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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 179-188

Impacts and challenges to education in academic international medicine during a global pandemic


1 Section of Emergency Medicine, Louisiana State University, New Orleans, LA, USA
2 Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital Medical Center, Brooklyn, New York, NY, USA
3 Department of Surgery, St. Luke's University, Allentown; Department of Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
4 Emergency Medicine, St. Luke's University Health Network, Bethlehem, USA
5 Department of Emergency Medicine, Oak Hill Hospital EM Residency Program, Brooksville, FL, USA
6 Department of Emergency Medicine, Weill Cornell Medicine and Columbia University Vagelose College of Physicians and Surgeons, New York, NY, USA
7 Elitra Health, New York, NY, USA
8 Surgery, St. Luke's University Health Network, Bethlehem, USA
9 Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Brooksville, FL, USA

Date of Submission19-Aug-2020
Date of Acceptance01-Sep-2020
Date of Web Publication26-Sep-2020

Correspondence Address:
Dr. Rebecca Jeanmonod
Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, PA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_108_20

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  Abstract 


The novel coronavirus (COVID-19) pandemic of 2020 has had profound impacts on medical education, both domestic and abroad. In this consensus paper from the American College of Academic International Medicine, we systematically discuss the impact of the pandemic both immediately and long term on international medical education, bedside teaching, procedural teaching, didactics and curriculum, accreditation, and mental health of medical teachers and learners. We discuss some strategies that have been implemented to mitigate the negative impact of the pandemic while providing reasons for hope in the future.
The following core competencies are addressed in this article: Practice-based learning, Patient care, Interpersonal and communication skills, Systems-based practice

Keywords: Academic international medicine, COVID-19, graduate medical education, international medical education, pandemic


How to cite this article:
De Wulf A, Bloem C, Mcdonald MP, Paladino L, Jeanmonod D, Kaban N, Tucci V, Garg M, Garg S, Stawicki SP, Anilus V, Miranda E, Jeanmonod R. Impacts and challenges to education in academic international medicine during a global pandemic. Int J Acad Med 2020;6:179-88

How to cite this URL:
De Wulf A, Bloem C, Mcdonald MP, Paladino L, Jeanmonod D, Kaban N, Tucci V, Garg M, Garg S, Stawicki SP, Anilus V, Miranda E, Jeanmonod R. Impacts and challenges to education in academic international medicine during a global pandemic. Int J Acad Med [serial online] 2020 [cited 2020 Oct 21];6:179-88. Available from: https://www.ijam-web.org/text.asp?2020/6/3/179/296136




  Introduction Top


Since its recognition as a pathogenic entity in December of 2019, the novel coronavirus (COVID-19) has reached pandemic status and has rapidly circled the globe. In addition to causing hundreds of thousands of deaths, the pandemic and the global response to it has resulted in the overwhelming of healthcare systems, disruption of supply chains for goods and services, destabilization of the world economy, increases in unemployment and homelessness, widespread social isolation and separation, withdrawal of children from primary and secondary education, and politicization surrounding all these issues. There is virtually no segment of private or public life that has not been impacted by this scourge.

Academic International Medicine (AIM) is a multidisciplinary field that seeks to advance clinical care, research, education, and policy through global collaboration and support. Although the COVID-19 pandemic has created many challenges and barriers to AIM in all of its forms, our goal is to address the challenges of the pandemic on medical education, including international medical education.

In its mission statement, the American College of Academic International Medicine (ACAIM) states that it seeks to promote educational collaboration and create a platform for the coordination of educational efforts, both domestically and abroad, for Academic International Medical professionals. Each year, the College authors and publishes a consensus statement that is timely and relevant to AIM. For 2020, the College intended to compose a “Best Practices” consensus statement encompassing graduate and postgraduate medical education (GME), both domestically and internationally. However, as we consider the substantial barriers to best practices in education that have occurred as a result of COVID-19, we felt it would be prudent to instead identify those barriers in a granular fashion as a first step toward overcoming them. Therefore, it is the purpose of this consensus statement to itemize and explore the impacts and challenges to domestic and international education brought to light by this global pandemic. We will address impacts on international education, bedside teaching, procedural teaching, didactics and curriculum, accreditation, and impacts on teacher and learner mental health. We will examine the ethical impact of international educational programming in this unique time, and conclude with a look to the future, including areas to grow, and reasons for optimism.


