Portal de Periódicos da CAPES

Medical Education During the COVID-19 Pandemic

2020; Elsevier BV; Volume: 159; Issue: 5 Linguagem: Inglês

10.1016/j.chest.2020.12.026

1931-3543

Viren Kaul, Alice Gallo de Moraes, Dina Khateeb, Yonatan Greenstein, Gretchen Winter, JuneMee Chae, Nancy H. Stewart, Nida Qadir, Neha Dangayach,

Empathy and Medical Education

All aspects of medical education were affected by the COVID-19 pandemic. Several challenges were experienced by trainees and programs alike, including economic repercussions of the pandemic; social distancing affecting the delivery of medical education, testing, and interviewing; the surge of patients affecting redeployment of personnel and potential compromises in core training; and the overall impact on the wellness and mental health of trainees and educators. The ability of medical teams and researchers to peer review, conduct clinical research, and keep up with literature was similarly challenged by the rapid growth in peer-reviewed and preprint literature. This article reviews these challenges and shares strategies that institutions, educators, and learners adopted, adapted, and developed to provide quality education during these unprecedented times. All aspects of medical education were affected by the COVID-19 pandemic. Several challenges were experienced by trainees and programs alike, including economic repercussions of the pandemic; social distancing affecting the delivery of medical education, testing, and interviewing; the surge of patients affecting redeployment of personnel and potential compromises in core training; and the overall impact on the wellness and mental health of trainees and educators. The ability of medical teams and researchers to peer review, conduct clinical research, and keep up with literature was similarly challenged by the rapid growth in peer-reviewed and preprint literature. This article reviews these challenges and shares strategies that institutions, educators, and learners adopted, adapted, and developed to provide quality education during these unprecedented times. More than 58 million cases of COVID-19 have been confirmed worldwide. Medical education has been dramatically affected by this pandemic. Transmission of COVID-19 was decreased by social distancing but resulted in a significant need to adapt the delivery of education. Trainees and educators faced significant challenges due to economic repercussions, in preserving wellness and upholding equity, diversity, and inclusion (EDI), particularly with a fully virtual interview season for medical school, residency, and fellowship applications. Surges in the number of patients with COVID-19 led to redeployment of trainees and staff from noncritical care specialties to serve on dedicated COVID-19 floors and ICUs. An unprecedented increase was noted in peer-reviewed literature and nonpeer-reviewed preprints.1Chen Q. Allot A. Lu Z. Keep up with the latest coronavirus research.Nature. 2020; 579: 193Crossref PubMed Scopus (185) Google Scholar,2Singh L. Bansal S. Bode L. et al.A first look at COVID-19 information and misinformation sharing on Twitter. arXiv:200313907 [cs]. March 30, 2020.http://arxiv.org/abs/2003.13907Google Scholar Clinicians struggled to differentiate facts from misinformation and remain up to date.3Ordun C. Purushotham S. Raff E. Exploratory analysis of Covid-19 Tweets using Topic Modeling, UMAP, and DiGraphs. arXiv:200503082 [cs].http://arxiv.org/abs/2005.03082Google Scholar,4Shahi G.K. Dirkson A. Majchrzak T.A. An exploratory study of COVID-19 misinformation on Twitter. arXiv:200505710 [cs].http://arxiv.org/abs/2005.05710Google Scholar The substitution of traditional lectures with digital learning platforms to meet the unique needs of learners due to these challenges was accelerated by COVID-19. The goal of the current review was to highlight the impact of COVID-19 on trainees, educators, and adaptations to the delivery of medical education in the midst of an ongoing pandemic. A team of educators from the American College of Chest Physicians met digitally in June 2020 to address the topical issue of the impact of COVID-19 on various aspects of medical education. Following the first round of discussions by the lead authors (V. K., A. G., and N. S. D.), a list of topics to be addressed was created based on a literature search and personal experience. The common themes identified included challenges to didactics in the traditional format, rapid adaptation to virtual platforms, the economic and mental health challenges related to the pandemic, and how different types of learners, medical students, residents, and fellows have been affected by the pandemic with alteration to their training. These themes were divided into discrete topics and shared with the writing group for input. For the intended scope of the review with rapid availability of new information, and with a goal to be thorough yet concise, topics were condensed or combined and reorganized based on the input from the