-Series Editor: H. Steven Moffic, MD
On March 17, 2020, the Association of American Medical Colleges (AAMC) made the recommendation to remove all medical students from clinical learning given concerns for the COVID-19 pandemic.1 This has caused a significant disruption in medical student education. Third-year medical students were no longer permitted to be in the hospital and educators quickly needed to provide asynchronous learning opportunities or utilize virtual learning platforms for classes and clinical experiences such as rounding.2 Some clerkships will need to be rescheduled for a different time, likely changing the landscape of future fourth year rotations as well.
For all educators, this is a time of great uncertainty, yet we must continue to engage and encourage students interested in pursuing careers in psychiatry, as well as facilitate comparable virtual clinical experiences for students who may otherwise have had limited or no experience “in psychiatry.” The purpose of this piece is to discuss some of the options we must consider in order to mitigate the loss of in-person clinical learning and how to provide facilitated virtual learning instead. It is in no way an exhaustive “how-to” list, as we will all learn rapidly together.
The majority of health care systems have already moved patient services to telehealth. Students can easily “sit in” on telehealth visits, rounds, case conferences, and didactics using most virtual platforms.3 Video visits include the potential for recording sessions, with patient permission, that can be used later as a stimulus for teaching interviewing skills and mental status observations. While there may be some limitations in the absence of true face-to-face care, there are also some potential benefits. Removing the limiting factors of travel time and distance, students can learn from multiple settings (inpatient, outpatient, consultation-liaison, etc.) throughout the clerkship.
Subspecialty experiences may be easier to arrange. Faculty who may typically have had limited interaction with clerkship students can now participate in remote discussion groups. For example, a clerkship could invite subspecialty faculty to take turns presenting and discussing a case with students. Many institutions have recorded grand rounds, extensive reading lists which students can complete and briefly summarize, or online modules. Students may keep a log of their activities and email assignments several times a week to the clerkship director, in addition to participating in regularly scheduled virtual activities. The lack of patient contact cannot be ignored, but the opportunity for honing various skills is still possible (eg, analytical skills, written communication, and virtual interpersonal communication).
It is possible that reduced patient load in psychiatric settings due to quarantine restrictions may leave faculty with more time to devote to one-to-one teaching with students, though this may not hold true in regions of the country where faculty and trainees are being asked to provide care outside of psychiatry. Regardless of future specialty choices, students who learn how to appropriately to interact with patients using telehealth will have an advantage in the post-COVID-19 era of medicine.4 Remote psychiatry clerkships should include curriculum on telehealth services; we recommend reviewing the excellent telepsychiatry toolkit from the American Psychiatric Association (APA).5
Psychiatry departments should also consider expanding remote psychiatry elective experiences. Subspecialty services can use this opportunity to gain more contact with students; developing a robust remote elective could be an excellent recruitment opportunity. By utilizing telehealth services, students can gain broader exposure to rewarding career options. For example, programs that previously relied heavily on inpatient child psychiatry settings could expand to include outpatient, residential, or partial hospital or other settings.
Students can be paired with passionate fellows or faculty, allowing them the opportunity to build mentorship relationships. Combining patient care and interdisciplinary team meetings via telepsychiatry, remote didactics, online assignments (Table 1, Table 2), and individual remote sessions with faculty or fellows has the potential to provide students with a more valuable elective experience than previously possible. Departments might also use this time to create some truly niche psychiatry electives, such as psychiatry and the law or psychiatry in popular culture. Online learning could be a mixture of self-directed learning coupled with web conferences where students engage in active discussions with class leaders.
While most universities have had to put a pause on certain types of research, opportunities to involve medical students in scholarly activity remain. Many are looking to get involved in something that will strengthen their resumes and keep them engaged in psychiatry, even if working remotely from home.
Students can perform a chart review, conduct a literature review, complete a book review, or collate quality metrics from home. While this may take some time initially to arrange, the final products during this time may be well-worth the investment.
We would be remiss not to mention that pre-clinical course work in psychiatry may also be disrupted depending on the timing at one’s medical school. Thus far, our personal observation is that attendance at virtual courses has improved. Professors are utilizing the breakout feature on virtual classrooms to continue small group learning. Course directors should become intimately familiar with the technology used for this type of learning as soon as possible. Those directing clinical skills courses may be able to use off-site standardized patients for teaching the psychiatric interview and teaching students how to utilize telehealth for initial visits.
