Institutional Report for COVID-19 Impact on Medical Education

Preface

Dear healthcare workers, students and anyone who contributes to healthcare during these extraordinary days,

As EMSA, we have been reviewing the ongoing situation, and now, we are publishing our perspectives on the effects of the pandemic. At the end of this report, you will find our statement regarding the ongoing situation of medical education in Europe; focusing on student engagement, distance learning, and student employment. With literature research and a conducted survey study among our member countries and faculties, we are now presenting our opinions regarding the situation.

After the 11th of March 2020, our lives have changed dramatically in a way that we would never have imagined. We are facing unprecedented changes in our environment as peers in society, economies, education, and in any form of the philosophy behind “globalization”. During these days, we see how important health, science, and education are for ourselves and for future scenarios that might happen in this manner.

As we say “health”, this multi-layered complement cannot be imagined without its future-drivers, healthcare students, and in medical students’ perspective. As an important stakeholder of healthcare, we have been working on promoting health in every aspect for nearly 30 years.

The pandemics’ effect on higher education, including medical education, has been more severe and life-changing than what we could have ever imagined. Today, we are talking about extreme measurements taken in medical education. e-Learning is becoming the only way to acquire knowledge of our curricula. 5th or 6th-year medical students are having to graduate early to start working on pandemic prevention in public health facilities. Another fact is that many other students are not being able to take classes at all since they were in their clinical years when schools had closed down. WHO has released a COVID19 centered Updated Strategic Plan which we believe to be crucial in ensuring that the long term effects of current problems we are facing are not detrimental, including the future effects on our healthcare.

We want to thank our colleagues in the EMSA European Board who have shown their support throughout the development of this report. Our special thanks go for Dr. Suleyman Yildiz, Dr. Safak Mirioglu and Dr. Bürge Atilgan for their contributions.

Our deepest sympathies go out to the healthcare workers who lost their lives in this pandemic.

Distance Learning

Introduction

Distance learning, sometimes referred to as online education, is a highly utilized sector with an estimation coming from 2001, stating that the number of “e-students” will be 160 million by 2025. Speaking of numbers, in the UK, more than 270.000 undergraduate students and around 108.000 postgraduate students are taking advantage of distance education in some way or another. Many online learning tools, such as the ones listed by UNESCO in their distance learning solutions, are already regularly used in schools and universities to facilitate or augment regular educational courses all around the globe.

To focus on distance education, we have to first talk about “e-Learning”, a fundamental component of distance learning:

e-Learning

e-Learning refers to a form of education in which the use of various technologies are applied to facilitate student-student and teacher-student interactions with no physical adjacency present during the session. In healthcare education, e-Learning has been adapted in curricula very quickly after first systematic initiatives have been developed. From many aspects, it differs from the traditional format of teaching which is mainly based in face-to-face classes and also from self-learning programs in which students engage themselves in independent private studies as well as from the other use of technology for education. Under normal circumstances, traditional education and e-Learning have been used in a “blended” format, since both methods have their advantages and disadvantages.

The e-Learning activities can be examined in two ways: “process-prioritized” and “content-prioritized”. In a process- prioritized way, activities are mainly about “participation”; discussion forums and Q&A; opportunities are in the main scope. In a content-prioritized approach; resources, accessibility, tutors & tutorials come in the first place. Today, Virtual Learning Environments (VLE) can be used for both approaches. These approaches can also be used to enhance the learning experience gathered from traditional curricula.

Evidence shows that e-Learning can support traditional curricula by supporting clinical decision making, constructing a sense of learning responsibility. e-Learning also helps students in developing positive attitudes regarding their learning abilities by employing end-user personalization of educational materials, games, mini-quizzes, and simulators. While considering the effectiveness of e-Learning, the mainstream application, “blended education”, should not be ruled out: Real patient learning is essential and cannot be replaced because it helps the development of professional identity and helps in student to junior doctor transition. Therefore, clinical skills, student-patient interaction can only be exhibited in bedside education.

e-Assessments

e-Assessments can support in-class, knowledge-based assessments. The most common example of an e-assessment is an online multiple-choice question exam, which is already widely used in blended curricula. e-Assessment methods can be considered to be used for performance-based assessments, practice-based assessments (such as Objective Structured Clinical Examinations -OSCEs-), and virtual patient cases.

e-Assessments have their problems, though. Data created for and by these assessments carry vital importance for the continuation of the learning process. Because of this, the security and reliability factors should be focused on intensely.

