Challenges and opportunities for undergraduate clinical teaching during and beyond the COVID-19 pandemic

As the UK struggled to cope with the burden of COVID-19, measures aimed at controlling the spread of disease and reducing viral transmission were introduced. Among these measures was the sudden closure of educational institutions, forcing rapid adoption of remote teaching. Medical students faced particular difficulty as clinical placements were immediately suspended and patient contact was often replaced with virtual learning.

Although the measures were implemented as a temporary response, it has become clear that across all areas of society, a return to pre-pandemic normality is unrealistic. ¹ Restrictions of some sort will likely remain for years to come. NHS hospitals, and particularly general practice, now bear little resemblance to pre-COVID times, with many outpatient services running remotely, hospital visiting restricted and personal protective equipment now ubiquitous. To complicate matters further, restrictions will be dynamic and vary between locations. ²

Medical education thus faces a dilemma. How can students safely gain the skills and experience they require to become competent doctors under these circumstances and in these changed clinical environments?

Focus has been almost exclusively on using technology to replace in-person teaching. Online platforms have enabled medical schools to continue some form of curriculum delivery for all students, but this can only be a short-term solution. Remote teaching is acknowledged to be a poor substitute for clinical exposure,^3,4 and it cannot replace the attachments that define medical training. Although the implications of the pandemic on UK medical education have been discussed widely,^5,6 there has been relatively little consideration given to the practicalities of delivering patient-facing teaching under post-pandemic circumstances.

Here, we discuss the challenges faced by UK teaching clinicians and outline various responses to them. We advocate that a more comprehensive rethinking of clinical teaching is required to mitigate disruption over coming years. We suggest that this crisis may prove a catalyst for overdue modernisation, allowing us to better align clinical education with current practice and prepare students for the new ways of working that have emerged over this period.

Challenges faced during the pandemic

During the first wave of the pandemic, planned teaching and assessment were abruptly ended for over 40,000 medical students in the UK alone. ⁷ For those in their clinical years, four months of workplace experience were lost. The immediate challenge faced by medical educators is therefore how to make up for this ‘lost time’. Delaying qualification is not an option as the demand for new doctors every August does not change. ⁸ Similarly, the standards expected by graduation are fixed and minimum competence must be achieved before professional registration can be granted. We must therefore find ways to bring these students to an acceptable level of skill before they join the medical workforce.^9,10

Many technological innovations were employed during the first wave to try to reduce the impact of disrupted clinical learning. Remote online teaching was widely adopted and new ways of engaging with students were found. Most UK medical curricula are spiral in design, whereby topics are introduced largely through lectures and tutorials on a university campus, alongside early clinical visits to aid contextual understanding. ¹¹ Naturally, technological teaching methods lend themselves more to this pre-clinical stage as near-equivalence to lecture or classroom sessions can be achieved.

Adapting practical or patient-based teaching is more problematic. In later years, medical students revisit topics and build upon existing knowledge through immersion in the clinical environment, which is much less easily replicated online. That said, suggestions such as virtual ward rounds, online case-based discussions, and inviting students to dial into telemedicine consultations or recording them for asynchronous learning have been made.^4,12,13 Although beneficial, it was clear that remote sessions are no substitute for direct clinical teaching. Furthermore, surveys of student satisfaction revealed that although the value of remote learning was recognised, students still considered their learning compromised.^3,14

Students returned to university in September 2020 and clinical placements were resumed in many UK medical schools. In the interim, NHS hospitals have undergone massive structural change in order to manage the burden of COVID-19 and accommodate new infection control measures. Non-urgent service provision has been reduced and clinical resources diverted to the crisis at hand. ¹⁵ Much elective surgery has been deferred, many routine outpatient appointments postponed, and many more carried out as telephone or virtual consultations. General practices have moved even further into telemedicine, performing the majority of their work remotely to protect vulnerable patients. In many instances, doctors have been redeployed to areas of higher clinical need, and specialist teams have merged to provide more general care to a greater number of patients.

This reformatting of NHS services has reduced both the quantity and variety of learning opportunities available for returning medical students. The loss of usual team structures and frequent rota changes mean that clinicians are often less available to teach students on placement. Infection control measures restrict movement between clinical areas, disrupting rotations, and individual site capacity is limited to comply with social distancing rules. The situation is exacerbated by significant numbers of staff and students needing to self-isolate after viral exposure, which becomes more likely with increasing time spent in clinical environments. There is a real risk that students will not have adequate opportunity to meet their learning objectives and will reach the end of their placements underconfident and underskilled.

