Medical Education in the Midst of a Pandemic

Story by Dirk Hoffman. Photos by Sandra Kicman.

“Our students, perhaps especially the first-year students, are profoundly aware of the significance of undertaking their medical education during the worst global pandemic in a century,” says Michael E. Cain, MD, vice president for health sciences at the University at Buffalo and dean of the Jacobs School.

During this extraordinary time in the school’s history, much effort has been dedicated to keeping the lines of communication open between administrators, faculty and students.

At the onset of the pandemic, the Jacobs School put in place a number of mechanisms for gaining feedback from medical students.

“We have monthly discussions with the deans for our first- and second-year students,” says Jennifer A. Meka, PhD, assistant dean for medical education and director of the Medical Education and Educational Research Institute. “These are open sessions where students can meet with us and bring to us any questions, concerns or suggestions.

“Every class has curriculum representatives, as well as student organization representatives,” she adds. “It is the responsibility of the curriculum representatives to collect feedback from their classmates and bring it to us—and they often do that at our curriculum meetings. We also have town hall meetings for our third- and fourth-year students, along with mandatory class meetings for all fourth years to check in and provide important informational updates.”

In addition, students fill out evaluations related to learning experiences they participated in each week, and, at the end of each course, they complete a course evaluation.

“Part of what we are hearing is that students are thankful to have the opportunity to come together and participate in learning experiences they have with one another,” Meka says. “Learning is a very social activity and relationship-based, and what we know from all of the literature is that relationships—especially the relationship between the educator and the student—can make a huge difference not only in students’ overall learning, but also in their motivation, their engagement and their success.”

Lisa Jane Jacobsen, MD, associate dean of medical curriculum, says the school’s leadership is aware that many of the medical students are feeling more stress than usual.

“A lot of student are expressing feelings of isolation, which is hard,” she says. “Medical school, in general, is a difficult time. The students spend a lot of time studying and they don’t have a lot of free time. If they don’t have much opportunity to interact with others, it becomes even more difficult. Their mood is not as ideal as it could be.”

Jacobsen says that last spring, when it became clear the school would need to move to hybrid or remote learning, there were certain elements of the curriculum that the school’s leadership wanted to preserve.

“We knew we had to be quick to come up with ideas, but we did not want to sacrifice the quality of the education,” she says. “We had to keep our students engaged, and we needed to try and find ways to keep them interacting with us in the classroom, even though we were going to be online.”

Along with lectures, crucial teaching elements such as small group learning and team-based learning continued to be emphasized.

Jacobsen, a clinical associate professor of obstetrics and gynecology, says she tried to let the second-year students in the course she was teaching know she was aware that some of them may be struggling.

“I incorporated some COVID-19 updates during the course so they knew we were not ignoring the world around them,” she says. “I tried to acknowledge the stress they were going through.”

The idea of starting medical school during a global health pandemic was simultaneously distressing and exhilarating, according to Nadia Vazquez, Class of 2024.

“The unknown is daunting, but the opportunity to forge ahead and create a better, healthier world is exciting,” she says. “I am proud to be a part of a team of aspiring physicians that can appreciate the frailty and the fortitude of life and medicine.”

First-year medical student Danya Ziazadeh says she is passionate about working at the intersection of public health and medicine in order to address the system-level factors that influence the health of populations.

“The COVID-19 pandemic has uncovered significant structural inequities in our society, amplifying the importance and urgency of improving access to high-quality affordable health care,” she notes. “I am so grateful for the opportunity to attend medical school at this time—at an institution that recognizes the impact of structural, social, environmental and biological factors on health outcomes.”

The sense of isolation the pandemic has caused is an ongoing concern for many as well.

“I do better when I am with people and in the hospitals,” says Micha Gooden, Class of 2021. “I live alone in a studio apartment, so being cooped up in my apartment is rough. It’s so much better being with people and patients.”

