Introduction

In December 2019, a statement was released by the Wuhan region of China describing cases of viral pneumonia. The causative virus was identified as SARS-CoV-2, the novel coronavirus that causes COVID-19 [1]. As of December 16, 2022, there have been nearly 650 million confirmed cases of COVID-19 globally, and over 6 million deaths worldwide. The first case of COVID-19 in New York State was identified on March 1, 2020, and the first case in Westchester County was identified two days later [2]. During the ensuing days and weeks, there was rapid community spread of SARS-CoV-2, and COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020. On March 15, 2020, NYMC made the decision to suspend all clinical rotations for third- and fourth-year medical students. In response to this decision, clerkship leadership was tasked with designing new curricula that fit within these evolving guidelines. Within 24 hours of this announcement, the virtual pediatric clerkship was designed and implemented, and modifications were made throughout the clerkship. In July 2020, medical students were partially allowed back into the clinical arena; the hybrid clerkship was developed.

To our knowledge, there are no studies comparing different curricular models of a single clerkship in response to the COVID-19 pandemic. Previous studies have described changes in clinical education due to COVID-19 restrictions in many fields [313], most of which have been brief and largely descriptive. Some authors have performed systematic reviews identifying challenges to medical education due to the pandemic and innovative solutions [14], others have assessed the perceptions and attitudes of medical students toward clinical training during the pandemic [15,16], while still others have argued that innovations in medical education due to COVID-19 should be studied as quality improvement [17]. Few studies have been performed describing changes to the pediatric clerkship due to COVID-19; one evaluated the virtual curriculum but did not compare it to other curricular models [18]. In this study, we analyze a single clerkship’s response to the COVID-19 pandemic over time, and use student perceptions to evaluate three distinct curricular models.

We hypothesized that medical student perspectives on the three clerkship models would differ according to the changes made in response to COVID-19, particularly regarding changes to time spent in direct patient care and virtual learning. In our study, we aim to identify strengths and weaknesses of the different clerkship models, and use medical student feedback to further improve the pediatric clerkship.

Methods

Description of clerkship models

Traditional: The traditional (pre-COVID-19) pediatric clerkship at NYMC was six weeks weeks in duration. Students spent three weeks on inpatient teams, one week in the emergency department (ED), one week in an outpatient primary care clinic, and one week in the well-baby nursery. In addition to clinical work, students participated in weekly small group sessions during which they had the opportunity to practice their presentation and clinical reasoning skills, as well as simulation days.

 Virtual: The pediatric clerkship was fully virtual for two rotations, between April and June 2020. The duration of these rotations varied from 4-5 weeks. Students spent time on different “clinicalvirtual experiences”: inpatient pediatrics for approximately half of the rotation, with the remainder divided between ED, outpatient and nursery. Students engaged in self-directed learning, including mandatory interactive virtual cases using the Aquifer platform, as well as textbook and online learning. Students also had virtual sessions with clerkship leadership during which they discussed clinical aspects of pediatrics pertinent to their clinicalvirtual experience. In addition, students continued to participate, now virtually, in weekly small group sessions, as well as virtual simulation days. To supplement the virtual clerkship, students later returned to the clinical arena during their fourth year; the survey was filled out before this return.

 Hybrid: In July 2020, medical students were allowed back into the clinical arena, with modifications. Clerkship leadership designed a 6-week hybrid curriculum, blending clinical and virtual elements. All students spent two weeks on inpatient and one week in the well-baby nursery. Only a minority of students were able to participate in outpatient clinics, and time in the ED was limited. Students spent one week engaged in virtual learning, completing mandatory Aquifer cases and meeting virtually with clerkship leadership, and those students who did not participate in outpatient clinics had a virtual outpatient week. During the hybrid clerkship, students were not allowed to see COVID-positive or COVIDsuspected patients, including those with multisystem inflammatory syndrome in children (MIS-C). In addition to clinical and virtual work, students also participated, still virtually, in weekly small group sessions and simulation days.

