From the Office of Dr. Pedram Mizani, MD, MHSA
President & Chief Clinical Officer | acmedical.org
Former Chief Medical Resident | Morehouse School of Medicine Family Medicine Residency
Last updated: April 4, 2020 at 10:56 AM PST
We have heightened our screening and credentialing procedures, and are providing full scope support to our physician preceptors who are allowing AmeriClerkships clinical rotation to continue during the COVID-19 pandemic, uninterruptedly.
As of March 16, 2020, AmeriClerkships transformed itself into an emergency response center for all stakeholders, namely our Members (medical students and graduates), Employees, and Affiliated Attending Physicians (like yourself). As of March 25, 2020, >95% of our primary care affilliated attending physicians are seeing equal or greater number of patients and strongly encouraging AmeriClerkships to send our medical students and graduates to them; some of our subspecialty affiliated attending physicians (neurology, PM&R, etc.) and all of our at-risk physicians (those with cardiovascular or pulmonary diseases) on the other hand have seen varying degrees of drop in their patient volume (25-90% decrease) and style of practice (partial to full telemedicine, some only from their homes).
Our objectives were clear:
- Mobilize an online COVID-Match Response Team to guide our stakeholders, and make sure that all of our Members remain on track get all the support they need to competitively apply to residency by 9/15/2020, AND
- Document as many clinical site, physician and hospital COVID-19 policies, explicitly recognize and incorporate them into our already heightened screening and credentialing, AND
- Continuously gauge the impact of travel redirections and restrictions and on scheduled clinical blocks, both nationally and internationally, AND
- To encourage and do everything in our power to safely assist any Member who a) Is not high risk (CDC), and b) Is Asymptomatic (CDC), and c) Does not want their clinical education disrupted, and d) Is in their final year of medical school (or medical graduates already) in starting their clinical rotations with our physicians, safely and on-time, AND
- Delay scheduled start dates if a Member is uncomfortable to start (all change fees waived), AND
- Launch and constantly update a centralized COVID-19 resource portal online that discusses all of the above, AND
- Inform our Affiliated Attending Physicians about all of the above, and to support them in any way possible to allow for the uninterrupted continuation of clinical rotations.
Furthermore here at AmeriClerkships Medical Society, we are certainly humbled by the selfless acts of millions of healthcare providers who are on the frontlines of treating COVID-19 cases worldwide, and want to thank you all for keeping us safe. This article is meant to provide AmeriClerkships Affiliated Attending Physicians our position on COVID-19 as it pertains to AmeriClerkships Members who enroll in clinical rotations in order to graduate from medical school, or to secure the required amount of US clinical experience and letter of recommendation prior to September 15, 2020 (for the 2021 residency Main Match).
AmeriClerkships Medical Society has not stopped its clinical rotations at this time. We certainly are in unprecedented times, however to be involved and exposed to these exact times are also the precise reasons why most (definitely not all) medical students elected to attend medical school in the first place (read ‘Medical students can help combat Covid-19. Don’t send them home‘). Every large-scale disaster renews discussions of the proper role of healthcare workers in an emergency response, but too often, these discussions overlook the potential role a (final-year) medical student plays.
We are mindful of:
- Certain AmeriClerkships affiliated hospitals, clinics and medical schools who have decided to temporarily pause student clinical rotations (most do so because they view students as non-essential, temporary individuals who may not be well-trained in disaster response, and pose a risk to him/herself or the patient), AND
- AAMC’s recommendation for a 12-day pause on all student clinical rotations (in order to 1) for the medical education community, including learners, to develop appropriate educational strategies and alternative clinical experiences to best assure safe, meaningful clinical learning for students, and 2) help with current concerns about the availability of personal protective equipment).
- While students who are still in training can pose risks to themselves and to others, history demonstrates they can serve with distinction in disaster situations, AND
- With appropriate training and supervision, medical students can be used not only to leverage available professional resources but can effectively sustain interpersonal aspects of patient care in mass casualty situations.
- Medical student training to respond to these unfortunate [disaster] scenarios should be of the upmost priority, AND
- Their involvement can be used to provide much-needed human resources, and previous studies have shown that early involvement is essential in building a strong foundation and adopting a life-long passion for the topic.
