Flipped Learning Meets the High-Touch Needs of Online Medical Instruction

 

It’s a bitter irony that a clinical crisis, the COVID-19 pandemic hit the clinical workforce and clinical education, perhaps the hardest. Writing on March 31st for the JAMA Network blog, Dr. Suzanne Rose said, “One challenge is in providing authentic patient experiences for medical students as a key component of medical education under these circumstances. The profound effects of Coronavirus 19 may forever change how future physicians are educated.” Teaching science, teaching clinical skills thrives on hands-on learning, interpersonal experiences, patient student contacts. Yet when we moved completely online, we were thrown into our living rooms and on Zoom where those interpersonal contacts became nearly impossible. How are medical professors adapting?

 

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This panel discussion was part of the 2020 Second Wave Summit.  The second wave refers to the looming threat of the return of COVID-19 in the fall that may drive another round of school closures and remote learning. It also refers to the second round of contingency planning and preparation we all now need to do to prepare for the uncertainty of whatever is coming next. Watch the full panel discussion or read the transcript below.

 

 

Dr. Thomas Mennella:

Joining me today is an esteemed panel, including Richard Schwartzstein from the Beth Israel Deaconess Medical Center associated with Harvard University, Dr. Chaya Gopalan from Southern Illinois University, Catherine Snelling from the University of Adelaide in Adelaide Australia, Dr. Sandeep Bansal from TCU and UNTHSC School of Medicine, Dr. Jose Felix Castro from Anahuac University in Mexico City, Mexico.

Dr. Thomas Mennella:

Dr. Schwartzstein, let’s start with you. How is the COVID-19 pandemic and the subsequent school closings that you experience uniquely challenging for the clinical instruction and education that you provide to your students?

Dr. Richard Schwartzstein:

I would separate out a pre-clerkship education from the clinical. The pre-clerkship, when virtual, is probably for most people, the same thing happened. And while we conveyed most of what we wanted to do using online technology, including small group work, interactive things, the personal connections that we have between faculty and students was not as strong as obviously we would have had in person –and for a course that was interrupted in the middle– And it was actually my course because we already knew the students, it actually worked pretty well. The course had followed ours, where they had not had a chance to work together in a classroom setting, struggled quite a bit because of a lack of trust in some ways between faculty and students, that safe environment, we’re always trying to create to allow a really meaningful exchange among the students and with the faculty. Clinically, our students were sent home initially for their own safety, and they’re now coming back again. I think the clinical teaching while we tried to get students involved in supportive roles and so forth that were useful, what was really remarkable to me is how we had an opportunity to change the learning environment, particularly around the concept of lifelong learning and self-directed learning, which is a huge issue these days. And because this was new to everyone, faculty, residents, and students, the ability for us as faculty to truly model the fact that things were happening, we couldn’t fully explain. This is how we will begin to think about it. This is how we read the literature breaking by the minute. Some of which was not very good, some of which was very compelling. We had a chance to really raise the bar in some ways on some aspects of clinical education, that was really a unique opportunity and one that we tried to take advantage of.

Dr. Thomas Mennella:

How about others? How did you find your specific discipline challenged by the pandemic?

Catherine Snelling:

Well, I’ll just add that I’m from a dental school, and I’m not sure whether there’s anyone else on the panel that is from a dental school. But if you were looking at some of the statistics about the most dangerous occupations associated with COVID, three out of the top five had dental in front of them. So we were very much at the pointy end of things virtually straight away. And we’ve got I suppose an upside-down situation here. We were three weeks into our first semester when we shut down. So what was mentioned about the students not having worked together, lacking that kind of interpersonal relationships and trust was really amplified, particularly for our first year out, our freshmen students who barely knew each other’s names. So we are about to go back to some limited face-to-face teaching what is going to be our second semester. But we’re going to be online for everything theoretically based for the rest of this year because we’re kind of going in calendar years with our academic year.

Dr. Thomas Mennella:

Wow, amazing.

Catherine Snelling:

So, yes, it’s been a … Someone said to me you should never waste a good crisis, and that’s what we’ve going to do without teaching. And there’s been some, I’m sure like you’ve all found some absolutely amazing outcomes, which we’re not going to change now, which is kind of ironic, but maybe that’s how often things change through necessity rather than people thinking it’s just a good idea.

Dr. Thomas Mennella:

Absolutely, Dr. Gopalan?