Opportunities for change

While the evolving situation poses many challenges for delivering clinical education, this crisis can also be seen as an opportunity for overdue modernisation. Arguably, adoption of problem-based and integrated course styles was the most recent change to undergraduate curricula, 25 years ago. ¹⁶ Clinical practice has since undergone extensive change, which has not been sufficiently reflected in pre-registration training.

Technology accounts for the majority of this change. Video and telephone consultations are now widely considered as safe and economic adjuncts for many patient groups, and work is underway to develop these as educational opportunities. ⁴ In addition to facilitating undergraduate participation, we must consider how to equip students with the additional skills these practices demand, particularly considering many schools have started to include virtual stations in practical assessments. ¹⁷ This should involve training in how to triage patients remotely and overcome the relative lack of non-verbal cues in communication. ⁴

Data protection and confidentiality are also important issues. As for clinicians, if students are to be given access to patient information from their own homes, then secure, encrypted platforms must be provided by hospital trusts. Even so, there remains an increased risk of breaching confidentiality when students view patient records without direct supervision in a clinical setting.

The pandemic presents an opportunity for clinical education to catch up with recent technological advances. One of the most promising is the use of virtual and augmented reality set-ups. Immersive and interactive simulations can be used to replicate scarce resources, enabling access by more students, and even to provide demonstration-based bedside and skills teaching.^12,18 The added benefit that all technological solutions offer is the ability to record for later reference. Many of these solutions had been developed prior to the pandemic, but uptake within undergraduate training has since been accelerated. ¹⁹

For virtual technologies to offer a realistic long-term solution, significant improvement in infrastructure is required within the health service, for both educational and clinical purposes. Many clinicians are likely to need additional training before new modalities can be relied upon. In our own experience, larger-scale and longer-term adoption of these strategies is currently limited by inconsistent WiFi availability, outdated operating systems, scarce audio-visual equipment and insufficient space given social distancing and privacy requirements. We must now prioritise improvement in infrastructure to ensure that the value of these modalities is realised.

Outwith technology, this is a chance to revolutionise clinical placements. Inefficiency has long been a criticism of hospital rotations, due to competition for opportunities and clinicians’ busy schedules. With rising student numbers and new infection control considerations, there is an increasing need to condense clinical time and ensure equality of opportunity. It is now imperative that every moment in the clinical setting is useful and passive ‘shadowing’ is reduced, as we can no longer justify non-essential clinical contact.

Reducing student numbers should improve supervision but will require alternating groups between clinical settings and remote teaching. Weeks could be split between learning on placement and discussing experiences with tutors remotely. Supplementation with simulation will likely be necessary and its use in undergraduate training will become evermore important with increasing limitation on patient contact. ²⁰

If clinical time is to be reduced, learning objectives must be redirected towards clinical skills rather than medical knowledge. Restricted ability to rotate between clinical areas, as well as the dissolution of specialty-based teams during times of highest pressure, will also necessitate a more general approach to placement aims. ²¹ This approach is consistent with postgraduate training and is more reflective of GMC Graduate Outcomes. ⁹

The importance of considering final year as an apprenticeship has become even more evident, as was highlighted by the creation of interim foundation posts during the first peak. ²² Students were graduated early to aid service provision, though the appropriateness of this has been called into question, particularly given the intensity of the environment they were entering. ²³ However, students did describe greater supervision, integration and responsibility as beneficial, ²⁴ and it is clear that aspects of these posts could be incorporated into routine undergraduate training.

We should also consider how this pandemic should inform curriculum content. Increasing time dedicated to global public health seems obvious, but greater focus on medical ethics and resource management has also been suggested. ²⁵ Communication with patients and relatives has also become more challenging, and skills teaching should be tailored to reflect this, e.g. breaking bad news within the constraints of social distancing and personal protective equipment.

Conclusions

The COVID-19 pandemic has already caused huge disruption to medical education, with clinical students worst affected. As disruptions are expected to continue, adequate provision of workplace-based teaching is essential. Innovative responses have already been implemented to overcome many of the problems. However, while remote learning and technology are useful adjuncts, they cannot replace clinical experience. The current crisis presents a unique opportunity not only for adopting new technology, but for modernising clinical education as a whole, by improving efficiency, combining virtual and in-person approaches, and making student experience more reflective of clinical practice during the pandemic and beyond.