Medical students and COVID-19
Joint Statement on Education and Safety Considerations
The American College of Emergency Physicians (ACEP), Emergency Medicine Residents’ Association (EMRA), and Council of Residency Directors in Emergency Medicine (CORD) recognize the impact on undergraduate medical education as institutions respond to the coronavirus outbreak.
As institutions make decisions regarding the health and safety of their medical students and residents within the context of individual policies; local, state and federal regulations; and national public health guidelines, we encourage academic centers and schools to consider how best to balance their students’ educational needs with their safety and the safety of patients.
We understand that COVID-19 will have a significant impact on medical education programs moving forward. Residency directors should be prepared to adjust and must understand the need to be flexible during this time. It is in our nature as emergency medicine physicians to be adaptive and flexible, especially in times of uncertainty. We encourage you to work with your medical students and engage them in creating solutions.
We recommend the following:
- Student support:
- Recognize the emotional and psychological impact of the current pandemic on students and trainees. Offer support and provide access to counseling services whenever possible. Identify students who may be struggling psychologically and intervene early. Consider matching students to resident or faculty mentors and developing and distributing informational updates written at the medical student level.
- Consider additional accommodations for students with underlying health conditions that put them at high risk, or for students with extenuating circumstances, to allow participation in learning experiences that will contribute to their educational development.
- Novel alternatives:
- Explore novel programs to expose medical students to virtual clinical experiences, such as virtual away rotations, virtual scribe experiences, and other online clinical workshops, to continue clinical development.
- Encourage medical students, if relieved of clinical duties due to COVID-19, to serve the needs of their communities. This may include support for other health care providers, such as emergency medicine physicians, who may need things like babysitters or essential shopping due to higher clinical demands.
- Clinical rotations:
- When determining how best to hold introductions to clinical rotations, first evaluate educational resources, clinical volume, and safety capacity in your setting.
- For clinical rotations, students in clinical years who have received appropriate training can be involved in the care of patients with communicable diseases; however, given the lack of data on transmissibility of COVID-19, it is important to monitor community spread and consider limiting patient contact in order to preserve scarce personal protective equipment (PPE).
- Consider virtual Objective Structured Clinical Exams (OSCEs).
- Replace in-person end-of-rotation board exams with electronic testing.
- Virtual electronic or oral assessments are preferable to in-person examination(s).
- Communicate frequently with students and their clinical supervisors about institutional policy changes, emphasizing expectations, safety precautions, and the importance of their role within the health care team and system.
- Emphasize the importance of appropriate use of PPE. Distribute high-quality online instructional videos and resources to educate students in donning and doffing practices and the distinction between different levels of patient isolation (eg, contact, airborne, droplet).
- Review existing organizational policy statements or position statements delineating the roles and responsibilities of medical students, to ensure that they remain appropriate for safe patient care and institutional needs.
- Emergency medicine–bound student advising:
- Provide frequent support and advising to senior medical students as they select emergency medicine as a specialty, including advice tailored to the unique environment of the application and interview process through fall 2020.
- Clerkship directors and medical schools should preferentially consider students without home emergency medicine programs for away rotations in emergency medicine at their institutions.
- Promote collaboration within the specialty of emergency medicine to define reasonable expectations among medical schools and residency programs regarding timing and presence of USMLEs, SLOEs, and emergency medicine home and away rotations in the ERAS application.
- Develop rosters of asynchronous or online learning opportunities for emergency medicine–bound students to continue their personal professional development during a time when traditional clinical experiences may be suspended or substantially modified.
- Refer to CORD’s “Consensus Statement Regarding SLOEs and Away Rotations.”
- Refer to EMRA’s Clerkship Match for up-to-date information on program away rotation policies.
- Clerkships should update EMRA Clerkship Match to communicate how their programs plan to address COVID and away rotations.
- Update the “Additional Information Students Should Know” section to make it easy for students to know the latest information about how your clerkship plans to operate during these uncertain times.
- Update your “Spot Availability Indicator” to let students know which months you are currently accepting rotators. Keeping this up to date can help reduce the number of emails you receive from students asking for updates about each month’s availability.
- A CDEM subgroup is also currently working on a Google sheet with clerkship information that will be updated frequently. Complete the survey to add your program to the list. Look for emails from the group to update your information as it changes. The goal of this survey is to build a repository for clerkship directors to advise students on what programs are available for away rotations
Advisors and programs must recognize that expectations in the 2020 to 2021 application season will likely be dramatically different than in previous years. There will be evolving expectations and strategies to help students and programs optimize decisions as residency applications for emergency medicine change during this cycle.
Residency program accreditation
The ACGME has created a three-stage response for residency programs to address the COVID-19 pandemic. These responses are based on a continuum, with added flexibility for programs, depending on the severity of the circumstances.
- Stage 1 (“business as usual”):
- Suspended site visits (accreditation, recognition, and CLER);
- Suspended self-study activities; and
- Suspended ACGME surveys (resident, fellow, and faculty).
- Stage 2 (increased clinical demands guidance):
- Everything from stage 1; plus
- Fellows will be allowed to act as attendings in certain circumstances;
- Residents and fellows can be reassigned, given special consideration for not meeting requirement minimums, and may still graduate as scheduled, despite an inability to complete the curriculum as originally planned;
- Programs should continue to provide education and, where feasible, use remote or virtual tools; and
- If educational activities are disrupted for more than 30 days, contact the ACGME Review/Recognition Committee Executive Director.
- Stage 3 (pandemic emergency status guidance):
- Everything from Stages 1 and 2; plus
- Specialty requirements that are updated on an ongoing basis. Check back regularly.
However, there are some non-negotiables. Non-negotiable requirements that programs must continue to adhere to include:
- Work hour limit requirements (Those suspended by New York were much more stringent than those of the ACGME; relaxing them does not impact the current ACGME requirements);
- Adequate resources and training requirements;
- Supervision requirements; and
- Fellows allowed to function in their core specialty.
- CMS now allows teaching physicians to provide supervision virtually using audio and visual communication technology. (This allowance does not apply to surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, or anesthesia. Physical presence is required for either the entire, or key portion, of the service.) Medical records must document if the physician was there physically or through interactive telecommunications technology.
- The ACGME accelerated the use of the Common Program Requirements for supervision of telemedicine visits carried out by residents and fellows (originally scheduled to go into effect July 1, 2020). Effective immediately, the ACGME permits residents and fellows to participate in telemedicine. Further direction on supervision can be found in their letter to the community “ACGME Response to the Coronavirus (COVID-19).”
- The ACGME does not have a position on early graduation of medical students; however, it notes that with medical students graduating with binding match commitments to enter residency programs in 2020 and 2021, there are “serious ramifications to early appointment (CMS reimbursement for IME/DGME and match participation agreements, among many others).” The ACGME “urges medical schools and graduates to seriously consider...ramifications prior to initiating early graduation for any medical students.”
- See the Billing Section with IME/DGME — page 137 of the CMS rule.
- As of April 2020, the National Resident Matching Program (NRMP) has said that they have not made the decision to change the dates or deadlines for the upcoming Fellowship Match or the 2021 Main Residency Match. However, they will take COVID-related changes into consideration with any decisions (eg, cancellation of exams and rotations).
- Match commitments and offers accepted during the Supplemental Offer and Acceptance Program (SOAP) are binding contracts. Individuals that graduate from medical school early are still expected to enter the training program where they were matched on the date specified on their contract. Individuals cannot be registered into a training program other than the one in which they matched unless they get a waiver from the NRMP.
- The NRMP also recommends that fellowship programs conduct initial screening interviews for the Fellowship Match season virtually.