Some faculty may have changes in their schedule as they are no longer traveling between different clinical sites, new intakes may be restricted to urgent visits only or outpatient clinics may have reduced hours, and inpatient and consultation teams may be split up. With changes in work duties, consider devoting an hour once a week to medical student outreach.
Clerkship directors, alumni associations, and student interest groups should try to provide students with virtual opportunities to build relationships with faculty. For example, medical specialty webinars target pre-clinical medical students who are interested in learning more about psychiatry and psychiatry subspecialties. Students can ask basic questions about psychiatry and gain insight into life as a psychiatrist.
Electronic round tables bring together students and faculty in small videoconferencing groups where they can discuss psychiatric practice and its influence on families, personal relationships, and social life. These informal groups give medical students the opportunity to connect more deeply with faculty and ask questions about various stages of a career in psychiatry. Virtual mentoring connects individual medical students and faculty for one-time or continuous coaching to discuss medical practice and can be done via phone, email or videoconferencing. Social media such as Facebook has also been used to enhance interaction between faculty and students.6
This is also a great time to reach out to medical students whom you may have mentored in the past and check in with them. Again, encourage them to use this time to join the APA and subspecialty organizations, utilizing the online materials and connecting with others. We would encourage our fellow educators to also check in on the emotional well-being of our students. Many students may be alone during this time, unable to connect with families and loved ones or managing personal or family health or economic crises.
Students planning to apply for psychiatry residency may worry about changes to the application process, access to away rotations, canceled clerkships, delays in scheduling United States Medical Licensing Examination (USMLE) exams and the impact of these changes on their competitiveness for residency. Faculty providing career advising can guide students to ensure that they remain engaged in psychiatric work and that their residency applications remain competitive.
Faculty advisors should suggest that students participate in remote clinical or research electives if available or help students to design their own electives if necessary. Students can contribute to institutional COVID-19 related volunteer efforts, many of which may be patient-facing (eg, calls to isolated patients or scheduling outpatient telehealth visits). Volunteer opportunities that involve working with mental health clinicians and those that offer the prospect of a leadership role are especially desirable for students.
Encourage students to use this time to work on components of their Electronic Residency Application Service (ERAS) application, such as identifying programs of interest, updating their CV, and drafting their personal statement. Not all students will be in a position to engage in the above-mentioned activities. Perhaps most important is that advisors assure students that program directors will view applications holistically and continue to consider resilience and a passion for psychiatry as highly valued attributes.
The COVID-19 pandemic has impacted medical training in an unprecedented way. Clerkships and in-person electives have been canceled and it is not clear when some will be rescheduled, or what the new academic year will look like. Changes to the ERAS application timeline and the process for conducting interviews have yet to be determined. The current pandemic and its social and economic effects may further add to students’ feelings of being overwhelmed. Yet the rapid expansion of telehealth services and remote teaching resources also creates new opportunities to engage students in novel and exciting ways. Effort spent now in developing remote clerkships and electives, providing opportunities for scholarly activity, and mentoring students will live beyond the uncertain present.
Dr Klisz-Hulbert is Assistant Professor, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI. Dr Thomas is Associate Professor, Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX. Dr Ernst is Associate Professor of Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY. Dr Kerlek is Assistant Professor, Department of Psychiatry and Behavioral Health, The Ohio State University College of Medicine, Columbus, OH.
1. Association of American Medical Colleges. Important Guidance for Medical Studetns on Clinical Rotations During the Coronavirus (COVID-19) Outbreak. https://www.aamc.org/news-insights/press-releases/important-guidance-medical-students-clinical-rotations-during-coronavirus-covid-19-outbreak. Accessed April 29, 2020.
2. Woolliscroft JO. Innovation in Response to the COVID-19 Pandemic Crisis. Acad Med. 2020 Apr 8 [Epub ahead of print].
3. Sam AH, Millar KR, Lupton MGF. Digital Clinical Placement for Medical Students in Response to COVID-19. Acad Med. Apr 15 [Epub ahead of print].
4. Waseh S, Dicker AP. Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review. JMIR Med Educ. 2019;5(1):e12515.
5. American Psychiatric Association. Telepsychiatry Toolkit. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit. Accessed April 29, 2020.
6. Henry DS, Wessinger WD, Meena NK, et al. Using a Facebook group to facilitate faculty-student interactions during preclinical medical education: a retrospective survey analysis. BMC Med Educ. 2020;20,87