contributing group of educators. The key challenges placed on medical education by the COVID-19 pandemic with potential mitigation strategies are summarized in Table 1.Table 1Key Challenges Faced in Medical Education During COVID-19 and Relevant Mitigation StrategiesAspect of Medical EducationKey ChallengesStrategies to Mitigate ImpactThe economic repercussions1.Loss of income for institutions and training programs2.Decreased funding for GME and CME activities1.CARES Act provided relief to trainees participating in the Public Service Loan Forgiveness Program2.Offer financial guidance to trainees and educators3.Budget allowances for technological adaptation of educationImpact on equity, diversity, and inclusion1.Amplification of cognitive stressors linked to implicit bias2.Women trainees more likely to be affected3.Students from disadvantaged background may be more affected by lack of away opportunities and direct faculty interactions1.Use institutional resources or other open-access resources such as by the AMA to become more aware about implicit bias2.Provide resources to address potential stressors (eg, child care or elder care facilities)3.Implement strategies for factoring in impact of disruptions from unduly affecting application or interview processImpact on mental health and wellness1.Increased vulnerability to emotional suppression2.Exposure to stigma and resultant loneliness3.Development of mood and sleep disorders1.Establish and promote a culture of safety, well-being, and empathy2.Rotate trainees off high-intensity rotations regularly3.Provide accessible mental health resources4.Provide resources to stay in touch with family and friends digitally5.Institute surveillance and address programs for burnoutEducation delivery1.Cancellation of in-person classes and training1.Digitalize and encourage innovation in education delivery in the digital formatMedical students on the frontline1.Prevent coercion into service2.Development of feelings of guilt, shame, or moral injury by students not involved in direct patient care1.Institute strict guardrails to ensure that student participation in direct patient contact activities is voluntary2.Encourage involvement in nondirect care and nonclinical activities, including research and community serviceAlteration of training for residents and fellows1.Deployment of noncritical care specialty trainees to critical care areas2.Development of deficiencies in native specialty training1.Provide adequate clinical and on-ground guidance to redeployed trainees2.Monitor progress and assess competence of trainees individuallyHidden curriculum1.Redeployed trainees pressured to practice outside comfort zone2.Fear about speaking up about redeployment1.Ensure adequate supervision and support for trainees, especially those redeployed from noncritically trained specialties2.Create opportunity to discuss redeployment with program and institutional leadershipChallenges with interviewing1.Exacerbation of existing biases, especially against underrepresented minorities1.Creation of structured interview process to avoid biases during interviewsChallenges with testing1.Uncertainty about testing dates, testing sites, and deferral of testing1.Ensure flexibility and open lines of communication regarding frequent changes in testing schedules2.Acknowledge the uncertainty and provide plans in case testing needs to be deferred or cancelledImpact on international medical graduates1.Significant delays in visa processing and start times2.Difficulty in finding waiver jobs3.Inability to deploy to hotspot hospitals due to immigration limitations1.Plan for late start and allow adaption time and resources2.Assist graduating trainees in job placements according to their immigration needs3.Deploy international graduates within native systems where immigration rules would not be challengedImpact on medical literature and dissemination of information1.Need for rapid dissemination of information to be balanced with accuracy of peer review2.Rapid spread of misinformation1.Maintain integrity of peer review process despite the pressure to publish the deluge of data2.Create well-appraised literature banks that can be reliably used by clinicians and educatorsSocial media1.Compromise of patient privacy2.Creation and dissemination of insensitive content1.Review the purview of the HIPAA regulations and ensure patient privacy even when sharing anecdotes2.Careful creation of content keeping societal, social, professional, and personal responsibilities in mindAMA = American Medical Association; CARES = Coronavirus Aid, Relief, and Economic Security; CME = Continuing Medical Education; COVID-19 = coronavirus disease 2019; GME = Graduate Medical Education; HIPAA = Health Insurance Portability and Accountability Act of 1996. Open table in a new tab AMA = American Medical Association; CARES = Coronavirus Aid, Relief, and Economic Security; CME = Continuing Medical Education; COVID-19 = coronavirus disease 2019; GME = Graduate Medical Education; HIPAA = Health