jaqua

As the COVID-19 pandemic advanced, many rapid changes had to be made in medical education. Residency programs had to be adaptive and creative to deal with the ever-changing CDC landscape protocols to educate residents in a restrictive in-person environment.

In a matter of days, our family medicine residency clinic had to change all the in-person visits to telehealth. Video visits were something that was being tested and executed in the faculty clinic, but nothing similar was done on the residency side. At first, it was very challenging to our residents, but especially to our patients who had no idea how to use the app for the video visits. Many appointments had to be changed to telephone visits instead due to technical issues and poor literacy. However, as time went by, most of the residents, faculty and some patients started to get more familiar with the current system. Telehealth is here to stay, and I don’t think it will ever leave us. On the positive side, telehealth has now opened up opportunities for patients who previously were unable to attend their doctor’s visit.

Unfortunately, the pandemic just not affected the way we take care of patients but also negatively affected the training of residents. It led to many modifications for safety reasons within the clinics and hospitals that resulted in decreased volume of procedures, simulation laboratories, face-to-face teaching, hands-on training, and skill-based teaching activities. Elective rotations had to be canceled, reducing interpersonal connections in favor of social distancing and home isolation. The residents’ clinical skills competence in doing a physical exam weakened as they no longer have access to patients under supervision. The conventional bedside teaching where residents and faculty can ask patient questions in real-time and have essential discussions as a team had to be discontinued. Numerous residents were unable to attend conferences, complete research projects, or participate in extra-curricular activities that could help them get a competitive fellowship or their dream job.

Several residency programs at my institution had to restructure their residency training and redeploy many residents to services in need. Due to these rapid changes, the hospital shifts were at times very exhausting for the residents – not only because of the long hours and multiple days working in a row but also the constant fear of spreading the virus to a loved one. On top of all these changes having to wear personal protective equipment (PPE) all the time can be very uncomfortable. Residents many times felt a mix of anxiety, fear, emotional and physical exhaustion during these extraordinary times.

The weekly didactic teaching sessions, a crucial component of residency training, changed radically with the pandemic. All the in-person lectures moved online through platforms such as Zoom. The advantage of having the didactic session online was the ability to have everyone attend from any location and being able to invite speakers from different institutions. Virtual rounding was also implemented in countless residency programs to keep the whole medical team safe. The virtual rounds involve a pre-round done by the residents and medical students, and the attending physician would join remotely to discuss the cases with the whole team. During this time, it is an excellent opportunity for the attending physician to teach, showing research papers and PowerPoint slides about the cases that are being presented. As soon as the virtual round is ended, the attending physician would see the patients by him- or herself and resume the virtual round in the afternoon to discuss their physical exam findings and any other pertinent information from the patients or medical staff. Although there is no replacement for the face-to-face bedside teaching and observation of the resident or medical student performing the physical exam, this model is efficient, delivers substantial educational value, maximizes patient care time, and provides a safe environment to both trainees and patients.

Residency programs across the nation adopted video interviews for virtual residency recruitment. One of the advantages of virtual recruitment is the amount of money and time saved during the interview season. Not having these expenses can be a relief to the medical students and the residency program, especially as the financial crisis precipitated by the pandemic led to budget cuts for recruitment in many programs. Virtual recruitment also allows the residency program to interview more applicants as more interviewers may be available. The downside of virtual recruitment is the limited opportunities to socialize with current residents and faculty. It may also cause video fatigue if an applicant doesn’t take a break or stays uninterrupted for more than two hours in an interview.

Although these are challenging times, we were able to reconsider our current resident education and welcome ground-breaking methods while providing a high quality of care. Even though the pandemic affected residency education, several research studies show that the level of knowledge and clinical practices with virtual learning was acceptable. I believe we gained an understanding of how to integrate technology with the current teaching modality without compromising patient care. We also learned how to improve health care systems and redesign curriculums to ensure appropriate training.  

In the near future, as the pandemic subsides, we will see a hybrid of these models. Learning telehealth skills along with classroom and bedside teaching, the flexibility to have lectures in person and virtual so that everyone can attend, and virtual interviews with an option for an in-person interview and visit the residency program site. These adaptations are still a work in progress, but I am hopeful that all the changes and discoveries we had this past year will positively impact medical education.

By Suzanne Minor, MD, FAAP

Every month I receive the evaluation comments written by fourth year students about their rotations, sites, and preceptors.  I read through these looking for possible concerns around faculty development and resident development especially with regards to teaching our students.  I want to make sure that if there are any trends, I am on top of them; if there any opportunities, I can quickly work to support faculty as needed.  

