the second session of the workshop by noting that the first session presented three leaders who made the difficult decision to remove learners from in-person clinical and community experiences at the beginning of the COVID-19 pandemic. While learners continued to progress and gain skills through virtual or remote experiences, she said, it is not yet known how missing in-person experiences will affect their skills and competencies or affect their views of themselves as health professionals. In this second session of the workshop series, leaders who chose to keep learners physically present during clinical rotations shared the details of their decision-making processes. Before turning to the speakers, Robert Cain described a second iteration of a decision tree incorporating aspects of the first session speakers’ suggestions.

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES (USUHS) GRADUATE SCHOOL OF NURSING

Laura Taylor, Program Director and Chair Heather Johnson, Director and Chair, Family & Women’s Nurse Practitioner Program

Laura Taylor and Heather Johnson shared the decision-making process that led the Uniformed Services University of the Health Sciences (USUHS) to keep advanced practice nurse clinician learners in clinical settings during the pandemic. The mission of the Daniel K. Inouye Graduate School of Nursing, said Taylor, is “learning to care for those in harm’s way.” Students in the USUHS Graduate School of Nursing begin their educational programs with in-person didactic instruction and short clinical experiences in the first year. By the second year, instruction is conducted virtually and in the third year, students participate in a full clinical immersion. The school uses a cohort structure in which students start and end as part of the same cohort and attend the same classes. If a student fails a course, they are removed and sent back to active-duty service.

When the COVID-19 pandemic began, Taylor reflected, there were a number of concerns and challenges. Students come from dozens of different military locations; during the pandemic, this meant dozens of different decision-making processes were followed regarding when students could leave their military site and begin school. The program usually starts in May, but it was delayed until July so all students could start at the same time. Delaying the program longer was not an option because students may not be available later because of their rank and promotion status. Johnson commented that delaying the program would have downstream effects on the workforce of the military. Taylor added, “It was either we run an immediate, just-in-time curriculum, or we don’t produce nurses.” Furthermore,

said Taylor, first-year students who were able to arrive at school before the new start date were used in intensive care units (ICUs) and emergency rooms (ERs) to address pandemic-related needs, depending on their prior clinical or educational experience.

Johnson picked up the train of thought, saying students who were already in the program were kept in their clinical locations as long as it was safe. In late March, when borders to the United States were potentially going to close, students outside the country were brought back. Second-year students, who would normally have been moving to their third-year site, were placed in local ICUs, ERs, and U.S. Department of Veterans Affairs facilities, and the curriculum was adjusted so students had a longer period of didactic instruction and skill building. Third-year students, who were already immersed in clinical experiences at military treatment facilities, were able to graduate 6 weeks early in order to serve in their full capacity. Taylor noted that because of the students’ rich experiences, in terms of clinical hours in their third year, early graduation did not negatively affect their clinical hour requirements.

One challenge, said Johnson, was determining which parts of the curriculum had to be delivered in person and which parts could be adapted for virtual or simulated learning. For example, because some students were not getting hands-on experience in clinical settings, in-person skills labs and simulations were used to compensate for these gaps. Despite the fact that the pandemic forced changes in the clinical setting, there was no change to the required minimum hours of clinical experience. It was critical that students gain the required hours and graduate on time, said Johnson, because the system is “kind of a machine” that requires one student to move on so another student can take their place. To make up for lost clinical hours, students participated in simulations, delivered care via telehealth, and participated in face-to-face workshops with faculty. While students missed out on some experiences of delivering care face to face, said Johnson, their telehealth experiences were useful and helped them grasp the challenges and opportunities of telehealth.

The school returned to in-person simulations in September 2020, with limited faculty and students present, and relied on personal protective equipment (PPE) and physical distancing to avoid COVID-19 transmission. These simulation experiences were usually accompanied by peer-to-peer feedback, which was unfortunately not possible during the pandemic owing to limited numbers of faculty and students in the lab. An additional challenge, remarked Taylor, was ensuring the school had the technological capacity to support new and expanded types of learning; because of military restrictions, it could not simply buy products off the shelf.

