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April 8, 2020

A Bold Response to the COVID-19 Pandemic: Medical Students, National Service, and Public Health

Author Affiliations
  • 1Editor in Chief, JAMA
  • 2Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA. 2020;323(18):1790-1791. doi:10.1001/jama.2020.6166

Over the next few months it is likely that the coronavirus disease 2019 (COVID-19) pandemic that has surged in New York City, Seattle, New Orleans, and Detroit will move from city to city and state to state. After the initial peak, absent highly effective medical interventions, the US will likely experience outbreaks of lingering disease for months and potentially years to come. As the US enters the next phase of COVID-19, critical questions will involve the nation’s capacity to respond to outbreaks, protect high-risk populations, and limit community spread.

Because of inadequate and continued lack of testing for COVID-19, a depleted and overworked public health workforce, lack of sophisticated integrated public health and clinical health information technology, and substantial cultural issues, the US has yet to implement an effective disease control strategy. Rather, the US has moved quickly from focused isolation and quarantine at a large scale to mitigation, largely focused on a single approach—social distancing. The fundamental question is whether the US can build a more targeted response capability so that the country can return to work, school, and other normal activities.

A key milestone is the fall of 2020. If the initial social distancing and perhaps warmer temperatures reduce the scale of the outbreak this summer, there is a major risk of a resurgence during the traditional season of respiratory viruses. As a possible approach to respond to this challenge, the US should consider suspending the first year of medical school for 1 year and giving the incoming 20 000 medical students the opportunity to join a national service program for public health. Hopefully the vast majority of students would participate. Such a bold approach may be needed to ensure that the US has an adequate response to the next wave of disease and does not enter a prolonged depression that will further adversely affect the health of its citizens.

The program should begin at the start of July. Incoming medical students should spend the month in online training on infectious disease epidemiology, infectious disease control in high-risk settings, and outbreak response. In August, they should deploy to state and local public health departments to enhance the capacity to support a test, trace, track, and quarantine strategy. The federal government should fund this project as a national service effort with a salary for the students and health coverage; it could be part of a larger initiative to engage other students, including those in nursing and public health, as well as out-of-work community members in the national response.

Taking this bold step is justified on health and economic grounds. Today, localities have few resources available to stop community spread other than closing businesses, curtailing large gatherings, and schooling at home. As soon as the novel coronavirus arrives in a community, many are at risk for falling ill, straining the health care system, causing fear, and devastating the economy. Communities must use the next few months to build a robust public health response. It is in part this capacity that has allowed Singapore, Taiwan, and South Korea to respond more successfully to the coronavirus challenge.

Medical students should deploy to state and local health agencies for a variety of roles. One urgent task is to implement rapid testing that informs community surveillance. Even today, only a small fraction of people with suggestive symptoms can be rapidly tested; in some acute care settings, even the sickest patients wait days for the result. Access to testing is so haphazard that it is difficult to draw reliable inferences about incidence, prevalence, and populations at risk. As testing becomes more available—results available within hours—there will be an urgent need to use these data to assess the scope of the epidemic. Whereas the lack of adequate testing and surveillance has been a major weakness of the initial response, it must not be by the fall.

A second urgent task is to enhance protection of high-risk populations, with the goal of reducing the likelihood and effect of outbreaks now occurring in nursing homes and prisons. Medical students should help ensure implementation of critical preventive policies and join teams that swiftly and aggressively respond to infections that occur.

A third role for medical students should be to staff community call centers that offer guidance and services to individuals with symptoms of or exposure to COVID-19. In addition to arranging testing, medical students would ensure that adequate information has been collected from individuals who require quarantine. This information could facilitate efforts to provide food delivery at home, alternative housing if necessary, and additional medical treatment as needed.

There is precedent for such a massive mobilization to address infectious disease. To reduce the spread of Ebola, Liberia mobilized thousands of case workers. China reportedly used 18 000 public health workers in Wuhan alone.1 US public health departments have seen major losses of staff over the past decade.2

Hundreds of medical students have already found ways to help in the response to COVID-19, from offering childcare to health care workers to taking on short-term roles in the health care system.3 Now it is time to formalize an opportunity for future physicians to protect the nation at this critical moment. Paired with other students as well as with community health workers and other local resources, having 20 000 capable medical students as a source of energy and enthusiasm can contribute to a successful response.

Mobilizing future physicians now will complicate medical education in the short-term and the medical workforce 4 years from now. But there are solutions to these challenges. For example, because fewer students means less tuition revenue, the federal government should compensate medical schools for a portion of this lost income.

In July 2025, there will be a gap in medical students available for internships, and in 2026, there will be an excess number of graduates for available residency positions. To address the former problem, licensing authorities that oversee undergraduate and graduate medical education should permit medical schools to offer early graduation to highly capable students, and graduate medical education should make adjustments to reduce the reliance on first-year residents. To address the latter concern, future classes of medical students should be afforded the opportunity for national service before starting medical school, ideally in a broad range of health and social service settings.

