Dilshan Pieris,¹ Kevin JQ Chen¹

¹Temerty Faculty of Medicine, University of Toronto, Ontario, Canada

Corresponding to: Dilshan Pieris; email: dilshan.pieris@mail.utoronto.ca

COVID-19 has disrupted many aspects of medical education, including mentorship for medical students. Mentorship programs provide career guidance and support systems, especially benefiting students without pre-existing relationships in medicine.¹ Pandemic-related restrictions have forced mentorship programs to rely on virtual platforms.² The value of these programs prompts consideration of the impacts of this transition. We explore tensions in engagement; equity, diversity, and inclusion (EDI); and logistics arising from this shift through our lens as program coordinators.

For engagement, this year’s virtual program had substantially more participants (e.g., e.g., 410 in 2020-2021 vs. 256 in-person in 2019-2020), likely due in part to capabilities afforded by online platforms. Zoom, the platform adopted at many institutions, including ours,² can host hundreds of individuals whereas in-person capacity is often constrained by room booking policies. Virtual platforms also remove geographical barriers, facilitating engagement through flexibility across time/space (circumventing travel) and expanding the catchment for mentor recruitment.^2,3 However, despite more participants, virtual platforms challenged the quality of engagement. Mentors and mentees had more options for events in-person (e.g., shared meals), providing valuable face-to-face interaction to establish mutual trust/safety. Virtual environments hindered such connections by introducing new social norms (turning off microphones/cameras, multitasking), technical difficulties (poor internet connection, asynchronous audio/video), and issues interpreting non-verbal cues.^2,4 Moreover, with students spending hours online for classes,^2,3 many experienced videoconferencing burnout (“Zoom fatigue”),⁵ contributing to attrition in mentee engagement.

From an EDI perspective, the virtual setting enabled mentor recruitment from outside institutions, improving diversity and facilitating inclusivity for mentees. This option was an attractive benefit since medical students value diversity and a sense of community and shared identity from mentors.¹ While mentor diversity is always a priority; it can be challenging to achieve in-person due to regional constraints on recruitment. Furthermore, in-person iterations often carried financial barriers. Many groups met at restaurants or venues requiring entrance fees. Mentees often paid out-of-pocket, placing undue financial stress on those from lower socioeconomic backgrounds, potentially dictating how often they met with mentors. This problem was partially offset in the virtual program as there were more cost-free options (e.g., videoconferencing, free online games).

Logistically, our virtual program had fewer administrative costs. Though groups organized their own meetings throughout the year, we also hosted large events to facilitate socialization and debrief with participants. With an online program, many aspects of these larger events (e.g., catering, room bookings) and their associated fees no longer applied. The funding, therefore, could be reallocated toward subsidies to address the financial inequities or carried forward for future iterations. However, despite lower administrative costs virtually, there was a greater logistical burden of planning. We had to organize a larger number of participants into groups while still ensuring mentor-mentee compatibility by closely aligning their professional, academic, and personal interests. Additionally, with more participants came more intra-group conflicts (e.g., unresponsive mentors) requiring case-by-case resolution.

Amidst changes imposed by COVID-19, we learned that transitioning online offers several advantages for mentorship programs, though not without challenges. These programs help students catch their footing on the journey of career exploration and development, whose uncertainties/anxieties are exacerbated by the pandemic.^1,3 Virtual programs provide an equitable alternative with a greater capacity for participation. Thus, program coordinators should learn to pivot online as the pandemic continues to evolve.

While increased virtual enrolment may bring optimism, coordinators should prepare for tapering engagement. One potential solution is to create incentives. For example, in our virtual program, we implemented photo contests wherein groups won by having the most social media engagement (likes, comments). We also created nomination-based awards to recognize participants who actively engaged in their groups. Winners received gift cards that were funded, in part, by money saved from hosting the large events online.

As coordinators, we felt especially disconnected from groups during the virtual program, likely due to reduced face-to-face interaction. To overcome this, we incorporated frequent check-ins (emails, social media postings, surveys) that became useful logistically; proactively seeking feedback rather than waiting for it helped us identify and address conflicts more quickly. Checking in with groups often also enabled real-time, needs-based adaptation. For example, we cancelled our mid-year event in response to Zoom fatigue identified in participants.

Overall, shifting online revealed a need for mentorship programs to adapt to resultant changes in engagement, EDI, and logistics. Incentivization and more frequent (active) communication with participants are easily implementable strategies to improve virtual program delivery while providing the career guidance and support sought by students.

References

1. Zhou S, Balakrishna A, Nyhof-Young J, Javeed I, Robinson L. What do participants value in a diversity mentorship program? Perspectives from a Canadian medical school. EDI. 2021;ahead-of-print(ahead-of-print). https://doi.org/10.1108/edi-12-2020-0348
2. Serhan D. Transitioning from Face-to-Face to Remote Learning: Students’ Attitudes and Perceptions of using Zoom during COVID-19 Pandemic. IJTES. 2020;4(4):335-342. https://doi.org/10.46328/ijtes.v4i4.148
3. Abdelhamid K, ElHawary H, Gorgy A, Alexander N. Mentorship resuscitation during the COVID-19 pandemic. AEM Educ Train. 2020;5(1):132-134. https://doi.org/10.1002/aet2.10538
4. Dias M, Lopes R, Teles A. Will Virtual Replace Classroom Teaching? Lessons from Virtual Classes via Zoom in the Times of COVID-19. J Adv Educ Philos. 2020;4(5):208-213. https://doi.org/10.36348/jaep.2020.v04i05.004
5. Bailenson J. Nonverbal Overload: A theoretical argument for the causes of Zoom fatigue. TMB. 2021;2(1). https://doi.org/10.1037/tmb0000030

