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Dear Editor,
In three months, covid-19 evolved from an outbreak of severe pneumonia in Wuhan, China, to a global pandemic with hundreds of thousands of confirmed cases and many thousands of deaths.1 While China has all but stopped it, the pandemic continues to grow exponentially in most countries. Thanks to its exponential growth, covid-19 has been overwhelming healthcare systems and imposing a series of dilemmas throughout the world.
One dilemma is the involvement of medical students in the response to covid-19. On the one hand, higher education students have seen their in-person activities replaced by remote activities. On the other hand, healthcare professionals have been summoned to maximize their clinical activities, which involve increased exposure to covid-19, among other contagious diseases. What then should be done about the medical students’ clinical activities? Some say we should stop their clinical activities, while others say we must increase the activities or even fast-track the student’s graduation.
WHETHER TO SUSPEND CLINICAL CLERKSHIP
Clinical clerkship occupies the last one to two years of medical school and consists of practical activities in various clinical settings. The medical student’s clinical competence increases considerably during this phase, thanks to contact with real patients under direct supervision of qualified medical doctors. Depending on the context, contact with real patients involves exposition to contagious diseases, such as tuberculosis2 or SARS3. With the progressive focus of healthcare services towards handling the pandemics, keeping the clinical clerkship going on involves putting medical students in contact with covid-19 patients.
We disagree with three arguments that have been put forward for keeping clinical clerkship or even deliberately directing it towards covid-19. The first and most prevalent argument is the need to increase the workforce in health services. This argument comes up against the fact that students are not part of the workforce: their clinical activities are selected based on the educational potential, not on the assistance demand. Besides, direct supervision means students deviate preceptors from performing their own clinical activities.4 An effective increase in the workforce would require students to perform activities they are already qualified for, and without direct supervision, thus beating the whole purpose of medical education.
The second argument is that the presence of students would increase the quality of the health services. While this is a well-known phenomenon,4 temporarily removing medical students from the health services should not revert it. Furthermore, the covid-19 pandemic is depleting personal protective equipment (PPE) everywhere, and the continuing presence of medical students would multiply the demand for PPE. An early shortage of PPE would then result in preventable exposure of healthcare professionals and medical students alike to contagion by covid-19.
Lastly, the third argument is that public health crises would comprise unique opportunities for medical students to develop general and specific medical competences. We are not aware of any evidence supporting this putative benefit for students. What we do know is that healthcare professionals and, by extension, medical students, are more exposed to contagion than the general population and the impact of disasters and especially of pandemics on the students’ mental health is largely unknown.
ALTERNATIVES FOR THE INVOLVEMENT OF MEDICAL STUDENTS
Suspending clinical clerkship during the pandemic does not have to stop students from fighting covid-19. Voluntary involvement would eliminate the aforementioned issues: students would be free to help however they can, which might obviate the need for direct supervision or even for PPE. Perhaps more importantly, students with less support or resilience would not need to be involved.
The problem with voluntary involvement is that it should not be coerced. As an example, students who would not or could not participate might be forced to reconsider if volunteers received advantages, such as special praise on their medical student performance evaluations.5
Another way of getting medical students involved would be anticipating their graduation, as a compromise between the thoroughness of the education and the urgency of the society. For now, we have seen this issue being discussed or implemented in countries such as Italy, the United Kingdom and Australia, where medical school graduates receive only a provisional registration, and postgraduate experience (internship / foundation year / residency) is necessary to obtain a definitive registration.
For countries like Brazil, where “internship” means the same as clinical clerkship, and medical doctors are entitled to a definitive registration upon graduating from medical school, fast-tracking graduation would double the bet. The newly registered doctors would legally not need supervision to care for covid-19 patients but would also be free to practice medicine for the rest of their lives without any postgraduate education.
CONCLUSION
Involving medical students in the response to covid-19 is yet another dilemma imposed by the pandemic. As in other dilemmas, this question involves conflicts between different interests, and its resolution is made harder by the lack of information on the consequences of the potential decisions. For now, we believe medical schools should suspend their clinical clerkship activities and organize or join efforts to allow students to volunteer. Early graduation might be desirable for healthcare systems of which limiting factor is the number of medical doctors, along with optimized allocation of the already registered medical doctors and healthcare facilities across healthcare subsystems or geographical regions.
