When Mihir Joshi started medical school at UC San Francisco last fall, he expected to spend the year doing what most first-year students do: study the science of medicine and begin learning the ropes of the clinical environment.
But just months later, in March, Joshi and all the students in the University’s professional degree programs – dentistry, medicine, nursing, pharmacy, and physical therapy – and the Graduate Division had their education upended by the COVID-19 pandemic as shelter-in-place orders went into effect.
For Joshi, that meant that the time he would ordinarily spend shadowing and interacting with doctors in the hospital turned into an online experience, at least until August, when he was allowed to go back to an in-person clerkships. “It’s been a lot, trying to make up that experience with remote learning. It’s been very piecemeal,” he said.
We had a commitment to doing things well and a humility around knowing that we don't always get things right the first time. And I think this set us up for success this fall.
Adapting the curriculum and experience for medical students was a work in progress, and one that required a lot of listening to students, said John Davis, MD, PhD, medical school associate dean for curriculum.
“We had a commitment to doing things well and a humility around knowing that we don't always get things right the first time,” he said. “And I think this set us up for success this fall.”
UCSF’s professional programs, which enroll about 2,000 students each year, face unique challenges compared to primarily undergraduate institutions because the education is so hands-on, says Elizabeth Watkins, PhD, vice chancellor of Student Academic Affairs and dean of the UCSF Graduate Division. In addition, PhD students across the Graduate Division and other departments are embedded in biomedical research labs throughout campus and face their own challenges in completing research projects.
As the thousands of students head back to UCSF this fall, educators across campus have had to balance innovative distance learning opportunities with safely bringing learners back together for experiences that must take place in simulation labs, clinical settings, research labs, and more.
Through it all, education leaders across UCSF have seized on the current situation to make the curriculum more relevant to the times.
“There’s going to be change, and it’s been catalyzed by the pandemic,” said Davis. “There’s nothing like a crisis to make you focus on your principles.”
Tailoring Adaptations to Suit the Practice
Each of the schools has been experimenting with how to translate the hands-on UCSF learning style to an environment in which face-to-face communication may pose dangers.
Under normal circumstances, each school provides skills labs where students practice with drills, become familiar with glucose monitors or learn to work with catheters. In some instances, the learning has become almost fully remote, while in other cases it is split between online instruction and in-person work on campus in small groups.
The School of Pharmacy, for example, has moved almost all education online, sending students devices like glucose monitors and then using Zoom to teach hands-on demonstrations and letting students practice together in small, online breakout groups.
The School of Dentistry has provided students with kits that allow them to practice with their drills at home, and the school and has invested in new cameras to shoot classroom demos in detail. The recorded demos done during online classes will go into a library of resources that will be available to students in future years as well.
UCSF nursing and medical students are also practicing skills using advanced virtual patient simulations that help them learn to evaluate patients and propose diagnoses and treatments.
“The virtual simulations provide our students with interactive, life-like patient experiences that allow them to practice critical skills such as diagnostic reasoning and patient assessment,” said School of Nursing Dean Catherine L. Gilliss, PhD, RN, FAAN. “Adopting these types of innovative tools allows us to continue to prepare the next generation of nurse leaders.”
Medical students, who in their second year usually get to practice clinical skills in encounters with actors playing a patient, are able to meet with some of those “patients” online.
“It’s good because we still get the experience of working through a case with an unknown patient who has a whole bunch of symptoms, and we have to figure out the mystery,” said second-year medical student Joshi about the simulations and actor encounters. “It’s important for us to learn, because the future of practicing medicine will involve a lot more telemedicine. But it doesn’t fully replace the clinical experience of being able to do a physical exam.”
Adopting these types of innovative tools allows us to continue to prepare the next generation of nurse leaders.
In collaboration with the Kanbar Center, the School of Nursing and Medicine have transitioned these patient interactions to virtual telehealth visits. Students still get the experience of interacting with a live standardized patient and receive real time feedback from their faculty through Zoom.
Some learning experiences, however, must be done in person.
Graduate students pursuing PhDs typically spend much of their time working with colleagues in the lab. This year’s crop of new students are doing rotations in labs that are operating at only 50 percent capacity in order to maintain social distancing, meaning that their time in the lab will be significantly reduced.
While these students are still able to do literature reviews and data analysis from home, “their work will probably be a bit more intellectual rather than experiential,” said Watkins. “They might not get to work on as extensive a project. But both the faculty and the students know that these are different times, and students will still be able to get a good sense of which lab they’d like to join for their thesis starting in their second year.”
Dental students practicing at home with their electric kits are doing work that depends on microscopic details to be successful, so they need to also work with faculty in person so that their work can be evaluated and deemed safe for patient care. To achieve this, half of the school’s dental students are back on campus at any given time while the other half do remote learning.
A similar situation is true for School of Nursing students, who attend the school’s skills laboratory also on the Parnassus campus. There, items such as practice dummies are used for students to hone their skills.
Common Challenges Across Campus
In bringing students back to their clinical rotations and to campus for in-person learning, one thing reigned supreme: safety.
Everyone had a vested interest in making this work for everyone else, said Sharon Youmans, PharmD, MPH, Vice Dean of the School of Pharmacy. “We all needed to figure out how to do this right while minimizing our footprint on campus, because if the process for the return to in-person learning doesn’t work, it could impact whether students or faculty students or faculty can be on campus at all for in-person instruction,” she said.
To coordinate all of the schools and departments, Vice Chancellor Watkins invited the education deans to make lists of what was needed to continue their programs.