  The Impact of COVID-19 on International Education and Collaboration Top


Travel restrictions

One of the most concrete barriers to international educational offerings during the pandemic has been travel restrictions. By April 2020, domestic and international travel restrictions were introduced by over 130 countries due to the COVID-19 pandemic.[1] These restrictions affected the international academic medicine community as teachers, clinicians, researchers, and public health specialists alike were either unable to reach international sites, or unable to return to their countries of origin. With 90% of air travel grounded and quarantine a reality, an inherent dilemma was created between domestic and global missions for these professionals. Mandatory quarantine for 2 weeks both on arrival and upon return from any international destination effectively halted international educational endeavors. Finally, United States (US) Department of State mandates pulled educators back into the US, citing that: 1. Educators and learners abroad may face unpredictable circumstances, quarantine, and sudden travel restrictions; and 2. Adequate health care may not be available overseas for these educators and learners, and therefore, these personnel were asked to return to the US as soon as possible.[2]

Travel risks

For the AIM community who chose to continue to travel, the COVID-19 pandemic has made travelling a risky event. Each person carrying the Sars-CoV-2 virus infects approximately 3 new people through respiratory droplets, and the role of aerosol transmission is emerging. The risk of getting or unwittingly transmitting COVID-19 without any prophylaxis, treatment, or vaccine has made travel concerning for most of the AIM community. At the time of this manuscript, many countries internationally and states in the US have begun loosening restrictions on travel although virus cases are regionally on the rise. This is deeply concerning to the safety and well-being of the global community, as this is how the virus became a pandemic in the first place.

Collaboration

Clearly, the restrictions on travel reduced opportunities for educators to meet, teach, and collaborate, while the pandemic itself created an acute need for collaboration and education. AIM advocates have had to explore solutions to work as a global network to help in the COVID-19 pandemic. Crisis telemedicine, education, and idea sharing were quickly created with physicians of all specialties on an international platform to come up with real time solutions to aid in patient care, education and research. These developments are works in progress, and improve daily.


  The Impact of COVID-19 on Bedside Medical Education Top


Impact on students

Domestically, COVID-19 has had impacts on bedside medical student education. As students have been considered non-essential personnel, and as hospitals with large volumes of COVID positive patients have limited personal protection equipment (PPE), students have been removed from the patient care arena for safety purposes and resource conservation. This experiential loss will have profound cognitive and skill impact on the next generation of medical students who are in the clinical learning environment. Furthermore, it has the potential to disenfranchise them from their calling as physicians as the patient-physician experience is critical in the development of training milestones and core competencies. Medical students, who are talented adult learners and care givers in their own right, have not been given choice in their removal from hospitals, and have lost agency and experience at the bedside, being relegated as children in the hierarchy of medicine.

Medical student education, beyond the opportunity to learn from patients at the bedside, has also been affected by reduced “live” exposure with colleagues, where they learn not only clinical and core skills, but also professionalism and communication skills, not easily taught without human interaction and role modeling. This includes non-verbal communication and leadership skills that are often learned by trainee observation. It is unclear what the long-term impacts of this will be.

The lost experiential and undergraduate medical education (UME) skills will undoubtedly lead to weaker physicians if we maintain a traditional model without innovation. How do we make up this educational shortfall? Should medical schools be lengthened? Do we have to reduce expectations or graduation requirements? The solutions will need to be multifactorial and adaptable to our changing landscape. Educators are opening up virtual GME opportunities for junior learners and re-focusing touch points with mentorship. Students are utilizing shared learning creations from around the world to supplement gaps and blind spots. Will it be enough?

