This pandemic has taught us that undergraduate medical education is nimbler and more adaptive than we have previously assumed it to be. COVID-19 has propelled medical schools into an online, remote learning age. It has beseeched educators to creatively deliver new means of teaching human anatomy, pathophysiology, and clinical skills. It has driven administrators around the world to revise graduation requirements to enable students to enter the workforce in times of health care worker shortages.
Dr. Staci Leisman, a Mount Sinai nephrologist, in her physiology course for first-years demonstrated how pulmonary function testing works from her Manhattan apartment, calling upon the help of her children. Virtual sub-internships—with simulated patients and inpatient care scenarios—have been offered to fourth-year medical students pulled off the wards in March.
In truth, these transitions have not always been smooth. And these adaptations for distance learning will never fully replace the quality of in-person and on-site learning experiences. We miss the side conversations with classmates. We miss the off-mic “stupid” questions to our preceptors. We miss the bedside rounds with patient care teams and seeing our patients and their families in the hospital.
The decision to pull students off rotations and suspend in-person learning was surely not an easy one. With a strong recommendation by the American Association of Medical Colleges (AAMC), administrators were hard-pressed not to suspend classes and clerkships. Yet, swiftly, preclinical courses were moved fully online. Pre-recorded lectures were, at times, substituted for live ones. Some Mount Sinai instructors such as Dr. Tonia Kim, who teaches renal pathophysiology to second years annually, continued to deliver content in real-time. New curricula for the upcoming academic year were furnished to accommodate clinical rotations and shelf exams students missed.
Our “bureaucratic” and “inert” institutions are, in fact, adaptive in crisis situations.
We can harness this momentum to continue to reimagine the trajectory of medical education. Beyond times of pandemic, distance learning opportunities could be combined with in-person sessions, such as in the flipped classroom approach, incentivizing student preparation for case-based group learning and clinical skills sessions. Permitting the re-use of certain lectures year-to-year would save preparation time for medical school faculty and promote more active student learning during their teaching hours. We also believe these efforts can help decrease the cost of an MD across institutions in several ways: resources spent on preparing and delivering these lectures could be reduced and repurposed towards curricular innovation, patient care, or research. Utility costs (for heating, cooling, and electricity) would be lowered with decreased lecture hall usage.
The clinical experience could be the point of differentiation for institutions—for we agree that this experience cannot be standardized across the range of teaching hospital locations and partnering clinical sites. Decreasing the cost of education would bolster the diversity of the physician workforce by drawing in students from lower-income backgrounds who may have otherwise been disincentivized from pursuing expensive education.
We also believe that given forced cancellations of licensing exams at Prometric centers around the U.S, we should take this moment to reexamine the validity of such examinations. Students and educators have demonstrated a lack of correlation between scores and clinical performance on United States Medical Licensing Exams (USMLE) examinations. We have also seen how devastating the preparation for these exams can be on student mental health. Making Step 1 pass/fail was absolutely a step in the right direction. Step 2 CK is more clinically relevant but also remains in multiple-choice format, which cannot capture the nuances of practice. Another financial burden on students has been the $1,300+ price tag on Step 2 CS. The state of North Carolina has removed Step 2 CS as a requisite for medical licensing in response to increasing difficulties of administering the exam in-person. Similar decisions across state lines will have to be made soon to ensure the timely graduation of over 20,000 allopathic medical students.
Some educators have raised a fair point that devaluation or elimination of these licensing exams may have downstream (and potentially adverse) consequences on residency program selection criteria. We do not wish to overlook these consequences. But as students, we would like to reimagine what a medical education could be for those who may be our future trainees. We dream of a time when students need not curtail their courses to self-study with flashcards because of climbing average exam scores. We also dream of a time when paying for a standardized exam does not mean forfeiting placing money into savings.
The history of medical education in the U.S. is ripe with change and transition. Since the Flexner Report of 1910, medical schools formally established clerkships as a formative part of training. Competencies for graduating students were established to ensure that no “quack” doctors were graduating from credentialed medical schools. Medical schools were and are held to an ever-increasing standard of education and throughput. Even the research sector of medical institutions is not overlooked—consider the tremendous influence research dollars have on annual US News & World Report medical school rankings. The history of medical education, though, has not always been one of progress. Historian Kenneth Ludmerer reminds us, for example, in the recent era of managed care organization takeover, academic clinicians grew increasingly busier with their practices and were able to spend less and less time for teaching and mentorship. Even still, we have witnessed remarkable educators who care as deeply about training and mentoring the next generation of physicians as much as they do their patients. Every iteration of the medical education paradigm offers the opportunity to continue to form and habituate more adept and compassionate—need we say, competent—physicians-in-training. And COVID-19 is not a time to miss out on it.
Emmy Yang, Oranicha Jumreornvong, and Jasmine Race are medical students.
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