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COVID-19: Neurology Instructors Rethink Medical Clerkship Training as Clinical Rotations Are on Pause

Article In Brief

In the wake of COVID-19, directors of neurology clerkships have transitioned all work to remote learning for medical students doing rotations in neurology. The program staff discuss the opportunities and challenges of that approach.

With clinical rotations for medical students on hold at hospitals around the country, academic leaders and clinical instructors are beginning to rethink what clerkships might look like post-COVID-19. More telelearning is likely in the future.

The Association of American Medical Colleges (AAMC) on March 17 recommended that schools pause all student clinical rotations until at least March 31, a date that likely will turn out to be optimistic as the number of COVID-19 cases continues to climb in the US. The organization followed that recommendation with an interim guidance on March 23 that outlines steps that medical schools should take if they eventually decide to ease up restrictions and allow medical students back into clinical settings.

“Current medical students are students, not employees,” the AAMC said. “Although they are on a path to becoming licensed MDs, they are not yet MDs.” The AAMC said that “at this point in the COVID-19 pandemic, our medical students' participation with or without known or suspected COVID-19 must be voluntary, not required.”

The AAMC also said that if medical students decide to volunteer in the event of a critical shortage of health care workers, “schools must document with their students that their participation is purely voluntary for public service or humanitarian reasons only, it will not be compensated, and it will not be considered for any required medical school course credit.”

Switching Gears

For now, with many universities physically shut down amid the pandemic, medical students, just like undergraduates, have taken to online course work. Many medical students already prefer listening to lectures remotely, so the switch to online learning probably hasn't been that jarring, neurology educators told Neurology Today.

The pause in clinical rotations, on the other hand, has created a dilemma for medical schools and has prompted faculty who serve as clinical instructors in neurology and other disciplines to think creatively.

No Students in Clinical Settings

Lisa R. Merlin, MD, FAAN, a neurologist who is distinguished teaching professor and vice-chair for education at SUNY Health Sciences University, said that with New York City at the epicenter of the COVID-19 pandemic in the US, “no students are allowed currently in any clinical setting.”

“Our clerkship year usually begins in April of the second year but has been delayed for the rising cohort of students,” Dr. Merlin said in an email interview. “Our leadership at SUNY Health Sciences has instructed all clerkship directors to create virtual curricula that fulfill our learning objectives to the best of our ability under the circumstances.”

Dr. Merlin said neurologists involved in clinical rotations are swapping ideas on ways to revise the curriculum through the Synapse listserv of the AAN Consortium of Neurology Clerkship Directors.

“The AAN has been working in concert, sharing resources and insights on the quality of various online materials to ensure we are all successful in this endeavor, enhancing our efficiency in getting this up and running,” Dr. Merlin said.

The Push to Train in Telemedicine

Rachel Marie Salas, MD, MEd, FAAN, associate professor of neurology and neurology clerkship director for Johns Hopkins Medicine, said that even before their medical students were pulled from clinical rotations, they were barred from taking care of any patients who had tested positive for coronavirus. Medical students at Johns Hopkins do four weeks of neurology rotations as part of their core curriculum, and those clerkships occur both in the hospital and at clinics at the institution and in the community.

Dr. Salas said the challenges posed by the COVID-19 pandemic provide an opportunity for hospitals to make an even bigger push toward telemedicine, and she predicted that medical students trained with the technology will have an edge when they enter real-world practice.

But even with an expanded use of telemedicine and online coursework for some learning situations, medical students need the experience of being in person at the bedside, Dr. Salas said, and that requires “a new level of thought because you cannot replace the clinical experience with virtual simulation.”

She said Johns Hopkins is still figuring out how clinical rotations will be made up and said it may require decreasing elective time so that students get core rotations done.

Raghav Govindarajan, MD, FAAN, associate professor of neurology at University of Missouri and the neurology clerkship director, was part of a multi-center team that last year overhauled the AAN's 20-year-old guidelines for neurology clerkship, but now he finds himself doing the best he can with students who are no longer in the hospital.

