RESEARCH PAPER Virtual COVID-19 Clinical Teaching Session: A Substitute for ‘Sheltered in Place’ Medical Students Mohamad Moussa a Jessica S Allman b Shivam S Shah b Madison N Rectenwald b Casey A Pollard b Jake Goliver a Coresponding author(s): jallman@rockets.utoledo.edu aUniversity of Toledo Medical Center Emergency Medicine, D Toledo, Ohio 43614,, and bUniversity of Toledo College of Medicine and Life Sciences, Toledo, OH 43614. The novel SARS-CoV-2 virus, or COVID-19, has caused a pan- demic in the past year that has significantly impacted the health care system and medical education. This virus has uniquely im- pacted emergency medicine, as many COVID-19 patients suffer from acute respiratory distress or failure and require emergent stabilization. While physicians, residents, and medical students would all benefit from hands-on training on the medical manage- ment and stabilization of COVID-19 patients, this is not feasible due to risk of transmission and spread of the virus. Students have missed countless hours of hands-on clinical education because of the shift to online learning or emergency remote learning due to these concerns. A PowerPoint presentation was given via Webex by emergency medicine physicians and resi- dents to medical students in hopes of bridging this gap. The lec- ture presented information on diagnosis, clinical management, and clinical course of COVID-19 positive patients in the emer- gency department. Students were able to engage with emer- gency medicine physicians and ask questions in real time. A pre-session survey and post-session survey were administered via Google Forms to assess students’ confidence in six different domains. There was significant improvement in all six domains of the survey when comparing the pre-session and post-session survey confidence intervals with a p<0.05 being statistically sig- nificant. Storytelling by physicians on certain aspects of patient management, such as advocating for patients in the clinical set- ting, was found to be a useful tool in conveying information to students. This presentation highlights the utility and effec- tiveness of an interactive approach to the virtual education of medical students during the COVID-19 pandemic while adhering to online learning and social distancing formats. In addition, this model can be applied to substitute for other clinical learning opportunities that are not currently available to students due to the pandemic. Virtual | COVID-19 | Emergency Department | Medical Student | Pan- demic The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), also known as Coronavirus Disease 2019 (COVID-19), has become a pandemic, putting a strain on health care delivery (1). Moreover, COVID-19 has uniquely affected the field of emergency medicine. This virus has challenged, and in some cases, redefined traditional approaches to patient management in the emergency de- partment. The sheer number of cases has threatened to overwhelm healthcare facilities and has led to supply shortages across the coun- try. The clinical aspect of medical education has come to a halt for many medical students across the country as a result of the COVID- 19 pandemic (2). Most medical students are not currently able to participate in clinical experiences due to the high risk of expo- sure and transmission of the virus. Being excused from clinical duties, medical students are unable to gain valuable and necessary experience regarding COVID-19. How can in-person, clinical ro- tations translate to an online module or lecture? An article in Edu- casereview discusses the reality of the current educational solutions, specifically emergency remote teaching. The article notes the lack of a robust educational ecosystem in favor of a temporary, reliable solution that will disappear with the conclusion of the emergency state for which it was created (3). Some institutions are attempting to provide emergency remote teaching in lieu of clinical rotations for medical students, while others are pressing pause on their stu- dents’ clinical education (4). Emergency remote teaching differs from the traditional definition of online education. It provides tem- porary teaching resources not necessarily built to substitute educa- tional experiences in the long term, instead focusing on providing Submitted: 08/31/2020, published: 10/25/2020. utdc.utoledo.edu/Translation UTJMS 2020 Vol. 8 1–5 https://orcid.org/0000-0002-0356-2944 mailto: jallman@rockets.utoledo.edu the minimum necessary for continuing education. As students be- come increasingly responsible for their clinical learning, their re- sources are now limited to textbooks, literature, case studies and in some cases, online instruction (5). The COVID-19 crisis presents an opportunity for lessons on management of critically ill patients, infection prevention and con- trol, disaster preparedness, and resource allocation. It is imperative that current medical professionals as well as medical students learn from patient cases to improve COVID-19 management techniques and protocols. With safety concerns and personal protective equip- ment (PPE) restrictions prohibiting medical students from learning in the clinical environment, a type of temporary solution is in de- mand. The aim of this session was to enhance medical student un- derstanding of COVID-19, including patient presentation and clini- cal course, current approaches to management, and hospital opera- tions. Materials A PowerPoint presentation was given on WebEx due to cur- rent remote learning measures. During this presentation, students were able to view the PowerPoint slides and ask questions using a sidebar \chat" function. Example COVID-19 cases were presented within this PowerPoint and case management for each example was discussed. The session began with a presentation about the current clinical picture surrounding a COVID patient and the reality of daily life as an emergency medicine physician. Details covered included the presenting symptoms of COVID-19 positive patients, necessary medical workup, imaging, and management. The presentation also discussed PPE, daily routine with PPE and sanitation procedures. Following the PowerPoint presentation, there was a COVID-19 question and answer session led by a panel of eight faculty physi- cians and five residents. This was an integral portion of the ses- sion, as it was one of the first opportunities students had to discuss COVID-19 in an educational setting and to ask