Medical students are benched during the pandemic [PODCAST]

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“There is no single culprit responsible for this shift in medical education. However, two, in particular, should be noted. The first is the culture of defensive medicine, or more bluntly, CYA (cover-your-ass) medicine. This culture has been insidiously infusing itself within the modern health care system for decades. The fear of being sued for malpractice is ever-present. Undoubtedly, this has led to hesitations in allowing medical students to be involved in patient care. Another important consideration is our capitalistic health care system. In an era when physicians are being pressured by hospitals to see more patients, coupled with intense bureaucratic demands and documentation requirements, it is no secret that learners slow down productivity and drive down the bottom line. As a result, education suffers.

What is the consequence of all of this? The ‘finish line’ keeps getting pushed back further and further. More resident physicians are deciding to pursue fellowship before becoming an attending. For instance, in the field of general surgery, 80 percent of residents decide to pursue a fellowship. It is unclear how this will affect patient care in the future. Undoubtedly though, it begins at the medical student level. The decision to remove medical students from the hospitals in the midst of this crisis is the ultimate reflection of a much larger problem, that being, the regression of the role of medical students.”

Clayton Korson is a medical student.

He shares his story and discusses his KevinMD article, “Medical students are benched during the pandemic.”

This episode is sponsored by The Nuance Dragon Ambient eXperience (DAX). The Nuance DAX solution makes it possible to forget the tech-toggling and reduces documentation burdens no matter how or where care is being provided.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Clayton Korson. He’s a medical student, and he wrote the KevinMD article “Medical students are benched during the pandemic.” Clayton, welcome to the show.

Clayton Korson: Yeah, pleasure to be here. Thanks for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and your journey to where you are today?

Clayton Korson: Sure. So I’m a final-year medical student at the Creighton University School of Medicine. I grew up in a small town in rural Oregon, and I’ve kind of bounced around the country. I went to undergrad at Colorado State University, I spent a year in North Carolina working as a toxicology researcher, and then I was accepted to medical school. I spent a couple of years in Nebraska, and now I’m here in Phoenix at the regional campus, in my final year of medical school. I bounced around between a few different specialties and what I wanted my life to look like, and I decided on emergency medicine. I’m very excited to go forward and go from there.

Kevin Pho: All right, best of luck to you.

Clayton Korson: Thank you.

Kevin Pho: So your third and fourth years typically have clinical rotations. How has the pandemic affected those?

Clayton Korson: We were effectively benched. I guess that kind of leads into my article. Back in March, actually, there was a national recommendation for medical students to be removed from the clinical environment. That was back in March, and it lasted about three to four months, and that was the context surrounding the article that I wrote.

Leading up to that, I was at home. It was a completely virtualized medical education. It was actually my second rotation back when I was scheduled to be in the ICU, and the rules regarding patient care for medical students: We’re not allowed to see COVID patients, and we’re not allowed to see patients under investigation. I went into the ICU very excited, especially as a rising emergency medicine resident; you learn a lot, for sure. And our entire patient census was full of COVID patients. So effectively, after spending three months in this virtual education, in my mind, once again I was sent home, or I was sent to another rotation. It worked out well, but it certainly was disappointing. It was frustrating, and I went home that day and basically wrote this article, a lot of reflection on what happened over the last few months leading up to that rotation and also on medical education as a whole.

So, breaking down my article, I think of it in the short term and also in the long term. In the short term, I think in terms of the next one to two years, really how it affects our cohort, and basically I’m concerned about our cohort’s ability in a few different aspects. First is just the ability to choose a specialty. Some rotations were outright canceled; others were significantly affected by the pandemic in terms of clinical volume, in terms of elective procedures, for instance. Overall, I just think it’s not nearly at the capacity it was prior to the pandemic. So I think for some of my colleagues, not all of them, certainly not all of them, but for some of them, it is concerning, being able to rotate on the different services, and of course, as that relates to physician burnout and career longevity, I think that’s very important.

