By Martin S Davey, J Tristan Cassidy, Matthew G Davey, John M O’Byrne and James P Cashman
National Orthopaedic Hospital Cappagh, Dublin, Ireland

Corresponding author e-mail: [email protected]

The status quo undergraduate orthopaedic education in Ireland and the arrival of COVID-19

In the past, teaching medical students centered on rote learning with little emphasis on learning in the clinical environment1. Didactic lectures were delivered in theatres or academic institutions with little regard for the overall medical curriculum2. Contemporary teaching has moved away from lectures and libraries to a clinically based, goal-directed model3,4. Consequently, current undergraduate medical programmes are designed for the clinical, rather than the academic, environment2,5. Most recently, the 21st century has seen a movement away from ‘organ-based teaching’ towards a more ‘integrated learning’ style6, which has subsequently resulted in the mainstream use of problem-based learning (PBL). PBL facilitates small group work, methodically working through patient cases7-11. Furthermore, PBL is used to augment clinical teaching, particularly in examination- and assessment-based sub-specialties, such as that of orthopaedics12,13.

COVID-19 mandated unprecedented change for teaching medical students globally14. Worldwide, the delivery of medical education (including orthopaedic teaching) was abruptly abandoned, with medical institutions obliged to set aside previously standardised ‘best practice’ in order to counter the pandemic15,16.  In Ireland 'social distancing', a policy unlikely to change in the short-medium term, continues to be central to the national effort and thus, the bedside tutorial has been suspended. Furthermore, it is not known if or when it can return17. Only months ago considered being considered supplementary, education media (e.g. online pre-recorded video-based lectures, virtual tutorials and online examinations) are now central to the delivery of medical teaching. Innovation is now a key skill in contemporary medical education. For example, simulation (as advocated by Kneebone et al.18,19) is now widely used to optimise skills outside the clinical environment. Kneebone, a leading voice in medical education, noted in the pre-COVID-19 era that “the capacity to improvise is the hallmark of a true expert”20.

Alongside the continued provision of patient care throughout the COVID-19 pandemic, the medical schools of Ireland consider the consistent delivery of education to medical students and doctors alike as an essential service14,15. Like in other countries, Irish medical schools have had to adapt to the pandemic in order to ensure this16,21. The future of medical education, including orthopaedic undergraduate education, is in a state of flux and many questions require consideration. What are the potential implications of COVID-19 on the delivery of orthopaedic teaching at an undergraduate level? Specifically, what are the challenges and potential solutions? Can virtual examinations replace competency-based clinical examinations? Should they? Will the reduced number of students 'on the ground' in our teaching hospitals influence the learning environment positively, negatively, or at all? Sharing ideas, experiences and innovations during the current pandemic is key to maximising medical education worldwide. We therefore share our experience at the Irish National Orthopaedic Hospital. 

The goals of undergraduate teaching

Before considering the specifics of how COVID-19 has and will impact undergraduate orthopaedic education, it is worthwhile stating the major goals of undergraduate orthopaedic and musculoskeletal (MSK) training. Orthopaedic rotations provide the foundation knowledge for trauma and both acute & chronic MSK conditions. According to the most recent available statistics from the UK government (2016) fractures/dislocations/joint injury, soft tissue inflammation, sprain/ligament injury and muscle/tendon injury account for four of the top twenty diagnoses presenting to emergency departments22. Combined, they account for the largest proportion of Emergency Department presentations by a considerable distance (with fracture/dislocation/joint injury being the most common diagnosis). Similarly, MSK conditions account for 20% of GP presentations23. Thus, musculoskeletal teaching for undergraduates must equip students with sufficient knowledge and clinical skills to provide care for broad range of acute and chronic conditions, ranging from traumatic, congenital, paediatric and degenerative disease processes. We believe these pre-COVID goals should not be compromised or changed, however it is clear that the method for delivery must. This editorial will thus outline the impact, challenges and potential solutions of the COVID-19 pandemic on the delivery of orthopaedic education to undergraduate medical students at the Irish National Orthopaedic Hospital Cappagh (NOHC).

COVID-19 at the Irish National Orthopaedic Hospital

NOHC is responsible the delivery of orthopaedic teaching to medical students from three of Ireland’s six medical schools. In March 2020, all orthopaedic teaching for clinically based medical students was postponed until further notice15. This resulted in immediate cancellation of thousands of accumulated hours of clinical hospital rotations, bedside tutorials, face-to-face small group tutorial sessions including PBL sessions, as well as postponement of not only orthopaedic, but effectively all clinical medical examinations24. Therefore, adaptation in the delivery of standard-set orthopaedic and MSK teaching to medical students was required almost overnight.

Fundamental knowledge via online learning: the ‘new normal’

Although not previously utilised as a core component of the delivery of orthopaedic teaching within our institution, the use of electronic learning (EL) is now central to the delivery the orthopaedic curriculum to all medical students rotating through the NOHC. New teaching platforms including pre-recorded virtual lectures as well as virtual online tutorial and PBL sessions have been introduced to replace didactic lectures and ward-based tutorials. These case discussions with video visual aids, supplemented with the case-by-case undergraduate textbook, are key to our teaching strategy during the pandemic25. Such sessions are believed to facilitate the observation, recognition and reproducible examination of clinical signs for students using distance-learning26. Thus, our medical students have full access to all examinable theory through online portals at the time and place of their choosing. This not only allows teaching of major topics to undergraduate students but also facilitates social distancing and even social isolation if/when required15. However, while this solution appears satisfactory in theory, the potential impact minimal face-to-face social interaction on medical students must not be overlooked, even if it is as yet an unknown.