Levi J Ansell,¹ Davy Lau,² Noah Alexander,² Nicholas Taylor,¹ Kenzy Abdelhamid,³ Daniel Shi,⁴ Nardin Kirolos,⁵ Katherine Lacaille McGuire⁵

¹University of Alberta, Alberta, Canada; ²University of British Columbia, British Columbia, Canada; ³McGill University, Quebec, Canada; ⁴Queen’s University, Ontario, Canada; ⁵University of Ottawa, Ontario, Canada

The problem

Representation in medicine has been heavily discussed recently, especially in the context of the Black and Indigenous Lives Matter movements. Medical schools have long been challenged to create an admission process that promotes diversity and equity for all applicants. For students, gaining admission into medical school can be a complex, intricate process that requires years of planning.

Getting into medical school is influenced by a myriad of factors. Some applicants may have relatives or family friends in the medical field who can provide assistance through the rigorous journey. As intersectionality often works, those lacking social connections to medicine often face financial, geographical, and practical challenges to pursuing medicine. Pre-medical students often resort to forums, such as Reddit, for advice. Anonymous forums share many characteristics: the information is variable, unreliable, and potentially misleading.

A 2018 cross-sectional survey of demographics of Canadian medical students found that over half came from household incomes over $100,000 per year, in stark contrast to the overall demographics of the Canadian population.¹ This has implications for patient care, creating an empathy gap between future healthcare workers and the populations they serve. While there have been efforts to improve representation of marginalized populations in medicine, there remains an urgent need to address the systemic factors that prevent applicants from diverse backgrounds from entering medicine.

With the cost of the MCAT, interview preparation, and application review, there are immense financial barriers to becoming a competitive applicant. Costs for MCAT preparation courses and interview practice can be enormous. Those with greater financial assets may spend significantly more for additional consulting services. This puts an insurmountable divide between students who can afford these services and those who cannot. Without guidance, it is easy to mistakenly pour time, energy, and money into unfruitful aspects of an application.

The solution

Dr. Alexander, an emergency physician in Vancouver, and a small team of dedicated medical student volunteers formed the Medical Mentor Community (MMC) in January 2020. The MMC’s mission is to “level the playing field of medical school admissions.” Our team is dedicated to ensuring equal access to mentoring from medical students and others in the medical profession.

How is the MMC different?

Simply put, our community has people who have been through the gamut. With medical student, resident, and physician mentors from across the country, we have captured a breadth of experiences that help us relate to every incoming student. We have mentors who were accepted to medical school on their first attempt, and others for whom medicine is a second or third career. We are not a collection of hopefuls, but people that want to distill hope into those hopefuls.

Interestingly, our form of virtual, team mentorship was established before the COVID-19 pandemic shook the world. Because our mentors span the entire country, we had to be mobile and flexible to start. We use an app named Slack, with channels to categorize the components of the application process such as academics, interviews, volunteering, and research. We have channels, such as “Life as a med student,” that offer a holistic view of medicine and contribute to the MMC being more than just a resource, but a supportive network.

We respond to publicly posted questions and provide applicants with mentor-authored articles and resources to help guide them through the process. Our open-style mentorship encourages users to ask questions for the benefit of the entire community. Mentees can access this advice at any time, ensuring that our core value of ‘leveling the playing field’ and equitable guidance is upheld. We also help applicants prepare for their MCAT, CASPer, application submission, and interviews.

Growth and leadership structure

From a mere ten mentors in January 2020, we now have over 200 mentors from 13 Canadian medical schools. We have connected with over 600 students who want to learn about the world of medicine. Each time a need is identified within our community, someone steps in to fill that need. There are currently eight Associate Directors, each with specific responsibilities tailored to their interests and skills. Accountability and productivity are managed through regular meetings, live documents, and tracking of key performance indicators. Our leadership team has expanded to meet the growing needs of our virtual community.

Another interesting aspect of our community is that some of the growth is initiated by the pre-med students themselves. A prime example is one of our subchannels in the community, #non-traditional, where students distant from formal academic settings can discover how to highlight their achievements in the post-undergraduate world. Members of this channel have something that sets them apart from many other students who will apply and knowing how to capitalize on this is paramount. It is our hope that we can continue building subchannels for all minorities and marginalized communities (Black, Indigenous, 2SLGBTQ+, first generation immigrants, etc.) looking to demonstrate their unique strengths. Our dynamic growth and flexibility allows us to help individuals with greater precision and tailor the experience to the emerging needs of the community.

Wrapping up

So, now what?  If you are an early learner with an interest in medicine, check us out. If you are already a medical student and this sounds like a mission you want to be a part of, reach out and come on board. If you are already an established member in the medical community, perhaps you can mentor us. If you have means to share our message and community, please do so.

We are committed to knocking down barriers and helping every applicant on their journey. We are excited to announce that we have already seen members successfully gain acceptance to Canadian MD programs!. Find more on our website: https://www.medicalmentorcommunity.com/. Questions can be directed to myself or our community email at: MedicalMentorCommunity@gmail.com.