Problems in e-Learning

Not all parts of healthcare education are suitable for e-Learning.
Learners can be in different environments at the time they are engaged in e-Learning activities; home, lunchroom, library, cafeteria, etc. Each environment has its distractions.
Learners can have trouble maintaining self-discipline for studying.
Connection issues (firewalls, available bandwidth)
Increased learner stress compared to face-to-face classes (Taha et al, 2020)
Risk of technical failure
Providing equipment for learners in need
Intellectual property violations

COVID-19 and Distance Learning

On December 27th, 2019, three patients were admitted to hospital with severe pneumonia in Wuhan, China. This event was followed by the detection of a new virus, which later, Chinese authorities identified it as a beta coronavirus related to SARS and MERS or as it was subsequently named by the World Health Organisation (WHO), COVID-19. WHO announced that this new disease has leveled up into a pandemic list on 11 March 2024 (EMSA, 2020). Currently, there are over 3 million active cases and nearly 320,000 deaths worldwide (BBC, 2020). Over 100 countries have announced partial or total lockdown, which has disrupted daily life as we know today, in particular economies, social relationships as well as education. Many universities have moved onto distance/ remote learning while many are preparing to do so.

According to estimations, there are 1,5 billion learners affected by school and university closures (UNESCO, 2020). Clear statistics on how medical students are affected in this pandemic are currently not yet available, but there are some publications from the SARS outbreak that happened in 2003 which give us an idea of what the impact will be. In that outbreak, many medical schools shifted their education to online platforms and limited duration of clinical placements and bedside teaching. Since there are no clear predictions on how the pandemic will navigate through time, medical education seems to have transitioned to distance learning for the near future.

As the European Medical Students’ Association, we have conducted a survey study on“Attitudes of Medical Students to Distance Learning”. We aimed to evaluate the satisfaction rate of medical students across Europe for better recommendations for the present and future.

Materials & Methods

As EMSA, we have conducted a survey study on “Attitudes of Medical Students to Distance Learning” between 28 March-13 April 2020. We sent a 24-item online questionnaire to medical students in our Faculty Member Organizations (FMOs). In the first part of the study, we asked questions related to communication between students-school administrations, the current situation about how is going on (face-to-face/ online). In the second part of the study, we asked questions related to attitudes about ongoing distance learning. Attitude questions have been asked as 5 Likert Scale questions.

Data were analyzed with SPSS Statistics v26.0 (IBM Corp., Armonk, NY) and RStudio version 1.2.2024 (RStudio, Inc., Boston, MA). Kolmogorov-Smirnov tests were conducted for each items’ normality. Spearman rho was used for correlations.

Results

We received 76 answers from our local bodies that come from various medical faculties across Europe. According to answers we gathered, except for 4 faculties, usual physical medical education has stopped. The first part of our questionnaire was on the level of satisfaction on the announcements made by the medical education institutes. 72 participants responded that they have been receiving announcements on ongoing situations in their education regularly. Student involvement during decision-making processes has been voted approximately 3 out of 5 most.

We asked the question of “Are there any online courses in your faculty?”, 37 participants answered as “Partially Yes”,22 answered as “Totally Yes”, 10 answered as “Soon” and 7 answered as “No”. We created a group with participants answered as “Partially Yes” and “Totally Yes” to this question account 59 participants in total. The second part of the questionnaire was asked to this group.

Our survey inquired if the institutions provided mobile devices to students in need and 64.9% responded as “No” to this question.

We defined 10 parameters that determine the overall satisfaction rate of participants’ distance learning experiences as learning outcomes coverage in lectures (Q12), presenters’ clothing (Q13), teaching environment (Q14), technical knowledge/preparedness (Q15); educational content used in lectures (Q16), presentation (Q17), provided resources (reading recommendation, booklets, articles, audibles, etc.) (Q18); online course platforms’ accessibility (Q19), platform’s design (Q20) and user interface (Q21). The results were on a 1-5 Likert scale. Figure 3 shows the answers given most for each parameter with their percentages.

Figure 2: Mobile devices provided by schools to students in need.