Dr. Chaya Gopalan:

Yes. I teach a physiology course for certified nurse anesthesia students. It has been always taught in the flipped style where students do their work first and then meet in class for Q&A and assessments, individual, group–all of that was moved to an online format and more technology than what was already being used. I’m using the breakout room for group work and pull everywhere for individual quizzes. Another match table is now virtually displayed where we look at the different systems. It’s not the same as taking them to the lab and allow them to play with the table, but it’s neat that we can still do everything that we possibly could have done given the situation. So it has been a nice transformation, and students, a few of them, took some time to adjust, but majority of them were ready to move on. Technology wasn’t an issue. So yeah, it’s a nice adjustment.

Dr. Thomas Mennella:

Mm-hmm (affirmative). Dr. Bansal and Castro, what about both of you?

Dr. Jose Felix Castro:

Well, we were working here in Mexico in one new way because we were trying to put the student in front of clinical cases. We ask [for] almost a 400 clinical teacher or hospital teacher to give us some clinical cases, very accurate with a document with articles. And then the students who were working with those cases. Then we give them a little face-to-face, maybe on some or in teams, work together with their teachers that way we do it. First, in a flip mode, technical cases with all the very, very long case with a review on some of the stuff like that. And then they work with the teacher in a time face to face. I think they work … We have two educational platforms from some editorials like my or Panamericana Editorial, Panamericana from Spain. And we work in that way too, in a very self-assessment student’s way. And then with a teacher with a clinical teacher.

Dr. Thomas Mennella:

Mm-hmm (affirmative). Dr. Bansal?

Dr. Sandeep Bansal:

Hi. Just to correct a little, I’m from TCU and UNTHC School of Medicine. TCU stands for Texas Christian University.

Dr. Thomas Mennella:

My apologies.

Dr. Sandeep Bansal:

No, that’s fine. University of North Texas; this is in Fort Worth. So one beautiful thing is we are a very new school with an innovative medical curriculum. We have no lectures. It is purely flipped classroom based curriculum. Students learn their material before coming to class to apply what they have learned. So our all in classroom sessions are purely application-based sessions. So this actually made it a little easier for us because we were already kind of using something that came handy in this COVID-19 situation. I call it like using synchronous and asynchronous learning because it’s asynchronous is occurring when students are preparing themselves, they are gathering knowledge, they’re learning in their own space, at their pace. And then when they come to class, then it is synchronous to engage into our application sessions. So what we did, we are now using different ways. Mostly we are trying to duplicate what we did in class in real-time to present it online. We are using TBL format or case-based learning format, or sometimes a hybrid to try to engage students and make these sessions meaningful. Now, one challenge that has been shared by other universities also. I am a member of [the] marketing committee of TBLC in based learning collaboration. So we were talking the other day, people from Australia, people from Northern America and elsewhere, they all have this challenge of engaging students online. Obviously, when you are in real-time, you can go and show cues and motivate students physically with eyes. And you can give cues, but now being online is really a little challenging. But as we move forward in our discussion, I think we have to think about a little more about, do we really want to just duplicate what we were doing before COVID now trying to achieve the same thing, the same way online? Without talking much I think I will just leave at this point to come back to this as we discuss.

Dr. Thomas Mennella:

I think a great point. It’s certainly something I want to circle back to is how do we change our modality and our delivery, learning what we’ve learned? But you raise another really interesting point that I’d like to pick up on. Dr. Gopalan, I know you’ve been flipping for a very long time. Dr. Castro, you’ve begun experimenting with best practices of Flipped Learning, and Dr. Schwartzstein, I had the privilege and honor, and pleasure of sitting in on a day of your instruction there at Harvard Medical School, where you applied your novel case-based peer instruction model, that’s flipped. So to the group, how had your previous experience with Flipped Learning changed your transition to the online modality in the pandemic? How did it grease those wheels? What did you learn by being a flipped instructor first that altered your adaptation to the pandemic?

