Pandemics and Their Impact on Medical Training: Lessons From Singapore.

The ongoing coronavirus disease 2019 (COVID-19) crisis has hit Singapore hard. As of February 25, 2020, Singapore had the fourth highest number of confirmed COVID-19 infections outside of China, only trailing behind South Korea, Italy, and Japan. This has had reverberating effects on Singapore's health care system, and has, consequently, also affected medical education all the way from the undergraduate to the postgraduate level. While efforts are underway to contain disease spread and transmission, the authors believe that this is an opportune time to examine and reflect on the impact that medical crises like COVID-19 can have on medical training and education and to evaluate "business continuity plans" to ensure quality medical education even in the face of constant disruptions from pandemic outbreaks. Medical training is as important a mandate as patient care and service. The authors believe that even in trying times like this, rich and precious lessons can be sought and taught, which will immensely benefit medical students and residents-the health care leaders of tomorrow. In this Perspective, the authors discuss the various ways in which the COVID-19 crisis has affected medical instruction in Singapore and explore pertinent practical and creative solutions for the continuity of medical training in these trying times, drawing on their previous experience with the Severe Acute Respiratory Syndrome outbreak in 2003 as well as the current ongoing COVID-19 crisis.

The turn of this decade has seen China, and increasingly the world, being inundated by the emergence of the coronavirus disease 2019 (COVID-19) crisis. The first cases of COVID-19 infection were reported in late December 2019 as a cluster outbreak in Wuhan, China, in patients linked to a seafood wholesale wet market.[1] Since then, it has spread to involve countries across multiple continents—all in the space of 2 months. Infectious disease pandemics respect no boundaries and have rippling effects, which reverberate throughout global health care systems. COVID-19 is not the first, and will certainly not be the last, global health emergency that we will encounter in our careers as health care professionals. In the past 2 decades alone, we have witnessed a deluge of emerging infections, for example, the Severe Acute Respiratory Syndrome (SARS; 2003), the H1N1 swine flu (2009), and more recently the Ebola outbreaks (2016). These outbreaks will only become more commonplace given increasing urbanization rates, the widespread accessibility of air travel, and worsening climate change.[2] Hospital resources will be stretched in efforts to manage and contain these outbreaks. This may result in medical training taking a back seat, as critical resources are channeled toward frontline efforts to combat outbreaks. Medical education is just as important a mandate as patient care and service. Given this and the increasing occurrence of viral outbreaks, contingencies should be in place, ready to be activated to minimize disruptions to medical training. We believe that this is a timely opportunity for medical educators to examine and reflect on the impact that medical crises can have on medical training and education and to evaluate their “business continuity plans” to ensure quality medical education even in the face of constant disruptions from pandemic outbreaks.

How Have We Been Affected?

Singapore has been hard-hit by the COVID-19 outbreak. As of February 25, 2020, Singapore had the fourth highest number of confirmed COVID-19 infections outside of China, only trailing behind South Korea, Italy, and Japan.[3] With the escalation of Singapore’s alert status in response to early community spread of COVID-19, there have been reverberating effects on Singapore’s health care system. Consequently, medical instruction all the way from undergraduate to postgraduate training has been invariably affected. Clinical rotations for undergraduates have been suspended immediately; interhospital residency rotations and combined teaching sessions have also been ceased until further notice. Nonurgent elective surgeries and clinic consultations have been postponed or canceled to prevent hospital overcrowding, protect vulnerable patient populations, and free up hospital beds. In this, procedural specialties are perhaps the most adversely affected. For residents in surgical and other specialties heavily skewed toward elective and nonemergency work, this will inevitably affect their hands-on surgical experience and case logs, significantly disrupting residency training. Considerations of whether the fulfillment of entrustable professional activity targets in clinical training can be met in this situation of reduced clinical exposure present both educational and professional conundrums. The situation is compounded by the tremendous amount of uncertainty surrounding such viral outbreaks. No one is the wiser as to when an outbreak will abate. To suspend training indefinitely would be unnecessary and impractical. Medical educators will need to innovate and think out of the box to maintain quality medical education amid this current COVID-19 pandemic.