There are other challenges. This initiative will be expensive, but potential benefits to economic recovery would be substantial, and financially many would benefit. State and local Departments of Public Health likely do not have the capacity to hire and train a new workforce in such short order. The federal government should direct resources for this purpose to the local level that permit creative partnerships with the private sector to be able to hire and deploy people quickly. As demonstrated in Taiwan,4 health information technology that flows seamlessly between public health and clinical medicine is critically important. In the US, health care information is compartmentalized and siloed in ways that make a national effort to test, trace, track, and quarantine difficult to implement. This problem must be solved quickly to facilitate the response. The logistics of such a program are substantial, and time is short, but without such an effort, the US could well find itself largely shut down this fall.

How and when this initial surge of patients with COVID-19 ends remains uncertain. There is also much unknown about the effectiveness of social distancing, the transmission in the warmer months, and development of new therapies and vaccines. Even as there is hope of a major therapeutic advance, preparation is essential for the likelihood that the disease will continue. To return to work, education, and other activities as soon as possible, the nation should move swiftly to build a robust public health response, drawing upon a workforce that includes future physicians.

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Article Information

Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA (howard.bauchner@jamanetwork.org).

Published Online: April 8, 2020. doi:10.1001/jama.2020.6166

Conflict of Interest Disclosures: None reported.

Additional Information: Dr Sharfstein reported serving as Principal Deputy Commissioner of the US Food and Drug Administration from March 2009 to January 2011.

McNeil  DG. The virus can be stopped, but only with harsh steps, experts say. New York Times. March 22, 2020. Accessed April 5, 2020. https://www.nytimes.com/2020/03/22/health/coronavirus-restrictions-us.html
Taylor Wilson  R, Troisi  CL, Gary-Webb  TL.  A deficit of more than 250,000 public health workers is no way to fight COVID-19.   Stat. Accessed April 5, 2020. https://www.statnews.com/2020/04/05/deficit-public-health-workers-no-way-to-fight-covid-19/Google Scholar
Krieger  P, Goodnough  A. Medical students, sidelined for now, find new ways to fight coronavirus. New York Times. March 23, 2020. Accessed April 5, 2020. https://www.nytimes.com/2020/03/23/health/medical-students-coronavirus.html
Wang  CJ, Ng  CY, Brook  RH.  Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing.   JAMA. Published online March 3, 2020. doi:10.1001/jama.2020.3151PubMedGoogle Scholar
19 Comments for this article
Deploy New Public Health Graduates Now
Anne Newman, MD, MPH | University of Pittsburgh
Yes, we have a critical shortage of public health workers but we are about to graduate our 2020 MPH class. We also have just as many first year Master’s degree students who have achieved a skill level appropriate to many needed tasks. Create and give these jobs to public health students and graduates first! They have already demonstrated a commitment to public health and a desire to serve. Add a loan repayment program for them. They are standing in the wings right now!
Phillip Shaffer, MD |
1) Who will compensate medical schools for lost income from tuition? This is no small consideration.
2) You create a hole in medical education - there would be no incoming internship/residency class in 4 years. Who will cover this gap?
3) How does one justify coercing people into accepting potentially hazardous situations?
4) A case could be made for increasing rather than decreasing the number of physicians in training. We need fully qualified personnel to deal with this, and this proposal would be a net decrease in fully qualified personnel. This is a very appropriate opportunity to obtain
more funding from the government for graduate medical education.
4) There are tens of thousands of NPs who cannot find work. Hire them, pay them. They are qualified to do the sorts of jobs you outline.
MDs Who Do Not Match
Doris Koduah, MD | Ascension St Vincent’s Florida
As a former residency program director, I know there is a vast number of medical graduates who over the years have not matched in residency programs and their knowledge and skills are not being utilized. Most have completed their USMLE requirements but due to low marks or multiple test-taking have been sidelined over the years. We should at this point look into getting these doctors to help as they can easily be traced through the Match data base.

They definitely have more training and skills than NPs and PAs who now require no supervision to practice in a
lot of states.
Excellent Recommendation and Society Wins
Alvaro Garza, MD, MPH | Retired Public Health
Kudos for this excellent recommendation. As mentioned, the public health workforce has been systematically reduced since the beginning of the great recession; the National Association of City and County Health Officials has been monitoring and reporting on this for years. The public health system is in dire need of workforce boostering, even if temporarily, and especially to respond better to such a significant pandemic. This strategy can benefit many stakeholders including health professional students, health professional schools, local and state public health departments and, most importantly, our communities, particularly the ones suffering disproportionately. One important concept for this strategy would be to prioritize health equity to more effectively manage the pandemic, as Dr Aletha Maybank alludes to in her recent [April 7] op-ed in the New York Times. My strong suggestion is to focus on over-recruiting for those 20,000+ health professional students from under-represented communities. They would be highly welcome in their communities, would better understand the social problems and needs, and would be better understood by the residents. They would add an important quality and quantity to the building of a "robust public health response" to the pandemic.
Deborah Trojanowski |
This proposal is very unfair. Has anyone considered the path of momentum that will be broken by interrupting the career journey? What if the students refuse to be put in harm’s way at this point in their life? Would they be summarily dismissed? I, for one, would seriously have reconsidered career choices if that were proposed to me when I was entering medical school. I would also discourage any child of mine from entering into this type of conscription. Bad idea on so many levels.
Bold Response, Public Health Deployment Underway at Heritage College
Kenneth Johnson, DO | Ohio University Heritage College of Osteopathic Medicine
I commend Howard Bauchner, MD, and Joshua Sharfstein, MD, on their recommendations for making medical students available to support public health solutions to the COVID-19 epidemic and for their earlier graduation and entrance into the workforce. The Ohio University Heritage College of Osteopathic Medicine has already enacted these and other innovative solutions to respond to this health crisis.

