The Role of Medical Students During the COVID-19 Pandemic

Ideas and Opinions7 April 2020The Role of Medical Students During the COVID-19 PandemicFREEDavid Gibbes Miller, MSc, Leah Pierson, BA, and Samuel Doernberg, BADavid Gibbes Miller, MScPerelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (D.G.M.)Search for more papers by this author, Leah Pierson, BAHarvard Medical School, Boston, Massachusetts (L.P., S.D.)Search for more papers by this author, and Samuel Doernberg, BAHarvard Medical School, Boston, Massachusetts (L.P., S.D.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1281 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Coronavirus disease 2019 (COVID-19) has upended medical education. Owing to widespread uncertainty and disagreement about the appropriate roles for medical students during a pandemic, student participation in clinical care has varied across institutions. Some schools forbid any patient interaction, whereas others have recruited students for hospital-based roles or even graduated medical students early so that they can serve as frontline clinicians (1–3). The American Association of Medical Colleges (AAMC) has instructed medical schools to suspend student clerkships and has recommended that “unless there is a critical health care workforce need locally, we strongly suggest that medical students not be involved in any direct patient care activities” (4, 5). We disagree with the AAMC that medical student involvement should be reserved for critical health care personnel shortages. Rather, medical schools should offer students clinical opportunities that would benefit patient care and potentially help to prevent workforce shortages.Traditional Roles of the Medical StudentThe AAMC frames its guidance by highlighting that “medical students are students, not employees… They are not yet MDs” (5). Although true, this framing fails to acknowledge that medical students have roles not only as learners, but also as clinicians-in-training. The primary role of medical students is to learn medicine. However, students are also clinicians who care for patients. They interview patients, call consults, respond to pages, communicate with families, write notes, assist with procedures, and help with care coordination and discharge planning.During the COVID-19 pandemic, medical students acting solely as learners introduce unnecessary risks for patients and other clinicians. Medical students can act as additional vectors for viral transmission, consume personal protective equipment (PPE)—of which there are serious shortages (6)—and place additional burden on teaching physicians. Medical education alone does not justify these risks.However, allowing medical students to serve in clinical roles may benefit patients overall. There is precedent for this kind of involvement. During the Spanish flu outbreak of 1918, medical students at the University of Pennsylvania cared for patients in the capacity of physicians (7). In a 1952 polio epidemic in Denmark, groups of medical students were tasked with manually ventilating patients (8). In the current pandemic, medical schools in the United States, Italy, and the United Kingdom are graduating medical students early on the condition that they serve as frontline clinicians (3, 9).The health care system should not wait until it reaches a breaking point to invite medical students to serve. Medical students are adept at many clinical roles. Allowing them to serve may improve patient care long before the health care system reaches a personnel crisis, and in some cases may even help prevent such crises from occurring. In this article, we suggest several roles for medical students to play in offsetting the burdens caused by COVID-19.Clinical Roles for Medical Students During the COVID-19 PandemicWe presume that the AAMC's guidelines stem primarily from concerns about the risks for infection to patients and students, PPE shortages, and associated liability issues. These risks undoubtedly warrant careful consideration, but they can be mitigated. We believe that allowing students to perform clinical tasks may, in specific instances, confer benefits to patients that outweigh the risks associated with students' involvement.First, medical students can assist with routine outpatient clinical care. Medical students can boost the efficiency of lightly staffed clinics by taking histories, calling patients with laboratory test results, providing patient education, documenting visits, and fielding questions about COVID-19 (2). Even in a pandemic, patients with chronic conditions need ongoing care. Pregnant women need routine check-ins, and discharged patients require follow-up. Many of these tasks can be performed via telemedicine, so there would be no risk for infectious transmission.Second, students can provide care on inpatient services that do not have