Coronavirus: diary of a medical school dean in Cyprus

We made plans in the morning that were often obsolete, by evening”.

Elizabeth O. Johnson, Dean of European University Cyprus’ Medical School reveals her diary notes of the series of actions that became necessary to guarantee a quick adjustment to the new realities brought on by the rising coronavirus pandemic. As normal operations were halted and the shift to remote learning became necessary she records the consultations and collaborative effort put into creating innovative systems that managed to sustain the school’s student-centered programme and kept it true to its mission.

How does a Medical School deal with such a crisis? What does its most senior executive do?

Consult, discuss and, in my case, keep a diary… Look, no matter what, a virus like SARS-CoV-2, is going to test the resilience of the best Medical Schools. The acceleration of the pandemic and the domino of repercussions, with schools and business closing, travel restrictions, tested our School’s agility to respond, almost daily. We made plans in the morning, that were often obsolete, by evening.

Over the weekend, of March 7-8, there was a brief exchange of emails with the University leadership expressing concerns that with our international medical student body, and in light of the upcoming Easter holidays along with outbreak reports across Europe, that we should consider preparing for remote learning. On Monday, March 9, the prospect of the University closing became apparent, and we scrambled, working untold hours to figure out how to adjust our medical education program to the pandemic. That evening after the first report of a clinician testing positive in one of our teaching hospitals, we immediately moved to suspend clinical training and pulled our students from clinical rotations in all hospitals in Cyprus. With the acceleration of the virus and a growing sense of uncertainty, on Tuesday evening the University leadership convened, and decided that the University would officially close effective on Wednesday, March 11th.

At the same time access to the school’s premises, including research labs was curtailed, and then suspended. Only exceptions were for essential maintenance or critical access to records, which required permission. Many of our international students, if they hadn’t left already were making plans to travel home. Emails from students and parents, asking about whether the student should stay in Cyprus or travel home were coming in almost hourly.

We made many plans, and we communicated guidelines to faculty, staff and students, with endless emails. By the time we communicated to everyone what they were supposed to do, and they set it up, the day after we discovered something else, which changed everything. There is no exaggeration in saying that the vast majority of the faculty was putting in 12-14hr days to reformat their teaching material and keep up.

All events, including conferences and meetings, had already been postponed and then cancelled before the University closed. Initially they were postponed until after March, and then for the entire semester. This included the postponement of the Graduation Ceremony.

Operationally you had to keep going, how did you manage?

The biggest challenge for the school is to maintain some sense of normalcy at the same time when things change on a moment’s notice with so few answers. One thing is clear, that in effectively dealing with our medical students, no one size fits all. Pre-clinical training lectures, laboratory and practical exercises, case-based assignments, simulation training, clinical rounds, all have their own needs. Traditionally, only the first half of medical school is more classroom-based education. Students in their fourth to sixth year move to hands-on learning in clinical rotations.

Because of our initial scrambling, we were already able to put a couple courses online the day after we closed, Thursday, March 12th. This gave us the opportunity to try out the system. By Monday, March 16th, that is within less than a week of closing the School, the entire 6-year medical education program, including lectures and labs was functioning remotely.

For this to happen, the School’s computer and medical education guru, Dr. Dimitrios Ntourakis, Assistant Professor of Surgery, was recruited to help. In collaboration with expert teams of the University, he spent untold hours preparing and testing the online education platform, ensuring session recordings, attendance taking, and a myriad of other items. If that wasn’t enough, he spent the weekend and hours just before the School went fully online to train the faculty of the School of Medicine to teach online, as well as train over 1700 students on their new learning platform.

My staff was working nonstop with faculty to develop online alternatives to lessons in the classrooms, lecture halls and laboratories. Medical students in the three pre-clinical years were able to listen to lectures, attend interactive classes, as well as participate in digital practical activities online. The University state-of-the-art e-learning platforms, allowed the school to upload and save links with all lectures and practical activities, giving students the ability to review their coursework and the School to monitor that all learning outcomes are addressed.

Understandably a large number of our students were insecure about the online learning process and we were bombarded by dozens of questions daily. We quickly set up a Q & A Forum where students are able to pose questions and our administrative personnel and faculty act as moderators.

Online assessments were another important hurdle that was necessary to overcome with the remote learning program. Dr. Ntourakis after an intensive and fruitful collaboration with the IT, MIS and DEL departments, was able to tailor an exam platform and process suitable for the requirements of Medicine. Professor Theodoros Xanthos, Vice-Chairperson and curriculum coordinator, ensured that we appropriately adhered to medical education guidelines. Both faculty members worked together and devised online training sessions for both faculty and students on the assessment & lockdown browser platform, with over 600 participants in these sessions.

To test the system out before it was used on midterms faculty were asked to prepare mock exams for their classes. Students and faculty both, experienced the lockdown exam platform during mock exams that were run throughout an entire week. Based on the outcomes, a follow-up training session for faculty was made to address some of the problem areas, and students were given a Q&A sheet for their most common questions about using the platform.
What was the impact on Clinical Training for your senior students?

