Studying and Practicing Medicine in Midst of Pandemic

With a new semester underway, students, faculty and staff have returned to the medical school’s educational and research laboratories, offices and classrooms and are observing UB’s university-wide health and safety guidelines for COVID-19, in addition to specific guidelines for medical students when they are involved in patient care.

“Our students, perhaps especially the first-year students, are profoundly aware of the significance of starting 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 unique time in the school’s history, one of its most important efforts is keeping the lines of communication open between administrators, faculty and students.

Throughout the pandemic, the Jacobs School has had a number of mechanisms for gaining feedback from medical students.

“We have monthly discussions with the deans for our first and second year students. Those are open sessions where students can meet with us and bring to us any questions, concerns or suggestions,” says Jennifer A. Meka, PhD, assistant dean for medical education, director of the Medical Education and Educational Research Institute, and assistant professor of medicine. “Every class has curriculum representatives as well as student organization representatives. It is the responsibility of the curriculum representatives to be collecting that feedback from their classmates and then bringing it to us — and they do that oftentimes at our curriculum meetings. We also have town hall meetings for our third- and fourth- year students along with mandatory class meetings for all four years to check in and provide important informational updates.”

Additionally, the school sends out surveys and has structured feedback mechanisms throughout medical students’ courses. At the end of every week, a sample of students fills out evaluations related to the learning experiences they participated in that week, and at the end of each course there’s a course evaluation.

“Part of what we hear 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 very cognizant of the fact that many of the medical students are feeling more stress than usual.

“A lot of them 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 do not have a lot of free time. If they don’t have a lot of opportunity to interact with others, it becomes even more difficult. Their mood is not as ideal as it can be.”

Jacobsen says 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 the students 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 continue to be emphasized.

Jacobsen, an 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 first-year student Nadia Vazquez.

“The unknown is daunting, but the opportunity to forge anew and create a better, healthier us 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.”

Likewise, 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 caused was a legitimate concern for many.

“I do better when I am with people and in the hospitals. I live alone in a studio apartment, so being cooped up in my apartment was rough. It’s so much better being with people and patients,” says Micha Gooden, a fourth-year medical student.

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 by the Association of American Medical Colleges.

“We were sent home in the second semester of my third year. I was going to do an emergency medicine elective, but it was revamped,” Gooden says. “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.

Jacobs School students learned remotely via didactic core content while clerkships were paused, and they participated in clinical immersion once they could return to clinical settings in June.

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 their 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,” says Lesse.

Typically, fourth-year medical students travel to residency programs to interview for them in person. But this interview season most residencies will interview 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. I’m not sure how well that’s going to translate through the screen,” says Gooden, who is applying 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 agrees. “Figuring out where you ‘fit’ is going to be difficult when applying to programs in cities you have never even visited,” says the fourth-year student. He is applying to residencies in the field of physical medicine and rehabilitation. Since he cannot learn about programs in person, he has participated in virtual open house sessions and contacted programs’ residents and coordinators. “This has helped me get an idea of the attitude within certain residencies, especially in how they view wellness and lifestyle,” he says.

Meka says the Offices of Medical Education are helping 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 practice with faculty members on Zoom. We get advice and feedback about how we’re answering their questions,” notes Gooden. “There’s also a webinar on how to troubleshoot situations like Wi-Fi going down during the interview.”

Along with the drawbacks of virtual interviews, there are some benefits: “Students can 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.”

Residency program directors and staff at the Jacobs School are planning how to effectively alter residency interviews for a virtual format.

“Meeting with the current residents and faculty of the program, and witnessing our interaction together, gives the candidate an idea of the flavor and collegiality of the program. This is something that I think is telling to the quality of the program,” says Jeremy P. Doak, MD, program director of the orthopaedic residency and clinical associate professor of orthopaedics.

He and his program’s administrator, Tammy Smith, are developing methods — like 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 is also posting grand rounds sessions online, allowing prospective residents to glimpse the training at UB.

Patrick O. Kenney, MD, has had the unique experience of finishing up his internal medicine and pediatrics residency and starting his pediatrics infectious diseases fellowship — while also working with COVID-19 patients — all during the pandemic.

“From a training standpoint, the changes in how we approach a patient are really dramatic. When we see a patient who has a fever, it used to be we would look for all these causes of fever, but now we have to think of COVID-19 first and everything else second,” Kenney says. “It really changes how you approach a patient.”

The concerns don’t end when a shift does for physicians like Kenney, who has children at home.

“When we are treating someone in the hospital who has COVID-19 or who we suspect has COVID-19, when I come home I take my shoes and socks off at the door and go straight to the shower,” he says. “There are a lot more things you have to take into account when you don’t want to expose anyone else to the things you’ve been exposed to.”

It can all seem a bit overwhelming.

“This is a once-in-a-century pandemic. This is a big thing for a lot of us to process. COVID-19 is not just an infectious disease, it also impacts a lot of different systems, so your surgeons, your critical care doctors, your emergency doctors, everyone is involved in this in some step of the way. No one gets a break,” Kenney adds.

COVID-19 has also complicated research projects and clinical trials. All researchers and trial participants 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, 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,” Quattrin says.

That is despite the fact that they are entering an environment in which every precaution has been taken to make it safe.

“I personally have checked many of the environments in which clinical research is taking place on our medical campus. They are very safely controlled places,” Quattrin says.

Shirley Xu, a trainee in the doctoral program in pharmacology and toxicology, says she lost a lot of progress and momentum over the few months that labs were closed and that it was difficult transitioning to work-from-home and maintaining productivity with data analysis and writing reviews and grants.

“However, once labs started reopening, it was reassuring to return to a more ‘normal’ routine, and 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,” she says. “It encourages me to continue my work, even if it is indirectly related to the pandemic we face.”

Xu says the pandemic shutdown made her realize even more so how collaborative research is, including training new students and coordinating schedules for complex experiments.

Gary J. Iacobucci, PhD, a second-year medical student and a postdoctoral associate in biochemistry and family medicine, says it has been “a significant logistical challenge” to figure out how to resume work in labs where only limited numbers of people are able to work at a time.

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

“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 is handling the challenges the pandemic has brought.

“Strong senior leadership — particularly above my level — has been fantastic, so we’re not just 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 are continuing on with their research in the face of really difficult working environments,” Dietz says. “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, etc. 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,” he adds.

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

“There is a student-led wellness group with a faculty adviser that is very active and provides activities for students. There are a variety of different programs offered from UB Counseling Services including yoga classes or mindfulness-based stress-reduction sessions,” Meka notes.

“We have the availability of counseling and psychiatric services, and we ensure 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 stresses of being in a demanding educational program during this time of uncertainty,” she explains.

“Many of our students throughout this pandemic have certainly had to deal with their own challenges — educational and in their personal or families’ lives — and they are trying to navigate those complex situations,” says Meka.

“At the Jacobs School, we are doing 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 presents valuable lessons to be learned.

“Unfortunately, one of the skills you need as a physician is to be resilient and maneuver when things get tough and unexpected circumstances come your way and you need to keep going,” she says. “You need to tolerate rapid change that may occur in a difficult environment.”

“Every little disaster or difficult time that the students go through helps to ultimately prepare them for some of the things that will come their way as they are caring for their patients,” Jacobsen says.