What We Can Do as Medical Educators

Crises like this are opportunities for medical educators to leverage technology for both undergraduate and postgraduate medical education. While newer initiatives such as webcasts are increasingly being adopted, in-person didactic lectures and tutorials still remain a significant cornerstone of medical education. Given the highly infectious nature of COVID-19, and likewise most emerging infections, face-to-face interactions in large-group settings (such as lectures) can potentially be hotbeds for disease spread and transmission. To circumvent this, technology, for example, videoconferencing[4] and e-learning platforms,[5] can be used to deliver lectures or tutorials remotely via handheld devices and laptops. Faculty, residents, and medical students can then log in at designated times for discussions, which can be facilitated in real time via teleconferencing applications. In addition to lectures, teleconferencing can also be used to demonstrate medical procedures and surgical techniques.[4] Centralized teaching will, thus, still be able to continue even with the cessation of in-person lectures and interhospital movement. Lastly, residents and medical students should be encouraged to use online resources to facilitate their individual learning. In particular, for procedural specialty residencies, remote instruction via instructional videos or online webinars can be integrated into training programs. Faculty can follow-on with online discussions to further help residents consolidate their learning. Courses emphasizing skills in open communication, medical ethics, and even clinical research or statistics can also be organized via online modalities for medical students or residents to enable them to develop into more holistic medical professionals.

Medical education cannot only be about the imparting of domain-specific knowledge and skills. A highly skilled surgeon or knowledgeable physician does not necessarily make a good doctor. In addition to domain-specific knowledge, holistic noncognitive attributes such as teamwork, empathy, courage, and compassion are important qualities that should be inculcated in every medical student and resident in training. The involvement of medical students and residents in crisis relief work can help achieve this. In 2003, during the height of the SARS outbreak in Singapore, medical students were called upon to help with temperature screenings. With the COVID-19 crisis, residents across medical and surgical specialties have been rostered for shifts on the frontline, where they have assisted (and are still assisting) with the screening of suspected cases in the emergency department. Besides easing the manpower crunch, this has helped foster camaraderie amongst residents as a medical community, galvanizing them to combat this pandemic on a united front. Through this, residents have been taught important lessons in courage, empathy, and teamwork. It has also provided the opportunity for specialty residents to revise their general medical skills, which can sometimes be forgotten after years of highly specialized training.[6] This can only bode well for their development as holistic medical professionals.

In addition, pandemics provide an avenue through which to inculcate and further hone residents’ skill sets pertaining to systems-based practice, organization, and leadership. For example, our emergency medicine residents have been intimately involved in the designing of practical workflows for managing patients presenting with respiratory or fever symptoms during the COVID-19 outbreak. Important lessons in the rational management of limited resources that are in high demand have also been taught, with residents having been given real-life lessons on the optimization of limited resources, for example, the allocation of limited isolation facilities against the ever-increasing number of febrile patients. These learning opportunities can be hard to come by in training. For medical students and residents to fully benefit from these rich and precious lessons, medical educators should incorporate reflective practice into their medical teaching to encourage deeper introspection.[7]

Furthermore, pandemic crises are extremely fluid; plans change by the day (or even by the hour) and situations can exacerbate acutely overnight. These can be lessons in versatility, adaptation, and leadership as residents learn to adapt to ever-changing plans as the situation evolves. These skill sets are important attributes for the future, which medical students and residents will need to master as they develop into the health care leaders of tomorrow.

Conclusions

Medical crises like the COVID-19 outbreak will undeniably affect medical training. However, contingencies should be undertaken to minimize disruptions. Technology can be harnessed to facilitate medical instruction and courses emphasizing skills such as open communication and medical ethics. Beyond domain knowledge, the involvement of medical students and residents in pandemic efforts can be beneficial for their development of holistic noncognitive attributes such as leadership and adaptability. As medical educators, we can and must rise up to the challenge of continuing to teach even in times of crisis. The time is now.