Ethical aspects of Medical Education in the wake of the Covid-19 Pandemic

This report summarizes a global panel discussion webinar in the wake of COVID-19 held on Sunday night (Melbourne time), 3rd. May, 2020 under the sponsorship of the Department of Education’s UNESCO Chair in Bioethics located at the University of Haifa which works to encourage the teaching of bioethics in medical and health sciences and law courses across the world. The topic was the ethical aspects of medical education, a topic close to the UNESCO Chair’s mission.

The two and a half hour meeting was chaired by the Melbourne-based Professor Russell D’Souza, Chair, Department of Education (International Program) of the UNESCO Chair in Bioethics with the co-chair and facilitator, Professor Mary Mathew, the director of the Indian component of the Chair. Input came from eleven medical educators and students from eight countries in (with the % of deaths per 100,000 population from the John Hopkins University data centre): Australia (0.38), China (0.33), India (0.10), Israel (2.58), Portugal (9.95), the Sudan (0.10), the UK (42.42) and the USA (20.29). Approximately 740+ persons were registered online participants and spectators and asked questions through the chat box.

The webinar began with opening remarks from Professor D’Souza who set the scene, observing that India alone has over 600 medical schools. Since the March 11 declaration of a global pandemic by the World Health Organisation, the world had entered an unprecedented crisis with major challenges at policy and practice levels for medical education. He noted that “we are all in this together. We have to confront issues never previously faced”. There has been a worldwide and serious breakdown of structures which were and would impact, particularly upon those in the most vulnerable situations. The key concept to guide us must be mutual humanitarian solidarity with the common interest being the good of everyone.

The webinar was divided into two parts. The first part looked at the doctor-patient relationship.

Medical education services are in a totally new situation with universities closed and no face-to-face classes with no practical classes available. It has transitioned to online teaching and learning, including online assessment. In all this, have we lost the essence of the doctor-patient relationship in these new challenges with the loss of human interaction to digital interaction? How will distance learning impact on medical standards? Are there some virtues in digital learning? Is it the end of professional education as we have known it?

To gain a student perspective, Alaa Abusufian Dafallah from The Sudan reported that exams had come to a halt because of the limits of technology in her country and “so we are in a vacuum in our final year”. Dr Shava Joshi, from the student wing of the Chair now doing his residency, focused on theory vs. practice. Webinars can only help so far in developing the practical medical skills. Also lost has been the soft skills picked up from conferences and mutual collaboration. It is no longer possible to collect data for the small thesis as part of the residency requirement. Exams are tough at this level but “we are being called back to hospitals for duty”. Should exams be postponed?

Dr. William Pinsky, President and Chief Executive Officer of the Educational Commission for Foreign Medical Graduates (ECFMG) in Philadelphia, questioned the use of unqualified medical students in interacting with patients. There are many factors involved but it is very important that students be asked to do only what is within their capability, and they need to be supervised. Students should not be put at risk, and they must have the right skill sets. What happens when students really want to come into the frontline? The answer depends on the particular situation. If they are not fully licensed as medical practitioners, they can still help ‘on the sides’. Also there is the issue of payment for services. This depends on resources, and pay is not the defining element.

Professor David Gordon, Emeritus Professor of the University of Manchester and President of the World Federation of Medical Education, said that “our students are at the frontline and are being paid”. He added that no one can be exposed to a situation where they do not feel competent. But, “let us be honest. We do not always know what we are doing. Physicians are learning to deal with a nasty illness. Students are often more competent than what they give themselves credit for”. He related how 80 years ago, the UK faced the Nazi threat and senior staff went off to join the armed forces. Mid-level qualified staff and students were often called upon, and they learned a lot very quickly. Regarding payment, there is no single answer.

In China, according to Professor Ming Kuang, Vice-Dean of the Zhongsan School of Medicine at the Sun Yat-Sen University in Guangzhou, said that all medical students have had to stay at home, and their training is being delivered online. They are not paid.

