Importance of presence in medicine
Many careers could have a more or less soft landing in remote education; but there has been very little time for all of them, especially in Colombia. The health sciences had something closer to a hard landing.
The human being is the center of medical care: personal interaction with the health professional is essential. For this reason, “classically”, the undergraduate degree in medicine is divided into two stages:
- Basic medical science training, usually on campus. Students share courses with other careers and do internships in spaces such as amphitheaters, anatomy museums and laboratories; They complement this with activities typical of university life, such as cultural and sports activities. Usually in this first stage they will not participate in patient care or hospital services.
- Clinical science training, conducted in hospital settings. So contact with outpatient patients, hospital rounds, emergency services and operating rooms are part of the daily training routine.
It is clear that students were more exposed to infectious agents in this clinical setting, even before the pandemic. Even this is part of their training: they learn about biosecurity and personal protection. But now this risk seems to be similar in both stages of professional preparation, as indicated by the outbreaks in universities in the United States that returned to face-to-face.
How to adapt basic theoretical training
Clearly, basic and medical sciences could be transferred to virtuality, even if they sacrifice interaction with other disciplines and direct group work; the practices in a laboratory would also be missed.
These are not very popular with medical students; But “laying hands” on experiments or laboratory tests — for example, microbiology or immunology — supports the interpretation of clinical tests and the understanding of how the organism works.
In some cases – such as the basic study of human anatomy – it is difficult to replace the interaction with the human body to understand its dimensions and to establish respect and ethics.
Even so, some of these basic courses could use other forms of teaching, such as “dry labs” through videos or the simulation of home laboratories. In other courses (histology or pathology), one could resort to the excellent images on the Internet – obviously with the guidance of the teachers.
In any case, one must discuss and examine these study materials: the primary work of a teacher.
Thanks to technological advances such as live microscopy (two-photon microscopy), tissues can be viewed live or using simulators. For example, you can see how cells respond to different stimuli. There are videos of this type in articles in scientific journals and – even – on social networks.
Clinical practice after the pandemic
There is a part that can be virtualized without difficulty: the analysis of the tests paraclinical (laboratory tests or radiography, among others), using clinical cases obtained from daily practice and through discussion in groups of students guided by a teacher.
For another type of training, given the difficulty of having students in medical services during the pandemic, new strategies are needed:
- Simulated patients, played by actors trained to describe and react according to the diseases indicated to them.
- Simulated hospitals, which would represent each of the hospital services (emergencies, obstetrics, etc.)
- Digital assistance to interviews and physical examinations of the teacher with his patients.
Under this last alternative, students can participate by asking or indicating to the examiner what to do in the interview or exam.
The setting for the clinical practices of the more advanced semesters is another: contact with patients is necessary to acquire knowledge, but also to exercise communication and ethics. All of this is learned during the medical history, physical examination, and the integration and interpretation of these findings.
Taking care of students
At the beginning of the pandemic, most university hospitals canceled student rotations, with the intention of resuming this training a few weeks later. But the Ministry of Education’s restrictions lasted longer than expected.
In this way the clinical preparation of the students was seriously interrupted. Although simulated hospitals and other learning spaces were installed, the lack of direct contact with the patient can have repercussions on the training of future doctors.
Despite its rigid training, which requires face-to-face training, medicine has made great strides in remote techniques. The first robotic and remote surgery was done in 2001; since then, the use of various types of telepresence surgery and remote surgeon training has expanded.
But let’s not lie to ourselves: this profession requires physical contact and direct conversation with the patient. This essential characteristic has been diluted with the practices derived from what is now called telemedicine: the interaction is reduced to locating a symptom; From there, all kinds of imaging or laboratory studies are requested to guide the diagnosis.
Negative consequences of remote medicine and learning
- For the doctor in training, working or studying remotely is a challenge semiological. In medicine, semiology It is the study of the signs that tell the doctor what is happening with the patient. These signs are obscured without direct observation and actual contact.
- The anamnesis direct (medical history inquiry) and is replaced by bureaucratic reading of medical records.
With regard to the medical examination, the information received by the senses is limited: methodical observation, auscultation through a stethoscope, touch and — even — senses such as smell. These means contributed to reliable clinical practice.
It cannot become normal for the physician to conform to the quantitative physiological variables of his patient, such as laboratory tests. It could be said that the analysis of some images is qualitative, but these are symbolic and partial representations of the real person.
Of course, this is critical for medical training; Much didactic creativity is needed for students to consolidate the knowledge necessary for successful clinical practice. For this reason, medical schools have many times re-scheduled clinical rotations, as the epidemic allows.
For now, simulation has been used; but it is imperative that there are more suitable scenarios, scripts and practices. The pandemic has taught us the importance of doctors and health professionals distinguished by their academic excellence and, above all, by the empathy, resilience and ethics required by the Hippocratic Oath.
* The opinions expressed are the responsibility of the authors.