Dr. Richard Schwartzstein:

So maybe I’ll start with a few things. And I want to point out one of the problems that we had as a school that has a national student body, international to some degree, which was when the students went home in March. And this is just something to think about. They’re all on different time zones. So we have a class that starts at nine o’clock Eastern time in the United States, and God knows what time it might be for 5:00 AM on the West coast, to people who are in Europe and all over the place. And that was a real challenge. The other big thing was the students from under-resourced backgrounds, people who came to us on scholarships and all these sorts of things, they didn’t necessarily have good WiFi where they were. They didn’t have a quiet place sometimes in their home or they were suddenly responsible for some childcare of younger siblings because the parents were having to do other things and everybody was home from school. So some of these things really interfered with our ability to connect with all the students. And I would say that in general, when we were online, we never had a full class. And obviously, when we’re in person, everyone is there because they find the interactive stuff so useful and helpful. And this was just a challenge that we had not anticipated, and I think anybody who has a national or international body of students who are not going to be onsite, they need to consider that. To get more specific…

Dr. Thomas Mennella:

If I could jump right in though, to make one point. I think it’s incredibly interesting that what you expressed about under-resourced students and the type of technology and access they have at home is something we’re hearing in education from kindergarten now, all the way through medical school. These are the challenges that all educators were facing in the pandemic. I just think that’s incredibly interesting, but please continue.

Dr. Richard Schwartzstein:

Yeah. And then I would just note that I think interesting the students really wanted to do exactly what we did in the classroom, and we tried to replicate that as much as we could. But then having learned that it didn’t always work as well, tried to come up with other things, whether it was virtual office hours, whether it was times just for people to aggregate socially a little bit. They missed the casual conversations that were going on before class or during a break between classes. And so now one of our challenges, how do we go back and rethink some of those other things that we take for granted when we’re all together that actually contribute in a significant way to the trust, to the safe learning environment, to the peer interactions that are part of these new pedagogical approaches that we’re all taking? And so we’re heightened much more on those things that occur around the periphery of the pedagogy.

Dr. Thomas Mennella:

Yeah. The social aspect of Flipped Learning is I think a piece of the magic that we never really saw because we were so entrenched in the education, but yeah, that interaction between students and the relationships that build between students and faculty, one of the hallmark best practices of Flipped Learning, and it’s not as easy to capture online.

Dr. Sandeep Bansal:

And I was actually thinking of, as it is rightly pointed, I think that was all around the world we are focusing on economy, only economy, only economy. Absolutely. That is important. No doubt about that. Otherwise, we won’t be sitting like this. Similarly, I think even in universities, we are focusing primarily on building our courses and letting our students to know, and I’m listing all these assessments, but I think as you rightly pointed, social aspect is very important. Psychosocial wellbeing is so important and it’s not that we can’t do it. We should allow, in addition to teaching a direct interaction between students and faculties. Students should be able to hear from faculty how they are managing in these difficult times, how they are balancing work with their personal life. Right? And then let students to talk about it. I think that opportunity to be listened, I think that can alleviate a lot of anxieties that might be they’re well hidden in every other student. So just to point, my point.

Dr. Jose Felix Castro:

That’s a very, very good point of view doctor because here in Mexico, I was working with almost 60 residents from four different hospitals, pediatric residents. And even in each time that we gave them feedback from the class that I put on a repository of learning or learning repository, I was talking to them how they feel, what they were doing. I have to say that I record these feedback because all of those residents that was on the hospital in the time of the feedback, they can see the feedback recorded. And then I worked with them with some solid videos about what was doing other people in the world. I think inspirational videos to get involved in the clinical case because you have to see the person that is behind those health professionals. You have to connect with them. You have to be involved with them, to be worried about what they are feeling, how they are in this middle of uncertainty times, you have to work with that part of the people. It’s not only the medical knowledge, you have to give a little bit of humanism or professionalism to them because that’s the point, the medicine and the person both are in the same way. That’s a very, very beautiful point of view, doctor.

Dr. Sandeep Bansal:

Thank you.

Dr. Chaya Gopalan:

I gave the students this ownership. I pulled where students had to say what times were good for them to meet for our synchronous portion of the course, because again, students are spread out. Now, one is in LA, one is in New York and what time is ideal? And I wanted to create a window of time that is ideal for everyone. So we meet at 10 o’clock, which is eight o’clock in LA and 11 o’clock in New York. So, that kind of ownership is probably a good thing. They have a voice to say, “No, this is my ideal time.” So that was how I started the semester using data input and then giving orientation of the course management system, where things are and what they should be accessing, when and how to use the discussion board.And simplify things, make it easy for them to access. Lay down the dates, the due dates, and just don’t put all the unnecessary details, keep it simple. And that way they can navigate through the course management system. And we also are concerned about the social aspects between the instructor and the students and among the students themselves. And I feel that Zoom is a very good way to connect with students. I meet with them one on one, I meet with them during office hours, and I feel that we are more connected this way than before. When we were in a face-to-face setting, they were hanging around somewhere, and then only during class time I would meet, but now they all connect with me even more. The conversations have been very, very interesting and I get to know them. All the positive feedback that I give is kind of keeping our relationship much more stronger than I had imagined pretty much. And the breakout room is what the students like because then they have their own small group activity that they look forward to because it’s the same group that meets every class. So there is that continuity maybe that’s my learning this class.