Clinical training at hospitals was the first activity that the School suspended. Given that in their later clinical training, students have fewer lectures, for the majority of the time, they are exposed to the various specialities at hospitals and clinics that we are affiliated with, including grand round and case discussions. During clinical rotations, they are under the supervision and guidance of clinical instructors, where they interact directly with patients and perform basic medical procedures, and help with physical examinations, diagnoses and treatment plans. Because of their activities, medical students can be seen as a kind of “tertiary component” of the health care team, after physicians and residents. Without the medical students, there is an added work strain on the junior residents and physicians.

While some of the educational objectives of the clinical training clerkships are difficult to meet online, because the students had already done hospital training with only 8 weeks remaining, we were able to devise means to meet the majority of the learning objectives. To help counter the loss of hospital rotations, faculty were asked to find alternative means to address and supplement clinical training. By Monday, March 16th, when the pre-clinical program went online, the clinical program was introducing a myriad of online teaching tools with a full daily program, bringing the School to a high functioning level.

How did students cope?

With so many students feeling overwhelmed by the abrupt changes and confused by the rapid pace of information coming at them from so many disparate sources we decided to devise a central repository so that they could find and share the most accurate and useful information.

One of our technicians and graduate student, Sophie Themistocleous added a dedicated COVID-19 information system to its website, called “What you need to know – COVID-19 Portal”. (https://medicine.euc.ac.cy/) This allowed us to communicate regularly with students, faculty and staff about the latest announcements from deans and other senior administrators of the School and University, provide links to the rapidly changing health news and guidelines from our faculty’s experts on infectious diseases.

To ensure that our students and faculty were better informed, regarding COVID-19, the School prepared a series of webinars entitled “COVID-19 Education and Preparedness”. These remote courses were put together by the School’s faculty and collaborator experts and took place one-week after the University had closed. Sessions addressed various aspects of the COVID19 outbreak, such as basic epidemiology, understanding the various reporting systems (WHO, Johns Hopkins dashboard), clinical findings and the basic aspects of personal protective precautions in the community. In light of the growing concern of the EUC community, we included an open session for all faculty and staff of the University. All of these sessions were recorded, and uploaded on our School’s webpage.

Some of our students went from being members of a small group of personalised practical training to being dispersed all over the continent. A few who could not travel home, were stranded in Cyprus. This was an abrupt change for them. They no longer had the camaraderie and support of being on campus. Dr. Zoi Pana, a lecturer of Pediatrics suggested introducing “Medical Student COVID-19 remote supporting group sessions and chat group”, to support our students. Within a few short days (March 21, 2020), with the know-how of Dr. Ntourakis and Sofie Themistokleous, the online open initiative called the “COVID19 EUC student support session and chat” group was functioning.

Students and expert faculty members were now able to meet remotely at appointed times during the week and talk about the current situation of the outbreak, not only in Cyprus, but worldwide.

It’s understood that many of your students entered the fray?

Well you see many of our medical students were feeling sidelined, while their future colleagues in the healthcare workforce were working on the front lines, diving into the stress and uncertainty of the pandemic response. Many of our students asked for ways to volunteer, as they heard medical providers on the front lines were falling ill or going into quarantine after exposure, which was threatening an imminent shortage of healthcare workers. I laboured over what role should medical students play during a global health crisis particularly, when I was certain of the quality of their training. Could I turn to our medical students to help ease the strain on the health care system?

In a discussion with a consortium of Medical Deans, it was noted that “immersive and experiential learning is crucial for medical students’ education.  With the right roles, supervision and support, medical students can contribute significantly to patient care and healthcare teams.   Flexibility and adaptability will be the key factor in ensuring an effective response to this unprecedented situation.  Students do not need to be on the front-line of care for patients with COVID-19, rather senior students can make useful contributions in the routine aspects of care that will continue on hospital wards. The roles and tasks assigned to medical students must be safe for both patients and students and neither should be unduly exposed to the virus”.

At the initiative of the President of the Cypriot Association of Medical Doctors, Dr. Petros Agathangelou, and the Ministry of Health, students were asked to support during the crisis by working as call handlers for the emergency telephone service. Our students were called to help to man call centres for citizens to reach out for help and guidelines.

Dr. Agathangelou had warned early on that Cyprus would be facing a shortage of Physicians to manage the outbreak.  We discussed the idea that senior medical students could serve as clinician assistants. It was not long before specific clinics in Cyprus were already making pleas for support inquiring about the possibility of using senior medical students to assist.

In an effort spearheaded by Dr. Constantinos Tsioutis, Assistant Professor of Internal Medicine, students were asked to help with various tasks depending on the needs and their level of knowledge and skills. The scheduling of the students would depend on the needs of clinics and under no circumstance would they be placed at risk opting for assignments to be in low risk areas. We believe strongly that senior students can make useful contributions in routine aspects of care that will help continue the function of hospital ward.
The COVID-19 pandemic is unprecedented. The School was faced with unique challenges. On the one hand we had to maintain the high standards of our medical education, and on the other to define our new role in the community. We needed to make some extremely difficult decisions and respond with agility to the rapidly changing landscape. We did this and we did it well. Yet our greatest accomplishment was not the efficiency of our continuing operation. The key moment was when we saw our senior medical students volunteering to help the community. Nothing made us prouder.

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