The medical school curriculum was already on the verge of change. Then came COVID-19.
By Christina Hernandez Sherwood
October 2020. On the rooftop patio of the Jordan Medical Education Center (JMEC), the fleshy sedum plants are flashing their pink and yellow autumn blooms. The days are growing shorter; it’s fall and a new academic year is well underway at the Perelman School of Medicine. But this is 2020, and as is true in just about every other aspect of life these days, medical school doesn’t look quite the same as it did a year ago.
The earthquake that is COVID-19 rocked the ground on which modern medical education was built. Gone are the learning teams reviewing flash cards late into the night in the bright JMEC atrium. Gone are the pre-clerkship students hurrying after the physicians they’re shadowing in the clinic. Gone are clusters of clerkship students huddled around a patient’s bedside. But after the dust cleared, certain foundational principles of training to be a doctor today — collaborating with a team, prioritizing wellness, adopting technology, and embracing adaptability — still stand. As medical education is rebuilt around these foundational principles, the structure will remain familiar while the particulars are permanently altered.
“Going through the upheaval of the last year has forced us to shift our approach to medical education unexpectedly, necessarily, and quickly, leading us to innovate in ways we’re still learning from,” said Suzanne Rose, MD, MSEd, Perelman’s senior vice dean for medical education. “We committed every step of the way to tell our students that though the process is different, our goal was for the result to be even better. We’re going to help students be the best prepared physicians they can be.”
Players in Place for the Changing Game
Rose stepped into the senior vice dean role in February 2018, following the tenure of Gail Morrison, MD’71, GME’76, and just over a year later established a diverse leadership team of both new and familiar faces. Longtime academic programs stalwart Anna Delaney, MBA, is chief operating officer. Associate deans are Nadia Bennett, MD, MSEd’18, and Dennis Dlugos, MD, MSCE’02, sharing the curriculum role; Horace DeLisser, MD’85, heading diversity and inclusion; Judy Shea, PhD, in research and assessment; and Neha Vapiwala, MD’01, running admissions. In a newly created position, Jennifer Kogan, MD’95, serves as associate dean for student success and professional development. DaCarla Albright, MD, joined the team in July 2020 to lead student affairs and wellness.
After settling into their roles, the undergraduate medical education leadership team convened last winter for a one-day retreat to develop their playbook. By the end of the day of goal setting and strategic planning, they had renewed their investment in preserving Perelman’s top strengths: team-facilitated learning, flexibility, diversity, and the long legacy of Penn Medicine. They decided to kick off their efforts to reach their ambitious goals — including advancing technology in medical education, encouraging earlier clinical encounters for students, and engaging in more active formats of pedagogy — in eight weeks’ time.
Six weeks later, things changed, all over the world.
It was early March. First-year medical student Jeromy Gotschall was leading a student group on an educational Spring Break trip in Cuba when he received word the University of Pennsylvania had moved classes online for the remainder of the semester and asked students not to return to campus. “Everything escalated tremendously,” he said. Leaving Cuba, Gotschall headed to his family’s home in Wisconsin.
Back in Philadelphia, Rose had recently returned from a meeting in Florida and had noticed several people on her return flight wearing face masks. She soon began hearing from clinical faculty who were concerned about the safety of medical students on rotations in hospitals when national supply chain issues with personal protective equipment were becoming apparent. “That was a really quick transformation,” Rose said.
There was no national guidance at the time for how to handle medical students in clinical rotations. But Penn’s decision was swift. At 11:39 a.m., on the morning of Friday, March 13, Rose sent an email blast to the entire student body with the urgent message: Clinical rotations will be suspended at noon.
Building the New Playbook
By Monday, March 16, Rose and her team, who initially hoped the clinical hiatus for students would last two weeks, began planning for a whole new vision of medical school for a longer term. They dove into designing a new clinical curriculum that met the same goals and objectives, on the same timeline, but was entirely remote. “It was basically deconstructing the clerkship year and the sub-internship year,” said Bennett, associate dean for clinical and health systems science curriculum, “and seeing how we could put back in its core components...in a virtual manner.”
