As COVID-19 upends domestic and international hospitals, it is also interrupting medical education. On March 17, 2020, the American Association of Medical Colleges (AAMC) and the Liaison Committee on Medical Education (LCME) jointly issued a statement supporting “medical schools in placing, at minimum, a two-week suspension on their medical students’ participation in any activities that involve patient contact.”
The recommendation is unprecedented, as there is no evidence that medical students were pulled from clinical clerkships on a national scale during the H1N1 flu pandemic or recent epidemics such as Ebola, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). The joint recommendation by the AAMC and LCME leaves thousands of third-year medical students, who will soon enter into their final year of school, contemplating their role in the face of this evolving pandemic.
What makes COVID-19, caused by the virus SARS-CoV-2, uniquely dangerous enough to temporarily pause clinical medical education?
First, the virus is extremely contagious. Epidemiologists quantify how contagious an infectious disease is with a variable called R naught (R0), which represents the expected number of cases directly generated by a single case. While data is still emerging for COVID-19, early estimates from the World Health Organization suggest the R0 of COVID-19 is between 2 and 2.5, meaning that on average every infected person will spread COVID-19 to at least two other individuals. Comparatively, the seasonal flu R0 is slightly above one.
Becoming infected with the SARS-CoV-2 does not necessarily mean a person will develop clinical symptoms of COVID-19. On the Diamond Princess, a cruise ship with infected passengers, about half of the individuals who tested positive were asymptomatic at the time of specimen collection. Although not all passengers were tested for the virus, using data from this cruise ship and applying statistical modeling, researchers estimate 17.9% of individuals infected with SARS-CoV-2 are asymptomatic carriers. This data is important because asymptomatic carriers can unknowingly spread the virus, fueling the pandemic. As such, social distancing is crucial to slow the spread of the disease.
In addition to being contagious, COVID-19 leads to significant morbidity and mortality. The case fatality rate (CFR), an epidemiological term representing the proportion of people who die from a specified disease among all individuals diagnosed with disease, is between 0.25%-3.0%. This estimated range is broad but still significant; the CFR of the seasonal flu is less than 0.1%.
What is most concerning, however, is the stress COVID-19 will put on our health care system. One analysis predicts 20.5 million Americans will require hospitalization, with close to 4.5 million requiring Intensive Care Unit (ICU) level care. If the pandemic is concentrated to six months, this analysis predicts a capacity gap of about 1.4 million inpatient beds and 295,000 ICU beds. It is still early, and hospitals are already thin on resources: the Centers for Disease Control and Prevention (CDC) recommends using homemade masks such as bandanas and scarfs as a last resort, some hospitals are converting operating rooms to ICU beds and others are using one ventilator for two COVID-19 patients.
One would think that a health care system teetering on the verge of collapse would require all hands on deck, including physicians-in-training. After all, medical students play an important role in the care team: we coordinate care, speak with consulting services and case managers, explain confusing procedures and tests to patients and have time to spend with them and their families. Often, we are able to spend more personal time with the patient than the residents and attending physician on the service.
However, everyday operations are disrupted in hospitals. The American College of Surgeons recommended postponing all non-high acuity surgeries; medical students on surgical services are not spending time in the operating room, but rather seeing consults, many of whom are in the emergency department. But some emergency departments are limiting student activity due to personal protective equipment (PPE) shortages. Medicine services are overwhelmed with suspected or confirmed COVID-19 patients, and as the AAMC previously stated, “It may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19.”
In my experience on a neurology service, there were three patients awaiting COVID-19 results; it is safe to assume there are many more on internal medicine. For clerkships based in the outpatient setting, patients are no-showing or cancelling their appointments or the physician’s office is rescheduling them altogether. This environment is not conducive to learning, which is the primary objective of medical students rotating on clinical clerkships.
Of course, people are still falling ill with other diseases during the COVID-19 pandemic, and they need our attention just as much as before. Some argue that medical students could assume more responsibility with these patients, allowing residents and attendings to focus their time and energy on COVID-19 patients. This idea is fantastic in principle. However, we must humbly remember that all our clinical work is duplicated. Medical students do play an important role in the care team — but it is not vital. During this pandemic, it is crucial to limit patient contact with providers, as clinicians can serve as unintentional vectors.
There are over 20,000 third-year physicians-in-training at more than 150 medical schools in the country. Marc Lipsitch, an epidemiologist at Harvard School of Public Health, predicts at least 20% of the world’s population could become infected. Applying population data to third-year medical students suggest that about 4,000 third-year medical students will have COVID-19. Of these cases, about 700 would be asymptomatic carriers, potentially spreading the virus to other students, providers and patients. (These analyses do not consider that, as student physicians, medical students are at higher risk of becoming infected.) Importantly, everyone in close contact to a student who tests positive COVID-19 would be required to self-quarantine for two weeks; students work closely with nurses, residents and attending physicians. The downstream effects of a student testing positive would further stress the health care system, and the risks do not outweigh the potential benefit we provide to the clinical team, at least at this time.
If third-year medical students cannot help in the clinical arena, then what is our role in the current climate? It is unclear, as information changes every day. Meanwhile, medical students can find creative ways to stay engaged, assist clinicians,and help our society better understand the disease. We can educate our peers and parents about the importance of flattening the curve and that we are not immune to the risks of COVID-19 simply because of our age. We can help collect and enter data and conduct initial analysis for research studies. During the Ebola outbreak, medical students were able to identify gaps in infection prevention in close to 100 facilities in a city in the Democratic Republic of Congo. Blood is now scarce because thousands of blood drives across the country were cancelled; medical students can promote awareness and encourage our peers to donate blood.
More directly, we could assist with triaging patients via telemedicine. Already in progress, across the country, students are coordinating babysitting and grocery shopping for providers on the front lines. There are ample ways we student-physicians can help doctors on the front lines and our society as a whole while not putting patients and others at risk.
This pandemic is a rapidly evolving situation, and there might come a time when the benefit of deploying third-year medical students to the front lines outweighs the potential risks. COVID-19 patients will likely overwhelm the system and many providers will become exhausted or stuck in quarantine. This problem is currently unfolding in Italy, where the government is waiving the traditional graduation requirements and allowing thousands of student doctors to enter the workforce eight to nine months early. The National Health System in the United Kingdom is considering the same. Now Governor Andrew Cuomo of New York is calling on qualified medical and nursing students to assist, but their potential role remains unclear.
The COVID-19 pandemic is quickly developing into disaster medicine at hospitals across the United States. During disasters, it is paramount that medical providers do not become victims themselves. Disaster medicine creates challenging ethical situations, but the four basic bioethical principles — respect for autonomy, justice, beneficence and non-maleficence — still hold true.
First, we must do no harm. Having third-year medical students continue our core clerkships, where all our clinical work is duplicated, has the potential to do more harm than good. Nonetheless, we can contribute and play an active role in the COVID-19 crisis in unique and non-traditional ways. After the two-week clerkship hiatus concludes on April 1, third-year medical students should not return to our rotations, but rather be utilized in meaningful ways that help providers on the front lines.