Pilot virtual clerkship curriculum during the COVID-19 pandemic: Podcasts, peers and problem-solving.

Abstract

Many virtual curricula for medical students focus on asynchronous assignments, text and video resources, and independent study to prepare for an examination. These methods perfectly mirror the structure of pre-clinical courses but do not reflect how knowledge is advanced in clinical workplaces, where students construct meaning through synchronous activities with peers, conversations with physicians, and feedback from teachers on their analysis of clinical problems. During the coronavirus disease 2019 (COVID-19) pandemic, new instructional approaches are necessary when we shift clerkship students online but still aim to advance their thinking as novice physicians rather than increasingly sophisticated classroom students. Our medical school suspended clerkships during the COVID-19 pandemic. Six students who had completed 14 days of an internal medicine inpatient clerkship (IC) transitioned to a virtual clerkship curriculum (VCC) for 14 days. The objective of the VCC was to advance internal medicine knowledge and three clinical reasoning skills: schema construction (formulating frameworks for clinical problems, eg, anaemia); written diagnostic arguments (articulating prioritised differential diagnoses for cases), and verbal presentations of those arguments. The conceptual frameworks for the VCC were social learning and cognitive apprenticeship. We created a learning community through twice-daily interactive sessions with students and teachers (n = 25 videoconferences). Students remotely attended two resident-level case conferences daily (n = 27 sessions). We minimised assigned reading and maximised opportunities for students to hear physician dialogue using conversation-style medical podcasts (for podcasts and schemas see www.clinicalproblemsolving.com) Students listened to a daily podcast (11 overall) to learn about a topic (eg, hypercalcaemia). They analysed 11 cases (from podcasts or worksheets) and submitted diagnostic schemas and diagnostic assessments for each case; two assignments involved peer collaboration and feedback. Students also submitted verbal presentations for three of the cases. Every submission received feedback from the authors.1 To reinforce lessons from assignments, podcasts and case conferences, the authors held 30-60-minute ‘rounds’ each morning. All six students completed a post-VCC survey with 5-point Likert responses. The most highly rated exercises were drafting schemas (5.0), writing diagnostic assessments (4.83), oral presentations (4.83), and podcasts (5.0); case conferences were rated lower (4.0). Students cited ‘major improvements’ in their diagnostic assessments and schema construction and ‘moderate improvement’ in oral presentations. They hoped for ongoing feedback on schema constructions and diagnostic assessments upon returning to IC. Five students reported receiving more feedback on their diagnostic arguments during the VCC than in IC. Four students reported better classmate co-learning and collaboration during the VCC. We learned that substantial faculty time is required to foster a remote learning community and cognitive apprenticeship. Developing coaching relationships, reanalysing case conferences, explaining unfamiliar concepts and editing written arguments cannot be rushed or scaled. Therefore, recruitment of additional faculty members or residents may be necessary. Shared schedules, collaborations and video (not audio alone) participation were essential for community building amongst the students. We did not advance skills in data gathering, physical examination or patient communication. The transformative power of a clerkship is not the medical content; it is the simultaneous engagement with peers, patients and teachers around workplace problems. VCCs can advance reasoning skills, prepare students for clerkships and highlight best practices to adopt when they arrive.