The first step was to develop dozens of virtual electives — there were zero before — for clerkship students who needed clinical experience to graduate, but couldn’t enter a hospital, said Kogan, the associate dean for student success and professional development who took the lead on developing the elective program. To do this, she leaned on teams of administrators, faculty, and students, who took a larger role in the curriculum development process than ever before. Unlike faculty who had jumped into action to care for COVID-19 patients or scale up telehealth infrastructure, Kogan said, students had time, and many had an interest in future careers as medical educators. And, she said, it made sense to involve students in creating courses they would be taking in a matter of days. “For me having learners participate in the development of curriculum alongside faculty was valuable,” Kogan said, “and a helpful learner-centered approach to thinking about medical education.”
Jeremy Jones, then a third-year student, helped create an elective that let students provide virtual clinical care to hospitalized patients. “We were able to — from our house — help clinical teams and help our classmates feel like they were actually moving forward in their clinical training,” Jones said. A survey of the students who took the course, Virtual Clinical Support, found that taking the elective increased their confidence in writing discharge summaries to 4.4 out of 5, from 2.5. Pediatrics faculty and residents later ran a similar course supporting clinical teams at Children’s Hospital of Philadelphia, in which Jones, who plans to specialize in pediatrics, enrolled.
Meanwhile, administrative staff were working nights and weekends to move academic programs online. Throughout the spring, Rose and her team worked to ensure the quick pivot to virtual electives didn’t cause any accreditation problems. They kept students apprised of these and other updates through virtual town halls, some schoolwide and others by class. To support students’ non-academic needs, the administration arranged one-on-one virtual calls between some 600 Perelman students and members of the leadership team and advisory deans.
Virtual No Longer Optional
Within weeks, Perelman’s first-year, pre-clerkship students were settling into a new, virtual routine. Though the school was advanced in using digital and virtual tools for lectures — offering online streaming and replay of recorded lectures for more than 15 years — it was no longer optional. The quarter of the class who attended lectures in person before the pandemic no longer could, and learning teams now met exclusively online, said Dlugos, associate dean for science and discovery curriculum. But for the most part, he said, “the pre-clerkship curriculum was nicely positioned to pivot.”
Clerkship students — unable to be in the hospitals for the final seven weeks of the spring semester — enrolled in the virtual electives newly created with their classmates’ input, mostly two-week courses in fields including surgery, dermatology, radiology and anesthesia. With more than 40 virtual electives to choose from, students could learn about antibiotic stewardship, take a deep dive into palliative care, earn a certificate in quality improvement, or study culinary medicine.
One elective, Research During COVID-19, enabled medical students to earn academic credit for pandemic-related work. Christina Bax, then a third-year medical student who had returned home to Maryland in March, began working with her father, Adriaan Bax, PhD, a chemical physicist at the National Institutes of Health. The younger Bax, who had been researching autoimmune skin diseases in Philadelphia pre-pandemic, helped her father’s team design experiments on the role of speech droplets in COVID-19 transmission, publish their results in journals including the New England Journal of Medicine and The Lancet, and translate the findings into videos for the public at a crucial time when the airborne spread of the virus was considered uncertain and contentious. “[The medical school] made it so accessible for students to become involved [in COVID-19 work] and have it count,” she said. “With a lot of medicine you can’t just completely switch focus so quickly and so easily.”
Clinical Learning from a Safe Distance
Rose and her team never counted on virtual electives as a long-term replacement for medical students’ clinical rotations; they were always a stopgap measure. “During your elective year, most of the learning is experiential, doing specialty rotations in the hospital with patients,” Kogan said.
By June, with COVID-19 cases trending downward and personal protective equipment widely available, it was time to reinstate those clinical experiences. Instead of sending hundreds of clerkship students back at once, the leadership team began with a pilot of about two dozen students in sub-internships, which are post-clerkship rotations with increased responsibilities similar to those of a first-year resident. “We made sure it was safe, but we wanted to start with a small group,” Bennett said. “The goal was to make sure everything was in place for them.”