Catherine Snelling:

Just getting back to the original question about flipping. I’ve actually been flipping for many years. I am somewhat of an early adopter of it. And it’s actually been really interesting this time because it’s made me very reflective about this context. Suddenly things I might’ve thought were when I say flippable, I know that’s a silly word, but I think the idea of asynchronous and synchronous sits very well with me. And I’m looking at it through a different lens now because of some of the things that we’ve spoken about. But also too I’ve spent a lot of this last three months doing a lot of peer support. Because probably like most of us, the spectrum of staff capability in this space would be zero to a 100 in any institution. And so I felt that the peer support and collegiality has been, I hate using the word unprecedented, because it’s used all the time about these times. But it’s actually brought out some amazing generosity that maybe we just all got busy and forgot about the important things, but people felt very overwhelmed. A lot of my colleagues, who’d never used technology are terribly overwhelmed. And I think that that’s been a really important part of it too, that there’s been a lot of really good peer interaction and in this time, and I would say that that’s not just not at my institution, I’m sure it’s across the board.

Dr. Thomas Mennella:

Grace is a word I’ve heard bandied about. And I think that’s the perfect emotionally charged word for what’s been happening. We’ve been giving each other a lot of grace and rightfully so. I’ll comment that I’ve been flipping for many, many years as well. And I always thought of flipping breaking down to passive and active learning in the individual versus group space. When I had to migrate my instruction to completely online, I quickly realized, and I never really articulated it until I heard all of you speaking today, but I realized it also breaks down to individual and social, and not so many relationships and deep relationships in the individual versus group space. And I scrambled to create those environments and those places for students to work together and socialize in the material. So I think it’s really reaffirming that that’s coming out here. So what I’m hearing from you, as you continue to discuss this is both reassuring and not surprising. It’s that you’ve seemed quite pleased with how some things went and that there were still some challenges and some gaps that weren’t filled. So I’m curious if a second wave occurs or if we never fully emerge out of lockdown, and we go into the next academic year in the same type of pandemic mode that we were now, what specifically would you continue to do the same way and why, and what would you change and continue to innovate? And why would you think those changes were necessary? Dr. Castro, maybe we’ll start with you.

Dr. Jose Felix Castro:

Thank you. We are working right now. We are in the middle of pandemic time. I think we’re going to stop almost in July or maybe until October. We don’t know. We really don’t know, but we are in the top of the pandemic time. We are working in a hybrid way to set clinical learning. We are trying to … What do you think we are teaching our teachers to use a platform as a YouTube, as Microsoft Teams or maybe hearing Zoom. But we are where we were trying to operate in a clinical way. We have to set them in a clinical scenario. They had to work in that scenario, maybe in a beautiful simulate, a scenario or clinical scenario. Then they have to get back or feedback the teacher with the doubts or maybe questions about the patient, about the treatment. And then in a thorough space, they’re going to have a face to face feedback where we’re going to do in the first part of the semester, in that way in a beautiful way. We hope that in September or in October we can get back to the university and then in a real face to face live time, they’re going to do it. But we have to be very, very specific in how, I use the word a lot of times, optimization of the learning. We have to make our teachers give that information their cases in a very, I have to say, in a very inspirational or very beautiful way that the student wants to keep it. Then we’re going to work in a very structured way in questions and how they treat, how they decide. We have to put very big attention in how they are thinking in a critical thinking. We are going to work in a clinical scenario, beautiful scenario simulation, and that feedback with the teacher that the way we’re going to do it. Flipped Learning is right now a very inspirational way to do it. And we want to try to get involved or all of or almost 500 teachers, they can carry about the clinical teacher in the hospital. And 100 teachers in the campus to get involved in this new way of doing the things. Because I mean, I am fighting with this in a way of some universities to give one classroom hour in a one Zoom hour. It’s awful. It’s awful. You can’t do this. You can’t do this because the student is getting boring in this manner, in this way. We have to change with inspirational with instructional keys, the pedagogical keys to do it. That’s why we’re going to do it in a hybrid way.