Insurance Portability and Accountability Act of 1996. Significant loss of income was experienced by hospitals and physician practices due to the widespread economic impact of COVID-19. Health-care spending was reduced by 18% in the first financial quarter of 2020.5Bureau of Economic AnalysisNational Data National Income and Product Accounts.https://apps.bea.gov/iTable/iTable.cfm?reqid=19&step=3&isuri=1&nipa_table_list=31&categories=surveyGoogle Scholar Salaries had to be reduced by institutions despite increased working hours. Although hazard pay was provided by some centers, others had to cancel bonuses to meet financial shortfalls. The sharpest decline was experienced by surgical and pediatric practices, with many offices cutting pay, furloughing, and even laying off staff due to cancellations of elective procedures. Similarly, graduate medical education-related funding for continuous medical education was limited by institutions, and this could likely affect educators disproportionately. Trainees participating in the Public Service Loan Forgiveness Program were granted relief when Congress signed into law the Coronavirus Aid, Relief, and Economic Security Act on March 27, 2020, suspending payments and interest accrual on all government-held federal student loans from March 13, 2020, through September 30, 2020.6US Department of the TreasuryThe CARES Act Works for All Americans.https://home.treasury.gov/policy-issues/caresGoogle Scholar Challenges posed by financial uncertainty made it imperative for institutions to reach out to trainees and educators facing financial hardship and provide resources for obtaining financial advice or assistance to alleviate some of the stress. Studies describing the economic impact of the COVID-19 pandemic on students and educators will be needed to help plan better for the future and to guide institutions in making appropriate budget allocations toward technological adaptations needed for the delivery of medical education and for providing feedback, testing, and interviewing. Non-White populations have been disproportionately affected by COVID-19, and the long-standing disparities in health care7Hooper M.W. Nápoles A.M. Pérez-Stable E.J. COVID-19 and racial/ethnic disparities.JAMA. 2020; 323: 2466-2467Crossref PubMed Scopus (1520) Google Scholar,8Koma W. Artiga S. Neuman T. et al.Low-income and communities of color at higher risk of serious illness if infected with coronavirus. KFF 2020.https://www.kff.org/coronavirus-covid-19/issue-brief/low-income-and-communities-of-color-at-higher-risk-of-serious-illness-if-infected-with-coronavirus/Google Scholar have been magnified. Implicit biases of health-care professionals and the lack of EDI education in academic medicine has, at least in part, contributed to these disparities. Cognitive stressors linked to implicit bias9Johnson T.J. Hickey R.W. Switzer G.E. et al.The impact of cognitive stressors in the emergency department on physician implicit racial bias.Acad Emerg Med. 2016; 23: 297-305Crossref PubMed Scopus (122) Google Scholar have been amplified by the uncertainties of this pandemic. Therefore, now more formal curricula on social determinants of health and implicit bias training need to be prioritized by medical educators. To support this effort, resources provided by institutional EDI offices or published frameworks can be used.10Nivet M.A. Castillo-Page L. Schoolcraft Conrad S. A diversity and inclusion framework for medical education.Acad Med. 2016; 91: 1031Crossref PubMed Scopus (22) Google Scholar Open-access resources on EDI have also been provided by the American Medical Association Education Hub.11Online Courses and CME from the AMA Ed Hub, JAMA Network, and Steps Forward.https://edhub.ama-assn.org/Google Scholar Even prior to the pandemic over the past two decades, as medical school enrollments doubled, the percentage of underrepresented students fell by 16%.12Talamantes E. Henderson M.C. Fancher T.L. Mullan F. Closing the gap—making medical school admissions more equitable.N Engl J Med. 2019; 380: 803-805Crossref PubMed Scopus (74) Google Scholar Trainees who depend on campus-based resources may be disproportionately affected by COVID-19-related restrictions. The impact of these changes on trainees of all backgrounds must be considered by the educators and programs and take measures to improve remote access for these trainees. Female trainees, who constitute nearly one-half of our trainees, may be more affected by disruptions in the availability of child care or elder care due to COVID-19, which may then significantly affect work-life integration and academic productivity especially.13American Medical Women's AssociationCOVID-19: a gender lens statement from the American Medical Women's Association.https://www.amwa-doc.org/Google Scholar, 14Inside Higher EDEarly journal submission data suggest COVID-19 is tanking women's research productivity.https://www.insidehighered.com/news/2020/04/21/early-journal-submission-data-suggest-covid-19-tanking-womens-research-productivityGoogle