Fourth-year student Hannah Schwennesen, on her sub-internship at Children’s Hospital of Philadelphia, said she found the integration of COVID-19 protocols to be seamless. New physical distancing guidelines and personal protective equipment requirements quickly felt normal. But the pandemic did impact Schwennesen’s patient care experience. As a medical student, she was not able to be part of the teams treating patients who were positive or suspected for COVID-19.
Sarah Santucci, a fourth-year on her sub-internship at Pennsylvania Hospital, said the biggest change was having to keep a distance from the attending physician and residents on her team. Packed bedside rounding sessions were replaced with socially distant table rounds. Lunches in the residents’ lounge were swapped for outdoor meals, where a resident picked up a big group take-out order and students and residents grabbed containers and dispersed to their individual benches to socialize from a safe distance. “It was still a great bonding experience,” she said, “but it was just not the same.”
After a smooth pilot and hundreds of negative COVID-19 tests, some 300 clerkship and sub-internship students returned to the clinic on July 6. And just as educational leaders had adapted nimbly to a changed environment, it was clear that the clinical workforce had lessons to share about their own nimble transformations. Sophia Yapalater, then a third-year student, was struck by how doctors on her gynecology-oncology sub-internship adapted to COVID-19 visitation restrictions to help families reunite quickly. Patients wanted more time with their families than the hospital could allow, Yapalater said, so doctors made extra efforts to speed their discharge. “It was remarkable how the teams had integrated that understanding into how they were taking care of people,” she said. “I think [the pandemic has] forced us all to learn more of that adaptability that we’ll need throughout our careers.”
Helping Hands in the Pandemic
At the same time that the curriculum was being reimagined, Cindy Christian, MD, assistant dean of community engagement, set out to channel medical students’ volunteer efforts to safe avenues. Shutdown rules and social distancing had limited or closed off their usual opportunities, yet the desire to make a positive impact and help in the unfolding crisis had grown that much stronger. “Imagine that you’re a medical student and there’s a huge pandemic,” she said. “They don’t have all the necessary skills, but they have lots of skills and they wanted to help in some way.” Christian reached out to the Penn Medicine community with a simple ask: How can our students help you? She was inundated with hundreds of replies, detailing opportunities in research laboratories, in clinical settings, and throughout Philadelphia’s communities.
Heart Health Bridge to Care, a clinic for diabetes and hypertension patients, transitioned to virtual care to continue providing essential monitoring and medication. The clinic mailed patients blood pressure cuffs, checked in with them by phone, and supplied their medications through a partnership with the Hospital of the University of Pennsylvania pharmacy. “It has been a time for us to plan, reevaluate and restructure,” said second-year medical student David Hsu, the clinic’s leader. This reimagining of the clinic has worked so well, Hsu said, that when its doors eventually reopen, stable patients will likely continue to be monitored virtually.
Just as medical education leaders found that involving students in planning the new curriculum was key to delivering on what they needed, so too did student leaders engaged with members of the community. The United Community Clinic in the West Philadelphia Parkside neighborhood — where pre-clerkship medical students often get their first experiences interacting with patients — paused its operations in March. As the pandemic raged through the spring, the clinic’s student volunteers initiated countless conversations with community members, establishing connections and strengthening partnerships in the process, said Amanda Gottschalk, then a first-year medical student co-running the clinic with classmate John Connolly. Parkside residents were interested in personal protective equipment, so the students assembled and distributed thousands of “COVID Survival Kits,” which included masks and hand sanitizer. With funding support from the Penn Medicine CAREs grant program and other sources, they continued distributing the kits into the pandemic’s second peak in the late fall and winter.
“COVID, especially being in the community clinic space, has laid bare the huge health disparities that are prevalent in our country,” Gottschalk said. “Seeing that has shaped my trajectory as a future physician, to be an advocate for my patients, for the community, for the population that I’m serving. I don’t think I would have said that in that exact way [last] January.”