“Though there were differences in clinical requirements,” Watkins said, “there were common themes to the challenges each school was facing.”
She worked collaboratively with this group to create a set of shared guiding principles that prioritize making decisions that comply with all guidance from the San Francisco Department of Public Health. The goal is to do everything possible to allow students to graduate on time while coordinating safe returns to campus and using campus space in ways that prevent the different programs from interfering with each other.
“We want to ensure that we are operating consistently across programs in a way that’s respectful of their very different needs,” she said.
In addition, UCSF has put into place, both for students and all faculty and staff, strict guidelines for building capacity, social distancing and masking, which everyone must follow.
Perhaps the most anticipated experience in any of UCSF’s professional programs is the chance to work hands-on with real patients, but while some advanced students are still doing clinical work, it has been scaled back. Safety concerns account for part of the curtailment, in tandem with fewer opportunities for rotations because there are fewer patients in campus hospitals.
Dental students face particular risk because they spend their time looking into the face of an open-mouthed patient. The personal protective equipment for dental students includes an N95 mask, goggles, face shield, cap, and gown. Third- and fourth-year dental students provide direct patient care and manage their own patient portfolios.
Dental patients scheduled for certain procedures, such as those that generate aerosols, are tested for COVID-19 four days before their visit, and they are screened at multiple points before and during their visit.
Watkins said that as San Francisco Department of Public Health guidelines continue to be updated, making sure all students can get their education in a safe environment is paramount. “We’re absolutely committed to complying with all infection-control practices, and to making sure students have what they need, whether they are working at home, on campus, or in the clinic,” Watkins said.
The Pandemic as a Classroom
Amid the grim outcomes worldwide brought on by the deadly pandemic, there is perhaps the unexpected silver lining of once-in-a-lifetime educational opportunities for future health professionals.
For instance, while many medical schools around the country were saying that no students should be in the clinic at all, the medical school’s Davis saw the moment as a chance for students to learn about pandemics from mentors who have been there.
“We have students who are nearing graduation who can learn from those of us like myself, who have a bit more gray, who’ve been through HIV when it was happening, and through the Ebola scare. We can show them what that’s like,” he said.
Some students and faculty of the School of Nursing have had the opportunity to triage patients through UCSF Health’s COVID Hotline Call Center, participate in contact tracing, and help screen homeless individuals.
But practicing health care during a pandemic means students have to re-think and re-learn how to safely treat their patients.
“We’re all learning how to provide dental care and other types of patient care in times of disaster,” said Sara Hughes, MA, EdD, associate dean of Education and Student Affairs in the UCSF School of Dentistry. The experience may change health care education overall.
“This is unexpected, but we’re seeing how important it is. And we now understand that we have a duty to continue teaching students about this going forward,” said Hughes.
In addition, there are opportunities for students to learn telehealth, which has boomed during the pandemic.
Many students at the School of Nursing, who typically train at community clinics and hospitals throughout the Bay Area, transitioned to telehealth, which includes supervision by UCSF faculty trained in teleprecepting, allowing clinical teaching and learning to continue.
Pharmacy faced the same situation, said Youmans, and welcomes the expansion of telehealth practice.
“People often call their pharmacies to discuss questions with a pharmacist over the phone,” she said. “So we’ve essentially been doing telehealth for years.”
“Telehealth enables our students to connect with patients in ways that are different from when they would physically come to a clinic,” said Associate Dean of Academic Programs Maureen Shannon, PhD, CNM, FAAN. “They can meet with them in their home environment where they can obtain a more holistic understanding of a patient’s health and experience. And telehealth has helped increase health care access for patients in our communities.”
Students in the School of Pharmacy have made the same transition, said Youmans, and welcomes the expansion of telehealth practice.
In terms of educating students, telehealth requires a different set of skills, the medical school’s Davis points out. The practitioner really needs to engage the patient in conversation, ask a lot of questions, and be an active listener.
“Some students have been concerned that there’s so much telehealth, and I tell them “This is a really valuable skill set that you’re going to need,’” he said. “A lot of us who have been in the clinical environment for a while are still struggling with the skills we need for this technology.”
‘The Student Journey Has Changed’
Much remains unknown about the next few months, years, and potentially more when it comes to health care and biomedical research education in the era of COVID-19.
While some things will likely change, like the limited in-person class sizes, other things, like the emphasis on telehealth, are likely to remain, especially as the technology becomes more incorporated into the health care landscape.
The educators agreed that it also remains to be seen what aspects of online learning are continued once conditions return to normal. Videos of in-class demos, such as those the dental school is making, are a clear advantage.
“When we initially switched to remote learning as a result of COVID, we were scrambling to substitute with technology,” said Elizabeth Gatewood, DNP, RN, FNP, assistant dean of Education Technology and Innovation in the School of Nursing. “Looking forward, we are now shifting to utilizing technology to transform the learning experience.”
One thing that’s certain is that faculty and students have been learning a lot together through this time. Medical student Joshi said that because his generation of learners are digital natives, they have become more active stakeholders in shaping their own educational experiences.
“In that process, we actually have a responsibility to carry the torch for our instructors, to help them teach us by being open with them and telling them what’s working and what isn’t,” he said. “We need to be ambassadors for using these new technologies.”
Hughes in the School of Dentistry sees a similar shift.
“The student journey has changed,” she said. “None of us are experts in pandemic health care. They’re learning about this at the same time we are. So in that sense, they are our colleagues.”