- Most healthcare facilities are utilizing telemedicine to screen patients for COVID-19, and divert them to centralized command centers or ERs who are better equipped to handle these cases, AND
- Preceptors (MD and DO) are not dismissing medical students & graduates from clinical rotations; in fact, every physician I have spoken with encourages medical students to be on-site and not miss the learning opportunities that COVID-19 pandemic is presenting, AND
- Preceptors are telling medical students & graduates to shadow when faced with a presumed or confirmed case of COVID-19, AND
- Although naturally concerned about their well being, all medical students & graduates are aware that more likely than not, they will be faced with having to be on the frontlines of medicine during a disaster sometime in their lifetime, hence do want to be exposed to medical disaster response as students, but in varying roles, AND
- Although it may not be your traditional classroom, clinicals and emergency rooms and hospitals are learning environments (arguably better than classrooms) equipped with highly dedicated physician preceptors are trained to provide educational settings which are safe and meaningful when it comes to clinical learning experiences, AND
- It is not recommended for medical students to come in contact with, or enter isolation rooms of patients diagnosed with or even suspected of ANY infectious diseases during this pandemic. Medical students are expected to observe from afar in these situations and therefore, we do not recommend that the shortage of Personal Protective Equipment (PPE) be used as a reason to stop clinical rotations, AND
- Per WHO, for asymptomatic individuals, wearing a mask of any type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures, AND
- Per WHO, in areas of patient transit (e.g., wards, corridors) where staff and healthcare workers do not come in contact with COVID-19 patients, no PPE is required, AND
- As for conflicts of interest, there are none: Tuition and fees have already been paid by all medical students, and it would actually be much cheaper and quicker for AmeriClerkships Medical Society to simply remove students from clinical rotations and take a back seat while COVID-19 runs its course.
Therefore, we at AmeriClerkships Medical Society do not take the critical decision to stop a medical student’s clinical exposure and education during times when the greatest amount of critical and disaster medicine can be learned lightly, and do not believe that the decision rests solely with AmeriClerkships. We believe this is a highly individualized and life-altering decision which must be tailored to each clinical setting, and can only be made by the on-site and immediate preceptors of each student at each clinical site, and the trainee him/herself.
Who are ‘willing and qualified’ individuals? Final year medical students and medical graduates who do not want their clinical education interrupted, AmeriClerkships will support them throughout the COVID-19 pandemic by not discouraging their decision, and we deem them as ‘willing and qualified’ if they meet the following four criteria:
- Not high risk (CDC), AND
- Remain asymptomatic (CDC), AND
- Do not want their clinical education disrupted, AND
- Are in their final year of medical school (or medical graduates already)
Furthermore, we are encouraged to see nearly all of our physician supervisors, clinical sites and hospitals amending their existing COVID-19 (and other disaster/terrorist response) protocols to include medical students & graduates who meet all 4 of the above criteria, and look at this as a once in a lifetime opportunity to help our soon-to-be physicians develop their critical knowledge and practical skills in the realm of an ongoing disaster, and to even provide the groundwork and opportunity for further study of the effects of incorporating medical students into various roles on disaster medicine response teams (Verson et. al.).
Contact the AmeriClerkships 24 hour ‘COVID-Response Team Physician Hotline’ at +1(949) 579-8089.
Evidence-based solutions to safely keep Clinical Clerks in rotations, and allow them to learn from COVID-19 pandemic
Personal protective equipment (PPE) is recommended in only certain situations. AmeriClerkships recommends that willing and qualified medical students & graduates to remain in clinical rotations, but to only observe/shadow patients suspected of an infectious disease without coming in contact with them, and not enter an isolation rooms. For this reason, PPE is not recommended for individuals such as AmeriClerkships medical students & graduates. This recommendation is also supported by the WHO, below. Click the link below to view the WHO’s recommendation on when, where and who should wear PPE, in the context of COVID-19 disease:
Ensure PPE use is rationalized and appropriate
According to WHO, PPE should be used based on the risk of exposure (e.g., type of activity) and the transmission dynamics of the pathogen (e.g., contact, droplet or aerosol). The overuse of PPE will have a further impact on supply shortages. Observing the following recommendations will ensure that the use of PPE rationalized.
- The type of PPE used when caring for COVID-19 patients will vary according to the setting and type of personnel and activity (Table 1).
- Healthcare workers involved in the direct care of patients should use the following PPE: gowns, gloves, medical mask and eye protection (goggles or face shield).
- Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy) healthcare workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant (1).
- Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended time during previous public health emergencies involving acute respiratory illness when PPE was in short supply (3). This refers to wearing the same respirator while caring for multiple patients who have the same diagnosis without removing it, and evidence indicates that respirators maintain their protection when used for extended periods. However, using one respirator for longer than 4 hours can lead to discomfort and should be avoided (4−6).
- Among the general public, persons with respiratory symptoms or those caring for COVID-19 patients at home should receive medical masks. For additional information, see Home care for patients with suspected novel coronavirus (COVID-19) infection presenting with mild symptoms, and management of their contacts (7).
- For asymptomatic individuals, wearing a mask of any type is not recommended. Wearing medical masks when they are not indicated may cause unnecessary cost and a procurement burden and create a false sense of security that can lead to the neglect of other essential preventive measures. For additional information, see Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus (2019-nCoV) outbreak (8).
In case of a local, regional or statewide movement restriction, or a shelter-in-place lockdown, Disaster Response Healthcare Volunteers (DRHV) can serve as valuable assets in clinics and various other healthcare facilities. DRHV are professionals who want to volunteer during an emergency or disaster and provide valuable services before, during and after disasters and public health emergencies. This also requires a willing U.S. licensed physician to want to supervise the DRHV.