questions. Med- ical students had questions regarding current literature on clinical guidelines and were curious about the differences between the pub- lications, recommendations, and actual practice. Additionally, they were interested in being part of the clinical experience in some way. The organizers felt that the most effective way to bring students up to speed was through sharing their stories and personal experiences taking care of COVID-19 patients. The efficacy of using storytelling in education has been well documented (6). It provides context to the content and builds community within the educational system (7). In this circumstance, storytelling proved to provide an interac- tive, engaging, and beneficial learning experience for the medical students. A pre-session survey and post-session survey were administered to all participants. The pre-session survey was sent to students an hour prior to the start of the session and was completed via Google Forms. Participants were asked to rate their confidence in 6 do- mains, using a 1-5 scale (1= Not at all confident, 2= Slightly con- fident, 3= Somewhat confident, 4= Fairly confident, 5= Completely confident). The six domains were 1) Confidence regarding general knowledge about COVID-19 including spread and number infected, 2) Understanding of COVID-19 presenting symptoms and manifes- tations, 3) Understanding about management of COVID-19 patients in the emergency department, 4) Understanding about COVID-19 patient clinical courses, including outcomes and prognosis, 5) Con- fidence in managing a COVID-19 patient at a medical student level and 6) Confidence of knowledge regarding current COVID-19 test- ing protocols. The post-session survey was sent out to attendees immediately following the conclusion of the session. Participants were asked to again rate their confidence after the session in the same 6 domains following the same scale. The post-session survey also included a free-text space for students to submit comments regarding the ses- sion. Details can be seen in Survey Outline below. Survey Outline The survey below was administered via Google Forms: Please rate the following items on a scale of 1 to 5, using the scale below for reference 1 = Not at all confident 2 = Slightly confident 3 = Somewhat Confident 4 = Fairly confident 5 = Completely confident 1) Confidence regarding general knowledge about COVID-19 (spread, number infected, etc.) 2) Understanding about COVID-19 presenting symptoms and man- ifestations 3) Understanding about management of COVID-19 patients in the emergency department 4) Understanding about COVID-19 patient clinical courses (out- comes, prognosis, etc.) 5) Confidence in managing a COVID-19 patient at a medical stu- dent level 6) Confidence about current COVID-19 testing protocols 7) (Optional, free text) Please use this space to leave any comments regarding the session (what you felt was helpful, what could be im- proved, etc.) Data analysis was performed using Excel. Average confidence ratings were calculated for each item on both the pre-session and post session surveys. Two sample t-tests assuming equal variances were conducted for each item to determine significant differences between pre-session and post-session ratings. 95% confidence in- tervals for each item were calculated. Results and Discussion A total of 64 students completed the pre-session survey and 44 students completed the post-session survey. The largest dif- ference between pre-session survey and post-session survey confi- dence rankings was for item 3, "Understanding about management of COVID-19 patients in the emergency department". There was a 1.67 difference in pre-session survey and post-session survey aver- ages for this item, changing from 2.17 to 3.84, respectively. The smallest difference between pre-session survey and post-session survey confidence rankings was for item 1, "Confidence regarding general knowledge about COVID-19 including spread and number infected" There was an 0.61 difference in pre-session survey and post-session survey averages for this item, changing from 3.16 to 3.77, respectively. The average improvement from pre-survey to post-survey confidence was 1.13. Improvement between pre-session confidence rating and post-session confidence rating was significant in all 6 domains with p<0.05 being statistically significant. Pre- session survey averages and post-session survey averages for each survey item 1-6 are shown in Chart 1 below, with the 95% confi- dence interval represented by the error bars. 2 utdc.utoledo.edu/Translation Moussa et al. Fig 1. Chart represents mean confidence ranking for each survey item before and after the presentation. Error bars represent the 95% confidence interval. N=64 for pre-session responses and N=44 for post-session responses. Discussion The goals for this meeting were as follows; educate students using the personal experiences and challenges of The University of Toledo College of Medicine and Life Sciences (UTCOMLS) Emer- gency Department staff during the pandemic, prepare students to take care of COVID-19 patients when they return to clinic, and an- swer any questions from students about the evolving clinical envi- ronment. The faculty provided valuable insight, emphasizing the evolving nature of their protocols and the importance of staying up to date with the current research. The faculty and residents contin- ued to fill in the gaps of the clinical picture in the acute management of COVID-19 patients using storytelling. For example, a resident discussed her experience advocating for the admission of a non- COVID-19 patient. She walked students through the case of a heart failure patient who was COVID-19 negative. The admission center was hesitant due to lack of available beds and suggested sending the patient to a different hospital. She explained her thought-process that patients should be admitted at this hospital as their cardiologist could have easier access to them and why that was important. As she told the story, she emphasized the value of being a true advo- cate for your patients. Learning how to advocate for your patients is a crucial skill learned almost solely in the clinical setting. With- out being able to observe this skill or put it into practice, hearing the resident’s first-hand account provided a unique learning opportunity for medical students. To better clarify the nature of the anecdotes students found use- ful, another example is in regards to a resident’s discussion about a patient on a nonrebreather mask. "We are proning awake patients now, not just intubated (as previously done)." The exchange can be seen in Table 1. Dr. Moussa built on this by explaining the care- ful management of these patients. He continued speaking to his experience of pharmacological treatment for COVID-19 patients in the emergency department and beyond. Students continued voicing their questions in the chat and were met with answers containing Moussa et al. UTJMS 2020 Vol. 8 3 physicians’ personal experiences. An example can be seen in Table 2. Table 1. Webex chat transcription example 1 Time Stamp of Webex Physician/Student Comment 0:30:55 Faculty We are proning awake patients now, not just intubated (as previously done) 0:31:09 Student 1 Is that improvement from proning in general or just for covid 0:31:43 Faculty Its used in ARDS to improve oxygenation, we used it more liberally. starting in the last couple weeks. 