Ingenuity in Teaching Medicine

Medicine is a high touch profession. In the absence of touch, it is difficult for physicians to examine patients, and equally difficult to train medical students in this fundamental skill. When COVID-19 cases began escalating in March and guidelines on stemming the rise in cases were shifting daily, medical schools needed to rethink and modify how to teach this essential skill along with other aspects of medical education.

To protect the campus community, Dartmouth closed libraries and labs. Mandating remote teaching and working, students, faculty, and staff were sent home for the remainder of spring term. Within a matter of days courses pivoted from in-person to remote learning—an adaptation that could have resulted in chaos.

Yet within this uncertain and rapidly evolving environment, there were signs of resiliency and opportunities for collaboration, creativity, and experimentation in teaching medicine. Amid this global public health pandemic, the Geisel School of Medicine’s hallmark commitment to holistically training physicians brought these opportunities together to not only smoothly complete the academic year, but with an eye toward the future.


When news of the coronavirus broke, Steven Bensen, MED ’90, associate professor of medicine, and Lawrence Meyers, PhD, associate professor of medicine and of biochemistry and cell biology, who co-direct the then new integrated first-year GI/Metabolism/Nutrition course, had an inkling that a mid-course shift to remote teaching wasn’t far off—though the number of COVID-19 cases in the Upper Valley were few, they suspected the pandemic would affect medical education.

Their observation was indeed astute.

Remote teaching was new for most of Geisel’s faculty, so speedily preparing them for an overhaul of in-person teaching to teaching via Zoom (a widely used online audio and web conferencing platform) became a priority.

Roshini Pinto-Powell, MD, works with second-year students in a small group On Doctoring session in Chilcott Auditorium as they talk with a surgical resident via Zoom. Photo by Kurt Wehde

Bringing together faculty with diverse teaching styles was a demanding and collaborative process. The transition required taking a fresh look at course fundamentals, thoughtful planning for reconfiguring physical spaces, and remaining flexible in the face of unfolding challenges while safeguarding the health and safety of the campus community.

Terri Eastman, MEd, CHES, director of the preclinical curriculum, says her experience in risk management allowed her team to mobilize quickly to prioritize what needed to be done in order to teach the curriculum. “We communicated daily, sometimes hourly, to students and faculty on how to access course materials and worked on the ground level to provide direct support to faculty. The preclinical team pulled together in a crisis and for that I am grateful.”

Meyers pulled together a team of 20 first-year medical students in his class to talk about remote learning and how best to maintain the relationships everyone formed with each other. He knew that if courses remained virtual in the fall, it could be tricky to both establish and maintain relationships.

“Their input was invaluable. Initially, I was not confident we could quickly implement this shift, but they said, ‘We’ve taken online classes before and here’s how to do it—this is what works, and this is what doesn’t.’ That gave us the confidence to move forward,” he says.

More than 60 faculty teach in the three-month, 110-hour course that includes six gastrointestinal conferences, three surgical small group conferences, an anatomy small group conference, and four anatomy pathology labs split into multiple groups.

With medical students sent home and scattered across various time zones, course timing presented an attendance problem, but Meyers had an idea about how to bolster attendance. He created geographically specific group sessions—an 8 a.m. morning conference that meant 5 a.m. for students on the West Coast, was switched to an early afternoon conference.

“Timing was definitely a challenge in our course,” says Andrew R. Crawford, MD, endocrinology course director. “The course has three main components—live didactic lectures, small group sessions (where a faculty member reviews cases with each group), and four lab sessions that are a mix of microscope slides and live anatomy,” he says. “We had about seven or so days to quickly change the format of these activities.”

Small group case review sessions are well-suited for Zoom, but Crawford says labs were more challenging to figure out: “We ultimately devised self-learning modules and live Zoom interactive exercises for the students to work through with a faculty member.”

Second-year students in a small group On Doctoring session in Chilcott Auditorium talk with a surgical resident via Zoom. Photo by Kurt Wehde

With larger groups, Rima Al-Nimr, MS, a lecturer in medical education who leads the Nutrition in Medicine Longitudinal Curriculum and teaches in the GI/Metabolism/Nutrition course, says everyone was a bit nervous at the onset, “but it was such a good team effort—there was a lot of communication between everyone, including the administrative staff.

“And the fact that Steve and Larry were so present really helped faculty in our course. When I gave a lecture or worked with breakout rooms, they were always there managing the chat and answering questions.” Al-Nimr has taught remotely, but not on this scale.

There are few large group sessions in On Doctoring—a two-year course introducing medical students to essential clinical skills. “For the ones we do have, we redesigned those in a panel format that actually worked better,” says Roshini Pinto-Powell, MD, course co-director. “In an auditorium, the most vocal students ask the most questions. But on Zoom because of the chat, everyone participated. Our major limitation was transitioning our physical exam skill sessions because they are truly difficult to do remotely.”

On Doctoring is anchored by small group learning, making it somewhat easier to transition to a virtual format and the communication skills sessions lent themselves well to this effort. “First-year students were in the midst of discussing complicated issues, such as partner violence and abuse that require strong communication skills,” says Adam Weinstein, MD, course co-director with Pinto-Powell. “We used Zoom for students to role play with each other and with some of our standardized patients via a telemedicine-like format.”

Something New

Geisel has been pursuing a modernist view of medical education for some time—culminating with the implementation of the medical school’s new interactive and integrated curriculum—but the pandemic presented further opportunities to review pedagogy.

“We thought that a GI/Metabolism/Nutrition course should introduce students to obesity in their first year and then move forward with how to treat it,” Al-Nimr explains, “because they will see obesity-related health issues wherever they practice.” To do this, she conceived a virtual obesity panel to familiarize students with obesity-related health issues.

