Manuscript title:
Adapting medical education to COVID-19 pandemic: Singapore’s experience
Authors:
- Dr Li Xinyi, MRCOG, Senior Resident, Department of Obstetrics and
Gynaecology, KK Women’s and Children’s Hospital, Singapore
- Dr Li Mingyue, MBBS, Resident, Department of Obstetrics and
Gynaecology, KK Womens’s and Children’s Hospital, Singapore
- Dr Rajeswari Kathirvel, FRCOG, Consultant, Department of Obstetrics
and Gynaecology, KK Women’s and Children’s Hospital, Singapore.
Adjunct Assistant Professor, Lee Kong Chian School of Medicine and
National University of Singapore, Singapore
Corresponding author:
Dr Li Mingyue, MB.BS, Resident, Department of Obstetrics and
Gynaecology, KK Women’s and Children’s Hospital, Singapore
Email: mingyue.li@mohh.com.sg
Telephone: +65 81385685
Ever since the first case of COVID-19 was reported in Singapore on 23
January 2020, the number of cases have increased dramatically. In view
of the unpredictable nature of this unknown virus and having learnt
valuable lessons from the SARS epidemic in 2003, Singapore authorities
took the decision to raise the nation’s Disease Outbreak Response System
Condition (DORSCON) 1 level from yellow to orange on 7
February 2020. This indicates that COVID-19 is considered a severe
disease which spreads easily from person to person, but has not spread
widely in Singapore, and is presently being contained. As of 13 March
2020, there was a total of 187 confirmed cases, with 91 active
cases.2 To ensure the timely containment of the
disease and prevent uncontrolled spread within the community and amongst
healthcare workers, strict measures have been taken to manage the flow
of visitors entering any healthcare institution and also to restrict the
movement of staff and patients between various healthcare institutions
unless in extenuating circumstances. All non-essential meetings have
been cancelled or moved online to further reduce risks.
Unsurprisingly, clinical postings for the medical students have also
been suspended, much to the distress of the Lee Kong Chian School of
Medicine (LKC) Year 4 students, who were about to start their clinical
posting in Obstetrics and Gynaecology (OBGYN) on 10thFebruary 2020 at KK Women’s and Children’s Hospital (KKH), Singapore.
Fortunately, this distress was temporary as the curriculum planning
committee promptly got together to find an alternative way of proceeding
with the clinical posting without any direct patient contact whilst
ensuring that all the learning objectives and the formative assessment
criteria are met.
The traditional LKC OBGYN curriculum included core sessions that covered
the theoretical part of the learning outcomes in an interactive manner.
The students were then rotated through the outpatient/inpatient areas,
labour ward (LW) and operating theatres (OT). They were expected to
complete a list of workplace based assessments including case logs;
partograms; direct observation of procedure skills (DOPS) evaluation for
speculum examination and Mini-Clinical Evaluation Exercise (Mini-CEX).
They were also expected to have observed at least one normal vaginal
delivery and a few surgical procedures during their postings.
We explain here how we managed to achieve these learning objectives
without the students’ actual presence in KKH.
- An online virtual classroom (Google©) was created
with all the students, administrators and the clinical leads to
disseminate the schedules, clinical case scenarios and assignments. In
order to ensure effective = and timely communication, a chat group
consisting of the curriculum planning committee and LKC student
representatives was set up. Detailed briefing was sent out to the
tutors to inform them of the changes in curriculum delivery format.
- Core sessions: These were conducted through the web-based video
conferencing tool (ZOOM©) that has the advantage of
screen sharing and interaction between the tutors and students.
- “Clerking the expert patient”: Various clinical scenarios were
posted on the virtual classroom on a regular basis. Standardised
patient (SP) script for these scenarios were sent to the tutors. This
allowed the medical students to elicit history from the clinician SPs
following which case-based discussions were conducted through
ZOOM©. This simulated patient encounter gave
students the chance to practice targeted history taking, formulation
of differentials and management plans and allowed an opportunity to
complete their Mini-CEX evaluations.
- Virtual OT posting: Live surgery was streamed online through
ZOOM© with patient’s consent along with voiceover by
clinicians to allow the students to get a close-up view of the ongoing
surgeries and enabling them to observe the required procedures.
- Virtual LW posting: Live video streaming of the LW showed the ward
set-up to the students. The learning objectives for the LW posting
were met through clinical scenarios discussion via
ZOOM© and clinicians used videos to demonstrate
various modes of delivery.
- The DOPS requirement was achieved by the students demonstrating their
examination technique on mannequins at LKC premises with the tutors
assessing this from KKH through ZOOM©.
- Formative assessments of clinical knowledge was done through weekly
single best answer assignments. These were published and completed
online through the Google classroom platform.
Having successfully completed our first online OBGYN posting in the
current COVID-19 environment, we have gathered feedback from our
students to look at areas for improvement that could be applied to the
next batch of medical students who will be embarking on their posting
shortly. As much as we all agree that clinical postings and direct
patient interaction could never be underestimated or replaced, in unique
circumstances like this, we need to look into alternative methods like
those described above to replace the traditional clinical teaching.
Novel portions of this curriculum such as the virtual OT experience has
been very well received and the students have requested for it to be
incorporated into the regular curriculum even after the clinical
postings have resumed. This experience has allowed us to build a
blueprint for medical education locally which can be applied to any
extraordinary circumstances that requires suspension of clinical
postings, like this COVID-19 pandemic. In addition, given the global
spread of COVID-19, it is expected that medical schools worldwide will
have to start suspending clinical postings as part of infection control
measures. By publishing our team’s experience, we hope that
educationists worldwide will be able to smoothly transit their clinical
curriculum to online learning using ours as a reference.
There is no doubt that since the arrival of COVID-19 in Singapore and
internationally, life as we know it has been thrown into disarray in
some form or another. It is heartening to see the international
healthcare community rallying together as we react rapidly on the
frontline to institute precautionary measures, publish travel
advisories, invent diagnostic kits and develop vaccines and treatment.
However, we must not forget that in times of pandemics, other aspects of
life must go on. This includes the need for medical education to
continue so that we can train our next generation of doctors well to
equip them with the knowledge, skills and tenacity to deal with the next
abominable pathogen which is lurking in the dark and waiting to strike.
COVID-19 is not the first virus that has reached epidemic proportions
and will not be the last3. What matters is as
educationists, we have to balance the challenges of continuing medical
education4 and strive to restore a certain degree of
normalcy in our students’ postings by harnessing technology widely used
in social and business platforms to aid in their learning. In this way,
learning can be maximised without compromising on student or patient
safety.
As Mr Bill Gates expressed in his opening statement in “Responding to
COVID-19- A Once-in-a-century pandemic?” published in the New England
Journal of Medicine5, medical educationists share the
“same responsibilities of solving the immediate problem and keeping it
from happening again”, albeit in a slightly different perspective. This
pandemic has revealed the vulnerability of our clinical curriculum and
the downstream impact it could potentially have on our medical students
and healthcare community. It is imperative that educationists adapt
quickly to provide alternatives to clinical postings and learn from
these experiences to ensure that the next time something of comparable
scale hits us, we will be equipped with a functional Plan B.
References
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Agency Website, 6 Feb
2020. https://www.gov.sg/article/what-do-the-different-dorscon-levels-mean
- Coronavirus disease 2019: Cases in Singapore. A Singapore Government
Agency Website, 13 March
2020. https://www.gov.sg/article/covid-19-cases-in-singapore
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Disease Control Priorities: Improving Health and Reducing Poverty. 3rd
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education” in a pandemic era. Ann Acad Med Singapore. 2009
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Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMp2003762