patients with COVID-19. Under the supervision of senior residents or attending physicians, advanced medical students (“subinterns”) usually carry their own patients. In the absence of medical students, these patients would need to be covered by house officers, potentially exacerbating the personnel shortage about which the AAMC is concerned. Although this form of involvement would require appropriate PPE, staffing hospital services with upper-level students could maximize the availability of other clinicians to treat patients with COVID-19.If students are permitted to work in hospitals, they would be at increased personal risk from severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). However, students are also at increased risk for contracting SARS-CoV-2 while screening visitors entering hospitals, hosting PPE drives, and providing childcare for physicians, all of which they are already being deployed to do, and some of which require PPE (2). In addition, the risks incurred from student involvement may be lower than the risks to retired clinician volunteers, who are more susceptible to complications of COVID-19 owing to their age (10). However, given that the personal risks cannot be eliminated, we agree with the AAMC (5) that any in-person involvement of medical students should be voluntary.Finally, medical students can remotely assist in the care of patients with COVID-19. They can monitor patients with mild COVID-19 symptoms who are not admitted; expedite care for admitted patients by reviewing charts, drafting notes, and ensuring tests are performed; and follow-up with patients after discharge. Although all of the roles we have discussed would require physician supervision, they would reduce the overall burden on clinical teams. We believe they would, on balance, improve patient care.In conclusion, as medical schools decide how to proceed in the time of COVID-19, we are wary of attempts to shelter students from voluntary service. Medical students are clinicians who have responsibilities to patients and who should be allowed to fulfill their duties as such. In addition to the benefits to patients and the health care system, allowing students to participate reinforces important values, such as altruism, service in times of crisis, and solidarity with the profession. Students are willing and able to fight in this historic pandemic and should be given the opportunity to do so.References1. Farber ON. Medical students can help combat Covid-19. Don't send them home. STAT. 14 March 2020. Accessed at www.statnews.com/2020/03/14/medical-students-can-help-combat-covid-19 on 20 March 2020. Google Scholar2. Krieger P, Goodnough A. Medical students, sidelined for now, find new ways to fight coronavirus. The New York Times. 23 March 2020. Accessed at www.nytimes.com/2020/03/23/health/medical-students-coronavirus.html on 23 March 2020. Google Scholar3. Teeman T. ‘This is what we signed up for': meet the med school grads fast-tracked to the coronavirus front line. Daily Beast. 3 April 2020. Accessed at www.thedailybeast.com/medical-school-graduates-fast-tracked-to-the-coronavirus-front-line-say-this-is-what-we-signed-up-for on 4 April 2020. Google Scholar4. Whelan A, Prescott J, Young G, et al. Guidance on medical students' clinical participation: effective immediately. Association of American Medical Colleges. 17 March 2020. Accessed at https://lcme.org/wp-content/uploads/filebase/March-17-2020-Guidance-on-Mediical-Students-Clinical-Participation.pdf on 20 March 2020. Google Scholar5. Whelan A, Prescott J, Young G, et al. Interim guidance on medical students' participation in direct patient contact activities: principles and guidelines. Association of American Medical Colleges. 30 March 2020. Accessed at https://lcme.org/wp-content/uploads/filebase/March-30-2020-Interim-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdf on 31 March 2020. Google Scholar6. Jacobs A, Richtel M, Baker M. ‘At war with no ammo': doctors say shortage of protective gear is dire. The New York Times. 19 March 2020. Accessed at www.nytimes.com/2020/03/19/health/coronavirus-masks-shortage.html on 25 March 2020. Google Scholar7. Starr I. Influenza in 1918: recollections of the epidemic in Philadelphia. 1976. Ann Intern Med. 2006;145:138-40. [PMID: 16801626] LinkGoogle Scholar8. West JB. The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology. J Appl Physiol (1985). 2005;99:424-432. [PMID: 16020437] CrossrefMedlineGoogle Scholar9. Goldberg E. Early graduation could send medical students to virus front lines. The New York Times. 