References

1. Khan R, Apramian T, Kang JH. et al. Demographic and socioeconomic characteristics of Canadian medical students: a cross-sectional study. BMC Med Educ 2020; 20: 151. https://doi.org/10.1186/s12909-020-02056-x

Yuvreet Kaur,¹ Leah Steinberg,² James E Teresi,^3,4 Carol J Swallow^1,5,6

¹Department of Surgery, University of Toronto, Ontario, Canada; ²Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Sinai Health System, Ontario, Canada; ³Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada;  ⁴Department of Anesthesia, Mount Sinai Hospital, Ontario, Canada; ⁵Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and Sinai Health System, Ontario, Canada; ⁶Division of General Surgery, Mount Sinai Hospital, Ontario, Canada

We first met in the surgical oncology clinic where you were referred for a recent finding of a retroperitoneal sarcoma. Your friend assisted us with translation as you spoke minimal English. You were in debilitating pain from the mass compressing your nerves and constipation from the opioids you were using. You told me you live by yourself, and have no close family members in Canada. We reviewed your investigations, and you were not a surgical candidate for resection of the mass. We admitted you, and I have since seen you every morning for three weeks. Some mornings your pain is manageable, and some mornings you are tearing up from the excruciating pain as you had not been able to sleep all night. We arranged radiation therapy and hoped that would help with the pain. Not once did you express disappointment in your diagnosis, prognosis, or treatment plan. The only thing you complained about during your hospital stay was your pain. Over the three weeks, with assistance from a multidisciplinary team, we tried a myriad of treatments for your pain, with little relief.

We first met on the ward. You had gone through four abdominal surgeries in the past eight months and required multiple hospital admissions. You were now in the hospital for weeks, and your major complaint was debilitating bilateral leg pain that significantly decreased your quality of life. You could not support yourself after some walking. When I tested light touch sensation on your leg with a tissue, you screamed in pain. We ordered multiple tests and investigations, consulted neurology and pain services, and yet we failed at identifying a cause of your pain and managing it. Some days when I saw you, you were up and walking and going to Second Cup and grabbing a coffee. Other days you were lying in bed in excruciating pain and had reduced physical function. We had to eventually tell you that there is nothing more we can do to improve your function. You asked us how you will be able to go back to what your life was eight months ago if you could not even support yourself on your legs for more than a few minutes. We had no answer for you.

When we first met on the ward, you were in bed curled up in a fetal position. You had a flat affect, and expressed the emotional pain you were in. You wanted to leave the hospital to be reunited with your passions- art and photography. You needed a few more days to physically recover. You opened up about your past suicide attempts, and that you would rather be dead than confined to the walls of your hospital room. We reflexively consulted psychiatry. The following week, I noted no changes in your mood or affect. Although I never saw you smile during your stay, I did see the joy in your eyes when your niece brought in your artwork to decorate your hospital room, and when we initiated your discharge planning. I wish we could have done more to address your mood during your hospital stay, and I can only hope that your emotional pain is more at ease at home. I hope we meet again, perhaps at an art exhibition, and I can see you in something other than a blue hospital gown.

I discussed my encounters with Dr. Steinberg and Dr. Teresi, experts in pain management. I learned two key things from them that I hope to take with me as I continue to work in patient care. Firstly, pain is multifactorial, complex, and inevitable. The goal of pain management is not to completely eliminate the pain, but to assist patients return to their baseline level of functioning. Multidisciplinary teams, a deeper understanding of the physical and psychosocial factors leading to the patient’s pain, and personalized management plans for each patient are essential when managing pain. Secondly, it is okay to not be able to fix everything, and it is critical for us to acknowledge those limits. We will see our patients suffer, and one of the most difficult aspects of our work is to sit with them through their pain, rather than walking away from it. This may come in the form of our continued availability and support for the patient, or involving other healthcare professionals when we have reached the limits of what we can do. It is not sufficient to try our best, but a lot more important to not abandon our patients in their suffering.

Christopher Gallivan,¹ Magnus McLeod¹

¹Dalhousie University, Nova Scotia, Canada

Across the globe, clerkship directors and other educators had to deal with the unprecedented chaos caused by the COVID19 pandemic leading to the cessation, modification, and then resumption of clerkship.  This posed a challenge for educators – and students. There had to be a balance between maintaining a safe learning environment for students and ensuring that students had adequate clinical learning experiences but still allowing students to complete their clerkship year in a way that does not completely disrupt the learning of the following cohorts’ clerkship year.  We would like to share some perspectives and lessons learned from the point of view of the internal medicine clerkship program at Dalhousie University.

One thing that certainly took us by surprise was the speed at which things changed during the first wave of the COVID 19 pandemic.  At Dalhousie, for example, we went from a Monday morning introduction for students starting their third of four clerkship blocks with some passing discussion about the evolving pandemic to a Friday briefing that same week that clerkships were suspended indefinitely across Canada.  It was obviously an incredibly stressful time for students; made worse by the fact that for most of their questions (such as how long they will be off, how this will affect their graduation date, how this will affect residency matching), we simply did not have any answers.  During this time, we felt it important to make sure students were receiving clear and accurate messages and not getting different information from different sources. To do this, I found myself communicating much more with my fellow clerkship directors as well as our undergraduate medical education department.  This also led to, what was for me, both a humbling and frustrating experience of having to tell students with legitimate questions or concerns that we did not have answers.  This involved fighting the natural tendency as an educator to answer questions and provide reassurance. Still, in the long run, it was certainly my experience that telling students to wait for more information caused fewer problems than students getting conflicting information from multiple sources.     

As the year progressed it became clear that the turmoil of stopping clerkship would pale in comparison to the challenges of restarting it.  At Dalhousie, after much discussion, it was decided that the final two clerkship blocks of the current class cohort as well as the first block of the following year’s cohort (that which started in the fall of 2020) would all need to be shortened with each department deciding how to give students adequate training in less time.  I came to the profound but obvious realization that it would be impossible to deliver all the content we do in normal year.  I found myself essentially applying “triage” thinking to the curriculum and focusing on the things that were vital or ‘life saving.’ We ended up deciding to keep the full length of what we felt were our core internal medicine rotations of the MTU (Medical Teaching Unit) and our geriatrics rotations while shortening the time for selectives in outpatient and subspecialty medicine.  Although this certainly altered the experience of clerks, I felt we were able to provide students with the necessary learning in core internal medicine patients and illnesses.