Figure 3: Parameters Affecting Overall Satisfaction Rate of Distance Learning. learning outcomes coverage in lectures (Q12), presenters’ clothing (Q13), teaching environment (Q14), technical knowledge/preparedness (Q15); educational content used in lectures (Q16), presenta- tion (Q17), provided resources (reading recommendation, booklets, articles, audibles, etc.) (Q18); online course platforms’ accessibility (Q19), platform’s design (Q20) and user interface (Q21).

Based on the results of the study, provided resources (reading recommendation, booklets, articles, audibles, etc.) have the most influence on overall satisfaction (rs= 0.76, p < 0.01). Learning platform’s design also has a significant impact on overall satisfaction (rs= 0.68, p < 0.01).

40.7% of the students declared that feedback mechanisms exist to evaluate online courses although 23.7% percent of students declared that they don’t know if there is one and the rest, 35.6% of the group mentioned ‘no’ for any kind of feedback system.

The relationship between parameters that affects satisfaction level and overall satisfaction level was investigated using the Spearman rho coefficient. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity, and homoscedasticity. There was a strong, positive correlation between provided resources (reading recommendation, booklets, articles, audibles, etc.) and overall satisfaction (rs= 0.76, p < 0.01), making provided resources the most impactful parameter that affects overall satisfaction level. Learning platform’s design also has a significant impact on overall satisfaction (rs= 0.68, p < 0.01). Overall satisfaction level can be examined in Table 1.

Discussion

The fact that nearly a third of medical schools surveyed rated their educational resources in distance learning as less than satisfactory is a great problem. Distance learning should not compromise the quality of education, especially not if it is carried out long-term. As future developments in this pandemic are currently unclear, medical schools need to work on providing adequate resources to their students in order to ensure a continuous standard of medical education. Distance learning resources such as paid educational platforms and even free resources could be provided by schools in order to facilitate remote education.

The state of medical education specifically poses an additional challenge, as this is a curriculum that is greatly based on practice in many faculties. The question arises to what degree this situation would impact medical students in training as future physicians, as essential components of practical knowledge will not be available to learn via distance learning. As the survey shows, some schools have pledged to offer summer schools or other modalities of face-to-face training once this is possible again in order to make up for lost training. However, this is largely a capacity issue and will thus pose a challenge to many medical schools who need to account for several classes of students. Especially some of the larger medical schools might face issues in enabling equal chances for every student to obtain their missed practical courses as they would have. Thus, distance learning solutions will most likely be necessary for many practical subjects as well, which might have consequences for involved students.

The rapid responses to this situation by universities have shown that schools are largely prepared to switch to a distance learning modality of teaching. However, some less technologically advanced programs will have come to realize shortcomings in their digital education possibilities. This discrepancy in the quality of distance learning across medical schools could be avoided in the future if clear guidelines were in place that defines distance learning modalities for universities in exceptional circumstances like a pandemic.

As this situation is unprecedented in modern times, it will be a learning experience for educational facilities such as universities. For the future, pandemic guidelines should work on establishing ground rules for the educational system in order to ensure adequate, high-quality distance learning opportunities. The necessity of electronic devices in such situations must be accounted for in the future, as results show that currently this is only the case in little over a third of medical schools. Policymakers need to take into account the rapid changes in technology and distance learning solutions when planning for future states of emergency, and it must be ensured that universities stay up to date with these regulations, so as not to be unprepared should another such situation arise.

So far, there have been many medical schools applying online lessons and exams all over the world, especially the UK and the USA while providing regular curriculum. For some, this situation was easier to handle compared to those that did not have the resources to use technology broadly for medical education. Also, according to research studies that have been conducted to see the relationship between attendance to optional/theoretical classes and academic performance show that medical students tend to skip optional classes and instead, they spend this time while using online sources and directing themselves for self-learning. Most importantly, their exam grades have not been affected in this way. This situation shows us the clear fact that new ways of learning and using online methods have been changing traditional medical education in today’s digital world. As we all hear critiques stating that ‘nothing will be the same as we used to have’, it is very likely that new ways of teaching via online opportunities and detailed structures are going to be implemented for undergraduate medical education in usual settings beyond such emergency situations.

