The COVID-19 Pandemic and the Transition to Virtual Learning Profoundly Affect Medical Student Education

Highlights

• Describes the increase in virtual medical education and the subsequent decrease in peer-to-peer interaction and early clinical exposure
• Explores how virtual resources have enhanced students’ exposure to surgery and surgical mentors but lack the nuances of in-person experiences
• Identifies how social media and virtual platforms have transformed the residency interview process

Over the past 2 years, the COVID-19 pandemic has significantly altered the practice of medicine and has created a new paradigm of training for a generation of medical students and surgical residents. The impact of COVID-related shutdowns includes shifts to virtual education, altered workforce structure, and changes in how patients access healthcare.

Both the preclinical and clinical phases of medical school present their own unique challenges and bore the effects of  the COVID-19 pandemic in complex ways (see Figure 1.)^1,2 Studies have demonstrated that many medical students and faculty believe that COVID-19 negatively affected medical education.^3,4 Furthermore, a nationally distributed survey of 1,668 US medical students found that more than 20% of respondents think their specialty of choice would be affected by the pandemic, with limited ability to explore specialties of interest cited as the most common reason.⁵

During the pandemic a rapid shift to exclusively online learning during preclinical years occurred to comply with social distancing mandates. Clerkships were restructured to minimize contact with patients to reduce chances of exposure to COVID-19. Many of the traditional panels and workshops designed to introduce medical students to the field of surgery were transformed into virtual meetings or recordings. Pandemic-related alterations to these formative experiences have changed how students are exposed to the field of surgery, modified how professional identity is formed, and transformed how medical students transition to surgical residency. This article explores some of the ways the COVID-19 pandemic has affected undergraduate medical education and medical students as they progress toward surgical careers.

Impact on Preclinical Medical Education

Traditionally, during the first 2 years of medical school, the focus is on a more structured learning style, including classes, lectures, and regular examinations, with little patient-forward care. Many students use the preclinical time to learn more about each specialty, meet potential mentors, gain peers and supporters, and focus on the transition to becoming a physician learner. At the start of the pandemic in March 2020, the Association of American Medical Colleges (AAMC) declared medical students “non-essential workers.” As a result, medical students had limited opportunities to participate in direct patient care.¹ Many schools also transitioned to virtual learning platforms for preclinical students to comply with social distancing mandates. This significantly restricted hands-on anatomic learning, interactions with peers and faculty, and opportunities for clinical experience.

Virtual learning platforms have been shown to have the potential to improve knowledge outcomes compared with conventional learning in medical education.⁶ However, for tactile specialties such as surgery, virtual platforms can never truly replicate direct experience. As an example, for students interested in surgical subspecialties using anatomic dissection, one of the first rites of passage of medical school, may be the inciting event that sparks an interest in surgery.⁷ Regarded by many as their first patient, the cadaveric dissection provides the opportunity to appreciate the body and all its interconnected parts in three dimensions. Prior research has shown that participation in a gross anatomy course that includes cadaveric dissection may significantly increase student interest in pursuing a surgical career.⁷

During the pandemic, many schools transitioned from cadaveric dissection to prosection, often via virtual learning tools, decreasing opportunities for hands-on learning.⁸ It is unclear if these changes will persist and how this change will affect medical student interest in surgery as a potential career.

The pandemic also negatively affected shadowing, mentorship, and networking opportunities in the preclinical years. Institutional mandates resulted in fewer shadowing opportunities for preclerkship students and decreased early exposure to specialties, including surgical specialties.⁹ At many institutions, public health guidelines also prohibited students from hosting in-person events. Surgery interest groups frequently were restricted to hosting virtual events. Suturing workshops and other hands-on events that could not transition to a virtual format were canceled. For surgical subspecialties in particular, these early opportunities have been shown to significantly increase student interest in surgery as a career.^10,11

Conferences, which traditionally offered students a platform to present their work and engage with others in their fields of interest, either transitioned to an online format or were canceled during the height of the pandemic. Many surgical disciplines engage medical students through travel scholarships and trainee-specific programs.¹² However, during the pandemic, these programs no longer offered the same immersive experiences and access to mentorship initially intended to attract students to the field. The lack of in-person research and conference experiences during the pandemic further limited the quantity and quality of opportunities for early medical students to engage with the broader surgical community.

Without these early opportunities to find surgical mentors and role models, it will be important to study the impact this phenomenon may have on the number of future students pursuing surgical subspecialties.