Impact on residents

Residents have lost critical procedures and elective rotations and have substituted it with pandemic medicine. Procedural/surgical specialty fields were closed down or limited for significant periods of time, often replaced with extended emergency medicine or critical care medicine time. Although this new skill set is valuable, the reduction in breadth of available patients from which to learn nuance and the narrow disease spectrum will negatively impact trainees. Since residents, too, may be considered nonessential workers (as all patients need to be seen by attending physicians, but not residents), some institutions have implemented policies requiring high-risk procedures be performed strictly by the attendings for safety reasons or for reasons of PPE preservation. Because of this, residents have often missed out on the diversity of experiences required by their specialties. This has the potential to create a skill gap in physicians who are about to go out and practice independently.

Recommendations by the Accreditation Council for GME (ACGME) have attempted to address these no-win challenges by reducing case log requirements, allowing for delayed milestone assessments, and excusing program administration requirements. These measures, although beneficial for program prioritization, may have the undesired result of delaying supervision, identification, and assistance to residents who are vulnerable and/or struggling.

Impact on procedural teaching

Surgical procedures

In March 2020, all elective surgical procedures and virtually all nonemergency procedures in the United States were shut down by recommendation of the Centers for Disease Control and various national societies, such as the American College of Surgeons (ACS), the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and others.[3] This was encouraged and then mandated, for several reasons. The anticipated surge of COVID-19 patients was expected to overwhelm hospital and health-care resources. Thus, nonessential surgeries were shut down to conserve supplies such as PPE and ventilators, as well as to allow for a re-purposing of nurses, technicians, and physicians to other critical areas of the health-care system during the influx of COVID-19 patients. Great resources were mobilized and continue to be so in certain areas of the country, to focus on the response to the pandemic. Surgical education took a hit. With no “live” cases to perform, and as the COVID response was largely non-surgical, there were few cases upon which to learn, practice skills, and develop clinical decision-making. Highly complex procedural training, such as oncologic procedures, was diminished by an estimated 30%–60%. This reduced the ability for chief residents and fellows to refine their skills in these complex cases for an extended period of time.[4] Surgical trainees also had limitations in their opportunities to learn the art of obtaining consents and facilitating effective family interactions as the leader of the team.

The ACGME stepped in to define the effects of the diminishment of cases in states. They developed stages of operations for educational institutions. Stage 1 is “business as usual,” with minimal disruption of surgical education. Stage 2 is increased but manageable alteration in clinical demands and Stage 3 is an overwhelming alteration of clinical demands so that educational requirements need to be altered.[5] This included alteration of clinical responsibilities and educational direction to meet the pandemic needs, while still adhering to the clinical work hours and supervision requirements. Guidelines were developed to assist in using residents in nonspecialty areas and developing new ways of procedural education.

New ideas in surgical education developed. While virtual learning was slow to be adopted in procedural specialties, suddenly the art of learning by watching “film,” a technique used frequently in elite sports, now was a necessary technique of learning for surgical residents. Online resources were quickly developed by governing societies and local teaching institutions. Residents were being asked to stay at home and complete didactic modules from home, while remotely participating in teaching conferences. The ACS as well as SAGES offered a variety of online courses to enhance core surgical knowledge, skills, and techniques. While nothing can replace live experience, “watching film,” once an underrated pedagogical technique, became de riguer.

The American Board of Surgery (ABS) also took an active role in developing guidelines for surgical specialty training, reducing clinical requirements and case volumes for chiefs and fellows, relying on the discretion of the Program Directors (PDs) to sign off on sufficiently trained chief residents.[6] The ABS has allowed for great flexibility in completing case logs and the resumption of testing programs for Board certification, while maintaining the need to respect and preserve the public safety in their certification standards.