This past Fall, I read our first evaluations since our students started back after the pandemic.  I did not know what to expect.  Actually, I expected negative comments to jump out at me.  In the months since our faculty had last worked with students, the coronavirus pandemic had ravaged  South Florida.  Our affiliate hospitals were overwhelmed with COVID-19 admissions and our already busy faculty had born the burden of caring for sick patients with limited PPE. They had to attend to patient families through virtual means, and do so while working long hours. They often had to isolate from loved ones to protect them from possible illness.  And there was not reprieve in site.  One of our affiliates had asked community physicians to do hospital shifts to spell over-worked hospitalists.  I didn’t know what students would experience as they returned to the clinical setting. 

As I read, I noticed I had been holding my breath and my shoulders were tight with tension. But I didn’t need to be worried, after all.  I felt my throat catch and a surge of sad happiness, probably a release of pent up emotions related to this crazy pandemic.  The comments by students were amazingly positive.  Over and over students spoke about the excellent, high-quality teaching provided.  Students on hybrid rotations commented about the incredible learning experiences they received through virtual rounding and cases plus in-person scrubbing for surgeries. Particular patient care experiences were sometimes cited.  I know those hybrid rotations were crafted quickly and with great effort in order to provide optimal learning experiences despite the pandemic.  Some faculty took more students than usual yet still provided outstanding teaching and supervision.  They were taking on added duties even in this situation and I imagined that they would probably write quite a few letters of recommendation in the coming months, adding further to their time demands. 

There are just a few comments about faculty performance being negatively impacted by COVID-19.  Still, those comments are rare.  Our dean of clinical education took great care in working with sites to ensure that students would not work with patients suspected of having or diagnosed with COVID-19 and to ensure the safety of patients, students, staff, and faculty.  The COVID-19 admissions slowly declined; students are only able to be in the clinical setting because the numbers were coming down. Yet, in spite of this pandemic, our faculty is giving their all to students and patients.  Not only are faculty teaching during a pandemic, they are teaching well even in this different environment, providing meaningful experiences to learners while also accounting for safety. 

As I continue to review the report, I am aware of the halo/horn effect and wonder if students were so grateful to be back in the clinical setting that they are providing more positive comments about faculty that they might have  had there not been a pandemic-mandated pause in their clinical training.  I also wonder if faculty were just so grateful to have students back that they were nostalgically reminded of the joys and wonders of teaching and passing on our wisdom and passion for patient care to those coming after us – those who will probably be our doctors one day.  Whatever the reason, joyous teaching interactions leapt from the report with jubilant aplomb. 

The end of the report contains students comment about the teaching they received from residents.  The comments about resident teaching were just as positive and strong.  I admit that I shed a few tears when I read comments about our former graduates who are now residents in multiple clinical programs and sites teaching our students in such a challenging situation.

These comments weren’t just positive.  They detailed specific high-quality teaching moments.  I’m so grateful to bear witness to the interpersonal connections at play with each other: patients, students, staff, residents, faculty.  

These observations carried through to the personal statements of our fourth-year students applying to residency.  So many students were inspired by the physicians that cared for them or their loved ones in their formative years.  We are all interconnected.  It may sound very “airy fairy” or New Age, but I notice this connection again and again: physicians inspiring patients to become physicians-in-training, physicians and residents teaching students who will one day become physician educators themselves, patients receiving care but actually who are educators.  We are all connected and in this report I see this so clearly.

I’ve been thinking a lot lately about the interconnectivity of each person within society and on this planet.  It is so clear to me during this pandemic that we as a people are only as strong as the weakest link.  If just a few people are not wearing masks or are gathering together, the novel coronavirus will continue to spread.  But if we follow basic guidelines, we are strong together and our unity-in-action speaks to our interconnectedness.

Medical education and patient care are intricately woven together like a tapestry with every thread contributing its own texture and color to the pattern and strength to the structure. I am so honored and grateful to witness and be a part of the beauty on the report before me, because I know that the words written are just a glimpse of the overall experience students had at their sites with their preceptors, residents, and patients. 

Dear Dr. Wang,

Your article was recently  retracted by the editors of the Journal of the American Heart Association and was denounced by the AAMC and the American Heart Association. As researchers and leaders in selective admissions and medical education, and as Asian Americans, we are deeply disturbed and offended by your article’s lack of conceptual rigor and its perpetuation of racist tropes, namely that a race-conscious admissions process produces unqualified Black physicians and physicians of color.

