All emergency medicine residents are essential members of the work force. Medical students, however, find themselves in a challenging predicament: how to balance their knowledge, attitudes, and abilities with the demands being placed upon them by health systems. Here, we suggest a simplified version of the KNOW-CAN-DO aspects of clinical training to help illuminate ethical issues confronting front-line students.

The “KNOW”

What do trainees know about staying safe and clinically effective?

In general, medical students are fairly unfamiliar with infection control practices. An audit of U.S. medical students showed that only 7 percent of students donned and doffed properly for simulation.¹ Perhaps, this is because 59 percent of U.S. medical students did not receive any personal protective equipment (PPE) training. In this same study, only 53 percent of residents, fellows, and attending physicians from 67 medical schools received training in PPE use.²

Can students be trained accordingly?

One study showed that students could be easily trained either with live or video instruction. The mean donning/doffing scores were 84.8/79.1 (live), and 88/73.9 (video) for 19 trainees.³ Another study using fluorescent laundry detergent showed an improvement in contamination while doffing from 31.7 percent to 9.4 percent from first to second attempts in 249 medical students.⁴

What have pandemics taught us about the role of education?

Approaches to the SARS CoV-2 virus that has caused the COVID-19 pandemic are probably most similar to the educational strategies during the SARS epidemic in 2002–2003 (see Table 1). With sufficient PPE supply, the ability to translate attending competence to resident and student proficiency is important for capitalizing on this situation.

In summary, students have had low knowledge scores about proper PPE and demonstrated poor proficiency, but they can and should be trained to perform better with various modalities, including live or video instruction, simulation, and objective structured clinical examinations.

The “CAN”

How do trainees feel about practicing emergency medicine?

COVID-19 has taken a serious toll on the mental psyche of medical students. Despite undergoing rigorous training for dealing with clinical uncertainty, personal safety, and the care of infectious disease, students feel stressed about practicing emergency medicine.

A recent study containing 316 anonymous surveys from third- and fourth-year medical students showed feelings of anxiety, vulnerability, fear, and moral distress among other attitudes.⁵ Others have written about the passionate wishes of some to contribute during this crisis.⁶ Our specialty faces an ethical dilemma: how to engage the youngest members of our workforce with special educational training opportunities while properly balancing their emotional distress.

What stance have organizations taken in response?

Organizations have tried to guide institutions and set new expectations. The Association of American Medical Colleges recommended that medical student clinical rotations be suspended for several weeks during the initial height of the pandemic (April 2020).⁷ The Accreditation Council for Graduate Medical Education has since released flexible guidelines in response to unpredictable workforce and clinical demands.^8,

The “DO”

How to balance medical student skills with clinical expectations?

Students may not be qualified or essential to our delivery of patient care but their future value as professionals cannot be underestimated: medical students are a precious resource and serve as the “doctors of tomorrow.”

Students may use their ingenuity to volunteer in other ways, but balancing the needs of clinical staff with the safety, learning, and wellness of students is imperative. Busy faculty must ethically attend to the needs of patients and satisfy patients above all else, often at the expense of learning and teaching opportunities. Additionally, students risk contracting illness and falling behind with other educational requirements. Students should be allowed to opt-out because of the current set of unique health circumstances.

Future Steps

An important goal of COVID-19 is learning how to educate amidst an unprecedented modern pandemic. Students are part of the knowledge translation process and may show up in the emergency department, provided there is sufficient PPE, in order to learn how to manage patients in the COVID era.

Safe learning is critical for students, although safety is not a guarantee. What if students are vectors for viral spread, or threats to themselves? What is the liability risk for programs? Society must continuously weigh the risk-benefit ratio of student learning amidst a rapidly evolving pandemic—a delicate balance that demands more data and consideration for all parties involved.

The ability of students to safely perform clinical work depends upon their knowledge, attitude, and skill set, especially pertaining to PPE donning and doffing. Emergency departments should prepare accordingly and further develop these areas to ultimately ensure student safety.

In conclusion, we submit that:

• KNOW: Medical students do not know how to use PPE properly
• CAN: Medical students can be taught how to use PPE properly.
• DO: Medical students do want to be part of the health care system’s effort to navigate and overcome this pandemic.

References

1. 1 Arandjelovic A, Arandjelovic K, Dwyer K, et al. COVID-19: considerations for medical education during a pandemic. MedEdPublish, 2020;9(1):87.
2. 2 John A, Tomas ME, Hari A, et al. Do medical students receive training in correct use of personal protective equipment? Med Educ Online. 2017;22(1):1264125.
3. 3 Christensen L, Rasmussen CS, Benfield T, et al. A randomized trial of instructor-led training versus video lesson in training health care providers in proper donning and doffing of personal protective equipment. Disaster Med Public Health Prep. 2020 Mar 30:1-15.
4. 4 Zach KM, Maloney LM, Praslick AD, et al. Medical student personal protective equipment training through simulated contamination. Med Sci Educ. 2016;26:517-518.
5. 5 Gallagher TH, Schleyer AM. “We signed up for this!” – student and trainee responses to the Covid-19 pandemic. N Engl J Med. 2020 Jun 18;382(25):e96.
6. 6 Klasen JM, Vithyapathy A, Zante B, et al. “The storm has arrived”: the impact of SARS-CoV-2 on medical students. Perspect Med Educ. 2020;9(3):181-185.
7. 7 Interim guidance for medical students’ participation in patient care during the coronavirus (COVID-19) outbreak. Association of American Medical Colleges website. Available at: https://www.aamc.org/news-insights/press-releases/updated-interim-guidance-medical-students-participation-patient-care-during-coronavirus-covid-19. Accessed Sept. 23, 2020.
8. 8 ACGME Reaffirms its four ongoing requirement priorities during COVID-19 pandemic. Accreditation Council for Graduate Medical Education Available at: https://acgme.org/Newsroom/Newsroom-Details/ArticleID/10188/ACGME-Reaffirms-its-Four-Ongoing-Requirement-Priorities-during-COVID-19-Pandemic. Accessed Sept. 23, 2020

Dr. Blutinger is clinical instructor of emergency medicine at Mount Sinai Queens Hospital in New York City.

Dr. Brenner is associate professor of emergency medicine at Upstate Community Hospital in Syracuse, New York.

Dr. Larkin is an ethicist and professor of emergency medicine at Northeast Ohio Medical University, Summa Health in Akron.