0:32:50 Resident In terms of physiology, it improves hypoxia due to V/Q mismatch. Table 2. Webex chat transcription example 2 Time Stamp of Webex Physician/Student Comment 0:33:56 Student 2 In terms of AC (anticoagulation) are we using NOACs/DOACs (novel oral anticoagulants direct acting oral anticoagulants)? Heparin ggt (gamma-Glutamyl transpeptidase)? Or just aspirin? 0:34:49 Resident People are not being anti-coagulated unless admitted. Heparin is preferred. 0:39:53 Faculty I personally have not used steroids because of concern it will worsen. Havent really seen the ICU [Intensive care unit] do it either. Problem is when you have a COPD (Chronic obstructive pulmonary disease) patient and you are trying to decide is it COPD or COVID, because steroids will improve the COPD. 0:35:17 Faculty Heparin drip is easy to titrate and turn on and off so that’s what we use in the hospital. Following the session, students showed a greater degree of con- fidence in all six survey domains. The largest difference between pre-session survey and post-session survey confidence rankings was for item 3, "Understanding about management of COVID-19 pa- tients in the emergency department". The presentation included case-based discussion, which allocated a significant amount of time for discussion of patient management. This may account for the greater improvement in confidence for this item. The improvement in confidence in this domain is encouraging given that the primary goal for this presentation was to better students’ understanding of COVID-19 patient management. The smallest difference between pre-session survey and post- session survey confidence rankings was for item 1, "Confidence re- garding general knowledge about COVID-19 including spread and number infected." One reason that there was a smaller change in confidence for this item could be that the primary focus of the 4 utdc.utoledo.edu/Translation Moussa et al. presentation was clinical management, with general knowledge on COVID-19 not being discussed in great detail. At the end of the post-session survey, learners were able to give feedback on the session. Comments included, "this" was an ex- tremely useful presentation for students and helped us see what is happening on the front line. . . this level of knowledge is integral to our understanding once we join the clinical scene." Other com- ments noted that the sidebar "chat" option was helpful, and that seeing computed tomography (CT) scans and images for clinical management enhanced understanding. One limitation to this presentation was that there was a brief (approximately 10 minute) period of time during which there were audio/video difficulties due to the online presentation format. Be- cause of this, some participants were not able to hear a short portion of the presentation, which may have impacted their reported post- session confidence ratings. However, the online presentation was supplemented with an ongoing "chat" in the sidebar, where partici- pants could pose questions to be answered by emergency medicine residents. Additionally, following the lecture, there was a question and answer session with a panel of 13 emergency medicine physi- cians. These two additional features allowed participants to clarify any information covered during the period with technical difficul- ties. Another limitation is that the assessment was administered as a self-report survey rather than an objective assessment to gauge im- provement in knowledge. It may be beneficial to develop a tool that objectively assesses participant knowledge in these domains and ad- minister this assessment before and after the presentation. Conclusion This lecture presented an opportunity for students to learn more about diagnosis, clinical management, and the clinical course of COVID-19 positive patients in the emergency department. The im- provement in students’ confidence scores across all six domains supports that this presentation was effective in improving student knowledge regarding COVID-19 in the emergency department. The ability to adapt in real time to changing clinical guidelines is a skill that clinical students need to emulate on their return to the clini- cal setting. If the students are exposed to examples of adaptation through storytelling, it could ease the reintegration of learners back into the clinical rotations. The physicians emphasized that the best way for students to prepare to return to clinic is to continue to stay up to date on the literature as well as participate in interactions like these to gain as much clinical perspective as possible. COVID-19 is a novel virus with a poorly described clinical course. Therefore, it is essential for healthcare professionals and students to learn as much as possible from each patient case and to share information on COVID-19 with the healthcare community. The interactive for- mat of this online approach to learning offers one way for students to continue learning in a meaningful way while adhering to distanc- ing guidelines. Conflict of interest Authors declare no conflict of interest. Authors’ contributions Conceptualization: M.M., S.S., M.R., C.P. Data curation: J.A., S.S., M.R., C.P. Formal analysis: S.S., M.R., C.P. Methodology: M.M., S.S., M.R., C.P. Supervision: M.M. Writing { original draft: J.A. Writing { review & editing: J.A., S.S., M.R., C.P., M.M., J.G. Acknowledgements The authors thank Amy Blevins and Dr. Amegee for organizing and coordinating this event. 1. 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