Development of a Single-Institution Virtual Internal Medicine Subinternship With Near-Peer Teaching in Response to the COVID-19 Pandemic.

PROBLEM: In March 2020, medical students at the University of Washington School of Medicine were removed from clinical settings in response to the COVID-19 pandemic. As subinternships are required for graduation and an important way to prepare for internship, a virtual subinternship was created to include practical elements of in-person learning and to address limited teaching faculty from COVID-19 inpatient surges. APPROACH: A virtual, interactive subinternship was developed with case-based teaching sessions, communication and critical literature evaluation skill building, professional development, and creation of independent learning plans. Near-peer teachers (NPTs) were selected from graduating senior medical students who matched into internal medicine. In addition to teaching topics from the Clerkship Directors of Internal Medicine curriculum, NPTs engaged in course development, recruited teaching faculty, gathered feedback, and facilitated small groups. Participating students completed pre- and postcourse surveys. OUTCOMES: The 10 students (100%) enrolled in the course who completed both surveys indicated significant improvement in mean scores across 4 domains: evaluating medical literature (3.1/5 to 4.5/5; +1.4, P < .001); developing individual learning plans (3.6/5 to 4.7/5; +1.1, P = .001); perceived ability to efficiently evaluate patients with common internal medicine concerns (3.7/5 to 4.6/5; +0.9, P = .004); and formulating initial diagnostic and therapeutic plans (3.6/5 to 4.6/5; +1.0, P < .001). Themes extracted from open-ended responses included initial skepticism of an online format, the course exceeding expectations, and feeling prepared for internship. NEXT STEPS: Although a virtual subinternship lacks direct patient care, students reported improvement in all 4 domains studied. Future courses would benefit from greater use of simulation and role-playing scenarios for practical skills. The experience with NPTs was encouraging, aiding in the success of the subinternship. The role of NPTs should be cultivated to fill gaps in content delivery and enhance the development of students as educators.

Problem

In March 2020, the Association of American Medical Colleges (AAMC) and the Liaison Committee on Medical Education (LCME) recommended medical students be removed from clinical settings during the COVID-19 pandemic. [1] The University of Washington School of Medicine (UWSOM) moved undergraduate medical education online to mitigate the spread of coronavirus and protect the health and education of its students. This shift to online learning presented a challenge for senior medical students with planned subinternships. Subinternships provide direct patient interaction with an opportunity to hone clinical skills and develop efficiency in conducting patient care in preparation for internship—aspects that are difficult to accomplish in a virtual setting. In addition, the University of Washington experienced a significant surge of COVID-19 cases, thereby limiting the availability of teaching faculty. We had 2 goals: to deliver essential elements of the subinternship virtually and to address limited teaching faculty availability.

Approach

We developed a synchronous virtual subinternship in internal medicine to reinforce students’ clinical knowledge and skills while fostering professional development in a supportive learning environment. Studies suggest that online learning in undergraduate health professions education is similar or better when compared with in-person learning for knowledge acquisition. [2,3] We hypothesized that while students in a virtual subinternship would not be able to gain additional experience in direct patient care, they could review the management of common concerns in internal medicine, reinforce clinical skills, and potentially feel more prepared for their internships. Learning objectives for the course were developed by the course director (S.E.M.) and near-peer teachers (NPTs, described below; M.H.H., A.L., N.L. E.d.C.) by modifying existing learning objectives from the traditional subinternship to reflect learning that could reasonably take place in a virtual setting. An overview of course structure and learning objectives is provided in Table 1. This undertaking was reviewed by the University of Washington Institutional Review Board and determined to be exempt.

Table 1

Virtual Internal Medicine Subinternship Structure Developed and Implemented During the COVID-19 Pandemic, University of Washington School of Medicine, Seattle, Washington, 2020

Differences between the traditional and virtual subinternships

Our traditional internal medicine subinternship takes place across 3 hospitals in Seattle where students are on acute care hospital medicine, oncology, cardiology, or medical intensive care unit teams. There are 6 hours of required didactic sessions for the traditional subinternship; topics include admitting a patient, common hospital emergencies, management of pain and diabetes, and antibiotic selection; subintern report sessions consisting of case discussions also take place. Students in the medical intensive care unit participate in resident teaching sessions and have recommended reading but do not have dedicated formal teaching outside of a formal ICU curriculum for all learners. As such, most learning in the traditional subinternship occurs during the course of patient care through independent learning or teaching on rounds by attendings or residents. The virtual subinternship lacked any direct patient care. The course instead consisted of case-based interactive teaching sessions, attendance at the residency program’s virtual morning report sessions, skill-building and professional development sessions, and independent study culminating in a presentation at the end of the month. The types of sessions are described below and in Table 1.

