Graduate and Postdoctoral Training

Since it began its rapid spread in December 2019, the SARS-CoV-2 virus has altered the landscape of nearly every enterprise in the world; higher education, including medical education, has not been spared.

At the Larner College of Medicine, one of the first major symptoms of the pandemic was felt on March 11, when Dean Richard L. Page, M.D., following guidance from University of Vermont President Suresh Garimella, announced that all non-clinical medical student education would move to a remote learning model until further notice. The decision, and others like it, affected over 92,700 students at the 150+ medical schools in the United States.

In April and May, as the number of cases in the U.S. continued to increase, many students in their final year of medical school graduated early to join their new colleagues at hospitals on the frontlines of the pandemic, while others worked to complete graduation requirements and prepared to receive their degrees in a rapidly changing healthcare environment. But what about students entering their second, third, and fourth years of medical school, and what does the future hold for those starting medical school this fall?

Larner faculty and staff have approached the past five months in much the same way they have for many years – with an eye toward data-driven innovation and improvements – this time, at breakneck speed.

Active Learning Set the Groundwork for Quick Adaptations

Students in the Class of 2023, who transitioned to remote learning during the second semester of the pre-clinical Vermont Integrated Curriculum, called Foundations, experienced the first changes to medical education as a result of the pandemic. With only six days from announcement to implementation of remote learning, Director of Active Learning Jesse Moore, M.D., took the lead in organizing the transition to remote delivery of the curriculum with input from level directors, course directors, curriculum and technology teams, and student leadership representatives. After ensuring that the plan was in step with the Association of American Medical Colleges (AAMC) emergency guidelines, the Leadership and Medical Curriculum Committees approved it for immediate implementation.

The structure of the Vermont Integrated Curriculum and the College’s transition to active learning modalities over the past few years meant that many of the materials and approaches needed for the continuity of effective learning were already in place. “Because we already had curated materials...the principles of the science of learning including spaced repetition, interleaving, and elaboration, could quickly be incorporated into an online experience,” says Cara Simone, the manager of curricular design and delivery.  Level Director of Foundations and Pre-Clinical Assessment, Karen Lounsbury, Ph.D., agrees. “The fact that materials were already available and regularly utilized on VIC management, a homegrown online system developed by the College’s Technology Services (COMTS) team, made for a much easier transition,” says Lounsbury.

Like many organizations, the College adopted Zoom as a platform for online teaching, relying heavily on support from instructional designers and coordinators on the Curriculum and COMTS Ed Tech teams. “We didn’t want to simply make Foundations an online course,” says Lounsbury, “We wanted to be able to deliver material remotely in a synchronous and asynchronous way. There’s a difference.” The transition to 100 percent remote learning was an adjustment for many students, but Lounsbury says curriculum delivery improvements continue to made based on requested student feedback. For instance, about a third of the class noted that when they left Vermont to continue their studies from home, they were in a different time zone, so synchronous learning sessions were scheduled to accommodate all US time zones. In another case, students noted experiencing “Zoom fatigue” in the early weeks of remote learning. As a result, Course Directors have been working with session calendars to limit the number of Zoom time per day.

Clinical Learning in an Era of Social Distancing

When COVID-19 hit the U.S., medical students in the midst of their clinical training experienced a huge disruption in their education and found themselves quickly adapting to a new reality.

Typically, third-year students at Larner spend six to seven weeks completing clerkships in seven specialties, at sites in Vermont, Connecticut, upstate New York, and Florida, for a total of 44 weeks of clinical experience. Three bridge weeks focus on topics such as global health, palliative care, and anesthesiology. Students in the Class of 2022 at the College were supposed to begin their in-person clinical clerkship on March 16.