26 March 2020. Accessed at www.nytimes.com/2020/03/26/health/coronavirus-medical-students-graduation.html on 4 April 2020. Google Scholar10. Murthy S, Gomersall CD, Fowler RA. Care for critically ill patients with COVID-19. JAMA. 11 March 2020. [Epub ahead of print]. [PMID: 32159735] doi:10.1001/jama.2020.3633 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Michele A. Riva, MD, PhD, Maria E. Paladino, MD, Michael Belingheri, MDSchool of Medicine and Surgery, University of Milano-Bicocca14 April 2020 Ethical consideration on the role of medical students in During the COVID-19 Pandemic TO THE EDITOR: We read the paper by Miller et al. on the role of medical students during the COVID-19 pandemic with interest (1). The paper reported the position of American Association of Medical Colleges (AAMC) that recommended suspending student clerkships during outbreak. The authors disagree with the AAMC position, suggesting medical schools to offer students clinical opportunities. In the paper, the authors reported several benefits of this choice to the patients and the healthcare system. In our country, Italy, more than 16,000 HCWs have tested positive for COVID-19 and at least 110 physicians have died after contracting coronavirus, confirming the high risk of healthcare professionals (2). The Decrees and Regulations, adopted by the Italian Government in the last weeks, have initially permitted healthcare student clerkships. Despite this position, most Italian medical schools have not allowed students to work in the wards, and this decision was shared by most hospitals, despite a shortage of workforce. Therefore, recently, the Italian Government partially modified its position, decreeing that student clerkship could be taken remotely. We do not believe that medical students are clinicians with duties, as stated by the authors of the papers. We agree with the position of AAMC that “current medical students are students, not employees” (3). In our opinion, the authors of the paper did not report any important consideration regarding the role of students in the pandemic. Firstly, some students live together with their family and they could not afford to live alone. Alongside concerns for their personal safety, medical students could be anxious about passing the infection to elderly parents, grandparents or young siblings. Secondly, we still do not know the long-term effects of COVID-19. We are wondering whether it is ethical to expose a young person to a disease whose effects we do not fully know. Medical profession requires a psychophysical integrity that could be damaged by the infection, compromising the future career of the students. Indeed, it should be considered that any disability of the student could affect the progression to graduation. Moreover, the risk of post-traumatic stress is high, therefore a psychological support should be guaranteed to the students. Finally, we think that the historical examples reported by the authors (Spanish flu in 1918, polio epidemic in 1952) are outdated by a modern conception of medical education, which does not consider students as simple workforce into the hospital. Michele A. Riva, MD, PhD, Maria E. Paladino, MD, Michael Belingheri, MD School of Medicine and Surgery, University of Milano-Bicocca Monza, Italy References 1. Miller DG, Pierson L, Doernberg S. The Role of Medical Students During the COVID-19 Pandemic. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M20-1281. 2. Belingheri M, Paladino ME, Riva MA. Beyond the assistance: additional exposure situations to COVID-19 for healthcare workers. J Hosp Infect. 2020 Mar 31:S0195-6701(20)30132-8. doi: 10.1016/j.jhin.2020.03.033. 3. Whelan A, Prescott J, Young G, et al. Interim guidance on medical students' participation in direct patient contact activities: principles and guidelines. Association of American Medical Colleges. 30 March 2020. Accessed at https://lcme.org/wp-content/uploads/filebase/March-30-2020-Interim-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdf on 31 March 2020 David Gibbes Miller, MSc, Leah Pierson, BA, Samuel Doernberg, BAPerelman School of Medicine at the University of Pennsylvania, Harvard Medical School22 September 2020 Authors' Response We are grateful to Riva et al for their thoughtful comments on our article.[1,2] Riva and colleagues voice concern about the risks of in-person medical student involvement during the COVID-19 pandemic. Our article identified some major risks associated with in-person medical student involvement, including the risk of viral transmission in the hospital and the consumption of scarce personal protective equipment (PPE). Riva et al highlight additional risks. Some build on the risk of viral transmission, including transmission of SARS-COV-2 to students’ families, and the unknown long-term health consequences of the virus. Others include potential psychological stressors of clinical work during a pandemic. We have several responses to the authors’ concerns. Our paper focused largely on remote clinical roles for medical students that could be widely adopted. We also suggested that advanced medical students could care only for non-COVID-19 patients, which would have minimized psychosocial and health-related risks of clinical participation. We continue to believe that the risk-benefit calculus favored involvement in these roles. It is also worth noting that some medical students were asked to volunteer in clinical settings early in the pandemic, despite the additional risks the authors proposed.