This is the first study in Mexico to evaluate last year medical student’s perceptions of changes in their clinical training during the COVID-19 pandemic and reveals several interesting observations, highlights inequities in training, and provides impetus to improve our educational environment. Students feel less prepared because of the COVID-19 pandemic restrictions on their education. In the UK, over 50% of the students felt less prepared to start postgraduate training , while in the US 18% of the third year medical students were willing to extend their training for an extra year . These results contrast with ours, where 82% of the students were willing to extend their training. This suggests potentially a greater impact of COVID-19 in our country’s medical education system.
Medical students want formal training on COVID-19, yet very few students reported having received such formal training. This can be accomplished via remote or virtual instruction. Most medical schools in both public and private sectors opted to use traditional teaching methods such as lectures and written educational materials. Students reported very limited use of simulation technologies, which might be related to the limited access to these centers in our country .
The role of medical students in the COVID-19 pandemic has been controversial. Some authors consider that the involvement of medical students can be beneficial for healthcare systems, patients, and their personal development as physicians, but given the existing risk of infection, their participation should be exclusively voluntary . Others agree that medical students should not be involved in any clinical activity because they are not yet fully trained clinicians, do not receive a salary and may represent a risk for the people they live with . In Mexico, most public hospitals care for infected COVID-19 patients. Public hospitals have also faced a shortage of personal protective equipment and high rates of infection among healthcare workers, which makes clinical rotations a very high-risk activity for medical students . Probably related to these findings, most medical students in our survey reported that they would not feel safe going back to their clinical activities.
Despite clinical rotations being regarded as very important by students, most medical schools cancelled them, and only a limited number of students received an alternative such as virtual rotations. The lack of alternatives was striking as most students considered the absence of rotations would negatively impact their training and performance in the pre-grade internship. Probably related to the perception of poor training, most students would consider repeating the last year of medical school. This highlights the importance of innovation in medical education. Some experts in medical education are proposing different teaching alternatives with the development of multimodal training strategies [19,20,21]. Schools can offer in-person clinical rotations when the public health recommendations of social distancing can be safely achieved and when the risk of infection remains low . If this is not an option, developing a virtual curriculum can be a safe and effective alternative. Even though the physical examination is not possible during virtual rotations, they can be asked to observe and evaluate different maneuvers elicited by the attending . To develop skills in interviewing, students can take history and physical examination by telemedicine from consenting patients. From these experiences, they can be expected to develop written reports that can be presented to attendings and peers for additional feedback . However, significant challenges also exist in the implementation of these strategies as many countries do not have the existent infrastructure to adopt a robust virtual curriculum . The cancelation of elective procedures and other procedural activities could also limit the potential exposure of the students in virtual rotations. Similarly, clinicians on the front-line are also very taxed by the extra workload of caring for patients with COVID-19 and may not have the time to participate in remote medical student instruction.
In Mexico, the Consejo Mexicano para la Acreditación de la Educación Médica (COMAEM), oversees the evaluation of the quality of medical training. Only 80 out of more than 140 medical schools are certified by this organism, suggesting that there could be unequal quality of training due to differences in the regulatory bodies that accredit each medical school . This study provides further insights into the inequities in medical education in Mexico. Medical students in private schools were more likely to have virtual instruction and were less likely to have their clinical electives cancelled. These issues can likely further accentuate the gap between medical students trained in private versus public schools. Further research should explore ways to enhance medical school training opportunities for public schools.
Simulation remains another unexplored area in medical education in Mexico. Studies have shown the effectiveness of simulation in facilitating teamwork, teaching basic science, clinical and procedural skills in different scenarios . Despite its proven benefits, these technologies might be difficult to implement during a global pandemic . Strategies limiting the number of instructors and medical students along with the proper following of public health measures could make simulation centers relatively safe . We consider simulation should be increasingly adopted by medical schools in Mexico to offer more evidence-based learning techniques for trainees. Similarly, personal at-home simulators with or without virtual feedback have been successfully used as an alternative modality to in-person simulation instruction for certain skill sets; [25, 26] and online simulation is another promising alternative under evaluation . Teaching faculty is able to develop simulated medical records that students can easily access anytime. For inpatients, students can give follow up to their simulated patients and solve the different complications that might arise from admission to discharge. Even though students prefer traditional in person clinical activities, most of them appear to be satisfied with this type of training . This type of curriculum could be an attractive alternative for low-income countries. It has the benefit of being low cost, [28,29,30] less time intensive for students and it can provide ample feedback from expert clinicians.
These results should encourage policymakers to update the Mexican regulations (Norma Oficial Mexicana, “NOM”) on medical education. Studies have reported heterogeneity among teaching hospitals . We propose that teaching hospitals should undergo continued evaluations to establish quality standards . Furthermore, telemedicine remains underutilized in Mexico . Investing in telemedicine could improve access to healthcare in rural communities and offer learning opportunities to medical students. Medical schools should consider integrating telemedicine and simulation into their curriculum and train educators on the usage of these technologies . In addition, vaccinating and training medical students on the proper use of personal protective equipment could facilitate a safe return to clinical rotations . Lastly, medical schools should train faculty members to provide educational and emotional support to improve academic achievements, and most importantly, their sense of security .
This study has some limitations. Due to the study design, we can only provide a representation of the perception of last year medical students during a specific time period. The participation in this study response rate is low and might not represent the perceptions of the entire population of last year medical students in Mexico, yet it still the largest study of its kind with a significant number of survey responses of students that represent diverse geographic regions and types of medical training (public vs. private schools). Because our study was distributed online by social media it might be susceptible to non-response and participation bias; students with access to internet could more readily participate. Furthermore, not all medical students engage in social media platforms and hence might have been unaware of the study. We attempted to overcome this by emailing medical students, but this method has its own pitfalls, and we did not have access to the emails of all eligible medical students.