Although there were many challenges to this year, it was also an opportunity for educators to improve and innovate.  We were pleased to see how many of our clinical preceptors and other educators were willing to step up and help find creative solutions to keep students engaged.  For example, many of or preceptors involved students in virtual care and remote or phone consults even though these were new for students and preceptors alike.  This allowed students to be part of the learning and innovation process as they worked with their preceptor to navigate the new clinical environment.  Some preceptors also found ways to involve students in patient care using new techniques, such as taking a table into a patient room and showing the physical exam and history without bringing in their whole team of learners.  The ability of our educators to be open and creative undoubtedly helped our students to get back into the clinical environment and resume learning.       

As we look ahead to the ongoing challenges, we can use some of the lessons we learned during the pandemic to prepare for the future.  By focusing on clear and open communication (even if this means telling students we do not have the answers), realizing that education will be different and that we may need to triage to protect the most important parts of our curricula, and being creative and open to new methods of teaching, we can hopefully make 2021 a smoother year.

Shaishav Datta,¹ Wafa Khoja,² Meera Dalal-Burns ³

¹Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; ²School of Medicine, Queen’s University, Ontario, Canada; ³St. Michael’s Hospital, Ontario, Canada.

Compassion and empathy are integral qualities in a good physician. Empathy is a multidimensional construct conveyed through verbal and non-verbal expressions, such as sustained eye contact, careful listening, embodied experience, and tactile contact.¹ Both the quality of clinical communication with patients and patient wellbeing are improved when patients interact with physicians whom they perceive as empathetic.^1,2 Thus, a physician’s ability to build a strong, therapeutic relationship is grounded in their repertoire of non-verbal skills. But how are these skills taught? While the vast majority of our medical curriculum is knowledge-based, clinical conversation skills are developed through practice and experience during clinical skills teaching sessions. Among other challenges raised by the COVID-19 pandemic, pre-clerkship medical students lacked some of their only opportunities to learn the critical nuances of the art of effective communication with patients during the 2020-2021 academic year. While we have established creative ways to take most of our learning online, pre-clerkship medical students may be missing crucial experiences to develop skills at the very core of what makes a good physician.

Now third-year students across the country experienced an abrupt end to in-person clinical skills sessions beginning in March 2020, while many now second-year students had their very first patient interactions over video-conferencing platforms. As we learned the skills of expressing appropriate empathy, it has been difficult in many ways to display these multidimensional emotions through a two-dimensional screen. Even for those of us who have had experience with patient interactions in the past, we have noticed a stark increase in awkwardness in learners as well as Standardized Patients (SPs). Non-verbal actions that display empathy, such as touch, were no longer possible and left many of us unable and untrained on how to express empathy. It was challenging to read the intricacies of body language and create a welcoming and comfortable environment online, particularly when technological difficulties occur.

Below we provide some of our experiences as first- and second-year medical students in Ontario during the 2020-2021 academic year.

During one of our few in-person clinical skills teaching sessions, I recall instinctively placing my hand on the shoulder of the SP while adjusting my stethoscope to listen for the mitral valve. After the examination finished, the SP remarked: “Of all the things you did during this session, I really appreciate you placing your hand on my shoulder during the physical exam. It made me feel comfortable and showed that you care about me.” This taught me a valuable lesson about the importance of touch in providing empathetic care. While it seemed so natural in person, this is a difficult skill to learn or practice over virtual sessions. – Wafa Khoja

I recall a virtual session on ‘How to break bad news’ with an SP. Throughout our heartfelt conversation in which I told them about their terminal illness, I kept thinking to myself how I wished I could have held their hand or passed them a tissue box. Even though this was a simulated experience, I walked away shocked at the restraints that virtual platforms placed on my ability to deliver empathetic care. I especially found it difficult to gauge the patient’s emotions and read their body language through the screen, and as a result it became very hard to connect on a deeper, more humanistic level. – Shaishav Datta

Over time, as virtual care becomes the norm and we focus more on verbal communication, will we lose our ability to communicate non-verbally? Even now, as my classmates assess their SPs virtually, our communication styles are notably different from our senior colleagues. How will the under practiced skills of eye contact, body language, and reassuring gestures affect current pre-clerkship students in our upcoming training; clerkship and onwards?

Unfortunately, this concern regarding virtual clinical skills training is widespread. A December 2020 survey of second-year medical students at the University of Toronto showed that more than 50% of students did not feel that they had the necessary clinical skills needed to start clerkship.³ This feeling of unpreparedness was directly attributed to the virtual clinical skills curriculum due to COVID-19.³ Many expressed concerns regarding the skills they lacked relating to clinical encounters with patients, including expressions of empathy and compassion.

What is in store for this COVID-19 generation of physicians and how does it affect the profession as a whole? Non-verbal skills are mastered through practice and as an ensemble, comprise the underpinnings of a competent physician in the 21st century. They are qualities actively sought out by admissions committees that are now being omitted from teaching curricula because of the limitations of virtual medicine. During the COVID-19 pandemic, pre-clerkship students have been wholly excluded from in-person clinical settings for public-health reasons. Our lack of experience with expression of these emotions and the current way in which we are learning to communicate effectively through virtual means is likely to make the transition to clerkship difficult and uncomfortable for us and the patients we encounter. While we will hopefully recover and build these skills over the course of our training, it is prudent to consider the extent to which these forms of communication are being undervalued in virtual teaching.