Dr. Thomas Mennella:

Very interesting. How about some of your others? What are you going to keep doing the same and why, and what will you be changing if you need to continue teaching in this way?

Dr. Sandeep Bansal:

Well, I can start. I think there are two scenarios, one is a second wave of COVID, and we are confined again the same way we were a month ago because now things are opening a little bit. Or if we don’t have a second wave of restrictions, continue to be in place to limit our movements to certain significant level. So, first I’ll talk about if there is a second way when we are confined in the same manner, I think that would be disastrous. If we continue doing things or we were forced to do overnight as we turned our eating styles to online using Zoom, which available and other things. If that is what we are going to face, I think we should make sure that, in addition to just focusing on teaching, we put a lot of emphasis on psychosocial aspects. I always have advocated for something similar town hall, or you can say a social or support group set up where everybody comes with their coffee mug, and we all are having coffee and chatting and sharing our lives and sharing our experiences and how we are going through this thing. I think that can be very positive for students as well as faculty. And as you said that it can build a confidence between students and faculty. And they would know students should not be left alone thinking that faculty is a group and they are designing this curriculum for a purpose because they have to, I think it should be a shared decision between students and faculty, especially this is more important than ever before now. Students should feel that what faculty is doing is for their benefit, and they are aware of all the issues that everybody’s going through, and they’re doing their best to achieve the best out of this students with student-centered approach. So that’s what I will do if COVID-19 hits us again in the same way. But if not limited restrictions, and you can say a stepwise opening of this lockdowns happens in the subsequent months and we are comfortable carrying forward our Zoom style of teaching. I think in that students are not that bored because they have the liberty and ability to go out between the classes. They can go to pubs, they can go shopping and other things obviously using all the precautions, masks and sanitizer, all that thing. So I think that would be a little different scenario and we can hope that students will be more engaged, they would have learned more about the situation. Because I’m really worried about this isolation. Isolation is killing. I mean, this is something I take it very seriously.

Dr. Thomas Mennella:

And that transcends to the education.

Dr. Sandeep Bansal:

Yeah, we can look happy out from outward, but what inside goes it’s very difficult to really judge when you don’t have anybody to really give ears to listen to your story. So that’s why I always advocate to create a social environment for students, especially in these difficult times. Having coffee and chatting, half an hour, more than an hour. Well, you never know how far these things, little things can go.

Dr. Richard Schwartzstein:

Just to build on that a little bit. We’re now talking about for our next entering class, that the faculty would all record a sort of low tech thing, even just with your phone introduction of themselves. Three to five minutes, this is who I am. This is what I’m interested in. This is why I love teaching, you know, whatever, and probably do the same thing for the students. So that as a recording, you could go back, you could look at it at another time, but it’s sort of building on the social way, the sort of things again that we take for granted, now we have to be much more explicit about. The one big area that I worry about is still physical diagnosis and how we can really do that virtually. I’ve been thinking about ways of more demonstrations of that, certainly from a teaching side, but of course, them practicing and getting feedback on what they do. Again, we may have to go into more having that record, trying to do this on a friend on a family member. Who knows? But something like that as a way of trying to still get some of that physical exam skill and instruction to take place.

Dr. Sandeep Bansal:

That’s right, I think that teaching clinical skills is more challenging then, yeah.

Catherine Snelling:

Well, I think you could all appreciate that you don’t really want to go to a dentist that’s never taken a tooth out on a real person. I’m sure you don’t. And I’m not making us out to be any more special, but we have got I think the theoretical side of it is one thing. And I think the clinical reasoning, which goes hand in hand often with the patient interaction is another. And we’ve been pretty nimble at being able to start to put a lot of that stuff together online. Our students, as I think it’s pretty common now in most dental schools around the world are very heavily immersed in simulation. We have a sort of a philosophy here at our dental school that a student is not allowed to do anything on a patient that they haven’t done on a mannequin or in simulation, because it’s a really important part of the learning process beyond the safety. When I was a student, and this is showing my age in stage, we used to practice taking x-rays on each other I mean. I love scaring the students with all those stories. Now we have some amazing simulation, and I know it’s right across the health system and we’ve actually had to simulate the simulation quite a bit in the last few months. We’ve had students practicing their instrumentation using a tissue box as an open mouth and getting hand wrists. And it’s been great, but nothing will replace the hand wrist being on a real mouth. And that’s for us going to be the biggest thing that’s going to be a threat if we get a second wave, because that will wipe us out and I don’t want to sound dramatic, but it would wipe out this year’s class.