Reaching out to experts across the U.S. who enthusiastically responded, the eight-member panel, including Al-Nimr, featured the full gamut of specialties to discuss treatment and bounce around ideas. “We designed this not as a lecture, but as an interactive group-wide discussion session with breakout and chat rooms so students could ask questions and make connections—something that is difficult to do remotely.”  Personal proximity does help build trust and understanding between faculty and students making it easier to facilitate conversations and learning, but virtual breakout and chat rooms give everyone a comparable way of getting to know each other. “And this panel helped do that,” she says.

Bensen cites this as an example of something that worked better remotely because they were able to have faculty participation well beyond Dartmouth. “This is the first time we’ve done something like this, and I think this type of panel is the perfect thing to keep even if we do return to in-person classes.”

“This has been a big transformation—we’ve been rethinking everything, including reviewing Scholar Rx course material, a comprehensive digital learning platform for medical students with a self-assessment tool, that we used to fill in some of our gaps,” Crawford notes. “We personalized this resource and will continue using it because it’s a great preparatory tool.”

Physical exam skills sessions in On Doctoring, though difficult to do remotely, were adapted to mimic a telemedicine health encounter via Zoom. “Students still met with patients and took clinical histories, but rather than performing a physical exam, each student described the exam they would perform and why—and then gave a presentation and summary of the patient encounter just as they would have otherwise,” Weinstein explains. “We were able to accomplish nearly all of what we would normally accomplish using this format.”

Bensen and Meyers agree they, too, mostly delivered what they initially set out to do.

“We designed this course to be more integrative, but because it was new, we faced additional challenges. One of our innovations was improving anatomy lab—we created a small group conference around a surgical case then planned to perform the surgery on a cadaver in the anatomy lab,” Bensen explains. “It was disappointing to be unable to do this, but we may be able to do it in the future.”

Learning physical exam skills, using standardized and actual patients, still looms large for On Doctoring. “We really haven’t been able to completely reproduce this virtually—talking about an exam is not the same as physically doing it in a safe, effective, and compassionate way,” Weinstein notes. Connecting with a patient who is not in the room with you and putting them at ease requires non-verbal communication skills—learning to see patients in an office still needs to be done.

“Telemedicine is here to stay—teaching medical students and seeing patients via Zoom has opened up this capability and it’s a tool that we will use,” Pinto-Powell says. “But it’s very important for students to gain experience caring for patients beyond telemedicine. If you don’t have success interacting with a patient in person, you will have less success interacting with them virtually. While physical exam skills still need to be learned in person, there are others that may be improved when done remotely. There is potential in both spheres. Our job as medical educators is to figure out what is best delivered in person and what can be delivered remotely and when. We have an opportunity here at Geisel to really think about and study this.”

Something they are thinking about is broadening their standardized patient base for clinical skills sessions. Weinstein says, “Student feedback tells us to increase diversity among our standardized patients—but we are limited to those who live in our region. With Zoom, we have the entire country to tap into to create a diverse patient experience for our students.”

The On Doctoring team is also taking a broader look at their foundational courses. “In preparing for the coming year, our best guess is we will be offering half of our sessions remotely and half in person with appropriate physical distancing. But in truth,” Pinto-Powell says, “the plug can be pulled at any time so we are remaining nimble in thinking about how we can accomplish this totally remotely if we need to.”

Transition to Fall

Lessons learned during spring term made the transition into the new academic year during the unfolding pandemic seamless.

Nearly all courses have developed a hybrid learning model for incoming first- and returning second-year students—a mix of remote learning and in-person small group sessions taking place in classrooms arranged to accommodate physical distancing. Knowing that navigating this model could be anxiety-inducing for new medical students, Geisel has boosted student wellness support and is well prepared to meet the challenge

med students in class
Roshini Pinto-Powell, MD, works with first-year students in a small group On Doctoring session. Photo by Kurt Wehde

“We want you to have the best experience possible,” John F. Dick III, MED ’03, interim senior associate dean of medical education, told medical students during a summer town hall. “This pandemic is very dynamic—and we are trying to stay on top of it. We have taken steps to mitigate risks, including individual responsibilities that are required of everyone in Geisel’s community, which allow us to provide the face-to-face learning we believe is essential to your medical education.”

In mid-August, after two weeks of quarantine and remote learning, entering and returning medical students returned to campus with strict safety precautions and clear community expectations in place for clustered small group sessions. Everyone received a PPE kit with masks, gloves, a face shield, and hand sanitizer to be used while on campus.

Wearing face coverings and adhering to physical distancing measures apply to all small group sessions whether indoors or outdoors. Full PPE must be worn in anatomy lab where students are split into groups so only one group at a time is in the lab.

“This term, we are requiring the same PPE protocols that third- and fourth-year students are observing with patients in the hospital so our first- and second-year students can have limited, dynamic in-person contact with patients while learning clinical skills,” Weinstein explains.

Even so, aspects of medical education at Geisel have been moving toward a virtual format for some time, and with more interactive software, Meyers says it will be easier to move this forward. He speculates whether a hybrid model is the future of medical education.

“We now recognize the unique opportunities that Zoom and remote learning provide,” Crawford says. “And I think the curriculum will become stronger because we have new ways to connect with students and tailor the course materials to fit their learning needs.”

Note: As this pandemic progresses, preclinical education and clerkships continue to be complicated, but Geisel students have expressed gratitude for the medical school’s efforts to provide safe and effective in-person learning. Geisel remains diligent in following policies designed to protect the health and wellbeing of its students, faculty, and staff.