Medical student education also took a significant hit in surgical and procedural specialty exposure. Most, if not all medical school institutions closed their doors and sent students home. Again, many developed online learning modules to substitute for patient-interaction learning. This greatly reduced exposure to various procedural specialties and eventually resulted in resumption of clinical responsibilities in a reduced fashion, with shorter rotations and less exposure to procedures, in order to remove most nonessential personnel from operating rooms and to minimize risk to the student. This impact on students' clinical clerkships may affect their choice of professions in the years to come.

Emergency procedures

Even in the emergency department, where procedures occur every day and are not elective, risk of exposure to COVID-19 necessarily led to policies and procedures to decrease the number of people in the room, especially during procedures. This has lessened the ability of others from learning by observing the procedure closely. One possible solution to this challenge has been to increase demonstrations in the simulation laboratory, however physical distancing limits the number of participants in this setting. Smaller groups must be scheduled, meaning more time must be spent in the laboratory by educators during a period when time is preciously being divided with critical patient care duties of over-worked, stressed, and even reduced staff. Both financial and faculty time constraints make increasing staff for the smaller groups neither a sustainable nor tenable solution.

Airway procedures

Arguably, teaching airway intervention has been most impacted during COVID-19. Airway procedures such as noninvasive ventilation, intubation, and suctioning are high risk and as such, have had the most profound decrease in hands-on teaching for residents and students in order to minimize their pathogen exposure. Indeed many COVID intubation protocols call for only the most experienced intubator (attending physician) to be present and perform the procedure. The ramifications on the procedure logs of residents are obvious, ironically during an event with unprecedented airway emphasis. The intubator, being in PPE (PAPR, n95, etc.,), makes communication difficult. This, coupled with distancing the resident by placing them outside of the negative pressure room, does not even allow the option of the educator to verbally walk the student through what is being done in real time. Recommended use of a video intubating device for safety, distancing, and first pass success has also led to a decrease in performance and therefore skill maintenance of direct laryngoscopy.

Ultrasound

Unlike other procedures, US has perhaps enjoyed an increase in use in an effort to rapidly diagnose COVID pulmonary findings without contaminating computed tomography (CT) equipment. There has been an explosion/increase in point-of-care-ultrasound (POCUS) literature and education to this end. POCUS education, however, has suffered the same constraints of other procedures that of limiting the number of observers congregated around the patient's bed.


  Covid-19 Impact on Didactic Education Top


Residency curriculum attendance is not only a time-honored method of distilling learning from teacher to student, but a mandatory component of residency training and a graduation requirement. In the US, the ACGME requires that programs hold 5 h of dedicated conference time each week and permit up to 20% of asynchronous learning. Residents must attend 70% or more of the planned residency educational conferences to graduate.[7]

The COVID-19 pandemic presents several unique challenges for faculty and residents in meeting this graduation requirement. Physical distancing to minimize disease transmission includes recommendations to place desks 6-feet apart from one another and to face them all in the same direction. Many hospital conference rooms and GME classrooms are simply not large enough to institute these recommendations.[8],[9],[10]

Given the inability to offer educational activities in traditional classroom settings, residency programs are utilizing various conference platforms to facilitate face-to-face learning and discussions.[11] Although distance learning via online or web-based modalities is not a new concept, it has been brought to the forefront due to physical distancing. Free Open Access Medical Education utilizing technological advances ranging from Facebook™ to Twitter™, YouTube™, medical blogs, and podcasts were some ways that residency programs communicated and enhanced the presentation of core content to the current generation of learners even before the COVID-19 pandemic.[12] Education research has shown that technologically savvy residents prefer online coursework, and online courses often lead to increased learner satisfaction rates and higher performance on exams when compared to their traditional counterparts.[13]