We are grateful that medical school faculties have tried to provide pre-clerkship students with the best possible teaching and skills while adhering to public-health guidelines during the pandemic. Some schools adopted creative and expedited methods to deliver clinical skills training to students. For example, the University of Toronto offered an expedited preparation for clerkship “bootcamp” for current second-year students during the summer of 2021. Alternatively, Queen’s University created a system to permit limited in-person clinical skills sessions within small groups. Schools in other provinces across the country also developed strategies that are in compliance with the COVID-19 guidelines in their respective locations. Despite this, we ask you to consider: Is this enough? Will vastly online clinical skills training affect the ability of current pre-clerkship students to competently maneuver clerkship, residency, and future career? These are important questions that we as a medical community must consider to be potential side effects of the COVID-19 pandemic and must answer to prepare for future pandemics.

References

1. Kelly M, Svrcek C, King N, Scherpbier A, Dornan T. Embodying empathy: a phenomenological study of physician touch. Med Educ. 2020;52(5):400-407. https://doi.org/10.1111/medu.14040
2. Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions. Br J Gen Pract. 2013;63(609):e283-e290. https://doi.org/10.3399/bjgp13X665251
3. Kao J, Chan T. COVID FAQ Survey: A Review of Student Responses [unpublished data]. Toronto (ON): University of Toronto; 2020.

Ricky Tsang,¹ Bailey Burrell¹

¹Faculty of Medicine, University of British Columbia, British Columbia, Canada

The emergence of COVID-19 has forced medical schools to adapt and re-imagine the delivery of curricular activities. Almost overnight, medical schools transitioned away from traditional, in-person instruction in favour of remote teaching to comply with public health orders. Digital technologies became paramount for the delivery of curricular activities and student assessment was no exception. Virtual Objective Structured Clinical Examinations (vOSCE) were developed and implemented at a rapid pace for the assessment of clinical skills.^1,2 Thus far, they have been met with positive feedback from students and examiners.

Some studies posit that vOSCEs represent the future of clinical skills assessment. Proposed benefits include time and cost savings, adaptability and scalability, and comparability in scores between in-person and virtual examinations.² Others maintain that in-person OSCEs remain the gold standard and should be reinstated once public health orders are lifted.¹ We certainly agree that vOSCEs have merit in assessing history taking, counselling, and associated soft skills – the virtual platform lends itself well to their assessment. Our exposure to virtual care through primary care placements has reinforced the importance of developing these virtual care skills in an era where COVID-19 has catalyzed the growth of telemedicine. During the early stages of the pandemic, telemedicine represented between 38-77% of ambulatory visits in Australia, Canada, and the United States, and while reliance on this modality has declined with the relaxation of public health restrictions, use of telemedicine is projected to remain well above pre-COVID-19 levels.³ If it is the mandate of medical schools to train their students as well-rounded generalists, then developing and assessing their skills to conduct telemedicine-based, virtual patient encounters would appear indispensable as telemedicine is poised to remain integral to primary care in the post-pandemic world. This is also consistent with the eHealth-oriented CanMEDS competencies addendums proposed by the CanMEDS eHealth 2015 Expert Working Group, which suggest that the Medical Expert should be able to, “adopt a variety of information and communication technologies to deliver patient-centred care and provide expert consultation to diverse populations in a variety of settings.”⁴

Conversely, we believe the assessment of physical examination skills is ill-suited for the virtual format. Physical examination requires complex psychomotor skills and sensorimotor integration. Consider, for example, how impractical it would be to examine a baker’s capabilities through a virtual demonstration of their skill, without the opportunity to touch, smell, or taste their craft. Similarly, clinical skills are the “bread and butter” of a physician’s work and rely on aspects of the physical world that cannot currently be conveyed through a screen with any comparable degree of concision. Such an examination is neither practical nor feasible when assessed virtually, save for brief screening manoeuvres. That is why, when conducting telehealth appointments, physicians must recognize the limits of the appointment and arrange for in-person follow-up when necessary.⁵ Simply put, elements of a physical exam are lost when conducted virtually, and you cannot assess that which you have made impossible for students to perform. Likewise, students will be unable to receive feedback on important physical exam manoeuvres, many of which involve sensory feedback and nuance.

In an era where the physical examination is being eschewed in favour of medical technology that is increasingly relied upon for assessment and diagnosis, it becomes imperative to faithfully teach and assess physical examination skills to ensure future clinicians have robust competence in this dying art. The horse must remain in front of the cart – at least until the automobile that is medical technology becomes robust enough to replace it completely. Perhaps the solution in the meantime is one of compromise; the creation of hybrid OSCEs, one where in-person stations are utilized to assess the lion’s share of skills but are thoughtfully supplemented by virtual stations to assess the full spectrum of clinical skills required of the modern physician. It seems vital to us that physical exams remain physical, but that students are taught to incorporate the expanding number of options available to them for patient interaction.

Certainly, we do not mean to disparage the extraordinary efforts of medical schools that have adapted vOSCEs out of necessity and with great haste. The COVID-19 pandemic has affected life in a seemingly endless number of ways and forced the innovation of new paths forward. Perhaps too, it has catalyzed a new dawn in clinical skills assessment, one where physical and virtual skills are treated and examined as independent entities, but considered no less important than one another for the comprehensive education of a physician.