Additionally, there’s our ability to truly experience a clinical environment. That is something I’m also concerned about, in terms of, like I said, the clinical census being down. Really, the rotations are suboptimal. They are much better than they were a few months ago, but absolutely, it’s something that’s impacted our ability to learn from patients. And then lastly, there’s the actual educational quality, through no fault of anyone or any institution, just the fact of a broadly changing clinical landscape. Faculty are overwhelmed. They have telemedicine, virtual health, and new clinical guidelines that change every single day. So all of the above, really, in the short run. I’m not entirely sure how it will affect our cohort going forward, and I think we will do a good job of picking up the slack, but undoubtedly this COVID effect will certainly have a role in the years to come.

And then I also think about it in terms of the broad term. That’s something else I wrote about. I was really thinking about how, 30 years ago, I’m not entirely sure that medical students would have been sidelined in the same way. In fact, I think they probably would have been enlisted, used, and invaluable to the care team. So I really thought about what’s changed. What has caused us to be at the point where we’re essentially expendable and sent home in a pandemic? And I think there are a lot of different reasons, a lot of good reasons. There’s a lot more ancillary staff. There are more rules regarding work hours, as that relates to resident wellness. But at the same time, I think that comes at a cost in terms of patient education and patient care, and it concerns me, looking forward to the next 10 or 20 years. What is our class, what is our cohort, going to look like in terms of our expertise and our ability to function in the same capacity as the people who came before us?

There are a lot of different reasons; it’s a very complicated issue. I boiled it down to two in my article. One of them is the medical-legal landscape. Medical students are viewed more as a liability nowadays than maybe in the past, largely due to a lot of reasons, but certainly medical-legal is one of them. Additionally, there’s the capitalistic health care infrastructure that we work in: the bottom line, efficiency, productivity. It’s no secret that learners slow down the bottom line, and as a result, education suffers.

When I was reflecting on and reviewing this, I came across a great article called “The four horsemen of the medical education apocalypse,” which is a dramatic title, but they make some great points. This was written 12 years ago, forecasting the challenges in medical education, including the medical-legal environment, including productivity and the clinical landscape of capitalism, and additionally increased class sizes and the expansion of midlevels. All these things contribute to our education becoming more and more passive, which ultimately culminated in us being completely removed from the clinical environment.

I’m not entirely sure what the solutions are, and I’m not entirely sure how this is going to impact patient care. I was just trying to make an observation, and it’s something that was frustrating. It’s frustrating to go through eight years, four years of undergraduate education and then multiple years of medical education, to just be sent home, and that I really couldn’t offer the help that I wanted to in that capacity. I’m not entirely sure what the solution is, but it does concern me, for my patients and for my colleagues. I am an optimist. I do think good things are happening, and there are always hard-working people everywhere. But I think it’s just something to take note of and to be aware of as we go forward in our clinical landscape.

Kevin Pho: Sure. So here you are in your third year, and you’re excited to do clinical rotations, seeing patients, going to the ICU, but you’re at home and not able to do all of that. You talk a little bit about what was going through your mind, but how are you passing the time? How are you trying to learn about medicine even while you’re not seeing patients during that time?

Clayton Korson: Sure. So our curriculum was largely virtual at that time. It was almost similar to the preclinical years. It’s such a huge achievement to finally get out of the books and into the wards, so in a sense, it was like we were being sent back to that. It was largely lectures. We also participated in telehealth and academic conferences that were virtual, and additionally, we were studying for boards. We still had to take our shelf exams; we still had to take our USMLEs. So that was the bulk of the clinical time.

But there was still a large gap in terms of our ability to learn from patients, which I believe is the best way, and the only way, to really, truly learn clinical medicine. And so being sent back to the books is definitely a very frustrating thing. There are other ways to help, through volunteer efforts and whatnot, but it still wasn’t the true capacity that I believe most students wanted, to be able to use their training. There are a lot of considerations, and it was a very tough call for administrators to make. I don’t think they made it lightly. I think in certain aspects it was appropriate, but it definitely came at a price for us.

Kevin Pho: Now, if you were in charge of that decision-making, what would you do?