Case-based interactive teaching sessions

In addition to the 4 topics in the traditional subintern teaching sessions, we added 56 additional faculty- or NPT-led sessions to address topics traditionally learned while caring for patients. Teaching session topics were aligned with the nationally recognized subinternship curriculum published by the Clerkship Directors in Internal Medicine (CDIM). [4] The pedagogical approach for individual sessions was at the discretion of the instructor but was generally case-based and interactive; some sessions involved prework (such as reviewing electrocardiograms before a session). The students also attended the internal medicine residency program’s morning report sessions, which are designed to help residents and students practice clinical reasoning and review the diagnosis and management of common diseases in internal medicine.

Skill-building sessions

Many skills are taught or reinforced in a subinternship, including essential physician tasks such as order-writing, communication, clinical reasoning, and answering clinical questions with medical literature. Ten of our sessions targeted these core skills, including 3 on admitting a patient, “cross-cover,” and handoffs; 2 on using the literature to answer a clinical question; 1 on independent learning; 2 on clinical reasoning; 1 on communication in the outpatient setting; and 1 on serious illness communication. All of these sessions were interactive, with the instructor presenting brief patient scenarios and asking the students how they would respond. The admission and handoff sessions included role-playing and debriefing with feedback provided by faculty and NPTs.

Professional development

Opportunities for mentorship and professional development typically manifest on the wards with residents and attendings. These moments often occur briefly and informally but can have lasting effects on a trainee’s professional identity formation. To address this essential component of an in-person subinternship, we included sessions dedicated to professional development. Attendance at virtual morning report sessions allowed exposure to residents, chief residents, and faculty. UWSOM’s chair of medicine conducted a discussion with students on being a leader in medicine. A guest speaker gave a lecture about the expanding role of physicians in political advocacy and public health. Finally, a faculty member with expertise in mentorship led students through a formal exercise in which students wrote their own mission statements based on a published rubric to aid in identification of their professional and personal goals. [5]

Near-peer teaching

To address the shortage of teaching faculty as a result of the clinical surge and develop students as educators, 4 senior medical students who had matched into internal medicine and had already completed a traditional subinternship were recruited as NPTs. These NPTs were selected informally after 1 reached out to the clerkship director looking for volunteer teaching experience; she recruited the 3. All 4 enrolled in a concurrent online clinician-educator elective providing formal training in key teaching skills such as small-group facilitation. [6] The NPTs were involved in all aspects of the course, including design, faculty recruitment, and development of course and instructor evaluation instruments. NPTs also attended many of the teaching sessions, gathering informal feedback from learners to guide day-to-day changes. NPTs developed and taught 2 sessions each on core internal medicine topics chosen from the CDIM curriculum. These sessions provided the NPTs an opportunity to develop and hone their skills as educators. Learners completed written evaluations of NPT teaching sessions that were shared with the NPTs in aggregate after the course; informal feedback on teaching was also provided by learners and co-NPTs.

Independent learning plans

Sessions in the first week of the subinternship focused on self-directed learning in the clinical setting, just-in-time evaluation of the medical literature, and development of personal learning objectives. Students were asked to write at least 2 learning objectives for self-directed learning per week and to document how these objectives were met. Students could focus on any topic relevant to internal medicine that would help them feel more prepared for internship. At the end of the subinternship, each student gave a 25-minute presentation to peers and faculty targeting one of their learning objectives.

Students completed an 8-question online survey before the course and a 10-question survey after the course regarding their experiences with the virtual subinternship. Survey questions were developed by all authors using a consensus process and the questions were based on the course learning objectives. Quantitative responses were recorded on a 5-point Likert scale; the same prompts were used for 5 pre- and postcourse questions. In addition, in the precourse survey, we asked students 3 open-ended questions about their goals for the course and their feelings about completing their subinternship virtually. In the postcourse survey, we asked 1 additional quantitative question about the extent to which the course fulfilled its goals and objectives and 4 open-ended questions. The survey questions are available in Supplemental Digital Appendix 1, at http://links.lww.com/ACADMED/B138. This survey was different from the usual postclerkship survey that UWSOM students complete, which includes 19 questions, is standardized for all clerkships, and is designed for in-person clinical experiences.