In this case, we strongly encourage our Affiliated Attending Physicians to welcome AmeriClerkships DRHV Members. Also in order to address any concerns about DRHV’s travel to/from a physician’s clinic may not be justified by a security government personnel (police, military, etc.), we recommend the AmeriClerkships Affiliated Attending Physician to draft the following letter on their letterheads and provide to each DRHV Member on the first day of their rotation:
Re: [Member First & Last Name]: Disaster Response Healthcare Volunteer
To Whom This May Concern,
I am a [medical specialty] physician, [State] license [#], and am the direct supervisor for [Member First & Last Name] at [name of clinic and hospital and residency, etc.]. [Member First Name] is a medical [student or graduate] serving as a Disaster Response Healthcare Volunteer, and [his/her] valuable help during the current COVID-19 pandemic in [City, State], is essential and needed in our medical practice.
Please contact my mobile at [###-###-####] with any questions.
[Physician First & Last Name] [Physician Address (if not on letterhead)] [Office and Mobile Numbers]
Contact the AmeriClerkships 24 hour ‘COVID-Response Team Physician Hotline’ at +1(949) 579-8089.
Reasons to consider
- Per Waseh & Dicker:
- The integration of telemedicine-based lessons, ethics case-studies, clinical rotations, and even teleassessments are being found to offer great value for medical schools and their students.
- Most medical students find such training to be a valuable component of their preclinical and clinical education for a variety of reasons, which include fostering greater familiarity with telemedicine and increased comfort with applying telemedical approaches in their future careers.
- Over 60 allopathic medical schools in the United States provide some form of telemedicine experience in their clerkship offerings.
- Per Chiron, other benefits of starting a telemedicine practice include:
- Increased revenue
- Flexibility in scheduling
- Better patient outcomes
- Fewer ‘No-Shows’ and last minute cancellations
- Improved work/life balance for provider
- Protection from competition
- Happier employees
- Reimbursement for more types of visits, and much more.
What other institutions have done
Per Waseh & Dicker, below you will find support for telemedicine-based clinical clerkships:
- The Cleveland Clinic, for example, has incorporated telemedicine into an ethics curriculum, allowing a panel of second-year medical students to interview dialysis patients over a live video stream to learn about professionalism, patient experiences, and health care ethics
- At the University of Arizona (Tucson) and the University of North Dakota, telemedicine is being used to foster interprofessional training and collaboration among students from different health professions.
- At the University of New Mexico, medical students are exposed to telemedicine as they rotate through a variety of clerkships, and students who show an interest are able to develop research projects and community interventions that utilize telemedicine. The scope of these projects has even included telemedicine in a global health context with students working abroad. As such, telemedicine training during the clerkship phase of medical education also represents a valuable opportunity for student learning to intertwine with genuine contributions to worldwide health.
- Medical schools such as Thomas Jefferson University, the University of Texas Medical Branch (Galveston), the University of Texas (Houston), and Southern Illinois University have all implemented distinct telemedicine clerkships.
- At Thomas Jefferson University, third- and fourth-year medical students can participate in an elective where they aid patients and the medical team in carrying out virtual rounds, which allow patient families to participate during rounds through telemedicine.
- At the University of Texas Medical Branch (Galveston), medical students learn about the field of telemedicine through study and exposure in multiple different practice settings. All participating students found that the experience proved helpful in focusing their future career goals and shared that they would recommend such an elective to fellow students.
Steps for AmeriClerkships Attending Physicians to implement
- Define the goals for your telemedicine program
- Engage your staff
- Study reimbursement rules and regulations in your state
- Decide if you will practice partial or full telemedicine
- Work hard to make patients aware of option
- Ask for feedback, then once live
- To protect private patient information, clinical rotation must be conducted mainly in a clinic
- AmeriClerkships Member:
- Reports to the clinic as they would have normally done for a regular hands-on rotation
- Reads all charts for patients being seen by telemedicine that day, and that week
- Sits next to the attending physician, takes notes, and be visible in the computer screen
- Should receive training on the EMR system you use in your clinic, so they can function as a scribe during your patient visits
- Inform each patient that there is a medical student or observer in the room, and asks for their consent
- After a few visits, you can start the telemedicine yourself, then ask the patient if it is okay for your student (AmeriClerkships Member) to take the initial history
- Discuss each televisit with each AmeriClerkships Member; encourage them to study the diseases seen that day, and to present on one the next day
Contact the AmeriClerkships 24 hour ‘COVID-Response Team Physician Hotline’ at +1(949) 579-8089.
Physician Response to: “Will you continue to accept AmeriClerkships Members during COVID-19?”
3/25/2020: SMS response in support of AmeriClerkships encouraging physicians to not send students and graduates home during COVID-19
“Saw your email. I’ve been screaming this for two weeks [about not sending students home]. Will respond to your email officially. Stay safe and SANE! My cousin Matt, Ortho resident at NYU; Told him my feelings about med students etc being sent home. His text to me…
Complete opposite here. They offered the 4th year med students to graduate early and start intern year next week “