References

1. Boyle JG, Colquhoun I, Noonan Z, McDowall S, Walters MR, Leach J. Viva la VOSCE? BMC Medical Educ, 2020; 20. https://doi.org/10.1186/s12909-020-02444-3
2. Lara S, Foster CW, Hawks M, Montgomery M. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. Acad Pediatr, 2020; 20(6): 760–761. https://doi.org/10.1016/j.acap.2020.05.029
3. Mehrotra A, Bhatia RS, Snoswell CL. Paying for telemedicine after the pandemic. JAMA, 2021: 325(5): 431-432. https://doi:10.1001/jama.2020.25706
4. Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth expert working group report [Internet]. 2014. Available from: https://www.royalcollege.ca/rcsite/documents/canmeds/health-advocate-ewg-report-e.pdf [Accessed May 13, 2021].
5. College of Physicians and Surgeons of British Columbia. Practice standard: telemedicine. 2020. Available from: https://www.cpsbc.ca/files/pdf/PSG-Telemedicine.pdf [Accessed May 13, 2021].

Aman Dhaliwal,¹ Karlee Searle,¹ Danielle Martin^1,2

¹Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; ²Department of Family and Community Medicine, Women’s College Hospital. Ontario Canada

Globally, the COVID-19 pandemic has overwhelmed health care systems in an unprecedented way. There are far-reaching impacts, including in medical education.

In Canada, the increase in clinical demands led to changes in health care infrastructure, requiring physicians, residents, and senior medical students to step into new roles. This “all-hands-on-deck” approach was essential to pandemic response but has tended not to include junior (pre-clerk) medical students. How do we best utilize the skills of junior medical students in a pandemic or emergency situation when the existing frameworks do not accommodate this?

Junior medical students face a dilemma: they are well-equipped with the key attributes to become successful physicians but lack the necessary clinical skills to serve a meaningful role on the frontlines. In response, and despite a lack of official guidance, many junior medical students have forged their own role in supporting the community through various student-led initiatives. This experience has lessons to teach about how the medical student community can be marshalled in future emergency response initiatives.

As the COVID-19 pandemic progressed, it became evident that junior medical students had a strong desire to participate in pandemic relief measures. Despite the limited scope of their clinical abilities, Canadian medical students rapidly began uniting to establish community supports on a voluntary basis. Across Canada, over 150 student-led initiatives were started to assist the community and support frontline workers through the pandemic.¹ Many of these initiatives shed light on the inequities faced by marginalized individuals in the pandemic and worked to mobilize community resources to better support these groups. For example, the COVID-19 Women’s Initiative focused on supporting women and gender minorities who experienced an increase in intimate partner violence during lockdown conditions in Canada. This group raised $30,000 and collected over 22,000 items for 35 women’s shelters across Canada in six months.² Other junior medical student initiatives focused on partnering with seniors to address senior isolation, sourcing personal protective equipment, and assisting frontline workers with life tasks such as grocery shopping and child care.³ Undeterred by their inability to help on the frontlines, these students banded together to make a powerful impact in their communities. 

These medical student-led initiatives required students to augment and practise the CanMEDs competencies of advocacy, communication, collaboration, and leadership.⁴ Although the health advocate role is a core role of the CanMEDs competency framework, integrating health advocacy into medical school curricula has been challenging.⁵ One of many reasons for this may be time constraints with respect to teaching, illustrating, and responding to the social determinants of health.⁶ During the COVID-19 pandemic, time constraints for many pre-clerkship medical students were eased as curriculum requirements were either cancelled or moved to an online format. This may have opened up space for students to, in essence, build their own advocacy curriculum.

Medical programs that provide voluntary learning opportunities to work with underserved and marginalized groups allow students to better understand the social determinants that result in health disparities, as well as the ways in which health advocacy can be practically applied.⁷ These skills turned out to be important for short-term relief during a pandemic, and likely also for the long-term development of these future physicians.

While there are guidelines for ways that senior medical students can contribute to reducing the effects of the pandemic directly, there is a lack of guidance around the contributions of junior medical students. We propose three ways by which Canadian medical schools can facilitate junior medical student community involvement in pandemic and emergency situations.

First, medical schools can provide education and training to students regarding the wide range of non-clinical needs of a population during pandemics and other emergencies. Integrating disaster training into medical school curricula will increase student preparedness and improve knowledge and skills prior to a disaster.⁸ This training could point out the capabilities of junior medical students (as well as other junior trainees across nursing and health disciplines), to increase their sense of agency in disaster response.

Second, medical schools could provide curriculum flexibility in a pandemic or other emergency situation to allow students to engage in voluntary community support initiatives. Junior medical students who have been given the time and flexibility to pursue professional endeavours outside of the core curriculum exhibit increased productivity and sustained interest in their topic of choice.⁹ Furthermore, this flexibility alleviates the time constraints, which frequently act as a barrier to medical student engagement in advocacy work.

Lastly, a unified approach to the role of the junior medical student as part of “whole system response” can promote community engagement to all Canadian junior medical students. Current CFMS guidelines include a role for a pandemic response for senior medical students but neglect to provide a role for junior medical students. Further statements and guidance from national medical education bodies on Disaster Management Plans should expand their guidelines so that Canadian medical schools can prepare junior medical students to be active participants, living up to their full potential as people with time, energy, and a commitment to the health of their communities.¹⁰

Junior medical students are an untapped resource during emergencies like pandemics when the societal need for effectively diverting resources is at its greatest. We have a shared opportunity to further explore the ways in which junior medical students’ skills can be translated into meaningful community engagement during an emergency situation, and to accommodate this into established medical education frameworks. 