Outcomes

All 10 students completed both pre- and postcourse surveys online for a response rate of 100%. We performed Welch’s 2-sample t test on mean scores from pre- and postcourse surveys. In each domain assessed, there was improvement in mean scores (see Table 2), most notably in areas of evaluation of medical literature (3.1/5 to 4.5/5; +1.4) and development of individual learning plans (3.6/5 to 4.7/5; +1.1). Other areas included self-perceived ability to efficiently evaluate patients with common internal medicine concerns (3.7/5 to 4.6/5; +0.9), formulation of initial diagnostic and therapeutic plans (3.6/5 to 4.6/5; +1.0), and ability to describe how to efficiently admit a patient to an internal medicine service (3.0/5 to 3.9/5; +0.9). Students were also asked the extent to which the course accomplished its learning objectives in the postsurvey (4.8/5).

Table 2

Pre- and Postsurvey Questions for 10 Medical Students Participating in a Virtual Internal Medicine Subinternship, University of Washington School of Medicine, Seattle, Washington, 2020a

Open-ended survey questions were assessed using a conventional content analysis approach. [7] First, 3 authors (S.E.M., A.L., M.H.) independently analyzed responses to the open-ended questions, identified common themes, and coded responses. The authors then convened by videoconference to discuss discrepancies and agree on a common set of themes. Responses were recoded with the agreed-upon themes and representative quotations were selected. Table 2 includes domains and representative quotations from participants. Before starting the course, students expressed skepticism and disappointment surrounding the virtual format, mainly citing the importance of in-person training. Concerns regarding preparation for internship focused on both clinical skills (i.e., fund of knowledge, clinical reasoning) and practical skills (i.e., placing orders, documentation, efficiency). Postcourse survey responses indicated that students had a positive experience with the virtual subinternship and felt it had exceeded their expectations in several areas. They described improvement in fund of knowledge and clinical reasoning, and specifically highlighted the supportive learning environment, case-based curriculum, focus on critical literature appraisement, and independent learning skills as beneficial aspects of the course (Table 3).

Table 3

Major Domains and Themes From Pre- and Postsurveys of Virtual Subinternship With Representative Quotations From 10 Medical Students Participating in a Virtual Internal Medicine Subinternship, University of Washington School of Medicine, Seattle, Washington, 2020a

Next Steps

Students completing the virtual internal medicine subinternship reported improvement in subjective knowledge acquisition, clinical skills, and professional development, and felt they received just-in-time review of internal medicine content. Most notably, they described improvements in their abilities to critically appraise literature and develop independent learning plans. In addition, the course offered a learning community in a time of social isolation. Students continued to express a desire for more practical skills development. Based on our results, future virtual subinternships will include more emphasis on practical skills development through greater use of simulation and role-playing scenarios.

Although faculty-run didactic sessions are traditionally preferred, they may not be feasible during a pandemic due to illness and clinical duties. We believe NPTs played a considerable role in the success of our virtual subinternship. Studies have shown that near-peer teaching has a positive effect on both NPT and learner while also producing similar test performance when compared with faculty-led sessions. [8] Benefits of NPTs have also been observed in clinical education. [9] As U.S. medical schools implement clinician-educator curricula for their senior students, [10] near-peer teaching allows opportunities for students to practice these skills. Based on our experiences with the virtual subinternship and other teaching activities during the COVID-19 pandemic, our institution has continued to offer a peer teaching elective and is exploring the creation of a clinician-educator pathway for medical students.

There are several limitations to our investigation. First, while students surveyed at completion of the experience reported that they gained knowledge and skills, we do not have objective data to corroborate this. Other limitations include a lack of comparative data between students completing the virtual subinternship and the traditional subinternship and the lack of data on clinical competence and EPA achievement among students completing a virtual subinternship.

Our findings and our experiences with the virtual subinternship suggest that a virtual subinternship can be a high-quality educational experience. Second, we have used our experience with independent learning, as well as recorded sessions from the virtual subinternship, in our learning plan for fourth-year students who are ill or quarantined due to COVID-19 exposure. Lastly, students in the virtual subinternship noted improvements in their ability to create independent learning plans and critically evaluate the medical literature, skills that are not currently a formal part of the fourth-year curriculum; we plan to add these objectives to the curriculum.