Experience

The Effect of COVID-19 Pandemic on US Medical Students in

their Clinical Years
Raed Qarajeh,1 Farah Tahboub,2 Nikita Rafie,3 Nurry Pirani,4 Mary Anne Jackson,5 C. Douglas Cochran.4

The Experience to propose innovative ways for students to continue learning using
online teaching. Tufts University easily merged existing online teaching
Since December 31, 2019, when China identified the first cases of SARS-
programs into “flip classrooms” which involve small video discussion
CoV-2 respiratory disease, this topic has dominated all news outlets,
groups with specialized software programs. Successful models already
medical journals, and household conversations. On January 30, 2020,
in place can be adopted by other programs. Hospitals have cancelled
the World Health Organization (WHO) announced coronavirus disease of
all elective procedures and resorted to telemedicine for clinics. This is
2019 (COVID-19) to be a global health emergency following identification
a good time for medical students to learn and participate in
of cases from 18 countries outside of China including 8 cases of human
telemedicine.
to human transmission. The declaration called on countries to
implement consistent evidence-based decisions, identify gaps in
Changes to remaining clerkships and electives length to allow missed
resources, share knowledge and experience, and move forward on
clinical experience to be made up would ensure students have
vaccine development. The first coronavirus pandemic was announced
adequate exposure to core clerkships. Many students faced
on March 11, 2020 following confirmed infections in 114 countries.
cancellation of electives inside and outside their institutions, including
Within the US, hot spots developed first in Washington State and then
opportunities overseas. These electives expose students to fields of
shifted to New York. The surge in disease overwhelmed resources and
interest and different patient populations and health care systems from
the ripple effect impacted the entire medical community. Medical
their own home institutions. The cancellation will impact the knowledge
students, like many others, are experiencing the repercussion of COVID-
and experience of medical students and their residency applications.
19 firsthand and are not exempt from its many lasting effects.1 The
Students should be given the opportunity to re-enroll in outside
Association of American Medical Colleges (AAMC) announced, on March
electives in subsequent years.
17th, 2020, a minimum two-week suspension of medical students’
participation in patient contact activities with possible longer
Medical students have the unprecedented experience of a pandemic, a
suspension left to medical school discretion.2 Herein, we present
new disease with unknown epidemiology, etiology and treatment. The
challenges, concerns, and impacts of the COVID-19 pandemic on
skills learned during this time will give students new insight to their
medical students across the nation as well as suggestions for possible
approach to medicine, patients, knowledge, and research. Students can
solutions.
reach out to their home institutions to explore volunteer opportunities
during clinical suspension. Some existing projects include answering
The Safety of Medical Students
phone queries via telehealth technology, using decision trees and
With the epidemiology, transmission, and treatment of COVID-19 still
prepared scripts, assisting with research, determining trial eligibility,
not fully understood, the safety of medical students is a major concern.
mask collections and sewing, making infographics, blood donation
Many medical students have never been trained to don and doff
drives, and restocking hospital warehouses.
personal protective equipment (PPE) and are not N95 fit tested. The
AAMC’s decision to suspend clinical rotations was twofold: to ensure
In response to the need for health care providers, Harvard Medical
the safety of both students and patients, and conserve PPE. Lessons
School (HMS), Boston University, Tufts University, and University of
can be drawn from medical student suspension in the 2003 SARS
Massachusetts issued an option for medical students to graduate
outbreak in Hong Kong and Canada which were successful in setting up
early.5 The ACMGE warned of “serious ramifications to early
several plans to be implemented based on escalation of the situation.3,4
appointment Centers for Medicare and Medicaid Services (CMS)
If this pandemic becomes prolonged, return of medical students to
reimbursement for direct graduate medical education (DGME)/indirect
rotations should be considered after receiving infection control and
medical education (IME) and Match participation agreements, among
transmission prevention training, and should be excused from
many others” and urged medical schools to carefully consider these
interacting with suspected or confirmed COVID-19 cases.
ramifications before making their decision.6 Many programs in the
harder hit areas have opted for early graduation, however, the majority
Changes to Clinical Rotation Structure and Exposure of programs are following their original calendar and are virtually
From institutional and personal perspectives, every stakeholder in graduating students on time.
medical education is concerned of the detrimental effect that loss of
face to face clinical teaching can have. Medical schools have been quick

1 MD, Department of Internal Medicine, University of Missouri-Kansas City, Missouri, USA.

2 Medical Student, University of Jordan School of Medicine, Amman, Jordan.
3 Medical Student, University of Missouri–Kansas City School of Medicine, Missouri, USA.

4 MD, Assistant Professor, Department of Internal Medicine, School of Medicine, University of Missouri-Kansas City, Missouri, USA.

5 MD, Professor of Pediatrics, Division of Infectious Diseases, Children's Mercy Hospital. University of Missouri–Kansas City School of Medicine, Missouri, USA.