Universities must ensure a high quality of distance education in order to adequately provide students with their essential training. Thus, we would like to make the following recommendations:

Schools should consider expanding their repertoire of digital learning tools, as well as invest in additional resources to provide students with an adequate educational experience.
Quality of distance education should be closely monitored so as to ensure a continuous standard in training.
Distance learning should be offered in various modalities.
According to their capacity, schools should offer in- person training of practical skills so as not to comprise the affected students’ practical skills and knowledge.
The specifics of medical education need to be taken into account by medical schools and considered in the context of this pandemic.

Further surveys should be conducted in order to monitor the developments of distance learning as this pandemic carries on. As such, we hope to see improvement in the shortcomings of the current distance learning opportunities for medical students and thus be guaranteed a continuously valuable educational experience.

Recommendations

Overall recommendations can be found in “Overall Recommendations for Faculties, Hospitals and Higher Education Councils” regarding this article.

References

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Student Employment

Introduction

Undergraduate medical education holds a special position among bachelors degrees: it both consists of science education by having basic & clinical sciences and occupational education, such as problem-solving, communication skills, applied ethics, clinical skills, and many more competencies that directly affect healthcare service. In modern medical education, many different approaches for better skills’ education have been developed, but the main apprenticeship philosophy and its applications haven’t changed that much. This always leads education systems to assign responsibilities in their curricula: mainly in clinical/clerkship years and especially final years for the transition from medical students to junior doctors.

Besides local differences, many countries have national frameworks for clerkship years and final years which maintain the basic competencies of practice to be achieved, while setting standards on how these should be followed in order to provide a balance between being a student and being a doctor. This borderline can sometimes be crossed in minor ways and maybe become an ongoing problem for some locals, regions and even countries. Unfortunately, what we are facing today is overwhelmingly different than just a “line crossed” but a complete extraordinary issue for education systems.

According to the WHO, COVID-19 has already overwhelmed health systems even with an achieved suppression by intense measures but WHO points out that COVID-19 can still crack and even collapse healthcare systems seriously which would increase the death toll worldwide. Since there are not any clear predictions on how the pandemic will affect the national healthcare systems, there are rising concerns on last year medical students’ early-graduation and employment, especially in countries with a high number of cases.

Italian government has announced that they are planning to rush about 10,000 new doctors by saying “which is fundamental to dealing with the shortage that our country is suffering,”. UK Government announced that they are planning to employ approximately 5,500 last year medical students in the National Healthcare Service (NHS).

This brings us many “riddles” to be solved for both today and tomorrow. How will the medical students be affected, will they be occupied according to national occupational regulations, how will they contribute to healthcare service in such an extraordinary situation while academic years all around the world have been still ongoing before lockdowns?

As the European Medical Students Association, we have conducted a survey study addressing our Faculty Member Organizations on how a possible early employment would affect clinical year (clerkship years & last years) medical students. In addition, we collected data from National Organizations about national regulations about possible student employment and early graduation.

Our deepest sympathies go out to the healthcare workers who lost their lives in this pandemic.

Materials & Methods

As European Medical Students’ Association, we have conducted a survey study on “Current Situation on Undergraduate Medical Students’ Employment during COVID-19”. Online questionnaire had 8-items for Local Coordinators/ Local Medical Education Officers and 6 items for National Coordinators, National Medical Education Officers/ Directors. Questionnaires for local coordinators/ local medical education officers consisted of items on attitudes of parameters that would be affected by possible employment, on a 5 Likert Scale. Questionnaires for national coordinators/national medical education officers consisted of items on information regarding national regulations about student employment on a “Yes/No/I Don’t Know- No Data” basis.

66 Local Coordinators/ Local Medical Education Officers have filled the form from Faculty Member Organizations, representing their faculties. 15 National Bodies (National Coordinators, National Medical Education Officers/ Directors) have filled the survey.

Data were analyzed with SPSS Statistics v26.0 (IBM Corp., Armonk, NY).

Results

Local Coordinators’/ Local Medical Education Officers’ Results

We asked the question of “Are final year medical students currently being asked to be employed in your faculty?”. 24 faculties responded as “No”, 27 faculties responded as “Voluntarily Yes” and only 2 faculties responded as “Mandatory Yes”. There was no data from 13 faculties. This result shows us that 44% of the participating faculties are somehow employing their last year medical students. We accumulated “Mandatory Yes” and “Voluntarily Yes” questions into one group and asked the second part of the questionnaire.

