Military Medical Students' Perspectives on Medical Education in the COVID-19 Era.

In response to the COVID pandemic, Uniformed Services University (USU) suspended clerkships. As the nation's military medical school, USU had to keep students safe while still preparing them to be military physicians. In this commentary, we, a group of USU students, explore what this experience taught us about military medicine. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

The COVID-19 pandemic has affected every aspect of modern life, including medical education. At the start of the pandemic in March of 2020, the Uniformed Services University (USU) School of Medicine, the nation’s medical school, moved medical students to online learning for the foreseeable future. As USU medical students, we were initially unnerved but remained optimistic that online learning would not undermine our mission to “learn to care for those in harm’s way.”

Before the pandemic, USU students typically traveled extensively to complete our clerkships. This routine drastically changed on March 11, 2020, when the Secretary of Defense announced a ban on travel for all members of the Depart of Defense.[1] Days later, the Association of American Medical Colleges (AAMC) issued a statement “strongly [supporting] pausing all student clinical rotations” throughout the nation.[2] Clerkships were suspended—cutting key clinical experiences short. The clerkship suspension was necessary for several reasons, although this may have affected USU’s mission to train future military physicians.

POTENTIAL IMPACTS ON OFFICERSHIP

Because of its commitment to the military, USU has a responsibility to promote the professional identity formation of its students. In this context, the goal of professional identity formation is to equip students with what we need as military physicians, and suspending clerkships may negatively affect this process.[3] In short, spending time on the wards is an excellent opportunity for our professional identity development.

Professional identity formation is universally recognized as the process all medical students undergo as we evolve into physicians.[4] A student’s development can be influenced by the “unofficial rules and implicit values” present in their environment.[5] This “hidden curriculum” is unique for USU students because our identities as military officers may commit us to “unlimited liability… on behalf of the nation.”[6] Asking military medical students to put our safety over our service to country risks ingraining a bias in our professional identity that our safety should be prioritized over the safety of those we serve.

Our serving on the wards also has several benefits that virtual learning does not. Significantly, medical students experience a “sense of ownership” regarding patient care during clerkships, and the responsibility we have for our patients is helpful in developing our professional identity.[7] Patient care might therefore be negatively affected when students are pulled, as medical students can make team-based care more effective. We provide an extra set of eyes on the patient, more people to review data, and another opportunity for the team to discuss the treatment plan, all of which help patients receive the best care possible.

POTENTIAL IMPACTS ON MEDICAL TRAINING

We feel that our curriculum prepared us to serve as effective physicians and encouraged us to think critically and innovate when practicing in austere environments. These lessons may have contradicted the idea of suspending clerkships. However, responding to COVID-19 forced USU to practice flexibility while overcoming obstacles to medical education. Successfully navigating this pandemic primed students for the challenges that we will face in future wars characterized by multidomain operations different from the most recent conflicts in Iraq and Afghanistan.

The commitment USU students feel to the military medical system echoes a striking example of medical students participating in care during the 1918 influenza pandemic. In 1918, students from Harvard Medical School heard “a public call for assistance…which the students met promptly and admirably.”[8] If medical students were able to positively contribute to the fight against an infectious disease in the past, we may be beneficial in the hospitals today.

On the other hand, the impact of sending medical students who may be a hindrance to patient care to hospitals during a pandemic must be considered. Junior medical students are generally not considered essential workers in hospitals.[9] We would also be at greater risk of contracting COVID-19 on the wards, thus “straining [the] already burdened health care system” with the need for our treatment.[9] Our presence in the hospitals during a pandemic therefore may endanger patients and other providers more than is necessary.

OUR EXPERIENCE

Although senior medical students were suspended from formal clinical training, we attended morning reports for residency programs across the country, developed shelf review curricula for future classes, and pursued health professions education certificates. We took advantage of this time to make ourselves stronger physicians for the sake of our future patients.

Despite the dilemma surrounding clerkship suspension, USU returned us to our educational schedule as quickly and safely as possible by mandating online COVID-19 training for all students.[10] As students were sent back to the wards, for the first time in its history, USU graduated fourth-year medical students early on April 1, 2020.[11] As new doctors, we assisted military hospitals overwhelmed with COVID-19 under the supervision of licensed physicians.[11] We screened for symptomatic patients, traced contacts of COVID-19 positive patients, and helped establish training programs for donning personal protective equipment. The University of Massachusetts Medical School had a similar idea as USU when they graduated their fourth-year students early to work as limited-license physician “surge contractors.”[12] As new graduates, we were described as “game changers” while assigned to medicine wards, “backfilling” for physicians working with COVID-19 patients.[12] Other schools maintained or delayed graduations for their senior medical students.

The first-year class at USU started medical school with primarily online learning, and the effect of this on their professional identity has yet to be determined. The third- and fourth-year students have resumed clerkships with significant schedule adjustments to ensure graduating on time.

OUR REFLECTIONS

The COVID-19 pandemic continues to have far-reaching consequences, yet the full impact of the virus on medical education has yet to be seen. Assessing the effect of the pandemic on medical students may be difficult, but enduring the challenges of medical school during this pandemic is bound to leave a mark on our generation of students. Recognizing our resilience through this troubling time, the President of the AAMC called current medical students to be the “great change agents” needed for a stronger health care system.[13]

We even received some benefit from the shift to online learning. For example, we became proficient with telecommunication systems, and we were forced to intentionally practice wellness. In this way, COVID-19 has represented an “enduring transformation in medicine” that has pushed us to adapt and overcome in creative ways.[14] Adapting to this crisis has expanded our understanding of how military physicians must prioritize both patient care and readiness of the unit. It cannot be just the patient or just the mission. It cannot be the patient over the population.

Military medicine’s response to COVID-19 has reaffirmed our commitment to military medicine. It has clarified our responsibility to maintain the health and readiness of our fighting forces. While our medical school experience was marred by this pandemic, our medical education and our officer training were both enhanced. As the “golden hour” and the global medevac system influenced military physicians in the past decade, unique experiences during the COVID-19 pandemic will likely define a new generation of military physicians. In an increasingly complicated world, the challenges of COVID-19 have prepared us to care for those in harm’s way.