About the Author: Raed Qarajeh is currently a PGY-2 at the University of Missouri-Kansas City internal medicine residency program

Editor: Francisco J. Bonilla-Escobar

Student Editors: Thanthima Suwanthawornkul
Correspondence: Submission: Apr 23, 2020
Raed Qarajeh Revisions required: Apr 25, 2020
Received in revised form: May 14, 2020
Address: 5000 Holmes St, Kansas City, MO 64110, United States Acceptance: Jun 9, 2020
Email: [email protected] Publication: Jun 15, 2020
Process: Reviewed by Student Editors

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Medical school examinations, USMLEs, and residency applications laboratories within technological capability can help alleviate research
Administering traditional exams given CDC recommendations against loss.
social gatherings is a challenge. Medical schools should explore
alternative options like changing exams to case presentations Cancellation of scholarly conferences and important milestones
simulating true clinical settings or by utilizing online resources such as All conferences and meetings have been cancelled causing students to
Lock Down Browser® and Zoom®. Evaluations can be assessed based lose the opportunity to present their work and meet with peers and
on interaction of students in online sessions and discussions. Grades experts in the field. Conferences should identify virtual options that
should be compared with previous rotations to ensure they are allow students to present their research and provide a chat or comment
reflective of the students’ performance; any discrepancies should be feature so traditional discussions with experts at these meetings are
addressed. not lost and the advancement of medicine and discussion is continued.

On March 16th, 2020, the United States Medical Licensing Examination An important milestone that medical students look forward to are
(USMLE) Step 2 Clinical Skills (CS) examinations were suspended until match day activities which have been cancelled forcing institutions to
further notice and the Prometric center announced temporary closure carry out virtual activities. Graduation ceremonies will likely be
of testing centers for 30 days starting March 18th.7 The USMLE program cancelled. Alternatives to the traditional celebration such as virtual
announced that it cannot resume the Step 2CS exam in its current graduation ceremonies allowing students and their families to actively
format and is exploring plans to employ a telehealth model via a web participate in this milestone should be explored.
browser and is expected to resume after July. Prometric resumed partial
testing for USMLE exams starting May 1st, however Prometric test Psychological effects of COVID-19
centers were erroneously listed as open but examinees were met with Rotenstein et al.’s metanalysis estimated that “the prevalence of
closed doors, and USMLE program is looking for alternatives outside of depression or depressive symptoms among medical students was
Prometric to increase capacity. Schools requiring Step 1 to start clinical 27.2% and that of suicidal ideation was 11.1%”.10 Adding the COVID-19
training and Step 2 Clinical Knowledge (CK) to start fourth year should pandemic to stressors can increase the severity and number of medical
extend deadlines to account for test center reopening and scheduling. students with depression. The uncertainty of schedules, rotations,
Delay in test taking, and thus reporting will also impact fourth year clinical requirements, exams, and cancellation of important milestones
medical students unable to have their scores by residency application including graduation and matching can further heighten depression
deadline. symptoms. Health care workers have suffered serious repercussions
from COVID-19, even death, which will negatively impact medical
The AAMC announced a change in the date where residency programs students’ mental health. Medical schools should proactively address
may begin reviewing applications from the usual September 15th to this and provide resources, including psychotherapy. Medical schools
October 21st. This change in deadline will help accommodate the should also provide students with as much transparency as possible in
cancelled testing and application requirements, however, the updating medical students via short, regular email notices or allowing
examination situation remains unclear and is uncertain if the testing virtual town hall meetings.
capacity will meet the needs and if the scores will be available for the
new date. The AAMC also issued a statement encouraging medical International Medical Graduates
schools and teaching hospital faculties to “conduct all interviews with International medical students (IMGs) faced cancellation of electives
potential students, residents, and faculty in a virtual setting - either by required for US residency positions as well as cancellation of Step 2 CS.
phone or through video conferencing”.8 Safety is the priority and whilst Many students plan months in advance for travel and are now faced
virtual interviews will eliminate the need for travel and will help with visa constraints and financial strain and would benefit from
maintain social distancing, much of the interview activities such as applications deadline extension. Perhaps the most immediate impact
taking tours of the campuses, meeting with the residents and on the health care system is on IMGs that have recently matched in
attendings, having in person interviews, and experiencing the feel of residency programs in the US that are set to begin this July. There is a
the program and campus would be lost. possibility that IMGs will not be able to travel to the US and will be
forced to delay the start date of residency. This would negatively impact
Scholarly activities the health care system and cause a shortage of residents that hospitals
Medical students’ research projects are also impacted by the COVID-19 are in dire need of.
pandemic. In a letter to the HMS Community, Dean George Q. Daley
wrote, “I understand that everyone is concerned about the very real Conclusion
loss of research productivity”, as ‘stay at home orders’ have The impact of the COVID-19 pandemic on medical students’ safety,
necessitated “for the emptying of our laboratories and encourage all to education, research, clinical rotations, residency applications and
pursue alternative scholarly activities in isolation”.9 The inability to mental health are important issues to address. Managing the needs of
continue research will result in loss of data, hours invested, having to medical students, finding innovative alternatives, and involving
redo parts of research and delays in completion and publication. Fourth students with dialogue and solutions are extremely important. Medical
year medical students who will not continue residency at their school’s students will soon enter the healthcare system as new doctors, and
institution, may not complete their research prior to leaving, resulting how they are handled will have a direct impact on the future of the
in significant loss of research output. Allowing remote access to healthcare system.
necessary documents and databases and setting up at-home

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Acknowledgments
None.
Conflict of Interest Statement & Funding
The Authors have no funding, financial relationships or conflicts of interest to disclose.
Author Contributions
Conceptualization: RQ. Supervision: RQ, and DC. Project Administration: RQ. Writing – Original Draft: RQ, FT, and NR. Writing – Review & Editing: RQ, FT,
NR, NP, MJ, and DC.
Cite as:
Qarajeh R, Tahboub F, Rafie N, Pirani N, Jackson MA, Cochran CD. The Effect of COVID-19 Pandemic on US Medical Students in their Clinical Years. Int J Med
Students. 2020 May-Aug;8(2):172-4.

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DOI 10.5195/ijms.2020.508 | ijms.info
The International Journal of Medical Students 174