Tina Jones’s foot hurts.
It started hurting after she scratched her ankle on a cement step. She covered it with a washcloth, but eventually it got bad enough that she decided to come to the clinic. Her mom came along, too.
Like many visitors to this clinic, Tina is a complex patient: she lives with asthma, hypertension and diabetes, for which she doesn’t take any medication. She’s overweight and doesn’t have health insurance. She’s obviously uncomfortable in the clinic setting as she kicks her legs every few seconds.
There’s one big catch in this scenario: this clinic doesn’t really exist, and Tina isn’t a real person. She’s an animated character created by Shadow Health, a company that provides “digital clinical experiences.”
As health systems around the world battle the novel coronavirus, Calvin nursing students train by clicking through online simulations of patients like Tina. Social distancing poses significant obstacles to students training to enter the medical field, and the long-term effects of health students’ disrupted education are yet to be seen.
Meeting clinical requirements
Nursing students were some of the first students at Calvin to learn that their education would be upended by coronavirus. They were alerted in early March that local health systems in Grand Rapids would no longer be able to accept students for clinical rotations.
“The nursing department was very clear and communicative with [students] about what the clinical rotations would and wouldn’t look like,” said Adrienne Niswander, a senior nursing student.
Calvin’s upperclassman nursing program consists of four semesters of clinical rotations in various healthcare settings. Second-semester seniors spend half of the semester in a community health setting and half the semester completing a leadership rotation, generally at an area hospital.
Niswander was scheduled to complete her leadership rotation during the second half of the semester, but like the rest of the nursing students, she is now completing her clinicals online. “Obviously it was a disappointment, but I’ve gotten over it now.”
Online clinicals for senior nursing students are completed on Shadow Health, which advertises itself on its website as a “digital clinical experience” that allows students to “practice the skills they need to care for their patients in a safe and standardized environment.”
For example, students conduct ear exams by picking an otoscope from a bar on one side of the screen. They then move their mouse over the ear of the patient avatar. The program then zooms into the patient’s inner ear and shows an image of what the ear looks like as seen through the otoscope. It’s up to the student to evaluate any irregularities in the exam.
Students ask the patient questions by typing into a text box. Patient avatars respond, moving their lips and bodies in an awkward mix of Muppet and grown-up Teletubbie. It’s like the SIMS computer game, only for a grade.
Niswander notes that there is value to the online simulation. She’s able to complete her degree on time and work on some leadership skills, such as prioritizing patient needs. “It’s meeting the objectives for the course. It’s the next-best thing. I’d give it a 6 out of 10, given the circumstances. Though it’s not like I’m going to be a better nurse because of the last six weeks.”
Rebecca Janke is a senior nursing student currently completing her community health rotation. In the community simulation, she travels through the Shadow Health community, identifying hazards and communicating with important people, such as the mayor.
“It’s hard because I really don’t care about this fake community with its fake health problems,” Janke said. If it was real, she’d be passionate about the mayor’s involvement in solving public health problems. With Shadow Health, it’s much more difficult.
Her experience is similar to that of Niswander. “It really takes all the stuff you like about nursing — the patient interaction, working with people — and all you’re left is essentially just doing the paperwork, which nobody likes,” she said.
Pre-med during the pandemic
Although nursing students’ education has been uniquely affected, they are not the only students who have struggled. Other pre-professional students, particularly pre-medicine students, have also dealt with unforeseen disruptions to their education.
The transition to online classes has stressed many pre-med students. Upper-level laboratory science courses, such as physics and biochemistry, don’t always lend themselves to an online format. Luke Batt, a junior pre-med student studying philosophy, biochemistry and Spanish, notes the difficulties that students have faced when suddenly given online coursework.
He explains that professors have adapted varying teaching methods. Some of his courses, such as philosophy, are conducted synchronously on Microsoft Teams during the normally scheduled lecture time. In these classes, he’s free to ask questions as needed and participate in live discussion. “It works surprisingly well, actually. It’s really not all that different than being in-person.”
Others, such as biochemistry, are conducted asynchronously. He prints out PowerPoint slides and then listens to voice-overs of the lecture content. If he has a question, he posts it on a Moodle forum and waits for his professor to respond. There is little screen-to-screen interaction with the professor or other classmates. “Biochemistry is much more difficult online, because it’s so visual and collaborative,” he explained. It’s impossible to draw out complex biochemical pathways and enzyme active sites on PowerPoint. “It just doesn’t translate well to the internet.”
Chemistry professor Kumar Sinniah, who mentors pre-health students, emphasizes that professors face many of the same challenges as their students. He conducts his courses synchronously, understanding that some students may be unable to attend. Overall, he’s been surprised at how open students have been to participating in live class sessions.
“I think it brings a semblance of normalcy to student interactions. I know it does for me.”
