The COVID-19 pandemic has changed all of our lives, and the impact on medical education has been remarkable. The forced rapid implementation of virtual curriculums and the heterogenous clinical experiences have had major impacts on our medical students and trainees. Educators should be applauded for the tremendous efforts made quickly to preserve clinical rotation integrity. Students and trainees have endured the changes with flexibility, grace, and resilience. Many of these changes were applied without prospectively determining if they are beneficial and will have long-lasting effects.

Clinical education impact

Early in the pandemic, the suspension of elective surgeries and lack of PPE resulted in a significant loss of clinical experience for medical students and trainees. The Association of American Medical Colleges released recommendations in March 2020 that encouraged all medical schools to remove students from direct patient care. Schools had to quickly revise their clerkship programs, and many shifted to virtual, case-based learning to meet clinical objectives. However, lack of a clinical component of a clerkship will affect the educational experience of these students. Many medical students were unable to complete anesthesiology rotations. The lack of exposure may result in fewer students choosing the specialty in the future. For those applying in the specialty, the limited clinical experience created anxiety about the inability to obtain letters of recommendation for residency applications.

For anesthesiology trainees, the reduced caseload and subspecialty experience, the redeployment to telemedicine and ICU locations, and the loss of procedural experience (given recommendations for experienced practitioners to perform airway management), had both positive and negative effects (Br J Anaesth 2020;125:450-5). Certainly the innovation in creating protocols for patient care, such as using anesthesia machines as ICU ventilators, developing airway teams, and the rise and fall of intubation boxes, clearly demonstrated anesthesiologists' leadership, judgement, creativity, and adaptability. However, given the schedule changes or need to quarantine, many residents and fellows struggled to meet their required case and procedure numbers, or failed to meet milestones at an appropriate time (Br J Anaesth 2020;125:450-5). Even as hospitals resume surgeries, some patients are more hesitant to seek care for non-COVID conditions (JAMA 2020;324:1033-4). Achieving rigorous clinical experience for our trainees may be challenging given lower case numbers and acuity. The impact on trainees in regard to clinical education depends on their training program and hospital's resources and will vary greatly in this current cohort.

Non-clinical education impact

Arguably the greatest change to medical education during the pandemic has been the widespread adoption of virtual and e-learning experiences (Anesth Analg 2021;132:585-93). There is no doubt that virtual learning will have a stronger presence in medical education curriculums moving forward. The use of learning management systems and virtual meetings has strengthened the use of adult learning techniques, including the flipped classroom and simulation, and also allowed greater multi-institutional collaboration for educational efforts (Anesth Analg 2021;132:585-93; Reg Anesth Pain Med 2021;46:188-9). However, just as with clinical education, the impact on students and trainees is heterogenous. Institutions and programs with greater resources can subscribe to established learning management systems or shift education to increased simulation and technical skills training, particularly with an interdisciplinary focus. The need for small groups due to COVID-19 restrictions requires more time of faculty, who may already be stretched thin with their clinical responsibilities. Financial deficits from reduced clinical volume, as well as social distancing requirements, have resulted in decreased ability to access simulation labs and conferences and little to no compensation to faculty for development of new teaching materials.

The concept of virtual lectures or meetings via Zoom, WebEx, Microsoft Teams, or other platforms is its own double-edged sword. Certainly learners appreciate the improved quality of life that comes with the ability for on-demand learning in any location of their choosing, resulting in increased attendance and the ability to spend time away from work. However, many educators have become frustrated by the limited social interaction in these platforms and the decline of professionalism exhibited. It can be easy for the learner to revert into a passive role and multitask with their video turned off, impairing interactions between teachers and learners. Proper “Zoom etiquette” and ground rules for virtual meetings and lectures must be taught, and the ability for educators to fully engage learners via a virtual platform is a steep learning curve. Additionally, the necessity to keep up to date with current COVID-19 information, combined with the need to learn basic anesthesiology concepts, can be overwhelming for the trainee. Overall, the efforts made by educators to preserve rotation integrity through use of website content, research projects, and virtual learning are incredible, but they cannot replace invaluable clinical experience and the indelible learning formed through patient interaction. The full impact of this shift will become apparent in the near future as our students and trainees graduate.