In the elective, entitled Service Learning During COVID-19, students earned academic credit for their volunteer work while learning the principles of service learning. One community service project, dubbed One Extra Bag, involved students buying and delivering groceries to homebound geriatric patients when food shopping was fraught at the height of the pandemic.
Third-year Sophia Yapalater volunteered with a virtual visitation program to provide emotional and communication support to families of critically ill, hospitalized patients. Later, she attended a Zoom funeral for one of her patients and wrote about the virtual visitation experience in the Annals of Internal Medicine. After witnessing so much suffering and loss from this vantage point on the pandemic, Yapalater decided to specialize in internal medicine with a subspecialty in critical care. The pandemic’s hardships are an experience no one would wish for, she said, “but that program helped me figure out what I want to do with my life.”
Back to (Virtual) School Season
Before COVID-19, orientation week for the incoming class at the Perelman School of Medicine was a whirlwind of hands-on experience coupled with a crash course in team building with 150 new classmates. For the class of 2024, however, the live program had to be transitioned to a fully virtual experience. To reimagine the student-centered aspects of the program, Christian, the assistant dean of community engagement, recruited second-year medical students whose summer plans had been disrupted by the pandemic. The rationale echoed the planning behind the new virtual electives in the spring: “We do our best work,” Christian said, “when we partner with our students, who have tremendous insight and knowledge about what they need from their education.”
For new medical students, one of the most memorable moments of orientation is meeting their learning team, the small group of other first-years who will be their core study partners in the coming months. But how could incoming students connect with these vitally important participants in their medical education when everyone was a disembodied face on a computer screen? The solution, it turned out, was to ramp up the silliness factor. Zoe Ruhl, Lina Ibrahim and Jeromy Gotschall, now in their second year, dreamed up this creative approach.
On the first evening of orientation, the new first-years entered a video call with their entire house — made up of about six learning teams — dressed in a themed costume, such as a pirate or an organ system (this is medical school, after all) or a vegetable. Find your fellow produce, they were told, and you’ve found your learning team. “We just wanted to increase the engagement and adrenaline, even if students were a little embarrassed,” Ibrahim said. “You're letting go of your pride a little bit and saying, ‘Hey, we're all in this together.’”
It could be easy for new students to fall through the cracks this year when the already challenging transition to medical school is compounded by the isolation of the pandemic, Albright, the associate dean for student affairs and wellness, pointed out. She has introduced students to the resources on the digital platform for mental health and support, Penn COBALT; connected them with academic resilience groups; and reminded them they are colleagues, not competitors. “[I’ve tried to] help students understand that you don’t have to be absolutely 100 percent perfect to make it through medical school,” she said.
The New Normal
The fall semester at Perelman has shaped up to be an amalgamation of the former ways of medical school before COVID-19 and the new norms established at the height of the spring shutdown. Pre-clerkship students chose fully remote schooling or a hybrid option that allows them to attend some class sessions in person, but at a physical distance.
While the cadaver laboratory was temporarily struck from the curriculum, first-year students did gather in small groups at the medical school for two hands-on ultrasound practice sessions this fall. While serving as an ultrasound teaching assistant, fourth-year student Sarah Santucci said she was struck by how prepared the first-years were for the hour-long sessions. “All the prep they had done was virtual and yet they were able to get in there and do an awesome job,” she said. “They were so excited about getting some actual hands-on experience.”
Second-year students, despite being unable to shadow doctors in the hospital or volunteer with patients, got some unique in-person clinical skills practice before their January clerkships. In an effort to prevent the spread of COVID-19, traditional standardized patients from the local community were eschewed in favor of Penn physicians, residents and senior medical students who took their place serving as actor patients, also known as patient instructors. “I’ve really benefited a lot from that,” said David Hsu. “We’re able to get very unique feedback in terms of how we’re supposed to approach asking patient history and what is appropriate from an experienced provider’s point of view.”
With greater flexibility in students’ mostly virtual fall schedules, Christian said she moved forward on a long-term goal to expand cross-school integration of community-focused programs. Medical students joined their peers in other health care-related programs, such as nursing and public health, for virtual evening sessions on community health. “It’s something we had been thinking about and working toward for a long time,” Christian said. “We got to accelerate things a little bit.”
