In this study, we primarily investigated the impact of the COVID-19 pandemic on final year UK medical student’s examinations and transition to FY1, as well as exploring their current attitudes toward the pandemic.
It was shown that the final year medical students that responded to this survey had a utilitarian opinion on the impact of COVID-19; almost all respondents (93.9%) felt changes that had been made were necessary measures during this pandemic. Seventy-seven percent of respondents had electives cancelled; although disappointing to many, students recognised worldwide travel restrictions as necessary. However, there are training issues that should be addressed in the immediate term, and the question of how best to support students transitioning into the workforce in the long-term remains.
The results of this survey highlighted two key topics: attitudes to student assistantship and the impact of this pandemic on the transition from student to doctor. In 2009, the General Medical Council UK (GMC) published guidance on medical education entitled ‘Tomorrow’s Doctors’ (8). It was recommended that medical schools introduced student assistantships, where a senior medical student could take up a role “assisting a junior doctor and under supervision, [undertaking] most of the duties of an [FY1] doctor” (8).
Amongst our respondents across UK medical schools, only 8% reported that student assistantship had been formally cancelled, whilst 49.8% reported that assistantships were postponed. Fortunately, 25.4% had no change to their assistantship as they were completed prior to the introduction of COVID-19 related nationwide restrictions. It is conceivable that these results reflect medical schools biding their time to make decisions on student assistantships due to the unclear length and consequences of the pandemic. However, it may also reflect the importance and value placed upon the student assistantship by medical schools.
The aim of student assistantships is to provide students with an enhanced opportunity to build upon the domains set out by the GMC. These domains are broken down into ‘scholar and scientist’, ‘practitioner’ and ‘professional’ (9). In contrast to traditional clinical rotations, assistantships are integrated in such a way that empowers students with greater responsibility and participation within the team, to help develop clinical, practical and administrative skills and ownership of responsibility in a professional capacity.
Further evidence that suggests the student body views assistantships in high regard, is that 71% of students agreed or strongly agreed that assisting in hospitals prior to formally starting as a doctor would supplement learning opportunities lost due to COVID-19. 59% of students agreed that they feel less prepared for FY1 because of the disruptions caused by COVID-19. Considering that 49.5% of respondents have been asked to begin assisting in hospitals earlier than expected, it is crucial to define the capacity in which final year medical students will be joining the workforce during this pandemic.
When gauging confidence levels of students about the possibility of assisting in hospitals earlier than anticipated, almost half the respondents agreed or strongly agreed that they felt confident but this was dependent on the level of support and protection provided for them. It is clear that students should not be brought in to enhance the workforce without proper inductions, pastoral support, and appropriate remuneration for their time. This is essential for maintaining both patient care and student wellbeing.
This global pandemic has created the opportunity to evaluate how to improve the transition from student to doctor. A survey in 2011 sent to all UK medical schools highlighted practical challenges of student assistantships such as the need for them to be long enough to create genuine responsibility for students (10). Currently, there is growing interest in a new model of undergraduate medical education in the UK: the longitudinal integrated clerkship (LIC). The model was initially created to address rural medical workforce shortages in the US in the 1970s (11). This has grown and spread worldwide and within medical education, it is most widely utilised in primary care. In 2017, UK medical school representatives met to discuss the potential integration of LIC into the curricula. Dundee School of Medicine was the first to introduce a comprehensive LIC lasting for a whole academic year (11). Other institutions such as Imperial College and Hull York Medical school have piloted LIC programmes that run in primary and secondary care.
During the LIC, students have prolonged continuity in the care of patients promoting ownership of care and responsibility whilst having adequate supervision. The students follow care pathways of patients within both primary and secondary care. This allows more time to integrate into their respective clinical teams and feel valued as a member of the team (12) (13). Further benefits of LIC are development of student empathy and patient-centredness due to their continued involvement throughout a patient’s care. Increased interaction between students and patients helps to create a greater sense of duty and responsibility. It remains to be seen within the UK whether LIC will be introduced more widely into medical school curricula, but early student feedback is positive (14) (15).
Perhaps, for medical schools deploying medical students to assist in hospitals during the COVID-19 outbreak, this is an opportunity to evaluate their involvement, level of responsibility and roles they are given. Feasible adaptations can be made during this time in liaison with NHS trusts for the future, given the unique position the NHS workforce and medical schools have found themselves in.
Another area of interest from the survey was the impact on final year examinations. A significant proportion of final year students had already undertaken written and clinical examinations prior to the COVID-19 outbreak, or indeed prior to implementation of social distancing, and subsequent university closures. For objective structured clinical examinations (OSCEs), just under half of UK medical schools had already completed them, and around a third had these clinical examinations cancelled. Four medical schools adjusted them by using actors rather than real patients.
Similarly, written examinations were completed prior to the disruptions caused by COVID-19 in more than half of UK medical schools. Interestingly, in a first for UK medical schools, 6 medical schools changed the written examination to be done remotely at home. If the COVID-19 lockdown continues, it may be possible that re-sitting of examinations may also be online. At Imperial College London, their online assessment consisted of an open book examination of 150 questions, with 72 seconds to answer each one. Question orders were randomised to prevent students helping each other. Students were presented with simulated patients and through provided history, examination and investigation findings were required to work through questions (5).
If psychometric analysis of the data from these remote examinations appear to be comparable with that of closed book examinations, it may dawn a new era of medical student assessment. However, it must be considered that some students may not have a home environment conducive to sitting an examination, or have difficult personal circumstances at home, or have technical problems, or barriers of access to adequate online facilities (5). A robust system to ensure standardisation for student’s remote examination setting and clear guidance on extenuating circumstances must be made. Formative online assessments are already widespread in medical education and so a move towards virtual assessments may begin taking prominence. This is another potential leap in revolutionising medical education enforced by COVID-19.
Our study has some limitations which should be stated. The first limitation is the retrospective nature of the study design. Although we established the perspectives of final year medical students on the disruptions caused by COVID-19 thus far, we did not have a follow-up period for the participants. Consequently, the long term impact of COVID-19 on the transition period from student to doctor cannot yet be determined.
Another limitation is the difference in the number of participants across medical schools (average of 13.75 participants per medical school ± 12.7). This variation between medical schools means that our data does not represent the entire cohort of final year medical students who will be entering hospital trusts to join the medical workforce.