World Journal of

WJ C C Clinical Cases
Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2020 August 6; 8(15): 3136-3141

DOI: 10.12998/wjcc.v8.i15.3136 ISSN 2307-8960 (online)

OPINION REVIEW

Impacts and challenges of United States medical students during the

COVID-19 pandemic

Stacey Rolak, Alexis M Keefe, Emily L Davidson, Prabesh Aryal, Sandesh Parajuli

ORCID number: Stacey Rolak 0000- Stacey Rolak, Alexis M Keefe, Emily L Davidson, Department of Medicine, University of
0002-8402-7096; Alexis M Keefe Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
0000-0001-6631-2937; Emily L
Davidson 0000-0001-8109-1423; Prabesh Aryal, College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu
Prabesh Aryal 0000-0003-2448-0363; 44600, Nepal
Sandesh Parajuli 0000-0003-1667-
7465. Sandesh Parajuli, Division of Nephrology, Department of Internal Medicine, University of
Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
Author contributions: Parajuli S
and Rolak S contributed to study Corresponding author: Stacey Rolak, BSc, Department of Medicine, University of Wisconsin
concept and design; Keefe AM, School of Medicine and Public Health, No. 1685 Highland Avenue, Madison, WI 53705,
Parajuli S and Rolak S wrote the United States. [email protected]
paper; Davidson EL and Aryal P
contributed to the figure.
Abstract
Conflict-of-interest statement: The
authors declare no conflict of
The delivery of medical student education has changed rapidly during the
coronavirus disease 2019 (COVID-19) pandemic. Students in their pre-clinical
interests.
years have transitioned to online courses and examinations. Students in their
Open-Access: This article is an clinical years are not permitted on clinical rotations, and face uncertainties in
open-access article that was career exploration and the residency application process. Medical students in all
selected by an in-house editor and stages of training are volunteering and helping their communities. The future
fully peer-reviewed by external presence of COVID-19 throughout the United States is unknown, and medical
reviewers. It is distributed in students are eager to return to their training. This paper outlines current
accordance with the Creative challenges in medical student education and the various responses that have been
Commons Attribution adopted. We also discuss possible future directions for students through
NonCommercial (CC BY-NC 4.0) involvement in telemedicine, outpatient clinic visits, and non-respiratory
license, which permits others to inpatient care tasks as adequate personal protective equipment, COVID-19
distribute, remix, adapt, build testing, and resources become more widely available.
upon this work non-commercially,
and license their derivative works Key words: COVID-19; Education; Medical students; Telemedicine; Healthcare delivery;
on different terms, provided the Schools
original work is properly cited and
the use is non-commercial. See: htt ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
p://creativecommons.org/licenses
/by-nc/4.0/
Core tip: The coronavirus disease 2019 pandemic has temporarily changed medical student
Manuscript source: Invited education. Continuous reassessment of clinical policies and guidelines is paramount in
manuscript guiding medical education back to normalcy. Improved access to personal protective

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 Rolak S et al. Medical students in COVID-19

Received: May 8, 2020

equipment, testing, and safety resources should allow medical students to regain their roles
Peer-review started: May 11, 2020 on medical teams. Further integration of telemedicine into school curricula could help
First decision: June 15, 2020 mitigate educational disruptions during the ongoing pandemic.
Revised: June 22, 2020
Accepted: July 23, 2020
Article in press: July 23, 2020 Citation: Rolak S, Keefe AM, Davidson EL, Aryal P, Parajuli S. Impacts and challenges of
United States medical students during the COVID-19 pandemic. World J Clin Cases 2020;
Published online: August 6, 2020
8(15): 3136-3141
P-Reviewer: Ulhaq ZS URL: https://www.wjgnet.com/2307-8960/full/v8/i15/3136.htm
S-Editor: Zhang L DOI: https://dx.doi.org/10.12998/wjcc.v8.i15.3136
L-Editor: A
E-Editor: Xing YX