A number of approaches were implemented by USUHS to keep students safe during in-person experiences, said Taylor. These included health

screenings, grouping students into cohorts for all classes, and strict limits on the number of faculty and students permitted on campus at any one time. Johnson said that the effect of all of the pandemic-related changes is still unknown. While students continued receiving the content either synchronously or asynchronously, and everyone fulfilled their clinical hours, there still may be some unfilled gaps.

For example, site visits are a normal part of the program, and during the pandemic, these were not always possible to conduct. In addition, students may have missed out on some normal, noncrisis types of care experiences; for example, many people did not come in for preventive screenings during the pandemic. It is necessary, she said, to evaluate the just-in-time approach to determine where gaps are and how they can be filled. Despite these potential gaps, said Johnson, students were able to stay safe and participate in the “incredible experience” of working and learning during a pandemic.

HOUSTON METHODIST HOSPITAL

Jessica S. Thomas, Department of Pathology and Genomic Medicine

Prior to the pandemic, said Jessica Thomas, Houston certainly had its share of experience with disasters such as floods and hurricanes. During these crises, the health professions education system found ways to maintain training and education. COVID-19 was different, however, with strict regulations that rendered in-person education “nearly impossible.” Houston Methodist Hospital (HMH) explored alternative modalities to meet the workload and educational requirements for trainees, including virtual research curricula, some trainees working from home, and conducting consults and handoffs by phone. Ultimately, the department of pathology and genomic medicine at HMH planned and executed a trainee-oriented, stepwise emergency response that began in March 2020.¹ The goals of the program were to optimize workflow, maintain high-quality patient care, give trainees a continuous education experience, and involve students in some of the unique pandemic-related learning opportunities.

The 4-year pathology training program at HMH, said Thomas, has residents doing 4-week blocks of rotations, with the majority of the trainees in anatomic pathology and a smaller number in clinical pathology at any given time. When the pandemic began, the number of surgical and other procedures decreased significantly, and the case load for anatomic pathology dropped in tandem (Figure 3-1). The consequence of this reduction

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¹ See https://pubmed.ncbi.nlm.nih.gov/32995494 (accessed July 6, 2022).

in cases was that residents did not have a high enough workload for an appropriate training experience.

Phase 1 of the response plan began in late March by dividing the trainees into two groups, one working remotely and the other working onsite. This had the benefit of both reducing potential COVID-19 exposures, as well as increasing the workload for the trainees who were on site. However, Thomas added, the trainees did not like this approach because they wanted to be involved in what was happening in pathology, particularly in regards to work related to COVID-19. By mid-April, all trainees were back on site, and most had been redeployed to work in clinical pathology. There was increased activity in the clinical pathology arena owing to demand for

SARS-CoV-2 testing, which involved development and clinical validation of assays.

HMH was the first academic medical center in the United States to obtain emergency approval for COVID-19 convalescent plasma therapy. This work involved recruiting consenting donors and collecting and distributing convalescent plasma. Trainees who had been redeployed to clinical pathology participated in a number of activities, including

• daily service work,
• optimization of existing workflows,
• organization of laboratory areas for SARS-CoV-2 testing,
• assay development and clinical validation,
• procuring reagents and dealing with supply chain issues,
• drafting documents to submit to the Food and Drug Administration, and
• research.

During the pandemic, the clinical pathology department underwent major reorganization; for example, the transfusion medicine service added trainees to assist with the convalescent plasma trial (Figure 3-2).

Trainees participated in daily education during their COVID-19 redeployment, said Thomas. A COVID-19 virtual daily seminar series was implemented, open to all trainees, program directors, laboratory medical directors, and pathology faculty. These seminars covered updates on laboratory medicine, details of workflow changes in individual laboratories, and overviews of literature related to COVID-19. There were a variety of special topics covered as well, ranging from autopsy findings in COVID-19 patients to informatics during the pandemic.