Dr. Thomas Mennella:

So you, you lead to my next question. I’m a preclinical instructor. So I teach undergraduates who are health science majors of various disciplines. And all of you are clinical or preclinical as well. And I have my own personal feelings about simulated labs at the undergraduate level and at home labs and how in my opinion, they don’t come close to approximating the experience that we can give students in a university laboratory. So my question for all of you briefly, but by all means share your full perspective. In your opinion, can clinical or preclinical instruction ever be a hundred percent effective in a 100 percent online modality? And in your comments, imagine you had the magic wand of unlimited budget, unlimited technology. Is there anything out there that could get us to a hundred percent effectiveness that right now is just cost-prohibitive? Or is it just that we don’t have the technology and the resources right now to train clinical students in a completely online space?

Catherine Snelling:

I’m going to say no, in my discipline, I’d love to be proven wrong.

Dr. Richard Schwartzstein:

I think we could do a great deal of it. Again, the clinical and physical exam parts we could get closer. I think what the cost here would be faculty time. In other words, if I could work with a group of four or five students instead of a larger group, even 45 students that we have in our sections, I could probably really recreate it. I could get that relationship with them. They would get comfortable with each other. We could do almost everything that we do in the classrooms now virtually, but it would require smaller groups and more faculty time I think.

Dr. Jose Felix Castro:

I think we have new methods to do this. I am trying right now to, to get some videos from our clinical teachers like these police cams that they have on them. And they talk with the patient. The student has the perspective of the teacher talking to a patient or doing a procedure and trying to do these with our pneumologist on one hospital and maybe going to work. It’s not the same. We won’t have the 100 percent because we don’t the real patient, but we can do a lot of new work a creative work as a Dr. Richard said. And we can do it. I think we’re not at 100 percent, but we can do some things very interesting.

Dr. Sandeep Bansal:

I see it as we use imaging techniques where somebody is examining x-ray film or CD film. We are trained to see what is hidden there. Right? So similar to that, I think it’s like telemedicine. You should be trained to see how the mouth will look through camera if you have to examine pharynx s or something. You don’t know if in future, it’s like a future talk, right? If we don’t know whether we will be able to, anything can happen. So well we will be really able to interact with our patients the same way in the coming time. We are thinking maybe it will be all over in one month, two months, but it’s all uncertain. So let’s say, I think it’s like teaching our students for future. I think all technology, all innovations are coming up. Maybe they reteach like how to make use of technology to teach medical diagnosis and clinical skills remotely. I know this can, somebody must be working on this. /that’s why I gave an analogy of like seeing x-ray films. We were trained to see what is there similarly, how the mouth looks when you see it on camera. A white patch is not abnormal for example, in mouth, which is just a reflection of tooth or something.

Dr. Thomas Mennella:

Dr. Gopalan, how about you?

Dr. Chaya Gopalan:

I do preclinical classes. So for me, the worst is over. The surprise is over. We now know how to handle it. If it were to repeat again and we would be better prepared. And because we have been flipping, the transition has been very easy and doable, manageable. So I think it would not be a big surprise anymore.

Dr. Thomas Mennella:

So let’s peek behind that curtain with our parting question for each of you, what are each of you specifically preparing or doing right now, as you look forward to the teaching you expect to do in your next term, in your next session?

Dr. Chaya Gopalan:

If there is COVID separation or if there is no separation?

Dr. Thomas Mennella:

Well, that’s part of the question. We all have that uncertainty from our own administration. So what are you doing even in face of that uncertainty?

Dr. Chaya Gopalan:

Yes, the university is encouraging faculty to evaluate their best teaching practice and to minimize the number of students on campus. And if there is a lab course there, if they cannot do it online, they would be given preference over those who are able to manage virtually. So yes, I told them that I will continue to do what I have been doing right now. A mix of synchronous and asynchronous online teaching is totally manageable for me.