Participants

Medical students who rotated through the pediatric clerkship during the 2019-2020 and 2020-2021 academic years were invited to participate in the study. Students were recruited to participate in the online survey via email. Inclusion criteria were students participating in the traditional clerkship (July 2019-February 2020), virtual clerkship (April-June 2020) and hybrid clerkship (July-December 2020). Students who rotated through the pediatric clerkship from mid-February to March 2020, whose clerkship model was traditional for the first four weeks and virtual for the last two weeks, were excluded from the study.

The study was deemed exempt by the institutional review board at NYMC. Students indicated their willingness to participate in the survey electronically, upon initiation of the survey.

Measures

Surveys

Surveys were created using Qualtrics software (Qualtrics, Provo, UT) and sent to students via email. Survey questions were divided into five categories: questions related to clerkship objectives, general questions, and questions related to clinical experience and skills, readiness, and wellness. There were 3-7 questions in each category, 25 questions in total, and questions were rated on five-point Likert scales. Anchors for clerkship objectives questions ranged from 1 = not well at all to 5 = extremely well, and those for all other questions ranged from 1 = strongly disagree to 5 = strongly agree. Answers to survey questions remained anonymous. Survey data were pooled for analysis and kept on a password-protected online database on NYMC’s secure network.

Post-Clerkship Evaluation Comments

It is NYMC’s standard practice to send formal course evaluation forms to each student at the completion of a clerkship. This post-clerkship evaluation is optional and anonymous, and includes both Likert scale questions and space for the student to provide comments. Comments completed by students in all curricular models were reviewed, pooled and analyzed for themes. Statistical Analysis

All statistical analysis was done using Microsoft Excel 2021.

Standard descriptive statistics were used to assess participants’ responses to survey questions. Responses were then compared by group based on clerkship model. Post-clerkship evaluation comments were reviewed individually by all three authors and analyzed for themes. Results

Survey Data

Forty-eight students completed the survey: 18 students in the traditional clerkship model, 7 in the virtual model and 23 in the hybrid model. Completion rate was 13% for traditional and virtual students and 22% for hybrid students.

Survey questions and results are reported in (Table 1) and grouped by category. Throughout their responses, student ratings followed a consistent pattern. Average scores in all categories were consistently highest for traditional students, lowest for virtual students, and returning almost to the level of traditional for hybrid students.

 

Table 1: Survey questions and results.

To help visualize this pattern, data from the Clerkship Objectives portion of the survey are shown in the Figure. Students rated each objective as being met best in the traditional clerkship (average 4.2) and worst in the virtual clerkship (average 2.8), and then ratings for the hybrid model increased (average 3.7). For the first of the clerkship objectives, “Demonstrate proficiency in pediatric history taking and exam skills for evaluation of children of various ages”, the percentage of students reporting that this objective was met extremely well or very well ranged from 83% for traditional students, 0% for virtual students, and 48% for hybrid students. Similarly, the percent of students reporting that the objective “Employ strategies for health promotion as well as disease and injury prevention” was achieved extremely well or very well ranged from 83% for the traditional clerkship, 29% for the virtual clerkship, and 52% for the hybrid clerkship.

Regarding general questions about the clerkship, average score for traditional students was 4.6, average for virtual students was 3.5 and average for hybrid students was 4.2.

In the Clinical Experience and Skills category of the survey, 89% of students in the traditional clerkship strongly agreed or somewhat agreed “The clerkship allowed me to practice and improve oral presentation skills”, 71% of students in the virtual clerkship strongly or somewhat agreed, and 78% of students in the hybrid curriculum strongly or somewhat agreed.

With respect to readiness, average score was 4.5 for traditional students, 3.8 for virtual students, and 4.1 for those rotating in the hybrid clerkship.

From a wellness perspective, 83% of traditional students, 43% of virtual students and 87% of hybrid students strongly or somewhat agreed that “My voice was heard during this clerkship.”

Figure 1: Survey results for Clerkship objectives:

Figure 1a: Survey results for Clerkship objectives for students in the traditional clerkship model.

 

Figure 1b: Survey results for Clerkship objectives for students in the traditional clerkship model.