For medical school students, beyond the science of what they need to learn to become physicians, there is also learning how to interact with patients: what questions to ask to find out a problem and work to a solution; what physical exam to perform to spot any physical abnormalities; and what things a doctor can do to provide information and comfort to their patients.

In March 2020, all medical education became virtual across the country due to the spread of the COVID-19 pandemic. Students were pulled from clinical rotations, classes were mandated to be online so students, faculty, staff, and patients could remain safe. This sudden stop of in-person learning posed a tremendous challenge to medical schools across the country to keep the students on track for graduation without sacrificing the institutional goals and expectations of their graduates.

“The need to transition to virtual presented complications for medical education, which is often very hands-on due to the nature of our students’ future careers,” said Rick Vari, senior dean for academic affairs at the Virginia Tech Carilion School of Medicine. “Our students learn best by doing – through patient interactions, observing faculty and peers, practicing hands-on skills, and more. The entire faculty made mammoth shifts to try to reach the same educational outcomes virtually.”

When VTCSOM switched to virtual classes in mid-March, one of the major challenges was figuring out how to properly and fairly administer exams. “Assessment is a critical part of our students’ education,” Vari said. “Beyond knowing that they are learning what we think is important, they also have to pass national exams in order to continue their medical education path. So, it is critical that we assess them to give them the skills and confidence to successfully complete those required exams.”

One challenge was figuring out how to move exams, normally administered at the school, to each student’s home environment realizing that the students were scattered across the country. “The customized assessment service we use for exams in the first two years of the curriculum was not going to be an option,” said Brock Mutcheson, assistant dean of assessment and program evaluation. “They didn’t have a secure platform to allow us to administer exams remotely.”

Mutcheson explained, “There were no other online options that would work for the content we were covering in our curriculum at that time, so we began blueprinting and developing our own institutional exams. We called on our local domain leaders, content experts, and block directors to put in a lot of extra effort.”

Between March and June, the school administered almost 50 exams sessions remotely. “You can imagine what it was like delivering exams to more than 40 people at a time in concurrent sessions across the country with a new secure testing platform and system,” Mutcheson said. “New guidelines required us to split into smaller testing groups which resulted in more sessions. I have to express my gratitude to Assessment Coordinator Caitlin Bassett, who stepped up, learned the new system, and took on extra proctoring, as well as the IT team who made extraordinary adjustments.”

In addition to exams that can be measured through multiple choice or short written answers, medical students practice and are assessed on how they interact with patients and their physical exam skills using standardized patients, who are essentially patient actors the students can interact with in a safe environment. This proved more challenging in a virtual environment.

All Year 3 clerkship clinical skills exams were canceled at VTCSOM in March. However, one of the larger exams with standardized patients routinely is administered at the end of that year. It is a comprehensive exam wherein they rotate through 12 patient stations and showcase their ability to interview patients and perform proper physical exams.

The clinical assessment team began planning for this exam to shift to virtual. This was keeping in line with the virtual national exams that were being developed for a national licensing exam. In essence, students were still able to interview the patient in a similar way to an in-person experience, but they had to verbalize everything else they normally would have performed.

“We developed a verbal physical exam checklist,” said Heidi Lane, assistant dean for clinical skills assessment and education. “In order to determine your diagnosis, if I was going to need to listen to your heart, I would verbalize something like, ‘I’m going to listen to your heart in four places.’ We had to develop that checklist and share with students so they would know what we would assess.”

Tarin Schmidt-Dalton, associate dean for clinical science years 1-2, oversees the clinical science curriculum for first- and second-year students. “The changes due to the pandemic came along fast in both the clinical setting where I see patients and also trying to adapt the medical school clinical skills curriculum without any previous experience to fall back on.”

In March, the second-year students had already transitioned to research and prep for their first national exam, but first-year students were reaching a critical point in the clinical skills curriculum.

“The first-years were in an extremely heavy, intensive physical exam portion of their studies,” Schmidt-Dalton said. “The block of study included probably the hardest physical exams for them to learn: the neurological exam and the head and neck exam. That was an added challenge. So, we looked at what could we potentially do remotely in a way that would still be effective? And it focused more on interviewing skills.”

“When we think of medicine, we look at physical exams as really being important, and they are. However, just as important, if not more so, is taking the patient’s history,” said Allie Strauss, student and vice president of the class of 2023. “It’s about asking the right questions to unveil parts of the story that may be relevant for the diagnosis. I think a lot of our class was worried about falling behind in our clinical skills, but we got a lot of good practice in interviews virtually and are now working to catch up on physical exam skills.”

Second-year medical students, wearing face coverings and face shields, prepare to enter practice exam rooms to interact with standardized patients.

The Governor’s Office allowed for medical students to return to in-person learning in early July, as long as certain safety protocols were met. This opened the door for the now-fourth year students to re-enter clinical environments and catch up on rotations. It also allowed the now-third year students to start clinical clerkships on time.

The clinical skills team prepared for the now second-year students – as well as a brand-new class of year one students – for in-person learning in a new environment with social distancing and personal protective equipment (PPE).

“The standard for in-person encounters is that students wear a mask and face shield and the standardized patients wear a mask and face shield. The number of people in the same patient room is also much more limited to allow room to spread out,” Lane said.

“This was a significant shift of having to be in a mask and wear a face shield,” Schmidt-Dalton said. “And there are still some physical exams that we do not feel are safe to do even with the PPE. For example, the oral health exam, looking in the nose. So, we have been able to come back in person, but it is by no means our normal, typical in-person.”

“The extra layers take some adjustment, but that’s what all physicians are dealing with now. I think there’s an understanding in our class that it’s a pandemic, and even if we were out in rotations, this is what we’d be dealing with,” Strauss said. “The fact that we have these precautions in place with our standardized patients doesn’t seem so odd. And, probably good practice for the next pandemic, hopefully not in our lifetime.”

Second-year medical student Sahana Nazeer interviews a standardized patient, while each wears personal protective equipment to prevent the spread of COVID-19.

Most clinical skills exams have transitioned back to being administered in person once again, following safety procedures like face coverings and distancing students while they take their exams.

“The students get a lot of credit for their flexibility under the circumstances from March all the way up until now,” Mutcheson said. “They have done an amazing job of asking questions, clarifying, and helping us to properly communicate what needs to be done in order to pull this all off, and to be doing it in a way that reinforces trust and reassures everyone that students had fair opportunities to show what they know.”

“It’s been nice that since we’ve been back in-person, it has felt like full steam ahead,” Strauss said. “We’ve had clinicians and residents coming in to teach exam skills. It feels like everyone wants to make sure we’re comfortable and feeling like we are caught up.”

In the end, both the transition to virtual and back in-person, though adjusted for safety, has been about working together.

“It’s been a team effort all the way around. Everybody’s had to dig deeper. It takes longer to do some of the things that we used to have efficient processes for, but the train doesn’t stop,” Mutcheson said. “We have to keep moving and we have to keep on coming through for the students and their future patients.”

“I have seen some remarkable adaptations and changes in medical education over the years at several schools, but nothing compares to the job that our curriculum leaders, assessment team, faculty, staff, and students have done in facing this pandemic,” Vari said. “They have risen to these challenges and truly make VTCSOM a unique and special medical school.”