Making medical education COVID-19-resilient
The team transformed the clinical exam stations to comply with the then-current COVID-19 safety guidelines
In February, Dr Sabina Sayeed had one more clinical posting left. It offered a last chance to practise her clinical skills before completing her four-year Doctor of Medicine (MD) programme at Duke-NUS. But just as Sayeed started her final posting, Singapore raised its outbreak response alert to orange. At orange, clinical spaces were closed to medical students for everyone’s safety.
“I was disappointed at not being able to engage in hands-on clinical learning. Still, I was thankful that our safety was prioritised,” said Sayeed.
The pandemic did not just disrupt students’ learning. Their final exams, too, were thrown into doubt. While many medical schools around the world graduated their final-year students without exams, that was never an option at Duke-NUS. Both the Ministry of Health and the School wanted final-year students to demonstrate proof of their clinical competence at graduation.
Within a month, the clinical exam stations were amended, safety measures introduced and the flow of students and examiners transformed to meet the necessary restrictions. Stringent hygiene practices and strict socially distanced segregation minimised the risk of infection. Students, patients and examiners were cohorted for the duration of the exams.
“Being cohorted into small groups was certainly different!” said Sayeed. But she was glad that the exams went ahead as the process reassured her that she had the necessary knowledge, skills and capabilities needed to start work as a competent, safe and confident junior doctor.
But it was not just assessments that had to be reconfigured because of the pandemic. Across the years, the MD curriculum was adjusted to ensure that students’ learning would not be compromised and that they would remain on track to graduate on time.
“It has been an outstanding effort from our entire team, who demonstrated great resilience, agility and responded nimbly to the ever-changing COVID-19 situation. I would also like to thank and praise the students for their stoicism, forbearance and ability to adapt to these significant challenges,” said Professor Ian Curran, Vice-Dean for Education at Duke-NUS.
“This collective ‘can do’ spirit has allowed us to stay on track with our training and assessments to ensure that the future pipeline of new doctors for Singapore is secure and to demonstrate that academic and professional standards are being maintained by our graduates.”
Going virtual for recruitment and admissions
While going virtual was not an option for the final-year exams, the School turned to Skype, Zoom and other video conferencing platforms to select the latest cohort. Applicants’ Day, which is key to Duke-NUS’ admissions process, had to change from a full day of in-person assessments to virtual assessments.
The traditional programme gave applicants a flavour of life as Duke-NUS students and interviewers a chance to observe students’ suitability. Shifting it online meant that the School lost some elements of personal interaction, according to Professor London Lucien Ooi, Associate Dean for Admissions, Recruitment & Financial Aid.
“[But] some of these changes brought about positive benefits. With the interviews held via Zoom, the timings were more flexible and we had the advantage of having senior clinicians join the interviews to better assess our candidates,” said Ooi, who would previously travel the globe to meet and interview prospective students.
First year students attend an introductory session to prepare them for TeamLEAD
What started as an interim solution is set to stay as the pandemic shows no signs of abating. Suitable students applying for a place in the 2021 intake will be invited for interviews and to participate in the new virtual Applicants’ Days. So far, this does not seem to have affected passionate individuals from applying to Duke-NUS. As of September, Duke-NUS has received two thirds more applications than last year.
“We are considering how to adopt some of these virtual practices to provide a more holistic assessment of applicants [even beyond the pandemic],” said Ooi.
Lessons go into the cloud while restructuring aims to maximise clinic time
For then-first year student Marco Lizwan Goh, the closure of wards had no immediate impact on his learning. The limits to in-person class activities, however, meant that his classroom lessons had to be reconfigured.
“At first, we tried splitting the students across two venues, but we realised very quickly that this did not work educationally and we rapidly moved the whole process to online learning via Zoom,” said Curran.
As an international student living by himself, the online learning scenario seemed lonelier to Goh at first. He missed eating lunch with his classmates and playing quick games of table football between lessons.
“So we came up with various creative ideas such as online Zoom lunches to still be able to have such interactions,” he said.
Goh and his friends have a virtual team lunch
Curran said that from an academic point of view, the shift had no discernible impact on student learning. All first-year students passed their exams.
When the hospitals and clinics closed to students in February, the School had to pivot rapidly. Having recently restructured the curriculum to increase clinical postings to 93 weeks in total, the School was keen to protect that hands-on clinical time for students. To do that, the education leadership team made bold changes, bringing forward the mandatory research project for students then in year two. Similarly, after completing their first year in June, the new year two students similarly embarked on their research block.
These changes allowed the deferment of students’ clinical training to a time when “clinical service has normalised and clinical training can resume without restriction,” said Curran. Students need to successfully complete all clinical training to graduate.
In Goh’s view, not being able to take on a clinical research project is a small price to pay. “I appreciate that we can do research first because that means we will be having uninterrupted clinical years!” he said.
For his senior, now a year three student, Nurul Ain Binte Rejap, the change to her schedule did not impact her choice of research project as she had already made plans.
“I had it sorted before my research year started, so my choices were not affected,” said Ain who will evaluate the Emergency Medicine-related myResponder mobile application.
“The amount of changes we need to adapt to was challenging at times. Though there were hiccups here and there, the School has done their best to deal with this unprecedented situation,” she added.
Overcoming physical restrictions to enable students to flourish
As if transforming the traditional Objective Structured Clinical Examinations into COVID-19-safe stations was not enough of a challenge, the assessments team also had to devise a set of supplementary exams that would comply with the even stricter requirements in place during Singapore’s circuit breaker measure.
“That was tricky because we had stations where they had to do procedures. So, the students had to come in and demonstrate their practical skills on manikins,” said Associate Professor Kathy Boursicot, Associate Dean for Assessment and Progression.
To ensure that all aspects of students’ clinical competence could be assessed, a simulated patient, usually a trained actor playing the role of the patient, was also in the exam room.
“It is often the [professional] interaction with the patients that leads students to fail such stations, so we had to find a way to keep that critical part of the assessment,” said Boursicot, adding that students did not touch the simulated patient and performed their skills on manikins instead.
For their safety, the students, simulated patients and key staff all complied with strict hygiene and safety requirements. Examiners, whose judgement was critical in ensuring that the required clinical standards were met, observed the students’ performances remotely via video link.
To tackle that challenge, the team fitted each station with two cameras that allowed the examiners to observe the student as well as the simulated patient’s reaction. At the end, the examiners would switch on their cameras and ask the student specific questions to explain their actions and reasoning.
The team has published two key case studies — “Conducting a high-stakes OSCE in a COVID-19 environment” published in March and “Managing the COVID-19 risk: the practicalities of delivering high stakes OSCEs during a pandemic” published in August — that detailed their hard-won practical experiences. These publications and the pioneering approaches that they described have attracted much attention from an international academic community that faced similar challenges.
“Our primary focus throughout this entire and unprecedented crisis has been to keep everyone safe — our patients, our students, our staff and faculty. We have also prioritised our efforts on protecting and enhancing our clinical learning to ensure that as a school, we continue to nurture mature, patient-centred, resilient, compassionate young doctors and human beings, who have humility and humanity, [are] grounded in a strong basis in medical science [and have] a wealth of clinical expertise and experience that, ultimately, they can bring to benefit patients and serve Singapore with distinction,” said Curran.
Curran added, “And despite all the challenges and the restrictions of this pandemic, we’ve been able to demonstrate that we are continuing to do that effectively and moreover share what we’ve learnt so that others around the world can benefit too.”