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“No students are allowed currently in any clinical setting.”—DR. LISA R. MERLIN

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“This is not an ideal way of training, but we are living in extraordinary times.”—DR. RAGHAV GOVINDARAJAN

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“I try to keep all non-patient care activities to a minimum because to my mind the goal of a clerkship is to be part of a patient care team.”—DR. DOUGLAS GELB

Dr. Govindarajan held a class using Zoom on how to do a neuroexamination (students could practice with family members/roommates with him giving feedback on their exam techniques) and he's encouraging online small group discussions and providing written patient case studies in which students make decisions about clinical exams, ordering tests, diagnosis, and treatment.

“This is not an ideal way of training, but we are living in extraordinary times,” said Dr. Govindarajan, who specializes in amyotrophic lateral sclerosis.

One upside is that “we are going to push medicine into the future,” he said, with greater use of telemedicine, which would help not only during a pandemic but in everyday circumstances where patients may not be able to easily access a doctor or where institutions want to share medical expertise. Stroke care is a good example of how telemedicine has already taken hold in some places.”

Dr. Govindarajan said a downside for him right now at a most basic level is that he likes teaching students and misses the spontaneous opportunities that arise during clinical rotations to spark a student's interest in pursuing neurology as a field.

For example, Dr. Govindarajan said he reached out recently to one of his students with an interest in neurology to write up a report for possible publication on an unusual case of a woman with adult-onset scapuloperoneal myopathy and cardiomyopathy with a novel MYH7 mutation.

No Substitute for Patient Care

Douglas Gelb, MD, PhD, FAAN, professor of neurology and associate chair for Education at University of Michigan, said that medical students, who will be gone until at least April 13, have access to a variety of resources that provide didactic material remotely, but he doesn't know of any way to offer a substitute for direct patient care. He said he is skeptical that any medical school in the country would be tooled up at this point to involve students in patient care remotely.

“I try to keep all non-patient care activities to a minimum because to my mind the goal of a clerkship is to be part of a patient care team,” said Dr. Gelb, who is regarded as a national leader in neurology education.

Dr. Gelb said neurology clerkships are a vital part of medical education, noting that while only some students will ultimately choose to be neurologists, every student, no matter what field they go into, “will see patients with problems with their motor function, their sensory function or their cognitive function.

”We are trying to train every graduate to be able to recognize when patients might have neurologic disorders and approach them systematically,” Dr. Gelb said. At Michigan, all medical students do a four-week clinical rotation in neurology in the second year, and they can also choose to do neurology electives in the third and fourth year.

When medical students will end up returning to their clerkships is anyone's guess. No matter the date, the classic image of entourages of gowned teams moving in and out of patient rooms during morning rounds is likely to change along with even tighter infection controls.

The AAMC said in its March 17 recommendation to halt clinical rotations “that this temporary suspension will allow medical schools a window of opportunity to develop and implement appropriate programs to fully educate all their students for their return to clinical rotations with (a) up-to-date information on COVID-19; and (b) appropriate steps in place to ensure their own and their patients' safety.”

It also said “this pause will allow the medical education community, including learners, to develop appropriate educational strategies and alternative clinical experiences to best assure safe, meaningful clinical learning for students.”

The Need for Hands-On Training

Mark Pierce, MD, a second-year resident in neurology at Ohio State University, said that no matter how much the coronavirus pandemic serves to move medical education more toward e-learning, he knows from his own experience as a medical student and resident that there are many aspects of neurology that can only be learned by doing them yourself.

“If you tie knowledge to a patient, you'll see it sticks so much better,” he said. “The subtleties of a neurologic exam are really impossible to get from a distance,” said Dr. Pierce, who wants to specialize in headache care. Assessing strength, reflexes, and tremor also are skills acquired by doing, he said.

Dr. Merlin, of SUNY Downstate Medical Center, said medical students should not worry that the disruptions in their clerkships will lessen their chances down the road for getting the residency they desire.

“The class of 2022, lacking this clinical training opportunity for a significant stretch of time, will be somewhat disadvantaged, but they should be able to overcome this handicap by taking full advantage of every clinical opportunity they get from the time they are permitted back at the clinical sites until their graduation,” she said. “If they are using this hands-off time to read their clinical textbooks so they don't fall behind, I am confident that they will ultimately do just fine.”

She pointed to another silver lining for medical students on hold. “One solace is that all students across the globe are similarly affected, so this should not impact their competitiveness or relative readiness for residency training.”