Scholar, 15American Medical AssociationCOVID-19 resource guide: women in medicine.https://www.ama-assn.org/practice-management/physician-health/covid-19-resource-guide-women-medicineGoogle Scholar Students from disadvantaged backgrounds may be more affected by the lack of away rotations and the lack of direct interactions with faculty on clinical rotations (which may affect faculty writing strong letters of recommendation).16American Medical AssociationProtecting underrepresented students and residents during COVID-19.https://www.ama-assn.org/delivering-care/public-health/protecting-underrepresented-students-and-residents-during-covid-19Google Scholar Similarly, students from minority communities maybe more affected by the current national conversations and unrest surrounding racism and social injustice, making it even more challenging than before for them to navigate the application process and coursework alike. In light of the pandemic and these growing challenges to EDI, special attention to sources of implicit bias will need to be paid by admissions committees for medical school, residencies, and fellowships. Strategies for preventing such bias from affecting the admissions process will need to be reinforced. A clear commitment to upholding EDI has been made by some schools; for instance, the Dean of the University of Washington published a letter that clearly states how the University will conduct interviews this year.17UW Medicine School of MedicineCOVID Pandemic Admissions Community Response 2020_0728 Web.pdf.https://www.uwmedicine.org/sites/stevie/files/2020-07/COVID%20Pandemic%20Admissions%20Community%20Response%202020_0728%20Web.pdfGoogle Scholar Special guidance on avoiding implicit bias has been provided by the guide from the Association of American Medical Colleges (AAMC) on virtual interviews.18AAMCConducting interviews during the coronavirus pandemic.https://www.aamc.org/what-we-do/mission-areas/medical-education/conducting-interviews-during-coronavirus-pandemicGoogle Scholar The mental health burden from this pandemic can be attributed to anticipatory anxiety,19HealthlineAnticipatory anxiety: how to handle worries about the future.https://www.healthline.com/health/anticipatory-anxietyGoogle Scholar dealing with a high degree of sickness and death, increased work commitments with significant reduction in recovery time, impact of the illness on colleagues and families, economic stressors, social isolation, and societal pressures, among other reasons. Health-care professionals, including trainees, have been cognitively and emotionally challenged by the significant morbidity and mortality occurring over a sudden and short span of time. Traditionally, emotional expression in medicine has been considered unprofessional.20Kerasidou A. Horn R. Making space for empathy: supporting doctors in the emotional labour of clinical care. BMC Med Ethics.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728886/Google Scholar Trainees observe the reactions of their role models and are vulnerable to emotional suppression and patient dehumanization. A culture of empathy and emotional well-being for all trainees should be emphasized by sponsoring institutions, programs, and faculty. This culture may be achieved by offering staffing schedules that rotate trainees from high-intensity to low-intensity responsibilities, providing appropriate and accessible mental health resources, fostering an environment that encourages expression of emotion, and offering psychosocial support in the form of regular check-ins with trainees.21American Medical AssociationManaging mental health during COVID-19.https://www.ama-assn.org/delivering-care/public-health/managing-mental-health-during-covid-19Google Scholar Mental health problems such as stress disorders, insomnia, and mood disorders, even in those with no preexisting conditions, can be worsened by social isolation. Health-care workers and trainees struggle with isolation just like the general public due to decreased social engagement, less sensory stimulation, and diminished engagement with meaningful activities.22American Psychological Association. Keeping your distance to stay safe. https://www.apa.org/practice/programs/dmhi/research-information/social-distancing. Accessed June 20, 2020.Google Scholar, 23Yamshon S. I'm a doctor fighting COVID-19. At times, I've never felt more alone. Los Angeles Times.https://www.latimes.com/opinion/story/2020-05-15/isolation-healthcare-workers-covidGoogle Scholar, 24'The hardest part is being alone': Volunteer doctors from across the US face life on New York's coronavirus frontline-far from home. The Independent.https://www.independent.co.uk/news/world/americas/coronavirus-new-york-volunteer-doctors-us-cases-a9489221.htmlGoogle Scholar In addition to isolation from quarantines and stay-at-home orders, avoidance from others due to stigma maybe experienced by health-care workers, which can further exacerbate loneliness.25World Health