First-year medical student Dana Arenz usually spends one day a week interacting with Spokane patients. Now, she’s all online from her South Hill residence to learn through the University of Washington School of Medicine.
This week, her virtual “patient” might be a paid actor or another medical student.
In March, all patient interactions for medical students stopped because of the coronavirus, both for safety and to preserve equipment. That meant UWSOM’s site on the Gonzaga campus and WSU’s Elson S. Floyd College of Medicine in Spokane had to adapt quickly to an all-virtual format.
“The trickiest part is the loss of patient interaction that we would normally get,” Arenz said. “I’ve helped with a lot of pediatric patients.”
Normally, hands-on exam skills taught on campus allow students to practice on each other, she said.
“That’s been moved online. It’s kind of hard to practice an abdominal exam because I live alone. But I’ve been impressed by our faculty. They’ve been putting in insane hours making this work. We’re in small groups with Zoom, which overall feels pretty similar to what we were doing.”
Although they can’t listen to a patient’s heart or do exams, students in the online formats are tackling realistic medical problems, administrators say.
“The second- and third-year students should be on clinical rotations now, and they’re not,” said Dr. Janelle Clauser, a local hospitalist and UW clinical skills instructor.
“Second-years usually start clinical rotations the end of March and early April, and third-years have mostly all learning that’s clinical-based and being part of patient care. They don’t take summers off.
“The big picture is it’s not ideal to delay physical exam skills, but they will catch up later. We just don’t know how much later until we can be in the classroom again or even in clinical settings again.”
To keep on track, administrators and professors charted new ground – tapping real cases for diagnosis and team-teaching in small online groups. (Identifying factors are removed from the cases to protect patient privacy.)
WSU third-year medical student Kendal Vann-Campbell normally spends most of a week with patients at a Spokane hospital or clinic in studies. But after spring break, she and fellow students spent one week together online to study local COVID-19 impacts.
From there, other online sessions have set up challenges, Vann-Campbell said. “Before this happened, I’d be in a clinic or hospital Monday through Friday with occasional weekends,” she said. “It’s definitely hands-on with a lot of interviewing and examining patients.”
Now, online models split students into groups of about six to talk over Zoom and complete daily activities as a team, she said. Later, a larger group of about 35 students analyze findings and learning.
Last week, Vann-Campbell’s small group began a virtual clerkship to study pediatrics. By Monday, each were assigned a child’s case to follow throughout the week.
“My specific patient was a 9-month-old who wasn’t gaining weight,” she said. She read about the case and a physical exam’s findings. It meant researching, deciding on tests and finding physicians to consult. She eventually arrived at a correct diagnosis of cystic fibrosis.
“I was still able to practice some of the skills I would normally use in the clinics and hospitals,” Vann-Campbell said. “Surprisingly, last week was as close as we could get to a true clinical experience.”
UW’s Clauser said first- and second-year medical students finish basic science classes. Current lectures are on the gastrointestinal and endocrine system. There’s a new two-week UW elective class, Pandemics and Health System Responses.
In current courses, students also review patient communication strategies and clinical skills. “We’ve kind of rearranged the schedule right now so we can do sessions with more communication skills,” Clauser said. Some hands-on clinical skills are still taught via groups online.
Other components online were more problematic, Clauser added. “We do hospital tutorials where we take first- and second-year students into hospitals to see patients who give their consent. They interview them and do a physical exam. Instead, we have to do that over Zoom.”
That now means third- and fourth-year students – sometimes faculty – posing as virtual hospital patients. “Sometimes we have paid actors,” Clauser said. “Faculty has created the cases; basically, we create scripts based on real cases but changed certain elements.
“That way, the students who would have been going into a hospital are interviewing a patient and asking questions. They’re given a written physical exam. In hospitals, you gather up afterward to debrief. We still do that over Zoom.”
The advanced students are eager to help, she said. Fourth-year UW medical students learned March 20 where they’ll start residency in June, and those positions are expected to continue.
To replicate virtual primary-care clinic work, students are working through typical cases with third- and fourth-year students, Clauser said.
WSU College of Medicine curriculum director Dr. Jaime Bowman, a family medicine doctor, said the abrupt changes affected the school’s medical students statewide. It has clinical campuses in Spokane, Tri-Cities, Vancouver and Everett.
“First- and second-year students spend the majority of their time on the Spokane campus in classroom and simulated learning,” said Bowman, with visits to clinical campuses three times a year.
WSU students also regularly spend time in hospitals and around primary care patients. “In mid-March, we made the difficult decision to suspend learning with patients,” Bowman said. Students had a 12-day spring break when WSU leaders rebuilt such things as a third-year clerkship for patient care.
Now, WSU is using online clinical patient cases with focuses on pediatrics, general surgery, obstetrics and gynecology, internal medicine, family medicine and behavioral health.
“They’re spending a week in each of those with these online cases and about eight hours per week of small-group discussion online. They’re facilitated by community faculty physicians,” Bowman said.
It can include two to three cases per day and about five hours of independent learning.
“They’ll practice presenting the case to the community doctor and really share what evidence they used, how they made the clinical decisions for diagnosis and management of care,” Bowman said.
This week, WSU medical students also did an online workshop about breaking bad news and end-of-life decisions, which used actors as virtual patients.
All-virtual has its flaws, but, “It’s the best and most innovative way to keep our students learning when they can’t interact with other people,” Bowman added.
These times also allow for more reflection on social determinants of health, she said. With schools closed, some families have food insecurity, a factor if treatment calls for more fruits and vegetables.
WSU, which started its first medical class in 2017, doesn’t have any fourth-year students yet. Leaders are already thinking about what’s ahead, Bowman said. “We don’t know when it will be safe for our students to return to clinical settings.”
“We want to keep our responsibility to keep our students learning. We have a plan to finish out the entire academic year and even the beginning of next academic year if we need to.”
Dr. William Sayres, a Spokane family doctor, teaches UWSOM pre-clinical education. It was a large undertaking to do the technology switches, but students have surprised him with ideas.
While teaching a group about diseases of the liver, one student used new technology to diagram a difficult concept for others watching.
“I learned a new way to teach,” he said. “When you have smart adult learners, that’s what happens.”
Sayres said he realizes it’s frustrating for students who want to do more in the coronavirus fight.
“I also tell them I know this is hard, when it’s all about the virus, and they’re trying to learn about diseases of the liver.”
Grayson Baden, a first-year UW student in Spokane, said she still feels connected to classmates and instructors in the online formats.
Only now, its from her home in Arlington, Washington. Her mom was a model for an abdominal exam. The group discussions help “to keep those same diagnostic muscles working and to think clinically.”
She credits faculty with being creative and putting in long hours. “The people who are teaching us are also the people who are responding to the crisis.”
Vann-Campbell said she is a little fearful about when she’ll get back to patients.
“I miss being around patients on a regular basis. I also really miss working with all the great physicians in Spokane. I don’t know when it will go back. I think it won’t be for a while.”
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