Formalizing use of these platforms and centralizing approved resources is one way of ensuring a common learning experience. Likewise, many programs have been utilizing Learning Management Systems (LMS) including Moodle TM, Edmodo TM, ConnectEDU TM, and Canvas TM. These LMSes can be used to provide online instructional materials ranging from videos to podcasts, quizzes, and articles and can track the residents' progress. The choice of these platforms is based on several factors including cost, availability of reliable internet service and bandwidth, program familiarity, and comfort with eLearning options. For the residency and fellowship programs which have not previously used LMS, educators, and learners should be provided with training/user's guide on how to use the chosen system. Moreover, educators must be cognizant that although audio, visual, and kinesthetic elements appeal to different learning styles, combining more than two of these at one time can lead to cognitive overload.[14]

Reliance on these digital platforms for medical education is not without its shortcomings. There can be a lack of engagement in platform-based learning and technological limitations with platforms unable to support true conversation or discussion. In addition, non-verbal communication from standardized patients, residents and faculty communication can be a significant component of the clinical and educational experience and many platforms do not allow users to visualize all persons present on the conference at the same time. Online platforms present challenges to make connections and facilitate participation in certain activities. These challenges may limit opportunity for adequate and worthwhile feedback. Some platforms may limit the ability to do breakout sessions, problem-based learning or team-based learning due to bandwidth or functionality. During pandemics and quarantines, there is an increased reliance on telecommuting not just in medicine, but with many professions and jobs. The internet providers and cellular networks can become overwhelmed during the more heavily trafficked times of day, 9 am to 5 pm. Programs might consider adjusting their didactics to less commonly utilized times or days (i.e., early mornings, evenings, or weekends).

There are a few benefits to digital platforms. The shift to online didactics and virtual conferences can enable programs to not only enlist the participation of their own clinical faculty and alumni, but to tap collaborative networks and to recruit new speakers, guest lecturers, facilitators and panelists. Programs can share grand rounds, lectures, and journal clubs. This will enable program leadership to avoid duplicating the efforts of others and even to solicit talks from experts across different geographic regions.[15] Virtual chat rooms and separate conferences can be run simultaneously to allow small group sessions. Faculty can also utilize synchronous engagement tools such as Slack™, WhatsApp™, and Poll Everywhere™ to assess resident interest and engagement during the conference. Re-integration of a mixed model of education with some form of face-to-face teaching supplemented by digital platforms that minimizes risk of pathogen exposure and limits PPE use is critical to adequate assessment of residents' professionalism, procedural competence and knowledge base, and is the optimal way to provide mentorship and connection with trainees.[16]


  COVID-19 Impact on Accreditation Top


Impact on accreditation of international medical programs

To understand the impact of the pandemic on international medical program accreditation, one must understand that accreditation process. Accreditation of International Medical Programs (IMPs) is the cornerstone required for the maintenance of both quality and academic standards across a broad range of settings, institutions, and collaborative paradigms.[17] The concept of IMP accreditation emerged out of the necessity to ensure relative uniformity in terms of stakeholder expectations and sustainable approaches to bidirectional (and multidirectional) exchanges and long-term growth of AIM as a well-defined specialty with unique characteristics, goals, and objectives.[18],[19] This is not dissimilar to the paradigm of initial and ongoing accreditation of GME programs.[20]

In 2010, the Education Commission for Foreign Medical Graduates (ECFMG) established that by 2023, all applicants applying for ECFMG Certification in the US must have matriculated from an accredited institution.[21] The physician's medical school must be accredited by an accrediting agency that is officially recognized by the World Federation for Medical Education.[22] ECFMG requirement seeks to standardize international medical education.