Medical clerkships are clinical rotations that enable third- and fourth-year medical students to experience various specialties and provide patient care. At the outset of the pandemic in the U.S., clerkships were put on hold across the nation in accordance with guidelines from the Association of American Medical Colleges.

As a result, on March 16, 2020, students at the Jacobs School were removed from direct patient care and received clerkship core content remotely. On June 15, 2020, they resumed direct patient care and completed their clerkships with clinical immersions.

“We were sent home in the second semester of my third year,” says Gooden. “I was going to do an emergency medicine elective, but it was revamped. At that time, I was considering emergency medicine. It was low on my list, but not being able to get a true feel for the specialty, it was hard to make a decision.”

Ultimately, Gooden decided against pursuing emergency medicine. “I think the pandemic affected decisions about specialties for a lot of students,” she notes.

For clerkships that would have spanned six weeks—like pediatrics and psychiatry—students undertook four weeks of core content with two weeks of clinical immersion. For longer clerkships—like surgery—they undertook four weeks of core content with four weeks of clinical immersion.

“Each clerkship director analyzed his or her course-level objectives and determined which objectives could be delivered effectively via remote instruction and which required clinical time to complete,” explains Alan J. Lesse, MD, senior associate dean for medical curriculum.

Lesse, associate professor and vice chair for education in the Department of Medicine, says the effectiveness of the curriculum was assessed, in part, through national “shelf” exams.

“Comparisons of the scores from the COVID-19-impacted clerkships did not show any differences from scores obtained over the last five years, suggesting that there was effective delivery of knowledge utilizing this format,” Lesse reports.

Typically, fourth-year medical students travel to residency programs to interview for them in person. But during the pandemic, most residencies have interviewed applicants via online video software.

Interviews are an important opportunity for candidates to assess whether programs are compatible with their goals and lifestyles. “You need to be able to experience a program’s vibe,” says Gooden, who applied to internal medicine residencies. “You want to see how people are treated in the hospital and how residents get along. But you also want to see the community and culture where you’ll be living.”

Saarang Singh, Class of 2021, agrees. “Figuring out where you fit is difficult when applying to programs in cities you have never even visited,” says Singh, who applied to residencies in physical medicine and rehabilitation. Since he could not learn about programs in person, he participated in virtual open-house sessions and contacted programs’ residents and coordinators. “That helped me get an idea of the attitude within certain residencies, especially in how they view wellness and lifestyle,” he says.

Meka says the Office of Medical Education helped students with interview preparations in different ways, including surveying them about their needs, creating a Zoom best-practices guide and conducting mock interviews.

“In mock interviews, we practiced with faculty members on Zoom,” notes Gooden. “We got advice and feedback about how we were answering their questions. There was also a webinar on how to troubleshoot situations like Wi-Fi going down during the interview.”

Along with the drawbacks of virtual interviews, there were some benefits. “Students could apply to more programs without worrying about airfare and hotels for interviews,” says Singh. “The interviewee might have an advantage on interview day as well, where you can tailor your environment to make it as comfortable as possible.”

Over the summer of 2020, residency program directors and staff at the Jacobs School, in turn, began planning how to effectively alter residency interviews for a virtual format.

“Meeting current residents and faculty of the program and witnessing how we interact gives candidates an idea of the flavor and collegiality of the program,” says Jeremy P. Doak, MD, program director of the orthopaedics residency and clinical associate professor of orthopaedics.

Doak and program administrator Tammy Smith developed methods such as a video question-and-answer session and an online socializing opportunity to help applicants experience this collegiality in a virtual format.

Additionally, Smith and Thomas R. Duquin, MD, clinical associate professor of orthopaedics, found a way to acquaint prospective applicants with the residency via the web. Over the summer, they created an online lecture series featuring faculty members, which included sessions where attendees could interact with current residents.

The department also posted grand rounds online, allowing prospective residents to glimpse the training at UB.

