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— Education

Tales in and out of school

During the pandemic, innovation and adaptability became virtual realities.

By Yadira Galindo

March 2020

In March 2020, rumors and uncertainty plagued Betial Asmeron, then a third-year student at UC San Diego School of Medicine who was, by nature, optimistic and assured.

With three classmates, Asmeron now crowded anxiously around a computer monitor to watch a virtual town hall in which school leadership would reveal how their education would be impacted by COVID-19 and the growing pandemic.

Prior to the pandemic, Asmerom’s routine was the same, day in and out: Wearing hospital scrubs and coffee in hand, she would arrive at 5 a.m. for a rotation at UC San Diego Health to check on the welfare of patients under her watch.

“As medical students, we have the gift of time in the hospital. We get to know our patients on a deeper level, which allows us to better help with their medical and emotional needs,” said Asmerom.

With consent from patients and under the supervision of resident and attending physicians, third-year medical students interview and examine patients, write notes in their electronic medical records, present findings to their team for review and are part of hands-on care, such as surgery or labor and delivery.

After a full day in the hospital, Asmerom would return home by 7 p.m. for a late night of studying for shelf exams — national standardized exams that evaluate competency over each core rotation or clerkship — before repeating the routine the next day.

Wuhan to WELCOME
UC San Diego Medical Center in Hillcrest was among the first hospitals in the nation to provide care to patients with COVID-19, notably evacuees from China.

Steven Garfin, MD,
interim dean of UC San Diego School of Medicine. 

Time Stands Still

Asmerom was beginning a six-week rotation in obstetrics and gynecology (OBGYN) when the pandemic struck with full force. The world shuddered, and then shuttered. Everything and everybody seemed to shut down and withdraw behind closed doors, except where she worked. As a provider of essential services, UC San Diego Health opened its doors wider.
One of the first hospitals in the United States to care for patients sickened by SARS-CoV-2, UC San Diego Health’s infectious disease experts recognized the expanding pandemic that would require all available hands to care for the millions of people who would eventually become infected and the millions more who would die, close to home or far away.

“We pursued medicine because we wanted to help people, and even though we knew that there was some risk to our own health by being in the wards, we really wanted to be there,” said Asmerom. She and her classmates eagerly offered to become contact tracers, to serve as symptom checkers or help patients sign up for the MyUCSDChart electronic patient portal that would allow access to telehealth visits. They wanted to do anything and everything to help during the crisis and to continue their education. But there were immediate challenges:
School of Medicine leaders were forced to make a difficult decision: Are medical students essential on site or should they be learning safely from home?

Standing before the computer monitor, a practice that would soon become very familiar, Asmerom and her classmates heard their fate echoing over the speakers. Rotations or clerkships were indefinitely suspended.

“A hurricane is devastating. The residual is terrible, but it sweeps through and it is over. There is a finite period when things turn around with enough resources, but with this pandemic, we had no clue when it was going to let up. If it would let up,” said Steven Garfin, MD, interim dean of UC San Diego School of Medicine. And just like that, Asmerom’s cherished time and connectedness with patients vanished, like a leaf in a hurricane.

“For the safety of our faculty and students, and to ensure our students had a way forward through this difficult time, we made tremendous changes over a very short period of time in a highly collaborative way.”

— Carlos Jensen, PhD

Virtual Class Rooms

All levels of education — from elementary schools to universities

— found themselves grappling with unprecedented challenges posed by a highly contagious virus that did not discriminate by age, gender, ethnicity or even health status.

Once lively campuses emptied as schools and districts took early or extended spring breaks to plan for online instruction and to implement safety protocols to bring staff and students back, when it was safe to come back.

UC San Diego faculty, program directors, course directors and information services scoured online resources to build and shift to virtual learning on a campus-wide scale.

“For the safety of our faculty and students, and to ensure our students had a way forward through this difficult time, we made tremendous changes over a very short period of time in a highly collaborative way,” said Associate Vice Chancellor for Educational Innovation Carlos Jensen, PhD.

“The way that administration, faculty and senate came together, because it was the right thing to do, is a tremendous testament to the kind of community that we are. We’ve shown that we can really change education if we want to.”

— Carlos Jensen, PhD

For example, the Division of Arts and Humanities quickly flipped its campus-based, 12-week transfer student Summer Academy to online only. The Preparing Accomplished Transfers to the Humanities partnership with the San Diego Community College District provides hands-on resources for students to succeed at the university, as well as two full academic courses.

For the class “Politics of Food: Justice, Diversity, Community,” led by Stephanie Jed, PhD, a professor in the Department of Literature, students would normally visit multiple community farms together. For the virtual class, students instead received a produce delivery from a San Diego-based Community Supported Agriculture (CSA) program, and seeds, soil and a planter box to grow their own vegetables at home. The program staff organized an online discussion about community gardens and food deserts and cook nights to help create bonds among the students.