Instead, as primary care offices and clinics moved to telemedicine for any non-urgent cases, hospitals cancelled elective surgeries, PPE shortages emerged, and physicians scrambled to handle a surge of critical patients suffering from a novel virus, it became clear that sending students into these environments would be unsafe and burdensome to an already strained system. Following guidance from the Association of American Medical Colleges (AAMC), the Vermont Department of Health, and clinical operations at Larner's clinical affiliates, the College delayed the in-person, clinical clerkship portion of students’ education until July 13.

Level Director of Clinical Clerkships Elise Everett, M.D., M.S., and course directors quickly adapted the layout of the curriculum and frontloaded any lessons or skills that could be taught remotely.

In the first month of their clerkship year, students were offered three options – continue working on research projects currently underway, take a medical Spanish course typically only available during fourth-year, or enroll in a newly developed pandemic course. Then, students completed a remote clerkship orientation week; participated in the global health, palliative care, and anesthesiology bridges remotely over the course of two weeks; and spent one virtual week per core clerkship; obstetrics and gynecology, family medicine, internal medicine, psychiatry, pediatrics, neurology and surgery.

Everett says she was pleasantly surprised by the advantages of remote instruction. When students were allowed to enter the clinical environment on July 13, they were able to immediately begin working on skills that can only be learned in-person. For instance, although students can learn the technical aspects of skills like knot tying, suturing, and pelvic exams through videos, online modules, and Zoom lessons, they need to be able to interact with patients to learn the nuances of verbal and non-verbal communication and variations in anatomy that cannot be taught online.

Positive Lessons & Potentially Long-Lasting Innovations

Despite the incredible challenges of offering medical education during this time, the pandemic has led to many positive and potentially long-lasting innovations.

Among them, a new course for medical students focused on telehealth. Developed by UVM Clinical Simulation Laboratory Education Director Cate Nicholas, Ed.D., the asynchronous online course, "Telemedicine: From Bed-side to Web-side," utilizes a 42-session module developed by the American College of Physicians. It also includes a presentation and documents developed and collated by Nicholas, with input from Everett, to educate students about the intricacies of this increasingly important form of medical care. Topics covered in the presentation include proper attire, physical space, and camera placement; telemedicine security; billing; and physician directed physical exams. Students practice web-side verbal and nonverbal communication skills, how to determine necessary follow-up physical exams, and how to document telemedicine visits during a remote encounter with a standardized patient.

Nicholas says that students will likely be expected to support telemedicine visits during their clerkship rotations and to provide this type of care during their residencies and into their medical careers.

In addition to new course offerings, Everett notes that the need to adjust clerkship year has exposed new opportunities to streamline student learning. “I think over the next few years our clerkship year will look different – designing it in a more longitudinal way that comes from the patient perspective rather from that of the physician,” says Everett.

The need for remote learning has also revealed hidden benefits. “Remote learning allows us to break out of our silos and promote cross-clerkship collaboration; more regularly access resources from other institutions locally, regionally, nationally, and internationally; and allows students to work at their own pace and revisit material if they need to, because it’s all recorded,” says Everett.

Lounsbury says the pandemic highlights the importance of educational equity. “We’re finding even more opportunities we hadn’t thought about before, to change the system, so that it truly works for all students,” says Lounsbury.

Everett agrees. “People are experiencing the pandemic in very different ways...the impact of COVID on your day-to-day life is going to be different if you’re a person of color, if you’re located in an area with significant community transmission, if you have underlying health issues, and if you’re a parent who’s balancing childcare and homeschool with class,” says Everett. “The pandemic doesn’t treat everyone equally...and it not only the pandemic, it’s the financial crisis, it’s the systemic racism movement...all of those are affecting our students in unequal ways.”

As the pandemic continues, faculty and staff at the College continue to rise to the occasion – making improvements to the curriculum and the learning environment based on regular student feedback, data collection, and guidance from local, regional, and national authorities.

“We love a challenge and we love the renewed focus on how to engage students meaningfully,” says Simone. “It’s a bit early to tell, but it’s likely that these new ways of communicating, teaching, and learning will impact medical education for years to come.”