References

1. Lu K, Schellenberg J. COVID-19 updates [Internet]. Canadian Federation of Medical Students. Available from: https://www.cfms.org/who-we-are/covid-19
2. Parsons C. U of T med students assist women’s shelters during COVID-19 [Internet]. Faculty of Medicine. 2020. Available from: https://md.utoronto.ca/news/u-t-med-students-assist-womens-shelters-during-covid-19
3. Bowden, S. COVID-19: Canadian medical students ready to step up. Univ Tor Med J. 2020;97(3):e8-e11.
4. CanMEDS: Better standards, better physicians, better care. CanMEDS Framework. The Royal College of Physicians and Surgeons of Canada. Available from: https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
5. Hubinette M, Ajjawi R, Dharamsi S. Family Physician Preceptors’ Conceptualizations of Health Advocacy, Implications for Medical Education. Acad Med. 2014;89(11):e1502-e1509. https://doi.org/10.1097/ACM.0000000000000479
6. Hancher-Rauch H, Gebru Y, Carson A. Health advocacy for busy professionals: effective advocacy with little time. Health Promot. 2019;20(4):489-493. https://doi.org/10.1177/1524839919830927
7. Borouman S, Stein M, Jay M, Shen J, Hirsh M, Dharamsi S. Addressing the health advocate role in medical education. BMC Med Ed. 2020;20(1). http://doi.org/10.1186/s12909-020-1938-7
8. Earnest M, Wong S, Frederico S. Perspective: Physician advocacy: what is it and how do we do It? Acad Med. 2010;85(1):63-67. https://doi.org/10.1097/ACM.0b013e3181c40d40
9. Peacock J, Grande J. A flexible, preclinical, medical school curriculum increases student academic productivity and the desire to conduct future research. Biochem Mol Biol Educ. 2015;43(5):384-390. http://doi.org.10.1002/bmb.20875
10. Cfms.org. 2021. [Internet] Available from: https://www.cfms.org/files/position-papers/2015%20CFMS%20Disaster%20Management.pdf

Malcolm M MacFarlane¹

¹Volunteer, Society of Canadians Studying Medicine Abroad (SOCASMA), Ontario, Canada

Back in April 2020, at the beginning of the pandemic, International Medical Graduates (IMGs) offered their services in the fight against COVID-19.¹ Despite this offer, few IMGs have been inducted into the battle,^{2, 3} and hospitals and Long-Term Care homes continue to struggle with staff shortages.⁴

In an effort to assess continuing IMG interest in assisting with the pandemic in Ontario, the Society of Canadians Studying Medicine Abroad (SOCASMA) informally surveyed its members.

In less than a week, a total of 63 responses were received; 83% of respondents were resident in Canada, 63% were in Ontario, 92% of respondents were ready and willing to go to work in Ontario as Supportive Physicians and in other roles, and 43% of respondents indicate they would be glad to accept work in other provinces.

This potential workforce is well qualified with 92% already graduated from medical school; half of them having graduated in the past five years. A total of 62% are currently licensed to practice medicine in other countries, and 56% have practiced medicine in the past five years.

Why are we not making use of this valuable resource? Indeed, why does this valuable resource continue to be marginalized in the CaRMS (Canadian Residency Matching Service) residency match? Despite all applicants, including IMGs, being Canadian citizens or permanent residents, in 2020 about 2,000 IMGs⁵ were streamed to only about 325 IMG positions⁶ resulting in about a 16% match rate, while there were more residency positions for 3,000 Canadian medical graduates than there were applicants.⁷ In the 2020 Match, about 1,400 qualified IMGs who have demonstrated competence through objective examinations went unmatched, their skills and talents lost to Canadian society.⁷

A BC human rights complaint alleges that this is systemic discrimination based on place of origin. The SOCASMA survey lends some support to this argument. A total of 49% of respondents identified themselves as being visible minorities, 10% reported they were not visible minorities, and 40% did not respond. However, other indications suggest that many of the 40% who did not respond may well be invisible minorities so that up to 90% of IMG respondents may be visible or invisible minorities.

When we are struggling with a pandemic that has killed over 26,000 Canadians to date,⁸ when there is a humanitarian crisis in our long-term care homes,⁴ when five million Canadians are without a primary care provider when existing health care providers are rapidly becoming exhausted and ill themselves, it is shameful that we are ignoring and marginalizing the valuable resource that IMGs represent.

As the Canadian Medical Association’s recent Policy on Equity and Diversity in Medicine⁹ states, it is time to open “the conversation to include the voices and knowledge of those who have historically been underrepresented and/or marginalized” and to ensure “that everyone has equal and inherent worth, has the right to be valued and respected, and to be treated with dignity.” “Equity in the medical profession is achieved when every person has the opportunity to realize their full potential to create and sustain a career without being unfairly impeded by discrimination or any other characteristic-related bias or barrier.”

Excellent words! It is past time we in Canada were true to the values of equity we espouse.

