Paul J. Schenarts, MD, FACS
June 1, 2020
The first case of COVID-19 in the United States was January 22, 2020, and by March 16, the country saw an exponential increase in the number of cases.1 In response to this pandemic, educational regulatory agencies, including the Association of American Medical Colleges (AAMC),2 the Liaison Committee on Medical Education (LCME),3 the United States Medical Licensing Exam (USMLE),4 the Accreditation Council for Graduate Medical Education (ACGME),5 and the American Board of Surgery (ABS)6 have all made adaptations to their specific requirements. While each organization is responsible for a specific aspect of medical education, they all share the goals of maintaining patient and learner well-being, decrease learner anxiety, safeguard educational equity of resident applicants, as well as maintain requirements for medical school graduation and residency completion that ensure patient safety.7
The purpose of this manuscript is to provide practical guidance to educators and learners about the modifications educational authorities have made in response to COVID-19.
The primary focus of these courses is learning and not patient care. Electronic and distance learning have been used for over a decade8-10 and was approved by the LCME in 2015.11 Once large gatherings are permitted, minimal impact on pre-clinical education can be anticipated.
On April 10, 2020, Prometric announced closure of all its testing centers in the U.S. and Canada. On May 1, 2020, some testing centers were reopened and all are anticipated to be opened on or around June 1, 2020.12 USMLE has agreed to automatically extend eligibility periods without requiring any action by the examinees.4 This may cause disruptions at medical schools requiring passage of this exam to proceed into the clerkship years. Further equity issues may occur due to a proportion of students having additional study time compared to others who took the exam prior to closure of the testing sites. For students who failed this exam, they may also experience a delay in retaking the exam as testing centers deal with the back log in scheduled first time exam takers.
Medical students have long cared for patients with other infectious diseases such as Human Immunodeficiency Virus (HIV) and Tuberculosis (TB). Participation in care of COVID-19 patients has posed different challenges. The rapidity of spread has led to shortages of personal protective equipment. Asymptomatic spread may result in students passing the disease to patients. Medical students are not essential health care workers, so shelter in place restrictions apply to them. Introduction of large numbers of COVID-19 patients may also significantly disrupt the variety of clinical conditions to which learners are exposed. Introduction of novice learners into a complex clinical environment may also have negative ramifications on the faculty. For these reasons, the AAMC has recommended suspending or postponing clerkships, clinical electives, away rotations, and Objective Structed Clinical Examinations (OSCEs).2, 7, 13
The LCME has provided important guidance to maintain accreditation during the pandemic.14 For schools that require fourth-year rotations (example: critical care), which may have been cancelled, schools are advised to look elsewhere in the curriculum where objectives may already have been met. While the LCME accepts virtual learning to meet preclinical and some clinical learning requirements, they do not support use of this technology for the entire clinical clerkship experience. The LCME also recognizes that the grading rubric used earlier in this academic year may not be appropriate for students taking courses later in the year. They also recommend that new grading rubrics not be applied to earlier students in a retrospective manner.
USMLE Step 2 testing was suspended on March 16, 2020 and was initially set to reopen on April 13 but has been delayed until at least May 1. The USMLE has waived fees for eligibility extensions and change of testing sites.4 However, this delay may cause difficulties in that some medical schools require passage of USMLE Step 2 for graduation, hospitals may require passage for credentialing, and certain states require passage for medical licensing.
On May 11, 2020, the Coalition for Physician Accountability, a cross-organizational group of all national medical educational organizations, released Medical Students in the Class of 2021: Moving Across Institutions for Post Graduate Training.7 This resource covers three major issues that applicants and training programs are facing as they prepare for the 2020-2021 residency cycle during the COVID-19 pandemic: away rotations, in-person interviews for residency, and the ERAS timeline.
While this guidance does not supersede the independent judgment of a medical school, sponsoring institution, or residency program, the following recommendations are anticipated to be fully complied with.
For the 2020-2021 academic year, away rotations are discouraged. Exceptions to this recommendation include learners who have a specialty interest and do not have access to a clinical experience with a residency program in that specialty in their school's system and those who are required to do away rotations for graduation. Individuals meeting these exceptions should limit the number of away rotations as much as possible. Students should consider geographically proximate programs, when appropriate, to meet learning needs.
All programs should commit to online interviews and virtual visits for all applicants, including local applicants, for the interview entire cycle.
Delay opening of ERAS for residency programs and delay release of the medical student performance evaluation (MSPE, also known as Dean's Letter); the opening and release should happen on the same day.
These recommendations have also been endorsed by the Association of Program Directors in Surgery.15
The ACGME has developed a three-tiered response to the COVID-19 pandemic.16 These tiers are primarily based on the clinical needs of the local population of patients.
In this stage, there is no disruption in clinical care or educational experiences. All common program- and specialty-specific requirements are in effect. However, site visits, Clinical Learning Environment Review, and ACGME surveys are suspended.
Some educational experiences are suspended as residents shift focus to patient care. Common and specialty-specific program requirements are in effect, but with some increased flexibility. Faculty supervision, adequate training resources, and duty-hour limitations are all in effect.
Majority of educational events suspended to focus on patient care. Duty-hour limits, appropriate supervision, and adequate resources remain in effect. Fellows may function as attending in core specialty. Programs must submit a "Pandemic Emergency Declaration Form."
The ABS has suspended both the qualifying exam and the certifying exams.17 They have also made significant hardship modifications, primarily for those graduating in 2020.
While the ABS encourages meeting the 48-week requirement, they will accept 44 weeks for 2019-2020 without the need for preapproval. Under extenuating circumstances, residents completing between 40 and 43 weeks may petition the ABS for approval. No one with less than 40 weeks will be allowed to graduate and will be required to extend their training.
The ABS has decreased the operative case requirement by 10 percent from 850 to 765, without need for documentation. Due to extreme circumstances, chief residents with only 680 cases may petition the ABS, but those under 680 do not qualify to sit for the written exam and must extend their training. Chief residents will also be assessed on their total number of cases and do not need to have 200 cases as chief or a required number of surgical critical care or teaching assistant cases. Residents completing their PGY-2 year, who have not met the 250-case minimum will have to complete this requirement within the first six months of the PGY-3 year.
Graduates who have had Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery™ courses canceled, may take the ABS Certifying Exam but must pass both courses before taking the Qualifying Exam. Graduates are not required to be current in Advanced Trauma Life Support
COVID-19 has led to an upheaval of every aspect of medical education. Regulatory agencies have adapted by modifying their requirements. While educators and learners are anxious to have more specific details, it is ultimately the virus that will determine when more information will be available.
Paul J. Schenarts, MD, FACS, is a professor in the Department of Surgery, University of Nebraska, College of Medicine.