INTRODUCTION
The emergence of the coronavirus disease 2019 (COVID-19) has placed immense strain
on healthcare, economic, and social systems globally. Social distancing practices have
been adopted in attempts to “flatten the curve” of the virus to protect the health of the
public and preserve healthcare resources. Multiple sectors of society have rapidly
adjusted to new technologies and communication modalities to remain operational.
Healthcare specifically has been hit particularly hard, with nation-wide shortages of
personal protective equipment (PPE), workforce shortages, and high risk of disease
transmission. Consequently, the emergence of COVID-19 in the United States has
heavily disrupted undergraduate medical education in all stages of training. This
opinion review will elucidate how COVID-19 has disrupted traditional medical
education, outline a variety of medical student responses to the pandemic, and discuss
the potential roles of medical students in the future.

COVID-19 AND TRADITIONAL UNDERGRADUATE MEDICAL EDUCATION

Medical student education in the United States has historically been structured as two
years of pre-clinical coursework, followed by two years of clinical training. During the
pre-clinical years, students learn the basic sciences, anatomy, pharmacology, and begin
practicing basic clinical skills. During the clinical years, students rotate through
different core clerkships, including pediatrics, internal medicine, surgery, neurology,
and obstetrics and gynecology, and participate in elective rotations. Many schools are
adopting innovative curricula with 12-18 mo of basic sciences, followed by 12 mo of
core clerkships, and 12-18 mo of individualized learning to explore different careers
through advanced clinical rotations, scholarly projects, sub-internships, and audition
rotations at different institutions[1,2]. COVID-19 has altered medical education at each
of the pre-clinical, core clerkship, and advanced career exploration stages[3].
As COVID-19 spread throughout the United States, the Association of American
Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME), two
governing organizations on medical student education and school accreditation,
published general recommendations for student education. For students in their pre-
clinical years, the AAMC recommended that each school guide their own education
delivery based on institutional policies and public health guidelines. Many schools
have implemented changes to protect students, faculty, and standardized patients, as
summarized in Figure 1. For students in their core clinical rotations or advanced
clinical rotations, recommendations have been even more varied, and the disruption of
education during this crucial time of career exploration has been stressful for many.
On March 17, 2020 the AAMC first suggested that medical schools temporarily
suspend clinical rotations. More recent recommendations suggest that unless there is a
critical healthcare workforce need locally, medical students should refrain from direct
patient care activities. They outline PPE restrictions and limited availability of COVID-
19 testing as reasons for this suggestion. Without these resources, it will be difficult to
resume providing clinical experiences to medical students.
LCME guidance stated that in preparing for future rotations, schools could shorten
their core clerkship lengths. Their standards do not support a complete clerkship being
taught online; however, they posit that it is acceptable for some course content to be
delivered virtually. Each school has been adapting differently to provide relevant
online coursework in lieu of in-person clerkships, and are adjusting how they will
format clerkships in the future[3]. Some of these adjustments are highlighted in

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Rolak S et al. Medical students in COVID-19

Figure 1 Education changes due to coronavirus disease 2019. Changes to board examinations, pre-clinical learning, core clinical rotations, and
advanced career exploratory clinical rotations during the coronavirus disease 2019 pandemic. COVID-19: Coronavirus disease 2019.

Figure 1.
In addition to these coursework changes, the ability to take the United States
Medical Licensing Exams (USMLE) was interrupted with the temporary closure of
Prometric Testing Centers, our nation’s proctoring sites for USMLE Step 1 and Step 2
Clinical Knowledge. Step 2 Clinical Skills, which requires interactions with
standardized patients, was also suspended, and on May 26th the USMLE announced
that the exam would continue to be suspended for the next 12-18 mo. It is generally
recommended to complete Step 1 and Step 2 Clinical Knowledge before residency
application season in the fall of students’ fourth year. There has been no
comprehensive national guidance on how testing delays will affect residency
applications or graduation, though the USMLE governing board has been pursuing
and implementing alternative test delivery options on medical school campuses.
Some medical students set to begin their internships in June of 2020 have graduated
early to bolster the healthcare workforce in areas most affected by COVID-19. The
LCME guided this transition. While some students geared up to begin their residencies
early, Match Day celebrations and graduation ceremonies were cancelled and held
virtually throughout the country.