Still, the sheer volume of virtual offerings for pre-clerkship students can cause a real-life headache. First-year Love Osunnuga is one of several course representatives who take student feedback to weekly meetings with faculty and administration. Early in the semester, Osunnuga and other representatives pushed for adjustments to students’ virtual schedules, successfully advocating for more breaks away from the screen to combat “Zoom fatigue.”
Clerkship students are back on hospital rotations, but some elements of the spring’s virtual electives remain. Students might take a virtual elective if, for instance, they need to quarantine for two weeks after a trip away from campus. Some of the new virtual electives that have not continued have instead been repurposed as coaching tools or other forms of learning support.
Fourth-year students spent the fall in an unprecedented, and delayed, residency application process. While interviewing for residency virtually is saving them thousands in travel costs, the process is rife with challenges. How do you look professional on a video call from your bedroom? Fourth-year student Jennifer Wineke’s solution: wear a suit jacket and angle the camera away from your bed. The school has also provided dedicated space for professional backgrounds and reliable internet for the fourth year interviewees as an answer to this challenge. How do you get a sense of the residency program without seeing it firsthand? Attend the program’s virtual Happy Hour, Wineke said, and watch how current residents interact. How do you make your ranking decision, sight unseen, in January? Review your interview notes, talk to medical school friends and, as Jeremy Jones put it, hope for a “blast of clarity.”
Never Going Back
It has been almost a year since the COVID-19 pandemic forced a rapid rethinking of medical education. But its impact could last decades or more. “Education is forever changed — I don’t think we’ll ever go back,” Rose said. “Before we do something, let’s ask a question about how we did it before. Was that better than what we transitioned to? Is there a different way? There’s an opportunity now to ask those questions about everything.”
January 2021 marked the start of a new clerkship year at the Perelman School of Medicine, and second-year students have stepped into a revamped program, shaped both by pre-COVID feedback and post-COVID learnings. Instead of interrupting rotations for intermittent classroom instruction, now each 12-week clerkship block begins with two weeks of inter-session training. This schedule change has the added benefits of providing didactic content up front and giving students time to bond as a class throughout the busy rotation experience, said Bennett, associate dean for the clinical curriculum. “COVID forced us to do things quickly. Now we have some time to...create an optimal curriculum on our terms that takes the best of the COVID curriculum in ways that may actually solve issues that arose pre-COVID.”
Also in the works before COVID: more student involvement in curriculum. A new governance committee for undergraduate medical education comprised of faculty and students convened in November after being deferred from its planned start in March. (Its chair, Keith Hamilton, MD, an associate professor of Infectious Diseases, was on the front lines of the clinical response to COVID-19.) Complementing this initiative — both to support input into the curriculum and to facilitate communication between different student groups — students led by third-year Olivia Oldridge created a structured Student Curriculum Council which has met monthly since August. Students have also pulled up seats at the (virtual) tables of a number of other committees for Rose’s leadership team.
COVID-19 compelled an overhaul of medical education that would have been unthinkable pre-pandemic. But why, Albright asked, should we stop innovating now? “We have potential where we may not have considered it prior,” she said. “That may create greater agility in learning, even for some of us who remember what it was like to take notes while somebody was writing on a chalkboard.”
Despite the stresses of COVID-19, first-year student Maurizio Porco said he optimistically sees himself as part of a crucial moment that could impact medical education forever — and his class’s pandemic-era education as an opportunity. “It’s a challenge we have that no one else has gone through,” he said. “If something like that ever presents again...we know how to respond.”
Albright agreed, adding that this COVID-19 cohort of medical students will use their unparalleled experience to advance not only their own education, but also the health care profession in ways that have yet to be imagined. Can we push the use of technology — already ramped up by the pandemic — even further to enable earlier interactions between pre-clerkship students and patients, for instance? What efficiency improvements for electronic health records might tech-savvy students dream up if we let them? “They’re the students who are really going to turn medicine on its tail,” she said, “in a good way.”