Dr. Jose Felix Castro:

Here we have three different scenarios with a full school and full hospital attending as normal I think is not possible. The second one is with half of students on classroom and half of our hospital working with us and a new one is all virtual. And we’re working with the worst scenario there is this one in all virtual, and we are trying to change the mind of our teacher that’s our working right now. We have two months to get involved all the teachers, and in these tools in these virtual tools. And then we have to work in clinical scenarios and then how they going to feedback because we don’t want classes online all the time. We want only discussion. We want only put scenario in practice with discussion, with critical thinking, and that there’s the way we’re doing. We’re preparing for the worst-case scenario all virtual, with no hospital, with no patients, and we’re going to do these clinical videos with virtual simulation, or even with real question but only filmed with their doctors, with a clinical teacher. As we are to work right now, we have two months to get all the stuff on.

Catherine Snelling:

I’m currently developing some virtual patients because our students are returning to clinical practice on the 13th of July here. But due to social distancing, they can’t see as many patients, not because of them. It’s because of the size of the waiting rooms. The waiting rooms are only a certain size, so they can only have a certain number of people in them, which then means the students can’t see as many patients. So we’re devising a series of virtual patients to supplement the real patients. And they’ll actually be appointed each week into an appointment book, a virtual appointment book, and they’ll be presented each week with information about that patient. They may virtually take a set of x-rays just like they would in the clinic and then book that patient in for the next week for what they find. So we’re trying to supplement the real thing with as much as can to give them that, because a lot of it is psychomotor, which is just basically practicing the dexterity of something, but so much more of it is up here, understanding why you’re doing the psychomotor. So that’s what I’m working on at the moment. I’m actually using some students to work with me because I think it’s really important to get their feedback because sometimes we forget about what a student sees. So I’m a big fan of working with students where I think it has great value.

Dr. Richard Schwartzstein:

I’ve mentioned some of the social things that we’re trying to do already. I also, because I love to draw things in my teaching experimenting more with a surface computer or iPads. They’re not quite as adaptable for some of the technology in terms of Zoom as I would like, but trying to figure out ways that I can draw a better for the students in the midst of teaching. We’re looking at virtual OSCEs where students can demonstrate clinical skills at home and have us watch what they’re doing. And I’m thinking about developing more ways of examining a patient, probably a college student who’s healthy, but demonstrating physical like diagnosis, recording that with links to the physiology at the same time. So make more explicit how, what we do with the physical exam relates to anatomy and physiology and create more resources for students to use in place of trying to be right there at the bedside with you.

Dr. Thomas Mennella:

Dr. Bansal, did you want to offer one last parting plan?

Dr. Sandeep Bansal:

So our plan is same for the upcoming class. We, as I shared already had flipped classroom approach and most of the stuff for pre-reading was, all of the stuff actually was online. Students were reading, preparing for the session in a synchronous manner. And the only thing that we are doing is we are transforming real time classroom communication sessions to online sessions using case-based or TBL format. And we will continue with that using Zoom at the time, what we are using, I think we have to be just reflective a little bit more on how to invite more student engagement, how to manage their anxieties as it continues. And to make them feel that they are partners in this educational journey. We are doing everything for them. All the efforts are directed toward their success. So I think these will be … I’m not talking as a representative of school, but this is how I envision and I expect things to go forward.

Dr. Thomas Mennella:

So before we close, let’s step into the gray just a little bit, because each of you have a foot in both ponds so to speak. You’re medical health professionals, physicians, and dentists. You understand this virus and pandemics in general, but you’re also educators in higher education. And you work for institutions who require students and tuition revenue to function. Given those two ponds that each of you are so familiar with, how much incentive, how much motivation should higher education have to reopen and at what medical and risk costs does that reopening occur?

Dr. Richard Schwartzstein:

The clinical level, we have reacted in a different way than what the original AAMC recommendations were, which was to get the students out of the hospital. And we have put our clinical students back, and we have made a very explicit statement that they must be there because they are part of the teams, and that is how they learn and the professionalism and other issues that are part of their training in this context are important as well. If we take them out again symbolically, what we are saying is they are superfluous to the teams and that will lead to a downstream effect potentially in years to come of them being less involved by the clinical services. So that’s been a very thoughtful discussion among many people at the med school decision that we must do that for our clinical students … The residents. We went through this with the residents a little bit early on, and should they go into the rooms? Should they not go into the rooms? And so forth, and we said, “No, this is part of the transition, the professional identity formation, which is so, so critical.” I think on the pre-clerkship level, we’re hearing it less than I sense the undergraduate university. A part of the university is hearing about this in terms of delaying. We’re not getting a lot of that sense. I think students appreciate that they can get at least close to what they normally would get because we’re working so hard at doing this with them. And the classes are probably a bit smaller than you in the undergraduate curriculum. So I don’t think we’re feeling that as much. But in terms of bringing them back, the clinical students, yes, but they tend to live like all of us, in an apartment, in some house they’re not in a dormitory. The dormitories worry us more for the pre-clerkship students. And so we are less likely to bring them back and still continue with remote learning regardless of some students perhaps being reticent about participating in that.