Clayton Korson: Well, I think that it largely depends on the clinical need: how much of an emergency it actually is, with the pandemic presenting. But I really think that it would have been valuable for students to stay on board from an educational aspect, just from having the foresight that these pandemics are definitely not confined to happening once in a career, certainly not. So for the educational aspect of being able to learn from a once-in-a-century opportunity, I would have been for students staying. It was unfortunate that we didn’t. I think there could have been ways to utilize this in the clinical realm.

I do think that it was a challenge, because it’s true, these were very hard decisions that needed to be made very quickly. And patient volumes were down, so if there aren’t enough patients for medical students to see, do they really want us just sitting around? So I absolutely appreciate how difficult a challenge that was, but at the same time, I think there was a lot of valuable learning to be had, and I think that it wasn’t taken advantage of in the right way.

Kevin Pho: Now, we’re certainly not out of the woods yet. Just in Arizona, just a few months ago, there was a surge of cases, and there’s no guarantee there won’t be another surge. Tell me what the situation is like now, and if there’s another surge in the coming months, do you envision medical students being sidelined again?

Clayton Korson: So it was kind of ironic, actually, that when we were initially benched back in March, the census was pretty low in terms of COVID patients, but then when we were brought back into the clinical environment, at least here in Phoenix, the cases were rising. So it was kind of ironic: We were out, and then as soon as we got back, the cases were rising again.

Basically, right now, we wear a mask, and we’re restricted from seeing certain patients. We’re not allowed to see upper respiratory infections, or certainly people who are intubated in the ICU who have COVID. But overall, I think we’ve done a good job of mitigating and being flexible in terms of what we’re allowing students to see or not see, and we are operating at a good capacity, I think, in terms of clinical volume and in terms of our ability to see these patients now. However, I do think that it’s not quite what it was before the pandemic. I would probably say it’s maybe 80 percent; we’re able to see 80 percent of the patients that we used to see. It is a lot of PPE, wearing masks at all times, personal hygiene, and we have eye protection. That’s been the new thing in the last month or two.

Overall, we have been able to get back into the realm, and I really wish that would have been the case all along. I wish it didn’t have to happen after months and months of debating and figuring out what the best role for us was. But it has improved, and in terms of the points I made earlier about being able to choose a specialty, the rotation quality has improved. But it doesn’t negate that we missed out on basically four months at that time.

Kevin Pho: Sure. We’re talking to Clayton Korson. He’s a medical student, and he wrote the KevinMD article “Medical students are benched during the pandemic.” Clayton, tell me what you’ve learned over the pandemic that you could share with the other medical students who may be listening to this podcast.

Clayton Korson: You know, it was kind of a blessing and a curse, right? We were pulled from the rotations, pulled from the very demanding studying all the time and working all the time. So in a certain sense, it was nice to take a step back and really reflect on your personal values, using that time for confirming the field that you went into, reaching out to mentors, and participating in other capacities like research and whatnot. So I think in terms of that, it was helpful.

But also, I definitely learned how much I truly, you know, you don’t realize what you love until you miss it, right? And I really learned that I truly love taking care of patients, especially patients in the emergency department. It made me appreciate coming back into the clinical realm that much more, and that’s something I think most students reflected on, and thought, “Oh, man, it really is a privilege to be able to take care of patients.” Other lessons that I learned: absolutely keeping up with studies, and keeping healthy habits in terms of fitness, mindfulness, wellness, and things of that nature. I think all of the above presented themselves throughout the pandemic.

Kevin Pho: And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Clayton Korson: Basically, I just think medical schools and medical students, we need to take ownership over our education. We need to be good advocates for our patients. We need to be good advocates for ourselves. There are a lot of problems in health care, and they’re never going to fully go away, and as soon as they go away, new ones will come forth. So I just think it’s a matter of identifying problems and where we can improve, and just going from there. And I would absolutely advocate that medical students should advocate for themselves, take ownership, and go on to be leaders of their health care teams and profession.

Kevin Pho: Clayton, thank you so much for being on the show, and thanks again for your time. Much appreciated.

Clayton Korson: A pleasure to be here.

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