As with UME, educators have attempted to establish consistent and transparent standards for GME. ACGME International LLC is one entity that offers GME accreditation to institutions and countries outside of the US for medical and surgical residencies and fellowships.[23]

The COVID-19 pandemic resulted in significant disruptions in the ability to implement the rapidly evolving paradigm of IMP accreditation for a number of reasons. The most obvious and dominant factor impacting this important area is the essential freeze in both international and domestic travel.[11] Another determinant of the ability to meaningfully engage programs in the process of accreditation is the financial uncertainty pertaining to the sustainability of bidirectional IMP exchanges, both from financial and nonfinancial resource perspective. To further complicate things, given that existing standards and expectations regarding any pre-COVID-19 “standard bidirectional operations” are simply not applicable or feasible, a set of alternative standards must be agreed upon, including the ability to maintain bidirectional exchanges on as many levels of the existing IMP platform as feasible. In the latter context, important decisions must be made by the AIM community regarding what constitutes a valid substitute (e.g., the use of telepresence in bidirectional educational endeavors, temporary transition toward bidirectional clinical research endeavors, or perhaps the use of telemedicine in place of on-site provider-patient interactions), under what circumstances, and how the determination of “return to normal” will subsequently be made.

Although direct site visits during the time of pandemic will be difficult to organize and carry out, the increase in virtual interactions may offer a way to at least partially compensate for the loss of direct, in-person presence.[11],[24] Similar paradigms for remote presence and virtual classroom education have been proposed in the past.[25] Virtual site tours can also be facilitated using modern drone and 3D or panoramic camera capabilities.[26],[27] Yet, despite these technology-enabled capabilities that could be employed within the “virtual accreditation framework,” important questions remain, including the validity of the remote assessment without the ability to directly interact with key stakeholders or perform an in-person, unbiased inspection of local facilities. Finally, the availability of adequate infrastructure will be a key determinant of the ability to conduct valid virtual site visits. Given the paucity of high-speed internet across many LMICs, the lack of adequate connectivity may constitute a dominant barrier to IMP accreditation visits.[28],[29]

Accreditation Council for Graduate Medical Education response to COVID-19

In the US, the ACGME adopted a three-pronged approach to GME during the COVID-19 pandemic. As described previously, programs operating in Stage 1 have not experienced any significant disruption of patient care or educational activities, but are planning for anticipated increased future clinical demands. Programs operating in Stage 2 have experienced increased clinical demand. Programs operating in Stage 3 are at pandemic emergency or crisis status.[5]

The ACMGE has suspended some of its routine activities, such as the annual Resident/Fellow and Faculty Surveys, to help institutions maintain focus on patient care and more effectively deal with the challenges associated with the ongoing pandemic.[5],[30] The ACGME also modified the concept of “Direct Supervision” to acknowledge the realities of telemedicine, with provisions made for trainee monitoring through “appropriate telecommunication technology.”[5],[30]

In addition to the general areas noted above, Stage 2 programs will be directed to focus on patient safety and resident wellness with a shift of patient care duties and suspension of some educational activities. As part of both patient safety and wellness, residents must be provided with and trained in the use of proper PPE and balance the needs of patients, clinical settings and health-care teams. The residents must have adequate supervision for trainee level/scope of practice, and the program must adhere to work hour requirements.

Programs in Stage 3 will be governed by the process under ACGME's Extraordinary Circumstances policy (ACGME 21.0), effective May 12, 2020, to accommodate the need for all physicians to care for patients to the best of each physician's (including resident physician's) ability.[5] The declaration of Pandemic Emergency Status lasts 30 days and is designed to allow programs to increase flexibility of physicians in clinical settings. Other than the areas noted for Stage 2 programs, the ACGME will suspend common program requirements and specialty-specific Program Requirements during the declaration of Pandemic Emergency Status.

The ACGME is permitting programs to delineate the ways in which their program was impacted by COVID-19 during their annual updates, and review committees will determine how disruptions will affect accreditation decisions. The review committees will focus on adherence to requirements for resident safety, supervision, and work hours.