BARRIERS TO MEDICAL STUDENT CLINICAL EDUCATION

Medical students receive their clinical education through preceptorships and
clerkships at teaching institutions. As these experiences cannot be readily delivered
virtually, students in their core clinical rotations and advanced clinical rotations are
most tangibly affected by the current medical education changes. Medical students are
considered non-essential in the delivery of clinical care, and require attending
physician supervision of their work. Students may potentially act as vectors of viral
transmission between different patients and personnel, and may be asymptomatic
carriers, although further research on viral epidemiology is needed to determine this
risk. These limitations, combined with medical institutional adaptations to COVID-19,
have made it difficult to strike a balance of providing supervised learning
opportunities to students.
As medical systems face furloughs and provider and administrative salary cuts,
there may not be sufficient faculty and resident availability for medical student

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 Rolak S et al. Medical students in COVID-19

teaching and supervision. Non-COVID-19 related emergency room visits and general
medicine admissions for non-COVID-19 problems have purportedly decreased at
some institutions. There is also limited capacity for medical students to be involved on
procedural and surgical rotations, given limited PPE and fewer elective cases being
performed. The adequacy of administrative staff to schedule and facilitate student
learners through their rotations also varies by institution and discipline, and is another
factor precluding medical student participation in the clinical environment.
Many health systems have transitioned to telemedicine visits for both inpatient and
outpatient visits in light of social distancing[4-6]. Telemedicine has been adopted to
triage and manage suspected COVID-19 patients, as well as outpatient non-COVID-19
patients, to ensure continuity of care for patients. Telemedicine is important in
reducing face-to-face contact between healthcare practitioners and patients, reducing
the risk for viral transmission, and eliminating the need for travel to visits. More
widespread use of telemedicine is a great adaptation to COVID-19, though there are
limitations to its use, including administrative and regulatory barriers to telemedicine
between institutions, and payment discrepancies between telemedicine and in-person
services[7]. Because direct contact is not required in telemedicine, one would think that
it is a system that medical students could readily be involved in. There has recently
been increased integration of telemedicine-based lectures, clinical cases, and case
studies in medical education[8]. The 2015-2016 LCME Annual Medical School
Questionnaire showed that over 25% of Medical Doctor programs have implemented
some component of telemedicine training into their pre-clinical education, and over
50% have integrated telemedicine education into the clerkship phase[8]. However, it is
not heavily emphasized in many curriculums, and medical students report low
confidence in utilizing telemedicine efficiently[8]. Therefore, more training is needed to
make this a viable option for students, and this is an option that should be explored in
the future.

MEDICAL STUDENT RESPONSES TO COVID-19

Amidst the turmoil of COVID-19, medical students in all stages of training have
demonstrated a true commitment to service by mobilizing to help their communities.
Some of these actions are highlighted in Figure 2. At Harvard Medical School, students
created a COVID-19 Medical Student Response Team for medical and community
education and activism, to efficiently mobilize students in the COVID-19 response[9].
Medical students at a variety of institutions throughout the United States are
volunteering at equipment donation centers, food drives, providing childcare for
medical personnel, and grocery shopping and running errands for residents and
physicians. Some students are using telecommunications to translate patient visits.
Others are involved in supervised telemedicine visits, such as virtual prenatal health
visits. The ingenuity and altruism of students in creating ways to help and mobilize
resources is remarkable. The prevailing sentiment is that medical students want to be
helpful and prepared for the future.
Some medical students have disagreed with the AAMC recommendations that
medical student involvement in patient care should be reserved for critical healthcare
personnel shortages[10]. They highlight the accurate point that medical students can
help with routine outpatient telemedicine visits by interviewing patients and
documenting their histories; following up with patients on lab and test results; and
assisting with patient education. They also argue that medical students can help with
daily hospital inpatient tasks for non-COVID patients that don’t require PPE. This is
all recognized within the need for student and patient safety[10].
As current third year medical students, we acknowledge and appreciate that staying
at home was a necessary precaution for us during this emerging pandemic, given the
current barriers to our education and safety, and the rapid changes required of the
healthcare system. However, as healthcare delivery adapts and we brace for the
possibility of a continuous presence and resurgence of COVID-19, governing
educational bodies and teaching institutions must be proactive in reinstating our
clinical roles in order to ensure that the future physicians of the United States receive
high-quality education. We want to have secure and equal opportunities to learn and
explore our career goals.

