Medical schools are being forced to redesign the way they offer teaching and placements on the hoof to cope with the fast-changing demands of the COVID-19 emergency.
Many 4th and 5th year undergraduate students worry that their COVID frontline placements are leaving them unprepared to deal with the routine cases they expect to see when the pandemic is brought under control.
Medscape UK has been talking to some medical students - who did not want to be named - about learning under lockdown.
One student at Queen's Medical School, Belfast did not see a single respiratory case during a 5-week placement in paediatrics.
A final year student at St George's Hospital said: "There is no doubt our education has been affected by COVID, both in terms of reduced placement time over the 12 months and the limited 'range' of conditions in hospitals at the moment. This has been particularly true for routine/elective medicine which has been very difficult to see and learn about. In normal times this is a large part of what we need to know but right now it is crisis management. This will leave many students, to varying degrees, with some gaps."
Loss of Learning Opportunities
The General Medical Council (GMC) and the Medical School Council (MSC) have issued a joint statement acknowledging the loss of learning opportunities for final year students as a result of the withdrawal of placements during the emergency and encouraging them to make it up by working on a voluntary or paid basis, for their local NHS health system.
A spokesperson said: "The current priority is to provide mechanisms for students to achieve the required outcomes in order to be able to graduate, thereby providing an important addition to the medical workforce in the summer.
"We believe that this approach will ensure that there is a new cohort of doctors who are well prepared to join the workforce in the summer, whilst still helping students to respond effectively to the immediate healthcare crisis. Both the GMC and MSC are very grateful to students, staff and the wider healthcare system for all they are doing through this very challenging period."
Across the UK, medical schools have adopted different tactics in order to maintain educational standards when the COVID pandemic made normal large-scale communal teaching and face-to-face contact with patients suddenly unworkable.
Manchester University Medical School had already put much of its class teaching online, putting it at an advantage from the start of the pandemic to deliver it all online. Since the start of the new academic year in September, years 1 and 2 have had no face-to-face time, but years 3-5 have continued to have placements, although not necessarily in the areas they had expected.
Dr Pip Fisher, GP and associate programme director for student wellbeing at Manchester Medical School, said: "The biggest change is that placements are being reorganised on a week-by-week basis as wards are suddenly taken over to deal with COVID patients. Students are sometimes ending up learning a different subject from what they expected.
"We have had to alter timetables to accommodate for how much the NHS has changed during the pandemic, such as by giving an extended induction on use of PPE. This was a complex logistical operation as 400 students could not be gathered in one place, but had to be trained in small groups."
In Manchester's case - because it is a large medical school - clinical skills normally taught in a clinical setting have been delivered in accelerated learning settings to equip students with basic skills like taking blood and inserting cannulas without requiring supervision on the wards. Current fifth years had an additional block on specialty training inserted to make up for what they had lost and to ensure they are able to graduate.
Lancaster University, a small medical school with an intake of only 129 students each year, has been drawing up individual placement plans for each student which can be changed at the last minute, and have kept year 3, 4, and 5 placements going normally. Second year placements have however been cut from 2 to 1 day a week.
All lectures at Lancaster are online but smaller PBL [Problem Based Learning] groups have gone ahead using larger than usual rooms, and clinical skills is still going ahead face-to-face, but with video demonstrations and resources provided in advance to maximise the use of face-to-face time. Moves are underway to move final year exams later in the year and to cancel electives.
Electives are a thorny subject at St George's Medical school, normally taken by fifth years in May or June. A student told Medscape: "We currently have been given no direction about what is on offer for us this year despite it being only a few months away, and sometimes electives are organised years in advance. This has left us feeling anxious due to the added uncertainty."
Deputy Director of Medical Studies at Lancaster University Medical School, Dr Karen Grant, acknowledges the anxiety felt by medical undergraduates. She said: "We need to make sure that this cohort do not miss something. On the way, they are suddenly being required to jump in and be flexible and innovative about their goals."
She expressed her admiration at the way many students had risen to the challenge of volunteering on the COVID front line. In her own school, second years were involved in asymptomatic testing of students on campus before they went home for Christmas, which she says boosted their communication skills.
Dr Martin Armer, undergraduate lead for fifth years at Lancaster Medical School said: "We are keen to prepare our students to practise in the NHS as it is, rather than the way we want it to be."
Adaptation is something all medical students are having to learn. A first year student at Sheffield University Medical School told Medscape he found the experience of working in the university's COVID testing centre valuable as he felt involved in a 'major issue' early in his training and that having to switch from face-to-face contact to online calls for community placements was teaching him skills he would need for practising alongside COVID for some time into the future. He said: "It's awkward to adjust to talking on the phone or online, but given that we live in a digital world, it makes sense for the future."
Other students spoke of their fears of having gaps in their knowledge because of the absence of routine/elective medicine, whilst some expressed the view that the pandemic had propelled them onto the front line and allowed them to fulfil their vocation.
At Sheffield Medical School, years 3 and 4 were most affected by COVID-related changes, according to Professor Michelle Marshall, interim head of department, University of Sheffield Medical School.
Theoretical aspects of the curriculum were brought together so that the best possible advantage could be taken of placements when they were possible. The school has a scheme called 'Patients as Educators' in which 800 real patients work with students in the community. Many of these were happy to switch to online so that students could continue to have regular contact. Year 5s on long placements were put onto a shift pattern to reduce the number of students on the wards.
The teaching area at Sheffield most affected, has been time available in operating theatres. This is being managed through careful timetabling so that students satisfy their learning goals.
"What has really stood out for me during the pandemic is the commitment of our students to helping," Prof Marshall told Medscape UK. "The medical society volunteering scheme, Helping Hands, has done an absolutely fabulous job of supporting the local community, helping the NHS through student assistant roles, and also the Sheffield Medical School involvement in the Oxford/AstraZeneca vaccine study.
"As part of our curriculum, third year students complete a Social Accountability placement, spending 4 weeks working with voluntary or charitable organisations and this went ahead just before Christmas, providing important support to over 70 organisations during this very challenging time."
BMA Medical Student Committee Co-chair, Tinaye Mapako, who is also a fifth year undergraduate medical student at Liverpool University, said the past 10 months had been "incredibly difficult" for him and his peers, but had taught them invaluable lessons about the need to be flexible and to deal with uncertainty.
He however is very positive about the experience of learning during COVID. He highlights invaluable practical experience provided by the Interim Foundation posts that were hastily created at the beginning of the pandemic for graduates waiting to go into their F1. Many also signed up to healthcare assistant placements, and lapped up the experience of being on the front line, unlike a group at Imperial College who protested against their so-called 'menial' roles in ICU.
There is now an appetite to create a medical assistantship shadowing an F1 to provide a structured transition from medical school into the NHS.
Other positives had been the greater use of remote medicine, telephone and video consultations, and the greater use of Zoom in medical education. Tinaye Mapako says: "COVID is going to be with us in some form for a long time, when disease stops being pandemic. It will fundamentally change the NHS. We've learned many things in a short time that will be with us permanently."