Impact on Clinical Medical Education

By the third year of medical school, most students begin their clinical clerkships, with direct patient care responsibilities. To limit patient and provider exposure to COVID-19, telehealth networks were employed to provide continuous access to care.¹³ Especially early in the pandemic, many medical schools also incorporated virtual clinical experiences to substitute for in-person clinical experiences, including during the surgical clerkship.^5,8,14-16 Work from one program showed that clerkship grades and shelf scores were not substantially different between students who participated in the virtual clerkship compared with those who participated in-person.^15,17 Some programs even allowed students from different institutions to complete remote or “away” clerkship rotations.¹⁸ Many students who completed virtual-only surgical clerkships also reported feeling comfortable asking for mentorship or residency letters of recommendation from the faculty with whom they worked virtually.¹⁸ Though there have been obvious successes using the virtual format for surgical clerkships, surgical specialties are inherently technical, and it has been difficult to replicate the skills-based and interpersonal components of these experiences. It will be interesting to see how students involved in truncated or virtual clerkships fare upon beginning residency.

During the COVID-19 pandemic, many students in their clinical years had at least some component of what traditionally would have been an in-person clinical experience converted to an online format. Students had less on-campus time to connect with peers, pursue leadership positions in their areas of interest, meet with mentors, and scrub in on cases.

These modified clerkships also decreased the opportunity for serendipitous experiences and exposure that can influence student career choice in unexpected ways and can be vital for recruitment of medical students into surgical careers.^5,9,11 Surgical leaders have recognized the negative impact of the pandemic on medical students’ clinical experience and have acted at a national level to provide more significant opportunities for student engagement in surgical subspecialties; one example of this is the American College of Surgeons National Professional Development Seminars for Medical Students.¹⁹ National organizations also have used virtual platforms to connect medical students with mentorship opportunities outside their home institutions.²⁰

Transition to Surgical Residency

The COVID-19 pandemic also dramatically disrupted the traditional residency recruitment and interview process. The 2021–2022 cycle’s “one away rotation opportunity per specialty” restriction changed how surgical specialties educate and recruit prospective applicants.²¹ The pandemic brought a new focus to online and virtual programming, which has led to a dramatic increase in social media use in surgical residencies.²² Social media offered a humanizing glimpse into residency programs—an aspect of the recruitment process that has been especially difficult to assess during the pandemic.^23,24 Social media has been effectively combined with the novel use of online platforms for virtual information sessions, open houses, meet and greets, and happy hours. During the height of the pandemic, these digital mediums often were the only available avenues to gauge a sense of the program culture.²⁴ Though perhaps lacking in the personal touches that in-person recruitment efforts possess, the uptick in virtual programming used by residencies has allowed for much greater ease and accessibility to network with residents and faculty across the US.²⁵

The transition to virtual residency interviews has had its share of challenges, but also offers many advantages for applicants.^26,27 Flexible scheduling and mitigating travel expenses were touted as major benefits of virtual interviews.²⁸ There is evidence that it may change how program directors evaluate applicants; one survey showed that program directors were found to place less value on applicants’ virtual interview day impressions and subsequently shift importance toward letters of recommendation, medical school ranking/reputation, US Medical Licensing Examination scores, and Medical Student Performance Evaluation comments when ranking applicants.²⁹ A hybrid approach for future cycles—for example, virtual interviews with subsequent in-person visits­—is one possibility, but this model is not without issues.³⁰ National recommendations for applicant and program best practices for virtual versus in-person interviews will best prepare rising fourth-year medical students to get the most out of the application cycle and create a competitive residency application.

Summary and Recommendations

The pandemic has affected all facets of life and society, including healthcare. The impact on medical student education has been profound. However, many of the changes that have come about as result have been beneficial to medical education and should be continued moving forward (see Table 1).

Virtual learning tools, such as anatomy applications and demonstrative videos, provide valuable supplements to traditional modes of undergraduate medical education; however, they are not substitutes for hands-on learning. Every effort should be made to have in-person skills labs, cadaveric dissections, and opportunities for participation in direct patient care during the preclerkship years to provide the necessary exposure to the technical aspects of a surgical career and help students avoid the loss of the human connection with peers, faculty, and patients. Virtual clerkship can provide students with access to away rotations without travel expenses and can serve as a valuable adjunct to more traditional clerkship formats. Virtual interviews and social media will continue to alter the face of resident recruitment moving forward, in a way that ideally will be beneficial to both applicants and programs.

As the next wave of surgically minded medical students venture into their desired career, we must be mindful of the unique challenges facing this new generation as they continue to navigate the novel, ever-changing hybrid learning environment.

References

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Madeline Sauer is a fourth-year medical student, University of Missouri, Columbia, and leader, ACS Medical Student Task Force.