While many of the solutions proposed above may be considered successful adaptation and innovation, still further questions arise as a result of such changes to previously established teaching methods. Can an online video fully replicate the tactile components of clinical examination? Having only ever seen a clinical sign on video, how can a student be expected to fully appreciate a potentially limb-threatening palpable, or impalpable pulse when presented with an open fracture27? Having evolved our medical teaching towards predominantly clinical-based teaching, how will reverting back to non-clinical environments affect the caliber of doctor developed during these challenging times? Many questions will remain unanswered until the post-COVID-19 era28,29. It is unknown if the clinical skills of those future orthopaedic surgeons whose precious clinical years of orthopaedic rotations (amongst others) at medical school have been compromised for many months by the pandemic, may ultimately suffer, and if so, to what extent30.

Developing clinical skills: Alternatives to the clinical environment

Managing the patient-doctor interface remains an important skill that is initially acquired in medical school, and honed over years of postgraduate training31. The recent pandemic has resulted in the abandonment of many of the aspects of ward-based teaching; including small group tutorials, case-based teaching, and ward-based clinical skills workshops14,32. Therefore, the continued nurturing of such skills poses a significant challenge for teaching bodies33. Although a demanding task for medical schools, replication of many clinical orthopaedic scenarios is achievable by simulation34. Simulation offers medical schools an alternative environment to train medical students in a wide range of verbal and practical skills, ranging from suturing to breaking bad news35. Furthermore, the widespread use of ‘distributed simulation’ as described by Kneebone et al.36 has resulted in enhanced learning opportunities for students and orthopaedic trainees alike, whereby skills may be practiced from the comfort of their own homes without compromising patient safety21. However, simulation may accelerate the learning curve, it is generally accepted that clinical skills may only be truly mastered when performed in the clinical environment37.

Remaining challenges and possible solutions

Although drastic measures were justly warranted, it has been concluded at our institution that they cannot go on indefinitely.  Eventually, a point will arrive whereby the absence of students from clinical practice will hinder future patient safety, as clinical experience is acquired through great summation of time spent clinically38. There are nuances to the clinical exposure that cannot be easily quantified by a list of goals39. The immersion of students in the clinical environment acclimatises them not only to being around patients, but also fellow healthcare professionals40. While simulated teaching, adaptations to assessment mechanisms and online technology have enabled students to return to learning, they are not without limitations41,42. For example, ultimately the learner knows they are in a fabricated scenario and may view it as a 'box ticking' scenario43. Before practicing as doctors, medical students should be comfortable on and familiar with wards, outpatients, emergency departments and operating theatres.  The remaining challenge is to achieve this without posing unnecessary risks to patients, staff and students themselves.

One potential solution is contact tracing and use of technology. Following the success of contact tracing in countries initially affected with COVID-19, contact tracing is a central component of the COVID-19 containment strategy for the Health Service Executive (HSE) in Ireland44-48. Medical students, as a general cohort, tend to engage in technology in their daily lives49,50. Therefore, perhaps their engagement with a contracting app may provide a solution for adequate tracing? Development of such an app, which requires a mandatory daily check-in for all medical students on our hospital wards, could potentially minimise risk of viral transmission, therefore maximising student, healthcare professional as well as patient safety. However, while these steps have the potential to minimise risk, they still remain unproven. This notable resurgence of COVID-19 cases in countries, which previously were successful in implementing contract tracing protocols, such as South Korea and New Zealand suggest contact tracing to be far from a panacea51,52. Therefore, the implementation of such protocols cannot be solely relied upon and other steps will be needed to facilitate ongoing teaching during the pandemic.

Furthermore, for a number of reasons, contact tracing for medical students is particularly challenging. Firstly, they are members of the public who not only enter hospitals, but also (due to the fact that they have no designated workplace in the hospital) traditionally moved from ward to ward, often in search of specific pathologies or clinical signs53. Secondly, they also attend additional educational facilities outside the hospital, including medical libraries, hospital restaurants and coffee shops etc. Finally, medical students are part of population cohort most likely to socialise with strangers outside the hospital54. Thus, it could be suggested that medical students are poised to be a high-risk cohort for spreading the virus. If a student is not a COVID-19 contact and is prepared to use this application and take all standard precautions both during and following hospital ward time, should medical students still be prevented from accessing the wards? If not, should the duration of clinical attachments be reduced to strict teaching schedule, even when it is known that the yield of time spent on wards is unpredictable?

This alternative, tightly controlled exposure of medical students to selected clinical cases and environments, will pose its own challenges. Such limitations will pressure the amount of time available to each student, especially at our institution, which caters for three medical schools. Furthermore, students only gaining access to select cases and clinical scenarios will surely make it impossible for them to acclimatise to the hospital environment. How can they build relationships with patients and other healthcare professionals if their clinical exposure is compartmentalised into individual 'learning episodes'55? Ultimately, both of these potential solutions create a contrived and unrealistic clinical experience for medical students, however at present there is no alternative.

Closing remarks and conclusions

The recent COVID-19 pandemic has resulted in a shift away from the previously predominantly clinically based delivery of orthopaedic education to medical students. As the interest of public safety ceased clinical exposure for medical students almost overnight at the NOHC, EL and DL are now central to teaching medical students the principles of orthopaedics during the pandemic. However, which (if any), of such teaching methods will ultimately establish themselves with solidified roles in teaching practice in the post-COVID-19 era remains to be seen. Furthermore, whether first-hand clinical teaching will ever really be truly replaced with virtual teaching adjuncts remains questionable.


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