Catherine Snelling:

Well, I guess just our experience here in Australia has been very different. We’ve had no active cases in the state that I’m in for almost five weeks. So it’s a very different scenario, but I think the original question about the foot in both camps is that I think we’re always very much relying on an evidence-based approach. And I think that the decisions made here have been very prudent. It’s left to somewhat isolated. We already are. We’re now more isolated, but I don’t think in my own personal area here, it’s too much of a risk, but I think different jurisdictions, there’s going to be different answers, but based on the evidence and the statistics here in South Australia–all Australia has only got 30 active cases. I know we haven’t got very many, we’ve got 25 million people, but it’s been a very different experience here for us. And I think our isolation, the fact we’re in Ireland and we have very low-density cities in terms of the spread of the housing has meant that we can probably make these decisions with not quite the trepidation that perhaps more populated places in the world have to grapple with.

Dr. Jose Felix Castro:

Here in Mexico we are working in that. We are thinking all people is infected that the way that, we have to see the patient, we have to see your permit. Then the isolation mood is in top. You know, we are a developing country and a lot of people has to work every day and it’s difficult to take them to their houses. Our students are working in that. That’s we are thinking that we won’t have hospitals in the next period. In every classroom, we’re going to have all these sanitation rules, and we have to work with half of our students. Each time I’m thinking doing almost as a Flipped Learning divided or shared, I know how to call them. We’re going to flip all the spaces clinical scenarios and then work with the discussion in a real face-to-face time if we have the classroom available or the university available, and we’re working in that manner. And there are some students that they won’t take the internship or the clinical semesters, but there are a few ones. They want to work with the school. They want to continue their dreams to becoming doctors. We have to take care of their integrity. And we are working in these clinical virtual scenarios and to work with them to be safe with them because all our teachers that are too in danger because they are working in hospital, and then they go to the university, to the campus. And we have that the different scenarios, but we are working with all of them. We don’t have … On the student and our own teachers too.

Dr. Sandeep Bansal:

So my take is necessity versus what is right thing to do? So opening universities, is it a necessity to keep them alive? Or is it right thing to do right now, or sooner than later to open them for a purpose? I would say that public confidence and government decisions is not that great today. Let’s say tomorrow, the government declared that it is safe to go out because there is no new case, an active case reported. Do you think the parents of students will be confident enough to send their children back to campus the very day the government declares and the university is saying, “Okay, we are open, come here to learn.” I think that will be a little challenging. It will take some time because the way the last two, three, four months have unfolded, well from the government side jurisdictions, how they have tried to guide us. I think people have lost a lot of confidence just to listen to them, to drive their lives. So I think Chaya is about to say something, please jump in-.

Dr. Chaya Gopalan:

I know our students also missed clinicals for the last three months, but they’re now back in their training. What the program did was to shuffle their reading heavy courses and move the clinical dates around so that they can still graduate. They can still fulfill their training as best as they could. And there are other limitations, like supplies of BP probably is not uniform. And those are some challenges that the universities are dealing with. And so given the circumstances, we are offering the best experience for our students and shuffling the curriculum in such a way that they are not missed out.

Dr. Thomas Mennella:

So I’d like to close by thanking this wonderful panel for an amazing and fascinating discussion. I think if you were to ask us a few months ago, what we would have foreseen as our biggest challenges, it would have been delivering a quality education. And from the sound of this panel, I think we all achieve that far beyond what we may have anticipated before. The challenges we did face are challenges we could probably never appreciate or foresee. The latent social aspect of learning–that’s always been present in our classrooms and among our students, but that maybe we never fully realized or embraced. In addition, lack of WiFi or lack of technology at home as well.

We also have unique challenges and those challenges are on the interpersonal connections that are made during clinical instruction. Having the feeling of a wrist, resting on a mouth, having the personal diagnosis into sitting across from us on the table. And these are challenges that we continue to face and continue to try to innovate around. It’s often said that necessity is the mother of invention. We definitely have a necessity now, let’s see what inventions come about. Thank you all for your time and for joining us, this was a wonderful conversation.