Professor Ved Prakash Mishra from the Krishna Institute of Medical Sciences at Karad, a small city in Maharashtra, spoke about students on the frontline. “We need to understand that we are in a contingency emergency situation. But they must not be put into a position beyond their capability – this would be unethical. Those in residency are in a different situation. They are qualified but they need to be under supervision”. It is important that health workers are not put at risk. Students are paid a stipend, not a salary.

Professor Trevor Gibbs, President of the Association for Medical Education in Europe (AMEE) in Dundee, argued that student frontline should be voluntary and not part of the medical curriculum. Safety is paramount e.g., PPE clothing. Role clarity is most important and all students should be indemnified by their universities. They must work at their level of competence with supervision that is supported. Universities must support their students. He added that disrupted clinical studies constitute a problem. Can face-to-face supervision be substituted in the transmission of hands-on skills?. This cannot be answered as yet.

Professor Jeanette Mladonovic, Professor of Haemotology at the Oregon Health and Science University and President of the Foundation for the Advancement of International Medical Education and Research, asked the question: should patients be told they are being treated by someone not fully qualified? Could the students do harm to a patient? Do we want them to learn on patients? There is always a risk. In the UK, the Dean of the Medical School at Swansea University, Professor Kamila Hawthorne related how social distancing had been in place for four weeks but already people were looking forward to their lifting.

Professor Gibbs raised the issue of empathy. He was of the opinion that student empathy for patients cannot be developed online. “A course on empathy does not achieve much. It cannot be learned from a lecture. But it should be a golden thread through all subjects”. Professor Pinksy related it to the more general issue of telehealth. “It is not a bad thing and it means more will have access to health care”. Professor Ming said that Wuhan is the epicentre of the coronavirus; it had been out of the imagination of the doctors and nurses. Postgraduate students worked with more experienced colleagues. “We showed the students what to do online”. Establishing collaboration is important.

Professor Jeanette Mladonovic said that there are different ways to learn empathy. “We should be capitalizing on the pandemic to learn empathy in face-to-face interaction. And to learn to communicate better e.g. for telehealth. It is a chance and opportunity to think differently”. Professor Madalena Patrico from the University of Lisbon and President of the Best Evident Medical Education (BEME), also spoke of how important is empathy. “We always need to ask the students to step up”. Professor Sujarah said that soft skills are MUST skills that you need for life, and should be embedded into the curriculum.

To round off this discussion, Ms Alaa Abusufian Dafallah reported that in the Sudan there had been no online learning sessions as 40 per cent of students do not have access to the internet. “Students are embedded in the strength or its lack in the national health system”. She added that in the aftermath of COVID-19 there was the urgent need to develop e-learning – with more collaboration, the impact of the shock would be lessened. Her preference was for face-to-face teaching. Professor Mary Mathews observed that students are very precious, and innovative ways of teaching and learning are being forced upon us.

The second part of the webinar looked at technology and medical education.

Most schools and faculties have moved over to the high use of technology, and so there are many opportunities for analysing the management of change. Professor Ming said that “we have learned a lot” from the SARS virus. But there is unfortunately a lack of collaboration between doctors at the frontline and research scientists. This needs to be reformed.

Professor Patrico saw a real dilemma in online education and maintenance of high standards. There was now enormous pressure on university teachers. There has to be a higher quality of online lectures but how does one protect the ‘humanization of education’? She also worried about cheating in online assessment. Professor Gordon argued that more medical education can be done online in the non-clinical aspects. Professor Pinsky suggested that there was the issue of access to technology in the various countries and the other issue of sharing and protecting intellectual property across the world. Professor Mladonovic said that with online learning, artificial intelligence and student access to online learning, the issue for her was knowing the students well and knowing their abilities. There would need to be much more workplace assessment.

Professor Abijath Sheth, President of the National Board of Exams in India, said that the various parts of medical training cannot be compromised. The knowledge pillar and the experience of dealing with practical cases lead to clinical insights. However, whatever is done online must be structured. And Professor Pinsky ended off by saying the challenge was in maintaining high standards which could be placed in jeopardy.