Residents can be reassigned from other clinical activities with the approval of the PD and Designated Institutional Official. Residents may not complete all planned educational or curricular activities and be permitted to graduate the program at the discretion of the PD and Clinical Competency Committee (CCC). Alternatively, the PD and CCC may opt to extend the resident's training due to the reduction in patient volumes, procedures, and operations due to concerns regarding clinical competency. ACGME International LLC will likely adopt the same approach for accreditation issues with international programs given the COVID-19 pandemic as ACGME plans for domestic programs in the US.


  COVID-19 Impact on the Mental Health of Educators and Trainees Top


The environments where we work, teach, and learn have all been affected by the pandemic, extending and heightening challenges that already exist in medical education. These stressors affect the mental health of both educators and learners, and while these impacts may differ between groups depending on their role and experience, there is also an overlap and an interplay between them.

With a novel illness such as COVID-19 and uncertainty regarding its pathology, clinicians find themselves unsure of best practices or the predicted clinical course for their patients. Although this affords opportunities for learning and education, accepted clinical reasoning is altered and challenged. Providers find themselves treating large volumes of high acuity patients, without the confidence afforded by familiarity with the presentation as is usually brought to their practice. Protocols for diagnosis, treatment, and prevention have been highly dynamic, if present at all, leaving clinicians quickly adjusting to an ever-shifting concept of how to provide the best and safest care.

While providers experience these challenges directly, learners in the clinical environment may also be affected by this uncertain and dynamic reality. Through witnessing the sheer influx of acutely sick and dying patients on top of the usual patient volume, the psyche of those within the clinical environment is impacted, even if they are not directly involved in those patients' care. Learners within medicine are also largely dependent on the engagement of educators to make their medical education robust and meaningful. When educators are stretched beyond their capacity or highly stressed themselves, it becomes difficult for them to be effective and inclusive.

As learners are marginalized in or excluded from the clinical space and coursework largely has transitioned to on-line or small group and physically distanced interactions, social isolation has developed. This sense of isolation is heightened by being separated from support systems through travel restrictions and concern for spreading the illness to vulnerable community members. Social isolation has physiologic impacts that worsen physical health.[31],[32],[33] These physical health impacts, in turn, can worsen the emotional burden of the COVID-19 pandemic and increase the sense of isolation, leading to a stress feedback loop.

Fear becomes real as health-care providers and learners witness large volumes of individuals come into health-care settings with severe illness. As providers see the morbidity and mortality of COVID-19 in themselves and their colleagues, an illusion of invincibility within the health-care profession is shattered. Individual providers and learners navigate the fear of getting sick while largely isolated and often less able to connect with their support systems due to anxiety about infecting family members and loved ones with COVID-19. Concerns about getting sick themselves may be exacerbated for learners who do not have agency or familiarity in clinical spaces, as they tend to be less empowered to advocate for their personal protection while navigating new clinical contexts and depending on ongoing evaluations from educators.

Disillusionment can result from functioning in a suddenly overburdened health-care system, with problems highlighted on several levels. Providers experiencing PPE concerns or the fallout from low hospital revenue leading to reduced staff hours come into conflict with their belief that the system values and will protect them, especially during such a critical period. This disillusionment can be exacerbated in some cases by a lack of transparency by leadership, especially if it is unclear that the providers' and patients' best interests are the guiding forces of new hospital policies.

One's conviction about the profession of medicine itself may come into question through a lack of confidence in being able to respond effectively to a crisis on the magnitude of the COVID-19 pandemic. While the nonmedical world heaps praise on health-care providers and calls them “heroes” for caring for patients in the face of personal risk, this incongruence with reality can worsen a sense of isolation, of not being truly valued or of worthlessness. Imposter syndrome, frequently experienced by medical professionals and trainees even during the most standard of times, may be heightened by this dissonant messaging.

Learners meanwhile, who have been pulled from clinical duties or separated from suspected COVID-19 patients for their own safety can feel useless during these important and historic times. Due to the necessary shift of focus away from education and towards confronting new clinical presentations, disengagement by learners who remain in the clinical space may also occur. These feelings of exclusion or irrelevance may contribute toward a feeling of disillusionment about the system in which the learners exist.