Bioengineering students at UC San Diego Jacobs School of Engineering completed senior design projects. They used many strategies, including creative use of Zoom for collaborative brainstorming and design; a focus on regular, precise communication with project sponsors and clients; off-campus, socially distanced outdoor work meetings; and limited use of labs following safety protocols. And, in a nod to the old days, they mailed parts and prototypes to each other.

Faculty members tapped into a wealth of resources available through the Teaching + Learning Commons. It became an important source of support for faculty, instructors, graduate instructional assistants and students. The Commons created an integrated approach that ensured educators had the tools they needed to keep teaching through partnerships with Educational Technology Services, the Library, Academic Integrity Office, Campus Privacy Office and others.

Summer session:

Under strict COVID-19 protocols, several thousand students were able to remain in or move into campus housing.

“Dealing with a new organism is the greatest challenge,” said Maria Savoia, MD, an infectious disease expert and dean of medical education at UC San Diego.

Savoia could have been talking about the novel coronavirus, which was previously unknown, but her words applied as well to teaching medical students during a pandemic.

“We did not know exactly how people would react. There were challenges and worry over access to personal protective equipment in the clinical arena. No one knew where we would end up, and what we saw happening in Italy was worrisome. People were afraid for their patients, afraid for themselves. And everything was changing almost every single day,” said Savoia.

Medical school is a minimum of four highly structured years of classes, myriad exams and countless hours of clinical experience that must be completed in a specific sequence and time.

During the first two years, students spend most of their time in classrooms. The third and fourth years are devoted to applying in a clinical setting what they previously learned. Going virtual meant trying to train medical students without access to clinics.

“We pivoted from in-person learning, where we work together in teams and take care of patients in the clinic, to deciding what could be virtual for effective student instruction. We had to implement the strategy as best we could on virtual platforms over the course of a couple of days,” said Savoia.

Julia Cormano, MD, assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences and director of the Third Year Medical Student Clerkship, said medical school scheduling can be unforgiving, especially in the third year.

Third-year medical school students are required to learn in-person rotations in seven specialties — internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry and neurology — before progressing to their final year and earning their medical degree.

Unique Challenges

“It was also a big pivot for physicians. We were trying to figure out very quickly how to do remote clinical visits ourselves. We realized there were a number of different ways we could include students in this sudden increase in telehealth, including pre-interviewing the patient and observing,” said Cormano.

Case in point: A hospitalist stepped back from the clinical setting and spent his days rounding virtually with students in the OBGYN rotation. Students were able to review patient charts, interpret fetal heart-tracing data and speak with the hospitalist in real time.

“It was essentially transferring what we would do on the wards to our house, with the added luxury of having an uninterrupted hour of the physician’s time. Something like that never happens in the hospital. I probably learned more pathophysiology doing this at-home rotation,” said Asmerom.

“Still, it’s not the same as being in the hospital and being with patients and I think that was the part we really yearned for.

“We wanted to be able to see our patients, interact with them, and really just feel like we were making some sort of impact or difference in their lives and in their care.”

In addition to the unique challenges of medical school, faculty and students across the entire campus were faced with a lack of at-home workspace or proper equipment. Some found that having multiple people working or studying from home affected their bandwidth and therefore their productivity.

“We tried hard to mitigate that by giving people resources as much as we could. I think the university was very good about trying to help and we opened up spaces for students to be able to find a quiet space to learn and to study,” said Savoia.

“We wanted to be able to see our patients, interact with them, and really just feel like we’re making some sort of impact or difference in their lives and in their care.”

— Betial Asmerom

Campus-wide virtual instruction was never intended to be long-term or permanent at UC San Diego.

From day one, a multidisciplinary team of leaders began formulating a plan to safely welcome back students, faculty and staff.

Through its transformative, adaptive and multilayered Return to Learn plan, which launched in May 2020, the university was able to bring students back to campus in a safe and strategic manner.
Among the first to return were medical students.

“None of the national requirements or dates changed so we could not select 10 students to come back. The whole class had to follow a pattern to get into the next year’s program. There is just no way to catch up in medical school without losing potentially a whole year,” said Garfin.

Guided by risk mitigation, virus detection and intervention, Return to Learn kept positive case rates low compared to regional and national case rates.

UC San Diego maintained a median campus-wide infection positivity rate of 0.28 percent throughout the fall 2020 quarter, while San Diego County’s median was 8.1 percent.

Return to Learn subsequently served as a model of best practices for other institutions and K-12 school systems regionally and nationally. The plan received the 2021 American Council of Education/Fidelity Investments Award for Institutional Transformation.

Return to Learn

“We see students as being integral parts of medical teams. So we wanted to introduce them back into the clinic as soon as we could, and we did that safely,” said Savoia.

“In addition, we did a lot of hands-on training in the Simulation Training Center. We broke classes into much smaller groups and had students mask and take COVID-19 tests. Many of our anatomy professors and the people in the simulation lab thought that the educational experience was better in smaller groups because it was more one-on-one.”