Board examinations

The road to becoming a physician anesthesiologist involves completion of multiple board examinations with written, oral, and clinical components. Medical students and anesthesiology trainees all experienced high degrees of uncertainty and stress around their board examinations in this pandemic. Some exams were cancelled or delayed, and the future impact of this decision on residency or job applications is unclear. It was unknown how safety precautions would be instituted for in-person exams at testing centers. There was concern regarding the integrity and legitimacy of exams if administered virtually.

For medical students, the pressure surrounding the importance of board exams may have increased as many medical schools shifted to pass/fail grading schemes for the modified clerkships. The American Board of Anesthesiology (ABA) made several changes to its examination process. The BASIC Exam in June 2020 was cancelled and rescheduled to August 2020 if programs were able to administer the exam with their own personnel. The November 2020 BASIC Exam and July 2020 ADVANCED Exam continued as planned, with testing centers taking safety precautions. The APPLIED Exam weeks two through nine were cancelled and shifted to a virtual APPLIED exam for 2021. The ABA made several exceptions for candidates to continue their eligibility for exams, such as counting institutional-required quarantine as clinical time. MOCA requirements for 2020 were also waived. As a result of all these changes, apprehension surrounding the amount time needed for preparation and the necessity and importance of the board exams is high. Furthermore, the technical difficulties surrounding the other specialty virtual exams, including the American Board of Surgery, and concerns about compromising ACGME program accreditation given the circumstances, created much unease among trainees.

Personal well-being

The changes in medical education during the pandemic have had a direct effect on the well-being of medical students and trainees (J Clin Anesth 2020;66:109949; Med Educ Online 2020;25:1818439). Without a crisis, medical school and residency are challenging times, with long days at work and nights of studying. The COVID-19 pandemic brought a level of heightened anxiety at both work and home. At work, protocols changed daily, exams were cancelled, PPE was rationed or unavailable, and case numbers decreased. COVID-19 entered every conversation had by a medical student or trainee. In addition to trying to learn anesthesiology, there was greater stress about contracting an infection, the protection level of PPE, and taking an infection home to others. Partners were furloughed while childcare services and schools closed, creating financial stress and fatigue. With social distancing restrictions in place, there was a loss of social support, creating feelings of isolation and emotional exhaustion. Fourth-year medical students face difficulty with informed residency decisions given limited exposure to programs without in-person interviews or away rotations. Residents and fellows on visas were concerned about their status should their training be halted (Med Educ Online 2020;25:1818439). Trainees were unable to attend conferences to present research and network for jobs, and those who had signed contracts worried about availability of jobs after graduation. Virtual Match Day and graduation celebrations did not promote the same feelings of accomplishment and excitement.

Looking ahead

The emergency authorization of a COVID-19 vaccine has created hope among residents, fellows, and medical students. There is relief that they will be protected at work from infection, reducing stress and allowing them to continue in their training with a vision of a normalcy. The widespread adoption of virtual learning has created opportunities for personalized learning plans using synchronous and asynchronous learning. It also gives us the ability to adapt to current issues in real time, reexamine assessment strategies, and collaborate easily with other medical education programs. Furthermore, it has reinforced the importance of teaching communication and professionalism skills, public health and health disparities, and crisis resource management (JAMA 2020;324:1033-4). There is no doubt that this generation has a better understanding of what to do in future pandemics. Thank you to the medical educators who have “made lemonade out of lemons” during this pandemic and created the best possible situation for ensuring our learners can succeed. This generation of medical students and anesthesiology trainees will be inspired by the innovation demonstrated and will be called to lead the future of medicine.

Elizabeth B. Malinzak, MD, Assistant Professor and Director of Medical Student Education, Department of Anesthesiology, Duke University, Durham, North Carolina.

Elizabeth B. Malinzak, MD, Assistant Professor and Director of Medical Student Education, Department of Anesthesiology, Duke University, Durham, North Carolina.