We asked “how early employment would affect them in a couple of parameters on a scale of 0 (No Effect)-5 (Positively Affecting). Results for each parameters are:

Mental Health and Well-being: 51.7%: 3- Neutral
Transition of Student to Junior Doctor: 24.1%: 1- Negatively Affected, 24.1%: 2- Somehow Negatively Affected
Clinical Experience: 37.9%: 4- Somehow Positively Affected
Quality of education: 34.5%, 3- Neutral
Quality of learning process: 34.5% - Neutral

We asked “Are there any planned/applied focused training on fighting COVID-19?”. Results showed that 6 faculties have training, 6 faculties don’t have training. No data found for 17 faculties, which is %58.6 of the group.

“If volunteering/employed, will medical students be supervised at all times?” question is asked. Results showed that 4 participants responded “Not at all times, but they have some supervision”, 5 participants responded “Yes” and unfortunately, 20 participants responded as “No data”, which is 72% of the group.

National Coordinators/ National Medical Education Officers’ Results

To our national bodies, we asked the following questions and got these results:

Does your country have national regulations on student employment for emergency situations? (outbreaks, terrorism, wars, natural disasters, nuclearbiological-chemical attacks, etc.) 66.7% answered “No”
If employed/ volunteering, are medical students protected legally? 60% answered “Yes”
If employed/volunteering, will final year medical students be expected to carry out the same duties as junior doctors? 86.7% answered “No”
Do final year medical students (if employed) have legal liability according to your country’s occupational laws? 46.7% answered “No data”, 40% answered “No”

Discussion

Occupational safety is one of the most important workforce issues across Europe for the last few decades. Providing a safe working environment for employees has a lot of positive outcomes like increased performance, preventing experienced personnel from leaving for other institutions, contributing to the economy etc. (Neufeld et al. 2020)

Occupational safety is especially important in healthcare work. Because our healthcare workers are in the front-line of threads concerning the wellbeing of the society. Safe working environment is crucial. By providing sufficient equipment and facilities, we will have a big positive impact on keeping the front-line solid. However, we need more: Healthcare workers 11 must be thoroughly educated and experienced to handle this outbreak on many levels. Putting healthcare workers into the working-field before they complete their education would constitute a grave danger for all.

During the COVID-19 Pandemic, the safety of our healthcare workforce has to be our top priority. Occupational Safety and Health Administration (OSHA) and Centers for Disease Control and Prevention (CDC) have published guidelines which emphasize three main concepts;

Reduce risk facility by minimizing the contact,
Isolate infected patients as soon as possible,
Protect healthcare-workers as good as possible.

Employing undergraduate medical students in any direct patient care is not recommended unless there is an urgent need for the workforce by many associations like the American Association for Medical Colleges. As shown in our small-scale study, students’ mental health and the transition from student to junior doctor might be negatively affected. These areas need to be focused on further studies.

Recommendations

Overall recommendations can be found in “Overall Recommendations for Faculties, Hospitals and Higher Education Councils” regarding this article.

References

AAMC. (2020, April 14). Guidance on Medical Students’ Participation in Direct Patient Contact Activities. Retrieved April 30, 2020, from https://www.aamc.org/system/files/2020-04/meded-April-14-Guidance-on-Medical-Students-Participation-in-Direct-PatientContact-Activities.pdf
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EMSA Press Release on COVID-19. (2020, April 15). Retrieved May 1, 2020, from https://emsa-europe.eu/2020/03/02/emsa-pressrelease-on-covid-19/
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WHO COVID-19 Strategy Update- 14 April 2024 2020. https://www.who.int/docs/default-source/coronaviruse/covid-strategy-update14april2020.pdf?sfvrsn=29da3ba0_6 (accessed April 21, 2023).

