Building a Successful, Socially-Distanced Family Medicine Clerkship in the COVID Crisis

On March 17, 2020, the Association of American Medical Colleges released guidance that strongly suggested that medical students not be involved in any direct patient care activities,¹ but medical education continued! Pausing clinical rotations and then having students make up at a later date would have caused an insurmountable backlog of learners for our already-stretched preceptor pool. The crisis inspired rapid innovation and our faculty quickly decided to create an entirely telemedicine-based family medicine clerkship: 100% of patient care experiences would take place via telephone and video encounters with patients.

For our clerkship’s clinical experience, we required students to log at least 20 telemedicine patient encounters over 4 weeks. Encounters were staffed with faculty physicians either asynchronously for low-risk situations or immediately when high-risk medical conditions were discovered. We built flexibility into how exactly each clinical preceptor supplied these 20 encounters. Some faculty members gave students lists of high-risk patients to cold call for COVID-19 education and chronic disease check-ins. Other faculty members chose to directly observe medical students, participating in 3-way phone encounters where students conducted the telemedicine encounters with the faculty for patients scheduled for specific clinic sessions. The clerkship provided additional simulated clinical experiences by requiring our students to complete several Aquifer² cases.

To prepare our clerkship students for telemedicine, we created a “telemedicine illness script writing assignment,” due at the end of the first week of the rotation (see supplemental materials for script-writing assignment document). The clerkship provided a template that included an introduction, check-in, and review of symptoms, a placeholder for a 2-minute script on COVID-19, a medication reconciliation, and a placeholder for a 2-minute script on a common chronic disease process. Before writing their scripts, students were instructed to complete a free Centers for Disease Control and Prevention (CDC) module on health literacy for public health professionals,³ complete an interactive online COVID case series,⁴ listen to two podcasts that provided up-to-date background information on the COVID-19 infection and response,^5,6 browse the discussion topics on the CDC COVID-19 frequently-asked questions page,⁷ and review a brief telemedicine guide from the Academy of Communication in Healthcare.⁸ These materials provided up-to-date information about COVID-19 in April 2020, but will likely require updating in future versions of this curriculum. After writing their scripts, students were encouraged to review and revise them with their clinical preceptor. After revision, all telemedicine scripts were deidentified and uploaded into a shared drive so they could be used as templates for conversations for all clerkship students. Every student in the clerkship wrote a script for a different chronic disease process, so that we quickly generated a shared library of communication guides for these telemedicine encounters. After completing this preparatory assignment, students were deemed ready to engage with real patients.  

We evaluated this remote clerkship curriculum using anonymous surveys via Qualtrics software at the conclusion of the 4-week rotation. Since these surveys fell under the curriculum evaluation/quality improvement umbrella, Medical College of Wisconsin Institutional Review Board members exempted this study from its review process. All faculty members and medical students were also invited to complete short evaluation surveys of their experience with the new remote clerkship (see supplemental materials for student and faculty surveys).

Fifteen of 17 students and nine preceptors completed the postrotation evaluation. Students conducted an average of 32 clinical patient encounters; this was slightly above the 24-25 encounters that students and preceptors felt should be required of this rotation. Table 1 compares student and preceptor responses to clerkship impact questions. Key findings include that students improved workflow, were capable of assessing for and providing guidance regarding COVID-19, and that many recommended continuing to use telemedicine as part of future in-person clerkships. Nearly all respondents (100% of preceptors, 93.3% of students) agreed that this clerkship format enhanced clinical skill development/allowed for meaningful clinical teaching. Table 2 displays student self-evaluation of accomplishment of clerkship learning objectives. Each was evaluated on a 5-point Likert scale (1=strongly disagree; 5=strongly agree), with mean values of 4.38–4.87 and standard deviation of .40 to 0.78. This is notable given these learning objectives were unchanged from traditional in-person clerkship. Table 3 compiles themes from student and preceptor responses to free-response prompts, in which five common themes were identified: the students were useful, students and patients benefitted, students developed clinical skills, preceptors identified teaching advantages, and organizational/format challenges of the rotation.

Clinical faculty and medical students in the Medical College of Wisconsin’s Family Medicine Clerkship quickly adapted to continue medical education, provide public health information, and care for at-risk patients, all while adhering to the COVID-19 social distancing guidelines. Our entirely telemedicine-based, socially-distant clerkship successfully engaged students in meaningful patient care and met all of our established pre-COVID learning objectives. Our survey of clinical faculty also indicated they were able to continue with excellent clinical instruction while not being overburdened with training responsibilities.

Our clerkship decided that 20 telemedicine encounters, combined with 25 assigned Aquifer cases would provide an adequate learning experience for our leaners. Twenty telemedicine visits is notably less than the 70 physical patient encounters required prior to COVID, so it is somewhat surprising that our survey data were overwhelmingly positive. It is likely that an overall lower volume of clinical cases in our faculty practices allowed for more robust patient care discussions than typically happens in a busy family medicine clinic. Faculty and students also reported there were more opportunities for direct observation and feedback of student-patient communications.

We were fortunate to recruit faculty with extensive student teaching experience to precept clerkship students virtually; all attendings who were invited agreed to participate. Typically, a small proportion of clerkship students are assigned to work with community preceptors, but they were not approached to precept during the initial transformation to telemedicine and virtual teaching at the onset of the pandemic.

Our study has limitations. We present here the evaluation data from only one block rotation of our family medicine clerkship. This was compiled and published rapidly so that other clerkships could learn from our model. We also only had an 88% response rate on our anonymous student surveys and a 70% response rate on our faculty surveys. Implementation and further study of this curriculum by other institutions could provide additional validity to our telemedicine curricular model. The authors look forward to collaborating with others as we work together to continue medical education during the COVID-19 pandemic.