key: cord-0977742-w79qeqyk
authors: Schumm, Max A.; Dacey, Michael J.; Moore, Alexandra M.; Graham, Danielle S.; Tillou, Areti; Chen, David C.; MacQueen, Ian T.; Wagner, Justin P.
title: A hybrid remote surgery clerkship curriculum during the COVID-19 pandemic: Lessons learned and future perspectives
date: 2021-11-12
journal: Am J Surg
DOI: 10.1016/j.amjsurg.2021.11.007
sha: 73fc8b0d9c7345f6b475acb56d2dd061a832b2ea
doc_id: 977742
cord_uid: w79qeqyk

nan

Early in the COVID-19 pandemic, medical educators recommended to conserve clinical 28 education despite the threat of an infectious agent 1-3 . The Surgery clerkship commitee at our 29 institution had a similar outlook and developed a 6-week remote curriculum (following 6-weeks 30 of a tradtional clerkship rotations) for third-year medical students in response to the California 31 "Shelter in Place" order. The success of the remote clerkship curriculum (RCC) mirrors that of 32 others 4,5 , and suggests that the adoption of specific elements of e-learning in traditional Surgery 33 clerkships be considered by surgical educators and clerkship directors hereafter. 34

The benefits of electronic learning (e-learning) were increasingly recognized in medical 35 education prior to the COVID-19 pandemic. Personalized instruction and feedback, greater 36 access to information, interactivity, engagement with content, and flexibility of learning style 37 enhance the effectiveness of instruction 6 . The pandemic accelerated the use of online 38 educational technology in undergraduate and graduate medical education 1 . Evaluating the impact 39 of these changes on undergraduate surgical learning is critical to establish new principles and 40 practices that may be used to complement conventional in-person teaching and contribute to the 41 advancement of medical education 4 . The aim of this editorial is to define our initiatives, to 42 describe lessons we learned while developing the RCC, and to empower those committed to 43 effective surgical education post-pandemic. 44

The RCC included daily didactics and small group discussions, in which 8-9 students 45 gave pre-assigned verbal presentations of surgical patients to faculty or resident preceptors. 46

Surveys were administered longitudinally to assess student perceptions of satisfaction, educational experience and mistreatment in prior, non-Surgery clerkships and in the hybrid 48 traditional/remote Surgery clerkship. Students' perceptions of mistreatment were compared 49 among RCC and historical Surgery clerkship cohorts. 50

Small group sessions were found to be a vital component of the RCC. Comparing survey 51 data from this experience with that of prior, non-surgery clerkships, students felt more confident 52 verbally presenting patients after the RCC. In addition, students reported high levels of 53 satisfaction and perceptions of educational value, and that they learned more effectively in the 54 remote curriculum than in person. Remote learning is not a replacement for experiential learning 55 in clinical rotations; however, its effectiveness does provide a channel to augment clinical 56 learning and its environment. Although logistical challenges certainly exist when scheduling 57 remote case-based discussions during experiential, traditional clerkship schedules, their positive 58 effects on educational value has led us to explore them in the current in-person curriculum. For 59 example, virtual small group sessions may be incorporated into pre-clerkship orientation blocks 60 or protected clerkship didactic time. The perceived effectiveness of clinical instruction was 61 improved by remote learning formats that promoted active participation, learner engagement, 62 and preceptor assessment. 63

The RCC was also associated with reduced rates of intimidation and mistreatment 64 reported by students in the Surgery clerkship. Abuse and mistreatment of students and residents 65 in a variety of specialty settings have been frequently cited in centers throughout the U.S., and 66 are associated with burnout and suicidal ideation 7 . In the RCC cohort, students were substantially 67 less likely to report mistreatment over the 12-week rotation (6.7%) than historically (22.1%), and 68 the proportions of students who reported feelings of intimidation by residents and by faculty 69 were substantially lower than they had anticipated prior to the clerkship. This may result from Students in the RCC also felt they contributed less to surgical teams, an 97 acknowledgement of restriction from direct patient care during that time. Inadequate exposure to 98 overnight call or surgical sub-internships among students with career interests in surgery is 99 associated with higher risks of attrition and decreased preparedness for residency 11 . These 100 circumstances may persist in peri-pandemic clerkship schedules when students become ill or are 101 quarantined due to COVID-19 expsoure. A library of recorded didactics from the RCC is now 102 offered to these students, and interactive video-based operative curriculums may be used to 103 deliver remote operating room experience while providing exposure to the surgical specialty and 104 engagement with faculty 4,9,10 . Although some aspects of undergraduate medical education 105 improved in the RCC, future remote curricula will require refinement to foster technical skills 106 acquisition, prepare students for residency, and interfere minimally with traditional in-person 107 clinical learning. 108 

Medical Student Education in the Time of COVID-19

Considerations and Implications for Surgical Learners

Using Technology to Maintain the Education of 130

Residents During the COVID-19 Pandemic

Creation of an Interactive Virtual Surgical Rotation 133 for Undergraduate Medical Education During the COVID-19 Pandemic

COVID-19 on medical student surgical education: Implementing extreme pandemic response 137 measures in a widely distributed surgical clerkship experience

The impact of E-learning in medical education

Surgical Residency Training

Associations Between Career Satisfaction

Personal Life Factors, and Work-Life Integration Practices Among US Surgeons by Gender

Surgical Training During COVID-19: Operating Room Simulation Platforms Accessible From 149

Practical Techniques to Adapt Surgical Resident 151 Education to the COVID-19 Era

A National Mixed-Methods Evaluation 154 of Preparedness for General Surgery Residency and the Association With Resident Burnout