Clinical Placements Adapt to COVID-19 Crisis

March 31, 2020    |  

As president of The Graduate School Physician Assistant Program’s Class of 2020, Donovan Young is eager to graduate and launch his career. But first, he and his classmates must adapt to a changing educational landscape, one that moves out of clinical settings and into the world of virtual learning as a result of the novel coronavirus (COVID-19) pandemic.

New clinical placement guidelines at the University of Maryland, Baltimore (UMB) put in place March 21 apply to students in their clinical rotations, field placements, and internships (whether in health, social work, or law). According to the guidelines, all in-person experiential learning activities with patients and clients must be halted and converted to virtual or other options that do not involve in-person activities; and distance simulation, special online resources, and online activities such as telemedicine, telehealth, and tele-behavioral health and similar means of care delivery are encouraged.

Members of the Physician Assistant Program Class of 2020 discuss their upcoming virtual learning assignments during a Zoom video conference call. Students and faculty were asked to show their school spirit by wearing UMB shirts.

Members of the Physician Assistant Program Class of 2020 discuss their upcoming virtual learning assignments during a Zoom video conference call. Students and faculty were asked to show their school spirit by wearing UMB shirts.

“Every day that passes, I get a little more concerned about whether we are going to graduate on time,” said Young, noting the class is due to graduate July 16. The program consists of 12 months of didactic learning in classroom settings and 14 months of clinical experiences during which nine clerkships are to be completed.

“We are lucky and unlucky in that we finished seven out of the nine,” Young said. “We have two more to do.”

Those will take place via virtual patient training sessions, Young said. The software platform they use, Aquifer, allows students to view patient encounters with animated virtual characters, and then document how those “patients” would be treated.

Physical examination of patients will now be performed on family members or anyone else living under the same roof. In Young’s case, that's his fiancée and two roommates, “all willing participants,” he said. Physical examinations will be performed using webcams and then critiqued by faculty members.

“It’s a little bit different [than conducting the exam in a clinical setting], but it is better than nothing,” Young said. “For the most part, I think morale has been pretty good. Everyone seems to be rolling with the punches as best we can.”

This is the time of year that Physician Assistant Program students are typically pulled out of their rotations for a few weeks of classroom instruction consisting of guest lecturers talking about research and writing for publications, resume writing, malpractice issues, contract negotiations, and test-taking strategies, all of which will now be done online, said Cherilyn Hendrix, DHEd, MSBME, PA-C, DFAAPA, program director.

“Your heart bleeds for the 10 weeks that they have left and they still badly want to get out there and swab people and protect people,” Hendrix said. “This is what they’ve gone into medicine for. They want so badly to help and they know it is not safe.”

Students in the Pathologists’ Assistant Program also will be exchanging clinical hours for virtual lessons, said Carlen B. Miller, MS, PA(ASCP), associate director/education coordinator for the program.

“In a normal atmosphere, they typically get plenty of clinical experience,” Miller said. “They are practically out [in the working world], so we are feeling pretty good now. We are not really that far off” from the clinical opportunities that the class would have accomplished by now in normal circumstances.

“At this point in their rotations, our students are pretty very well set,” Miller said. “Most of them have jobs that they are going to. I don’t have a problem saying that we have trained them as fully as could be at this point.”

The accrediting body for the program has offered “loose guidelines” about requirements for graduates. Instead, there is more of a focus on making sure students reach certain outcome measures, Miller said.

“They leave it up to the institutions’ discretion to make sure the students meet their requirements,” she said. Meanwhile, at the University of Maryland School of Nursing (UMSON), even before the UMB guidelines went into effect, students were already being asked by partner placement sites to stop reporting to their clinical rotations, said Maeve Howett, PhD, APRN, CPNP-PC, IBCLC, CNE, professor and associate dean for baccalaureate education.

“We started with eight students [being turned away from their clinical rotations] and then all of a sudden, it was everyone,” she said. Before long, all nursing students were out of their clinical settings.