OrganizationMental health and psychosocial considerations during the COVID-19 outbreak.https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf?sfvrsn=6d3578af_2Google Scholar It was noted by the World Health Organization that health-care workers are at an increased risk for mental health problems not only due to emotional distress from social isolation but also due to exposure to death and disease, personnel and personal protective equipment (PPE) shortages, and moral distress in the care of patients.22American Psychological Association. Keeping your distance to stay safe. https://www.apa.org/practice/programs/dmhi/research-information/social-distancing. Accessed June 20, 2020.Google Scholar,26Usher K. Bhullar N. Jackson D. Life in the pandemic: social isolation and mental health.J Clin Nurs. 2020; 29: 2756-2757Crossref PubMed Scopus (350) Google Scholar Another related issue is professional uncertainty for trainees applying for their first jobs. Hiring has been frozen by a number of institutions due to pandemic-related budget cuts. The full burden of the mental health toll on health-care workers and trainees is not yet known, but it will likely be significant. People have been encouraged by experts to stay virtually connected through telephone calls, text messages, and video chats. Leaders have been encouraged to reach out to employees to provide support and share information to minimize the effects of social isolation. Program leadership and faculty have been requested to update their trainees regularly and encourage virtual engagement.27Greenberg N. Docherty M. Gnanapragasam S. Wessely S. Managing mental health challenges faced by healthcare workers during Covid-19 pandemic. BMJ.https://www.bmj.com/content/368/bmj.m1211Google Scholar Avoidance could be a symptom of suffering mental trauma. Programs should reach out to trainees and faculty who miss virtual classes and meetings, as they may be struggling psychologically. Prior to this pandemic, academic medical departments across the country had wellness initiatives to prevent burnout. Such initiatives included meditation, yoga, peer-to-peer counseling programs, and faculty training in mind-body medicine among others. The effectiveness of the various programs is an ongoing area of research. Several of these were successfully transitioned to digital platforms.28AAMCWell-being in academic medicine.https://www.aamc.org/news-insights/wellbeing/facultyGoogle Scholar Meditation apps such as Headspace provided special discounts for health-care workers.29HeadspaceMeditation in the office-workplace wellness with Headspace.https://www.headspace.com/workGoogle Scholar With temporary closure of gyms, virtual yoga classes were started by physician leaders such as Arghavan Salles, and innovative solutions such as "recharge rooms" were built at some hospitals to provide frontline health-care workers a space to de-stress.30Virtual Yoga with Arghavan Salles 04/04/2020.https://www.youtube.com/watch?v=_tQeGYnuXDkGoogle Scholar,31Elliot D. How a virus triage tent became a serene oasis for health care workers. The New York Times. 2020 Jun 12.https://www.nytimes.com/2020/06/12/nyregion/coronavirus-doctors-mental-health.htmlGoogle Scholar To facilitate asynchronous learning while social distancing, educators relied on online learning and Web conferencing platforms such as Zoom, Google Hangouts, and GoToMeeting.32Goh P.S. Sandars J. A vision of the use of technology in medical education after the COVID-19 pandemic. MedEdPublish.https://doi.org/10.15694/mep.2020.000049.1Google Scholar,33Sandars J. Correia R. Dankbaar M. et al.Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic. MedEdPublish.https://www.mededpublish.org/manuscripts/3068Google Scholar In-person attendance at preclinical lectures was declining even prior to the pandemic, and students were increasingly viewing lectures online.34Emanuel E.J. The inevitable reimagining of medical education.JAMA. 2020; 323: 1127-1128Crossref PubMed Scopus (175) Google Scholar Broadly, all in-person training, including clerkships, medical school rotations, small group sessions, and traditional didactic forums, were suspended in the early part of the pandemic.35Theoret C. Ming X. Our education, our concerns: the impact on medical student education of COVID-19.Med Educ. 2020; 54: 591-592Crossref PubMed Scopus (154) Google Scholar,36American Medical AssociationCOVID-19: how the virus is impacting medical schools.https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schoolsGoogle Scholar Clinically oriented activities such as medical school rotations and clerkships were reinstated by some institutions following careful consideration of local factors. The future of these educational avenues remains uncertain. Didactic sessions, including national conferences, were predominantly held virtually.37Rose S. Medical student education in the time of COVID-19.JAMA. 2020; 323: 2131Crossref PubMed Scopus (990) Google Scholar Residency and fellowship programs were transitioned to digital platforms for conducting key didactic sessions, including grand rounds and journal clubs. Teamwork management programs (eg, Slack and Asana), game-based learning platforms (eg, Kahoot!), and social media networks (eg, Twitter) were being used to reinforce concepts based on the principles of spaced repetition.38Sharif S, Sherbino J, Centofanti J, Karachi T. Pandemics and Innovation: How Medical Education Programs Can Adapt Extraclinical Teaching to Maintain Social Distancing. ATS Scholar. 