References

1. Villan M. ‘We want to join this fight’: immigrant physicians make plea to serve on front lines of Covid-19.  CTV News, April 30, 2020 Available: https://calgary.ctvnews.ca/mobile/we-want-to-join-this-fight-immigrant-physicians-make-plea-to-serve-on-front-lines-of-covid-19-1.4881919 [Accessed June 17, 2021].
2. Atlin J. Covid-19 and Canada’s underutilized internationally educated health professionals. World Education News and Reviews, October 29, 2020. Available: https://wenr.wes.org/2020/10/covid-19-and-canadas-underutilized-internationally-educated-health-professionals [Accessed June 17, 2021].
3. Desai D. Where are Ontario’s internationally trained doctors in its Covid-19 response? National Post, February 8, 2021. Available: https://nationalpost.com/news/where-are-the-internationally-trained-medical-professionals-in-ontarios-pandemic-response [Accessed June 17, 2021].
4. Casey L. ‘We still have an acute staffing shortage,’ Ontario’s long-term care commission hears. Global News, October 16, 2020. Available: https://globalnews.ca/news/7400847/ontario-long-term-care-homes-staffing-shortages-coronavirus/ [Accessed June 17, 2021].
5. 2020R-1 Main Residency Match – first iteration Table6: Applicant pool by school of graduation. CaRMS. Available: https://www.carms.ca/wp-content/uploads/2020/05/2020_r1_tbl6e.pdf [Accessed June 17, 2021].
6. 2020R-1MainResidencyMatch-first iteration Table14: Dedicated quota offered to IMG applicants by discipline. CaRMS  Available:  2020_r1_tbl14e.pdf (carms.ca) [Accessed June 17, 2021].
7. 2020R-1 Main Residency Match Table1: Summary of match results.  CaRMS. Available: 2020_r1_tbl1e.pdf (carms.ca) [Accessed June 17, 2021].
8. Government of Canada. Covid-19 daily epidemiology update Government of Canada. Available: COVID-19 daily epidemiology update – Canada.ca [Accessed June 17, 2021].
9. Equity and diversity in medicine. Canadian Medical Association. December 2019. Available: https://policybase.cma.ca/en/viewer?file=%2fdocuments%2fPolicyPDF%2fPD20-02.pdf#phrase=false [Accessed June 17, 2021].

Neel Mistry,¹ Paul Rooprai,¹ Stefan de Laplante,¹

¹Faculty of Medicine, University of Ottawa, Ontario, Canada

Telemedicine has grown substantially since the advent of the COVID-19 pandemic. As global cases surged in March 2020, hospitals and primary care clinics quickly turned to telemedicine – the provision of medical care using telecommunication technology over a virtual platform – to increase access to safe and effective patient care.¹ Among US medical schools, an increase in telemedicine training in clerkship has been reported over the last five years.^2,3 In contrast, only one medical school in Canada includes a formal telemedicine program in the undergraduate medical curriculum.⁴ As COVID-19 cases continue to surge across the country, the need for medical trainees to achieve competence in telemedicine is crucial. In this paper, we provide an overview of the benefits and challenges of formalizing telemedicine training and discuss steps that Canadian medical schools can take to successfully implement this change.

The future of healthcare

Telemedicine is not yet formalized in the undergraduate curriculum at most Canadian medical schools and very few include it in post-graduate training. In stark contrast, over 25% of US medical schools include telemedicine training in pre-clerkship, and nearly half offer mandatory sessions in clerkship.² Recently, Wayne State University conducted a pilot study in which third-year medical students were introduced to telemedicine during their core internal medicine rotation.² The results were encouraging, with 95% of clerks acknowledging the importance of virtual care services and more than 80% considering it to significantly affect their future practice.² Similar findings were reported at Harvard Medical School, which instigated telemedicine training in clerkship at the start of this pandemic.⁵ Why, then, is Canada lagging behind when there are just as many reasons, if not more, to promote virtual care as there are south of the border?

An early introduction to telemedicine and virtual care provides multiple educational advantages to medical trainees. Aside from contributing to core competencies in patient care, clinical knowledge, and practice-based learning, it also fosters a greater sense of familiarity, preparing students for a practice where telemedicine is used and may be growing. This can be done in multiple ways. First, asynchronous learning can occur by creating videos that demonstrate how to perform physical exams virtually and allowing clerks to shadow their attending physician via video. Second, visiting electives that were originally suspended for the 2020-2021 cycle can still take place in a virtual format. This would allow students to diversify their clinical experience and, at the same time, help them decide which institution they would like to attend for post-graduate training. Finally, telemedicine can be included in core clerkship rotations such as family medicine, internal medicine, and surgery. Doing so would provide students with opportunities for independent practice while experiencing an array of topics including ethical dilemma, telemedicine-based cases, teleassessments, and procedural skills.

A call to action

The COVID-19 pandemic has instigated unprecedented change across healthcare settings. With hospitals and clinics rapidly shifting to virtual care, a few undergraduate medical programs have begun to implement virtual care; however, training must be formalized across all Canadian medical schools. An early introduction to virtual care offers numerous benefits to trainees as the use of telemedicine grows. This can be done in three main ways: (1) incorporating virtual shadowing opportunities, (2) re-instituting visiting electives via a virtual format, and (3) integrating students into virtual patient consults during clinical rotations. With COVID-19 accelerating the adoption of telemedicine, the need to prepare future doctors to deliver care virtually has never been greater.

References

1. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 2020; 20:1193. https://doi.org/10.1186/s12889-020-09301-4
2. Waseh S, Dicker AP. Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review. JMIR Med Educ. 2019;5(1): e12515. https://doi.org/10.2196/12515
3. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and Medical Education in the Age of COVID-19. Europe PMC. 2020; 95(12):1838-1843. https://doi.org/10.1097/acm.0000000000003711
4. Aires LM, Finley JP. Telemedicine activity at a Canadian university medical school and its teaching hospitals. J Telemed Telecare. 2000;6(1):31-35. https://doi.org/10.1258/1357633001933916
5. The Harvard Gazette. The mother of invention, 2020 [Internet]. Available from: https://news.harvard.edu/gazette/story/2020/05/harvard-medical-school-uses-telemedicine-as-a-way-forward/ [Accessed December 30, 2020].