He also notes that, although many pre-health students have found self-motivated learning challenging, it’s excellent preparation for graduate coursework. “In graduate school, no professor is going to tell you to come with them to class. They are going to give you a problem to solve and expect you to solve it on your own.”
MCAT cancellations and graduate school admissions
Although academic coursework is important for health professions schools, it’s not the only component of pre-health curriculum. The dreaded MCAT exam is also an important part of a student’s journey to medical school — and COVID-19 has disrupted the MCAT schedule, just as it upended academic classes.
Ethan Houskamp, a junior pre-med student studying biochemistry and biology, has been frustrated with the scheduling changes. He had planned his semester around taking the MCAT on April 4. The American Association of Medical Colleges, which administers the MCAT, cancelled the April exam dates a day after he completed his last practice test.
He then rescheduled his exam — only to have the rescheduled exam cancelled, as well.
“I’ve prepared all semester for this. I was finally ready — and it was cancelled two weeks before I was going to do it. It’s a huge bummer,” Houskamp said.
In order to make up for the cancelled dates, the AAMC announced on their website that they will increase the number of testing days available and add three testing times on each day. Exams will begin at 6:30 a.m., 12:15 p.m. and 6 p.m. on each additional day. The length of the exam has been reduced to 5 hours and 45 minutes — normally it takes 7 hours and 30 minutes — in order to accommodate multiple tests on a single day.
The rescheduled exam dates place pre-medical students who are applying during the 2020-2021 cycle at a particular disadvantage. The application opens on May 31, and students typically submit applications early in the summer.
“Without an MCAT score, I don’t know what schools I should apply to,” Houskamp emphasized. “It’s a waste of time and money to apply to a school that’s way above your MCAT range.”
In addition to cancelling exams, coronavirus has also upended pre-health students’ summer plans. Pre-health students typically complete research internships or healthcare-related work experiences during the summer. Such programs develop their critical thinking skills and help students discern their career plans before commiting to the grueling years of medical school and residency.
Houskamp originally planned to participate in a cardiovascular research program at the University of Michigan-Ann Arbor. His program was cancelled. “I’m not sure what I am going to do for the summer. As of now, there aren’t really too many options out there.”
What coronavirus has given health students
Sarah Hughes, a fifth-year pre-medical student studying biology and German, faces similar struggles. She had been studying abroad in Vienna, Austria when her program was forced to return to the United States in mid-March.
Upon her return home to West Virginia, she was quarantined in her room for two weeks. She had no physical contact with anyone from the outside world. Her parents left food at her bedroom door. They yelled at each other through the walls when she needed something.
“It was so hard,” she said, recalling the stress of being stuck in her room, hoping that she hadn’t picked up the virus from the plane or airport. However, quarantine did provide her an opportunity many pre-medical students don’t write into their four-year plans: time to reflect on her chosen profession.
“As a pre-medical student, this really made me think about why I’m going into medicine. It’s given me time to think about the dangers. I’ve had to ask myself, ‘is this what I really want?’”
The time of reflection was extremely valuable. “I don’t think many [pre-medical students] have thought about how dangerous doctors’ work can be.” She hopes that the COVID-19 pandemic will help pre-med students realize just how sacrificial doctors’ work should be.
The pandemic has been immensely difficult, but Hughes knows that the crisis will make her a better physician. “Nothing is without risk. This pandemic has shown how the impact of healthcare is so much broader than I thought.”
“[Community health] is an essential part of life. The health of a population is the basis for everything else in society — the economy, politics, all of that. It’s at the center of all functioning normalcy. And for some reason it took a worldwide pandemic for us to realize that.” Hughes’ unexpected return home has its benefits. She’s thankful to be in the same time zone as her mentors while she works on her medical school applications. But she still isn’t sure of what she will do for the next year. She had planned to work as a clinical research assistant, but the project has been placed on hold for the rest of the crisis.
Not all students have been struggling to find work, though. Many nursing and pre-med students work in entry-level jobs, such as nurse assistants in nursing homes and hospitals. Rebecca Janke works at St. Mary’s Hospital in Grand Rapids as a nurse assistant. Her floor is usually a step-down neuro floor, which cares for patients who don’t need an Intensive Care Unit but still require more support than a normal floor. But for now, it’s been converted to a COVID unit. Janke has continued to work during the crisis, donning her gloves, gown and mask each shift and taking her temperature multiple times a day.
“It’s kind of ironic that we can’t do clinicals but I’m literally going into the hospital all the time,” Janke said.
She realizes she’s fortunate, however. As a senior, she had already completed most of her clinical rotations before the pandemic and thus had developed many of the skills she needs to be a successful nurse. She’s more concerned for younger students who are completing their training with digital patients and may continue to do so if the pandemic continues into future semesters.
“I mean, really, what sort of nurses are we going to be after all of this?”