2020 Aug 4;ats-scholar.2020-0084CM.Google Scholar A notable consequence of the pandemic was the cancellation of many medical student clinical rotations, thereby limiting opportunities for hands-on learning. Virtual reality-enhanced classrooms and application of game theory via online escape rooms were being explored as exercises for critical thinking and communication skills in simulated clinical experiences.39Montanari S. What happens to medical education when the dissection lab is closed?. Slate Magazine.https://slate.com/technology/2020/06/med-school-cadaver-dissection-virtual-reality.htmlGoogle Scholar Although the full impact and perception of virtual education will only become evident over time, early evidence supports that trainees found virtual education engaging in settings such as virtual rotations.40Adams C.C. Shih R. Peterson P.G. Lee M.H. Heltzel D.A. Lattin G.E. The impact of a virtual radiology medical student rotation: maintaining engagement during COVID-19 mitigation. Military Medicine.https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usaa293/5908902Google Scholar Innovative amalgamation of virtual platforms and technologies with educational principles is expected to lead to educational offerings such as virtual and virtual reality-based clinical rotations, educational digital escape rooms (such as the one offered at the American College of Chest Physicians Annual Meeting 2020), and conference or meeting delivery that allows real-time interaction (such as offered by Gatherly).41Gatherly The Engaging Online Event Platform.https://www.gatherly.io/Google Scholar Facing an unprecedented shortage of qualified health-care workers, several safe alternatives for expanding the workforce, including deploying qualified and willing medical students, were considered by institutions.42Miller D.G. Pierson L. Doernberg S. The role of medical students during the COVID-19 pandemic.Ann Intern Med. 2020; 173: 145-146Crossref PubMed Scopus (177) Google Scholar Countries such as Italy, Ireland, and the United Kingdom engaged their students early as health-care workers while students in Canada were pulled from clinical duties.43CTV NewsMedical students volunteer on the pandemic front lines after classes cancelled. CTV News.https://www.ctvnews.ca/health/coronavirus/medical-students-volunteer-on-the-pandemic-front-lines-after-classes-cancelled-1.4993941Google Scholar, 44Editor COECoronavirus: hundreds of medicine students fast-tracked into fight against Covid-19. The Irish Times. March 18, 2020.https://www.irishtimes.com/news/education/coronavirus-hundreds-of-medicine-students-fast-tracked-into-fight-against-covid-19-1.4205676Google Scholar, 45Cole B. 10,000 med school graduates in Italy skip final exam, get sent directly into health service to help fight COVID-19. Newsweek.https://www.newsweek.com/italy-coronavirus-covid-19-medical-students-1492996Google Scholar A number of American medical schools graduated some students early. Guidelines were developed by the AAMC to ensure that students' participation in direct patient care was voluntary, with guarantees of sufficient PPE, adequate testing, and health-care coverage. Importantly, efforts were made by institutions to prevent students from feeling coerced into service.46Association of American Medical CollegesGuidance on medical students' participation in direct patient contact activities.https://www.aamc.org/system/files/2020-04/meded-April-14-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdfGoogle Scholar Guilt, shame, or moral injury may be experienced by medical students not involved with delivering clinical care or unable to do so. However, maintaining their focus on completing their education should be the main objective, even in the face of this pandemic, and such feelings should be addressed by mentors in a supportive manner, including providing guidance on alternative avenues to help during these unprecedented times.47O'Byrne L. Gavin B. McNicholas F. Medical students and COVID-19: the need for pandemic preparedness.J Medical Ethics. 2020; 46: 623-626Crossref PubMed Scopus (149) Google Scholar Student participation in direct patient care was restricted by another important factor. Some institutions had to limit the number of team members entering patient rooms and performing the physical examination each day to reduce the possibility of transmission to health-care workers as well as to conserve PPE. Usually more senior members of the team performed these physical examina