UMSON leadership purchased high-fidelity software that simulates patient care in 3-D modeling, providing students with learning experiences similar to virtual reality alternatives, but with no special glasses needed. Similar software programs are used for military, surgical, and submarine training, Howett said. The software, on three different platforms, vSim for Nursing, I-Human Patients, and DocuCare, simulates nurse scenarios using virtual patient encounters. These programs will be used by all students in lieu of clinical instruction until COVID-19 restrictions are lifted, Howett said.

“They will be able to meet all the learning objectives,” she said. “It is almost the same amount of hours and the intensity level is high. You are not taking the time to get a towel or bring someone grape juice. We can give a lot of experience in a short amount of time.”

Because UMSON already places a strong emphasis on simulation, with state-of-the-art simulation labs at its Baltimore and Universities at Shady Grove locations, “we are in a better position than a lot of other schools of nursing,” Howett said. “We are ready to roll and we are confident that simulation is a great substitute [for clinical settings]. The data is there that this is a good substitute. We have to do it in very unusual circumstances but it’s OK. We are going to be all right.”

At the University of Maryland School of Social Work (UMSSW), Dean Richard P. Barth, PhD, MSW, said in a virtual town hall last week that he was confident the transition from the field work required for graduation to remote field work would be successful. Options include videoconferencing, tele-behavioral health technology, and select volunteer opportunities in the community.

“Every school of social work across the nation will be doing something like this,” he noted. “We’re in close contact with the Council on Social Work Education, and they’re very supportive of what we’re doing.”

Social work students are being asked to fill out a Remote Activity Plan and were emailed resources for remote learning activities to get students thinking about what to include in those plans, said Samuel B. Little, PhD, associate dean for field education.

The school’s accrediting body, the Council on Social Work Education, has reduced the required number of field hours to an 85 percent level, Little said.

“Some of our students will have an opportunity to reduce to the 85 percent,” he said. Those students are consulting with their field instructors and wrapping up reports and submitting outstanding documentation. The school also has several students who have requested exceptions to not be removed from the field, Little said.

“Some students want to continue their field placements and feel to abandon those agencies would not be the right thing to do professionally and ethically,” he said. Those field placements, reviewed on a case-by-case basis, may continue as long as students do not come into direct contact with clients and social distancing measures can be maintained.

One such student is Simba Kapfumvuti. He is grateful for the chance to complete an internship at Veterans Affairs in Prince George’s County, where he assists veterans with individual and group therapy and general case management. In the age of COVID-19, the therapy sessions are now done over the phone. The center is closed to the public at this time.

“The learning opportunities and experience that are afforded to me at the Vet Center mean so much to me,” he said. “If I had the opportunity to be able to remain there I would welcome the opportunity to do so.”

Deanna Tran, PharmD, assistant professor, Department of Pharmacy Practice and Science, and co-director, Pharmacy Practice Laboratories, at the University of Maryland School of Pharmacy, said students typically complete six semesters of hands-on classes where skills such as how to counsel, how to complete a prescription, and how to administer an injection are practiced. The classes involve students working with their classmates or instructors to practice the skill.

“Our laboratory faculty have been very creative on how the students could gain exposure to these skills in a virtual setting,” Tran said. Faculty have been using multiple Webex “rooms” so that students can practice counseling on medications in small groups, similar to how they would do it face-to-face, she said. In another course, students are given an introduction to a case online via Webex and then work remotely on the case at the same time, before coming back together online to review the case as a class.

Some skills that require close contact, such as practicing how to administer injections, are being rescheduled to the fall semester in the hopes that the COVID-19 restrictions will be lifted by then.

Pharmacy student Maria Palmer said she is grateful that the school is providing “other forms of instructional learning.”

“With Webex and Zoom, we have live interaction with faculty that can answer our clinical questions,” she said. “And seeing body language and eye contact is crucial for gaining practical experience and learning what kind of practitioner you want to be.”

The main clinical experience, the Observational Structured Clinical Examination, or OSCE, happens in the program’s second year so it is thankfully behind them now, Palmer said.

"Luckily we have that over with,” she said.