The number of students returning to campus increased with each subsequent quarter. With access to COVID-19 vaccines for faculty, staff and students, as well as continued mitigation and virus detection efforts, the plan is to return to full, on-campus operations for fall 2021.

Teaching is primarily delivered through in-person instruction in campus classrooms. Appropriate remote learning options are available for students who are unable to arrive from abroad due to visa delays or travel restrictions.

Betial Asmerom

Asmerom is in her fourth year of medical school after taking a year to pursue a master’s degree in public health.

A School Tested

Shelter-in-place began in March 2020. It took approximately six weeks for medical students to return to clinics and hospitals and yet seniors still needed to complete rotations in order to graduate in May.

While medical students were ready, patients were not.It took a while for hospitals to have the resources to return to regular operations, but it took patients even longer to feel comfortable resuming routine screenings and active health care, affecting some clerkships and residency programs.

“We worked to find the right spots for students who still had requirements that needed to be met so that they could meet their graduation requirements. This necessitated adaptability and a lot of individual work with students. For example, surgeons who could not be in the operating room instead helped in the intensive care units putting in central lines to help their overworked colleagues,” said Savoia.

In the end, all students passed their tests and met the requirements to move on to the next stage in their medical education or career.

“Given the situation and how many unknowns there were, I think we adequately prepared students to be able to have the clinical information that they needed to move forward to their fourth year and to their future careers. Their test scores reflected that readiness,” said Cormano.

Charley Coffey, MD, associate professor in the Department of Surgery, who published three papers on student perspectives of remote learning during the pandemic, said that although first- and second-year students spend minimal time in clinics, they too felt the loss of clinical interactions.

“For many students, working with patients is one of the most gratifying things that they do. It is one of the things that keeps them motivated through sitting in lecture halls for hours and years on end,” said Coffey, co-director of the Third Year Surgery Clerkship.

“There were very creative and innovative things done to involve students in telemedicine and to rounding remotely on the surgical floor and labor and delivery floor. Those were things that students responded well to, ways to reconnect with those aspects of patient care that were so easily lost when we shifted to remote learning modalities.”

Students did appreciate the flexibility of learning at their own pace and working virtually in smaller groups, said Coffey. However, digital fatigue set in after one hour.

“It is nearly as easy for a professor to stand up in front of a lecture hall of students as it is to stand in front of a computer and similarly for students to be able to just sit in front of their computer.

”On the other hand, when it came to anatomic dissections, it is impossible to do that without being in person. It is nearly impossible to replicate during an overnight transition to remote learning and it is among the things that preclinical students missed most,” said Coffey.

Fellows are physicians who have already completed their residency and are now in specialty training. Because fellowships are entirely dependent on caring for patients, fellows were dramatically impacted during the pandemic. Thankfully, by this point in their training most fellows had met the required number of surgeries.

“The concern that many trainees had at that time was how they would transition into the working world. A lot of the hiring, or the interviewing process, or both, were put on hold due to the pandemic,” said Coffey.

Lessons Learned

Prior to the pandemic, some lectures were available virtually. COVID-19 forced the entire campus, from dance instruction to chemistry labs, to find alternative instruction options.

“We have learned a lot about how diverse our student population is, and their diverse needs, and how some of the small changes that we make in the classroom have a tremendous impact on student well-being, success and retention. We have learned to become comfortable with remote and hybrid teaching in a way that we were not before and it has made us think differently about classes,” said Jensen.

“This post-pandemic period is going to be an exciting time when we start thinking about what are the right pedagogical tools. It forced faculty to challenge their assumptions and learn new skills.

“I wish we could have learned these skills under better circumstances, but I think we need to take the good that has come out of this and take that forward. They are valuable skills.”

For the School of Medicine, small groups for hands-on learning has been one of the most touted changes by students and faculty alike. Cormano recognizes that less time in the labor and delivery ward may actually be a more productive and immersive experience if it allows for individualized teaching.

“I think one of the real take-homes for educators is to be critical in determining the modalities and the resources that are going to be most useful to students. How do we make those accessible, digestible and useful for student learning without just throwing a lot of information at them?

“Part of that comes with experience and listening to what students said worked and what did not.”

For Asmerom, who will start her fourth year of medical school in the fall after taking a year to pursue a master’s degree in public health as part of the UC San Diego School of Medicine Program in Medical Education – Health Equity program, remote learning was an effective experience. Still, she is not advocating to make medical school virtual.

“Remote learning is not how you learn to be a doctor. It’s really like an apprenticeship model where you have to go there in person, work with patients, residents and attendings, review labs, and develop your differentials. You have to do it over and over again in order to cultivate your clinical decision-making skills. You can’t do that very well from home,” said Asmerom.

“And I really missed seeing and interacting with patients, meeting their families and being able to bear witness to some of their hardest moments or laugh with them. Relationships are the heart of medicine and I really craved and missed that when we switched to remote learning. And, of course, I missed morning burritos from the Hillcrest cafeteria.”

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