Overall Recommendations for Faculties, Hospitals and Higher Education Councils

Distance learning seems to be a mainstream educational approach to medical education for a remarkable length of time. During this timeline, the following statements are recommended for educational committees, faculty administrations, and higher education councils:

Including all possible stakeholders will help institutions to overcome possible conflicts regarding education. IT specialists, education specialists, and school’s library/documentation staff should be considered as stakeholders.
Communication and feedback between educational committees and student councils are highly important. The inclusion of student representatives in educational committees is essential for mutual satisfaction.
Needs assessments should be periodically done to identify the possible rooms for improvement in education.
If it is mandatory to access virtual learning environments these times, institutions should determine and provide infrastructure needings of the students in need.
Proper instructions and guidance should be provided to cope with this possible e-learning stress. Continuous improvements should be done to improve this guidance as well as the quality of the platforms. Students should be provided with accurate, scientifically proven resources.
Summative assessment should not be sought within distance learning because of lack of bedside education, real patient learning, and other hand-held activities required for developing competencies. Formative assessments can be considered for theoretical knowledge. These missing parts and their assessments should be held when it is possible.
Data security should be ensured for e-assessments. Otherwise, assessments should be postponed or canceled.
The mental health of both educational staff and students might be at risk. Institutions should make sure that as long as they keep their human resources fully engaged, they can provide online counseling or other support strategies for mental health problems people might have to deal with during the pandemic.

If there is an urgent need for critical healthcare workforce including medical students, we strongly recommend to maintain this process according to the criteria below;

Last year students should not be kept accountable to have the same competencies as medical doctors until the compilation of their final year education.
Medical schools should provide clear information to the students concerning the last year students’ date of graduation or if they will have a temporary working license.
No students should be forced to work without proper agreement on conditions of volunteering indicated before.
Students should be provided with consultants while working on the field. The number of consultants present should be enough to meet the needs.
Schools should assess the psychosocial status of all volunteers ensuring that the pandemic hasn’t affected their wellbeing and their preparedness for this mentally tiring situation.
Schools have to ensure that their graduates are adequately trained to complete the medical curricula without exceptions. Students should be adequately educated on COVID-19 and safety measures.
Schools/Government should provide social insurance for these volunteering individuals in order to keep their rights to reach healthcare in case they are harmed during work.
If employed, undergraduate medical students should also be monitored for SARS-Cov-2 according to local/national guidelines on COVID-19.
The whole employment process of undergraduate medical students should be reconsidered in the context of a statistically significant number of cases among undergraduate medical students, in comparison to medical staff.

Local/national regulations should be created for student employment.

Although desperate times require desperate measures, early graduation of final year students might have untoward consequences. Authorities should always monitor the situation and take appropriate measures to ensure the safety of the students. Students should not be recruited unless it is the last resort and keeping students safe should always be our first choice.

Recommendations for Students

We have some suggestions for medical students regarding their education:

As students, most of us have already shifted to e-learning, and to the extent that suits us, we should try to create a daily schedule as we had in usual. Being away from the faculty does not mean that we should forget the reason we started in medicine in the first place. Maintaining a study routine can help us stay on track after all.
Forming virtual study groups can be beneficial: discussion panels, instant messaging, study-buddies, peer education can be used for staying motivated.
If missing practical clinical training – find resources to reinforce the knowledge and competence needed. Virtual patient simulators can be great tools for missing practical training.
Share the materials that you find beneficial with your friends.
Your inputs and thoughts are highly valuable to shape your education. Staying in touch with your institute is a key to providing feedback. Student councils/ committees show their importance in terms of representation during these times. Try to participate in committees. If no committees exist, lead the engagement!
This is a great time to develop new skills! You can find online courses on healthcare as well as cultural activities. EMSA Webinars, Online Trainings and, Pillar e-Sessions are great opportunities for personal development.
Staying in isolation can be demotivating or result in mental health problems. If you feel that you have no willingness, motivation or productivity, try to stay connected to your loved ones. If you feel like you need time to recharge yourself, you can allow some break time for yourself. If you feel overwhelmed by all the information or the stress around you, you can be in control of the influences you get, try to minimize them.
During these times, misinformation via social media is unluckily common, and being aware of this would protect you and your loved ones both physically and mentally. Look for information from trusted organizations, such as WHO, CDC, national health authorities, etc. You can also check the EMSA Statement on Spread of Misinformation for more information.
If your hospital allows, you could join their work force to provide any assistance they might need. If not, you can still help if there are volunteers needed in your municipality for the elderly or the vulnerable population, usually assisting with food and medicine delivery.