A sense of agency over your circumstances is important in the maintenance of mental health. When learners are removed from caring for certain patients and have their educational curriculum undergo changes that directly impact them, they lose agency over their education. This is worsened by learners not having the opportunity to make their own decisions about the risks they may or may not be willing to take to care for patients in this pandemic, and it counters the principles of adult learning emphasizing self-directed learning and personal responsibility in one's education.

Practitioners of AIM have been forced to watch their programs be placed on hold as travel restrictions and priority shifts occur, leading to a loss of momentum and funding. Learners in AIM have found field work similarly paused, unable to complete their projects and training requirements. For those AIM practitioners based in high-income settings, these lost opportunities lead to anxiety about the impact of their work and the trajectory of their career. Host communities can feel this strain differently, potentially through loss of assets. Decreased funding and human capital related to AIM projects can lead to re-allocation of resources toward in-country expenditures and an increase in provider burnout across health systems that may be under-resourced to begin with, and potentially further overextended in the context of the pandemic. Those in recipient communities may thus feel the dual emotional strain of the pandemic and loss of the assets related to AIM partnerships.


  COVID-19 and the Ethics of Future International Engagement Top


Learners in global health and AIM are vulnerable to tensions when working abroad related to cultural challenges, potential disconnects between expectations and perceptions, and discordant objectives.[33] Working to provide medical care in resource-limited settings can exacerbate these tensions, particularly when standards of care differ from those to which a health professional is accustomed. As COVID-19 does not spare under-resourced settings, the likelihood of an ongoing humanitarian disaster is high. Humanitarian disasters themselves present opportunities for moral distress and ethical dilemmas through, among others, rationing of limited care, questions about true informed consent, as well as the provision of futile care.[34] Given the inherent vulnerability of working abroad and the additional mental health impacts of COVID-19, a careful assessment of ethical impact of exacerbating mental health challenges must be balanced with programmatic priorities when considering international travel, especially for AIM learners.

Another critical element is an assessment of the risk to the host community. The risk of unwittingly transmitting COVID-19 to the host community or of the AIM practitioner themselves becoming ill with COVID-19 and further burdening a strained medical system are important considerations, particularly if there exist limited infrastructure or resources to handle these additional burdens.

Power dynamics can be complex between sending and hosting communities. Often, practitioners of AIM come from relatively well-resourced settings, and with their programs, bring offers of funding, human capital, technical support, or other resources. This may make it particularly difficult for a host community to decline a visit from international partners, potentially increasing the risk of worsening burdens on the host health system.


  Conclusion Top


The COVID-19 pandemic has presented many challenges to medical education within home institutions as well as in international academic programming. As medical educators grapple with these challenges, the pandemic provides a unique opportunity to examine institutional practices and reimagine solutions. Tied together through this global pandemic, the AIM community has the opportunity to reframe the field to be more innovative and inclusive, acting beyond traditional perspectives of donor-recipient relationships and geographic borders. This is an opportunity for AIM practitioners to practice true bidirectional exchange of designs and solutions with partners. By reimagining their approaches on the home front, AIM practitioners can ensure that traditionally underrepresented voices are heard and thus AIM will benefit from a broad array of ideas. While there is no doubt that challenges to medical education exist, both in our home institutions and in the international realm, the American College of Academic International Medicine is optimistic that necessity is the mother of invention. As such, exciting times lie ahead for AIM and medical education.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

For writing this review, the authors utilized data from reputed organizations such as the World Health Organization, Accreditation Council for Graduate Medical Education, Accreditation Council for International Medical Programs, Centers of Disease Control and Prevention U.S. Department of Health and Human Services, Medline, and PubMed. Only highly relevant articles from manual and electronic databases were selected for the present review. Applicable EQUATOR network (https://www.equator-network.org/) guidelines were followed.



 
  References Top

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