A flawed paper

The crux of your argument seems to be that by using a set of holistic admissions criteria, medical schools admit unqualified applicants and therefore, produce an unqualified physician workforce. However, you seem to confuse winning a competition on a single scale with being qualified. Being competitive is not the same as being qualified.  24,127 runners qualified for the Boston Marathon.  Not all qualifying runners will finish at the top, or even within minutes of the most competitive athletes, but most will finish and all were qualified through a rigorous process to pursue the marathon course.  The tripartite mission of medicine – education, research and patient care – is served best with attention to equity, not competition.

Dr. Wang, you falsely defined “qualified” applicants using only MCAT scores, which are incomplete metrics of an applicant’s qualifications for medical school.  Aggregate national acceptance data from 2017-2020 shows that 18.1% of applicants to medical school with MCAT scores between 514-517 were not accepted.  For those scoring above 517 (95th percentile) 12.2 percent were rejected by every school.  Practitioners in undergraduate medical education (UME) admissions understand that assessing academic preparation and personal qualifications for medicine is complex, nuanced, and cannot be reduced to the MCAT, which has  limited capacity to predict academic success (and does not predict clinical outcomes).  We would no more assess cardiovascular health using only body weight than admit applicants to a profession based only on MCAT scores. There are many other factors that must be considered in context.  Among these factors is the experience of racism.

Your paper ignored structural racism, and claimed that centuries of colonization and racism, and their implications for contemporary society, vanished with the Civil Rights Act of 1964.  This is tantamount to claiming lead poisoning ended when the Consumer Product Safety Commission banned lead paint in 1977.  Medicine takes place within societal realities that cannot be ignored.

Racism affects different populations differently, and solutions must acknowledge these differences. As Asian Americans we face anti-Asian racism and xenophobia especially in the COVID era, but the inequalities we face are different from other forms of racism, especially anti-Black racism. Regardless of economic status, Black people must survive murderous state racism and deep structural inequalities, as they pursue educational goals. Similarly, and in different ways, Latinx, Indigenous peoples, and the diversity of Asian Americans including Southeast Asian and Filipinx Americans confront different forms of intersectional racism. Systems of oppression (e.g., racism + patriarchy + poverty) intersect to affect us in different ways. We are not all playing the same “game.” Unfortunately a uterine lottery pick predetermines resources produced by deep systems of inequalities that are heavily reproduced in access to education resources, supports, and outcomes.  It would be odd if a fair admissions process could somehow simply ignore that fact.

Intersectional racism-conscious admissions

Talent is universal, opportunity is not.  Many schools already employ advanced, holistic evaluation and selection methods for choosing the next generation of physicians.  Affirmative action, or race-conscious admissions in education, is a critical policy and practice to advance diversity, which has been deemed necessary for robust educational benefits.

Higher education can seek to achieve diversity necessary to facilitate educational benefits, through narrowly tailored practices. Race cannot be the reason that anyone is admitted or denied, nor can race be considered to reach quotas or “parity.” The narrowly tailored consideration of race as “one of many factors” through holistic review should center and acknowledge how intersectional structural racism shapes students’ educational contexts. Everyone, including white and Asian Americans, benefits from diversity resulting from affirmative action and race-conscious admissions that account for individual students’ whole stories and contexts of education. Medical admissions should value a wide array of applicant experience to foster an appreciation of the wide array of patient experiences.

We are calling for robust praxis in intersectional, racism-conscious admissions, which affirmative action law allows. Using an admissions approach that is conscious of intersectional racism, we center everyone’s unique human dignity in evaluating their qualifications, moving beyond checking off a particular racial box to understand the totality of the applicant’s experience and talents. It does not guarantee admission for anyone. It offers a fairer, more equitable evaluation process. Only highly qualified applicants are admitted.

Equity is fundamental to medicine living up to its ideals to “do no harm” and serve all people. Black Lives Matter.

Sincerely,

Dr. Nakae and Dr. Poon

Sunny Nakae, MSW, PhD, is a clinical associate professor of social medicine, population, and public health and Associate Dean for Student Affairs at the University of California-Riverside School of Medicine. She has previously held administrative positions at the University of Utah School of Medicine, Feinberg School of Medicine at Northwestern University, and Loyola University Chicago Stritch School of Medicine. She is the author of Premed Prep: Advice from a Medical School Admissions Dean (Rutgers University Press, 2020)

 

OiYan Poon, Ph.D. is an associate professor affiliate in the Department of Educational Policy Studies at the University of Illinois at Chicago. Her research focuses on how race-conscious holistic admissions works, and the racial politics of Asian Americans and affirmative action.

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