[3] Moreover, we emphasized the voluntary nature of any medical student clinical involvement.[1] This stipulation provided an additional safeguard with regards to the concerns raised by Riva and colleagues, and it allowed for medical students themselves to determine the level of risk they were willing to take on. Since our article was published, it has become even safer for medical students to work in the hospital. We have more PPE, know more about transmission of SARS-COV-2, and have implemented safer infection control protocols in hospitals.[4] Consequently, medical students have largely returned to their clinical responsibilities[5] despite continued high numbers of cases across the US. Recent guidance from the AAMC highlighted the importance of continued medical education, calling medical students “the essential, emerging physician workforce,” and stating that “to address ongoing national physician workforce needs, the clinical education of our medical students… must continue, with appropriate attention to safety…”[4] We stand by our proposals for medical students’ clinical roles early in the pandemic. We are also glad to see evolving guidance from the AAMC acknowledging that medical education needs to continue, with appropriate safety precautions. We believe that medical students have roles to play in clinical settings that can benefit patients and be of educational value, all while staying safe during a pandemic. References: Miller DG, Pierson L, Doernberg S. The Role of Medical Students During the COVID-19 Pandemic. Ann Intern Med. 2020 Apr 7. doi: 10.7326/M20-1281. Riva MA, Paladino M, Belingheri M. Ethical consideration on the role of medical students in During the COVID-19 Pandemic. Ann Intern Med. Caldera CG, Ma V. Harvard Medical School, Partners HealthCare Criticized for Email Requesting Medical Student Volunteers. 22 April 2020. Accessed at: https://www.thecrimson.com/article/2020/4/22/harvard-coronavirus-medical-volunteers-criticism/ on 6 September 2020. Whelan A, Prescott J, Young G, et al. Guidance on Medical Students’ Participation in Direct In-person Patient Contact Activities. Association of American Medical Colleges. 14 August 2020. Accessed at: https://www.aamc.org/system/files/2020-08/meded-August-14-Guidance-on-Medical-Students-on-Clinical-Rotations.pdf on 3 September 2020. Weiner S. Back to Medical School During Covid-19. 11 August 2020. Accessed at: https://www.aamc.org/news-insights/back-medical-school-during-covid-19 on 6 September 2020. Author, Article, and Disclosure InformationAuthors: David Gibbes Miller, MSc; Leah Pierson, BA; Samuel Doernberg, BAAffiliations: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (D.G.M.)Harvard Medical School, Boston, Massachusetts (L.P., S.D.)Acknowledgment: The authors thank Nicholas Adamstein, Joseph Martinez, Angela Ross Perfetti, Sophia Gibert, and Nicolas Mathey-Andrews for their comments on earlier drafts of this article.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1281.Corresponding Author: David Gibbes Miller, MSc, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104.Current Author Addresses: Mr. Miller: Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104.Ms. Pierson: Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.Mr. Doernberg: Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.Author Contributions: Conception and design: D.G. Miller, L. Pierson, S.N. Doernberg.Analysis and interpretation of the data D.G. Miller, L. Pierson, S.N. Doernberg.Drafting of the article: D.G. Miller, L. Pierson, S.N. Doernberg.Critical revision for important intellectual content: D.G. Miller, L. Pierson, S.N. Doernberg.Final approval of the article: D.G. Miller, L. Pierson, S.N. Doernberg.Provision of study materials or patients: S.N. Doernberg.Statistical expertise: S.N. Doernberg.Obtaining of funding: S.N. Doernberg.Administrative, technical, or logistic support: D.G. Miller, L. Pierson, S.N. Doernberg.Collection and assembly of data: D.G. Miller, L. Pierson, S.N. Doernberg.This article was published at Annals.org on 7 April 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoFighting COVID-19: Enabling Graduating Students to Start Internship Early at Their Own Medical School Dawn E. DeWitt The Role of Medical Students During the COVID-19 Pandemic David Gibbes Miller , Leah Pierson , and Samuel Doernberg The Role of Medical Students During the COVID-19 Pandemic Michele A. Riva , Maria E. 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