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Rolak S et al. Medical students in COVID-19

Figure 2 Medical student responses to coronavirus disease 2019. Medical student responses during the coronavirus disease 2019 pandemic. COVID-
19: Coronavirus disease 2019.

FUTURE INVOLVEMENT OF MEDICAL STUDENTS

There are many questions regarding how long COVID-19 will continue to interrupt
medical education. Since much is unknown about the future of the disease, a
contingency plan must be set in place so our education will not be so heavily
perturbed in the future. Students in their clinical years of medical school are overall
eager to resume their clinical rotations. Some options for future medical student
involvement are summarized in Figure 2.
As access to PPE and supervision improve, students should have the opportunity to
return to critical learning experiences. With these resources available, the historical
roles of medical students as part of the healthcare team should not change. Medical
students in their clinical years positively contribute to patient care by obtaining
medical histories, initiating documentation, and communicating with patients, family
members, and consulting services. As health systems phase in elective and non-urgent
surgical procedures and in-person visits, students should be able to return to these
learning environments as well. Additionally, pre-clinical students can be reinstated to
in-person clinical skills sessions to build their framework for the approach to physical
exams and histories.
We recognize that some students have personal health concerns or objections to
participating in clinical care at this time. Students should not be coerced to participate
in potentially unsafe situations, and it may be necessary for medical schools to adopt
no-consequence opt out policies for students in certain medical settings such as caring
for patients with respiratory complaints or in intensive care units. Medical students
are adult learners with the decision-making capacity to participate in patient care, and
we argue that these opportunities should, at the very least, be available to us.
As continued social distancing will likely be required barring the development of a
vaccine and widespread testing, alternative avenues must be explored to maintain
student involvement in clinical activities. As mentioned previously, implementation of
a telemedicine curriculum would be beneficial, and could include proper virtual
etiquette and remote physical exam skills. Training future physicians on how to utilize
this technology would continue the momentum that COVID-19 has kickstarted. Like
any other clinical training, this too would require physician supervision, but is
especially advantageous in allowing for non-contact clinical experiences during
COVID-19 and beyond.
Medical students have demonstrated professionalism, dedication to the field,
compassion, and humanism in their efforts to engage with communities and support
residents and physicians during this COVID-19 pandemic. We are the future of the

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 Rolak S et al. Medical students in COVID-19

healthcare workforce and have clinical skills to offer to medical teams, and arguably
should be involved in learning to care for patients during a pandemic, as we will be on
the frontlines in the future. Many of us are eager to return to “normal” life to continue
learning medicine and serving others. Overcoming the logistical barriers to achieve
this transition will require continuous adaptation and resilience from medical
institutions, educators, and students alike.

CONCLUSION
We have addressed many uncertainties surrounding COVID-19. For student and
population safety, valuable clinical experiences have understandably been traded for
temporary online coursework, leaving much unknown about the transition back to in-
person training and clinical clerkships. Across the nation, medical students continue to
engage with the communities that they will serve as physicians. Teaching institutions
have quickly evolved to deliver an online curriculum to best meet the needs of their
student learners. As testing, personal protective equipment, and information about
virus epidemiology become more available, medical students are eager to return to
their studies and contribute as members of their healthcare teams. As long as options
are available to students and safety is protected, we believe that students should be
welcomed back to doing what they want to do most–learn medicine. Specific policy
adjustments concerning clinical care, along with an implementation of telemedicine
curriculum, will help transition students safely back to the bedside.

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