COVID-19 has also impacted research projects and clinical trials. In accordance with a directive from the UB Office of the Vice President for Research and Economic Development, all nonessential university labs were closed March 15, 2020, and reopened June 5, 2020, in strict conformity with safety guidelines provided by the office.

All individuals participating in clinical trials must be screened and vetted, and a strict COVID-19 related protocol must be followed for every visit.

“There are additional tasks and precautions that all teams have to take,” says Teresa Quattrin, MD, UB Distinguished Professor of pediatrics and senior associate dean for research integration. “It’s not only before entry into a study, but also during a study.

“Potential participants are hesitant to enter studies,” adds Quattrin, “especially if they require an in-person visit to the campus. Things like a focus group in person—which we recently ran successfully—become very cumbersome. You have to screen and social distance everybody and make sure that you provide masks in case someone doesn’t have one.”

All this is done despite the fact that participants are entering an environment in which every precaution has been taken to make it safe.

Shirley Xu, a trainee in the doctoral program in pharmacology and toxicology, is energized to continue her own research in the lab.

“Once labs started reopening, it was reassuring to return to a more normal routine. Also, as more research about SARS-CoV-2 is published, I find a lot of similar molecular interactions between the immune reaction to the virus and some of my own research in the lab,” Xu says. “It encourages me to continue my work, even if it is only indirectly related to the pandemic we face.”

Xu also notes that the pandemic shutdown made her realize even more strongly the importance of collaborative research, including the training of new students and coordinating schedules for complex experiments.

Gary J. Iacobucci, PhD, a postdoc in the Department of Biochemistry, agrees that despite the disruptions it has caused, the pandemic has created more cohesive research lab environments.

“It was a steep learning curve on the new regulations,” he says, “but scientists always enjoy a problem to solve. We became even more fastidious with our cleanliness and with polite, respectful enforcement.

“And most importantly, when people were going through challenging times, everyone was always there for support. So, in some ways, the shared struggle to overcome these new barriers helped foster more camaraderie and an even more cohesive lab environment.”

Despite the disruptions, David Dietz, PhD, professor and chair of pharmacology and toxicology, has been impressed with how the Jacobs School has handled the challenges the pandemic has brought.

“Strong senior leadership—particularly above my level—has been fantastic, so we haven’t just been running around doing things in a vacuum. That has been enormously helpful,” he says.

“I also have new respect for the faculty and their commitment to the students, and I have new respect for the young trainees, the scientists, who have been continuing on with their research in the face of really difficult working environments,” Dietz adds. “And the unsung heroes have been the staff. I can’t emphasize that enough. They were busier at the start of this pandemic than they normally are, setting up Zoom meetings, and so on. They really made it work.

“We’ve all come together in a way that I haven’t seen before, to get the educational mission completed and to facilitate safe research.”

The Jacobs School also established services and activities to support student wellness.

“We have a student-led wellness group with a faculty adviser who provides activities for students, and there are a variety of programs offered by UB Counseling Services, including yoga classes and mindfulness-based stress-reduction sessions,” Meka notes.

“In addition, counseling and psychiatric services are available, and we make sure that students know these resources are available to them. The counselors and psychiatrists have been proactive in terms of being aware of the different challenges of medical school and the stresses of being in a demanding educational program during this time of uncertainty.

“Many of our students throughout this pandemic have certainly had to deal with their own challenges—both educational and personal—and they are trying to navigate those complex situations. At the Jacobs School, we’ve tried to do our best to provide them with the support and resources they need to succeed and have the best possible educational experiences,” she adds.

Jacobsen notes that while studying medicine during a global health pandemic is taxing, it has presented valuable lessons to be learned.

“One of the skills you need as a physician is resilience—the ability to maneuver when things get tough and unexpected circumstances come your way, and yet you need to keep going,” she says.

“Every difficulty that students go through ultimately helps to prepare them for some of the things that will come their way when are caring for their patients.”

Bill Bruton Jr. and Alexandra Edelblute contributed to this story.