We have taken quick, bold, formalized steps to put future physicians – our entire class of 250 third-year medical students – to work while engaging in meaningful academic experiences that fulfill their academic requirements. In the past few weeks, we worked
with Ohio Department of Health’s Amy Acton, MD, MPH, director of health, and Mark Hurst, MD, medical director, to develop the COVID-19 public health rotation. This public health initiative deploys our class of 2021 to local health agencies across the state to support overburdened public health teams. On April 13, our students begin doing exactly the kind of service work described by Drs. Bauchner and Sharfstein.

The Heritage College has also made possible the earlier conferral of medical degrees for students who have achieved program completion. Our intent is that early degree conferral – scheduled for April 18 – will enable our class of 2020 to pursue licensure sooner, with the potential for earlier entrance into the workforce.

Even before this pandemic, we developed an innovative curriculum, our Transformative Care Continuum, in partnership with Cleveland Clinic, which is designed to shorten undergraduate medical education with direct matriculation into primary care residencies. Students are embedded into their Cleveland Clinic site within their first days of medical school, which is a three-year program, and they progress at that same site through to graduation, residency and board certification. Public health is a fundamental part of the curriculum. Our first class graduates next year, having served in their communities for the past three years.

Through our leadership and our relationships with state agencies and health systems, we have been able to react quickly and work together to find innovative solutions that benefit the public, our public agencies, our health system partners and our future physicians.
Low Income Medical Students
Shabatun Islam, MD |
While this is an interesting and commendable theory, I want to bring to the forefront that a lot of medical students cannot afford to take one year off from their career trajectory. Many medical students, myself included, came from low income backgrounds and this is not something we could afford to do. Will the medical students be paid? How will you make up for lost income down the line? For many of us who were in my shoes as a medical student, one part of our decision to go into medicine was to become financially secure and have the capacity to help our families. There are a lot of hurdles that low income students face in just being able to start medical school and I think we should recognize that.
Public Service
Nancy Tilson-Mallett, Internal Medicine | Retired Physician
I was fortunate to receive a National Public Health Service Corp scholarship which paid for my medical training. After completion of my internal medicine residency, I served in rural Nebraska, a wonderful experience. My opinion is that all medical students, upon graduation, should serve one to two years in the public health service. The article recommends incoming students, but they are totally unprepared to help. Graduating students would be well equipped.
Use Public Health Graduate Students NOT incoming Medical Students
Alvina Janda, MD | HealthPartners
As a practicing ophthalmologist of 35 years whose husband has spent the better part of his career teaching in graduate Public Health programs at the University of Minnesota and ASU (along with extensive research), I would like to make an opposing comment to this article. We are faced with an unprecedented assault on our medical system and failure of a unified national public health response to the COVID-19 pandemic. There are multiple reasons for this. There are also multiple potential solutions with uncertain efficacy. None of us know what the next few months or years will hold as the COVID-19 pandemic, and likely others, unfold. What we do all know is that we need to be far better prepared . Prior to COVID-19 we were all aware of a physician shortage and read multiple articles of physician “burnout” and “moral injury.” There are now physicians and residents that have tragically died from COVID-19. One wonders how this will affect future medical school applications. We need to do everything we can to keep a steady stream of medical students entering the profession without a “gap year” that would delay 20,000 graduating medical students from entering a residency and then getting into practice. The havoc this proposal would impose is extraordinary: any residency program would have a full year of NO interns, then no G2’s,G3’s , etc. as time progressed. How do we support medical schools absent a full class over their 4 year term? I do not disagree with the proposal as regards the work that needs to be done to deal with this crisis and be better prepared for the next one. There is literally a small “army” of graduate students in public health that are “prime” candidates for this work. Look to that pool for help. You will find many willing public health graduate students without disrupting our graduate medical education system.
Borrow from Peter to pay Paul
Devra Cohen MD, Child & Adult Psych | Private practice
I agree we have a national health crisis and need able bodies to train for public health.

However I feel that this would be a terrible “ solution.“

We need more doctors and it is shortsighted to take the students who have worked for years to have the privilege of training in medical school from their chosen trajectory in order to fill another need . This will simply create a dearth of new doctors when we will be desperate for them in the future. It will also be very upsetting to students who are ready to dedicate
themselves to an important and arduous path of medical study.

Additionally, what will hospitals do without a year of Interns to fill their programs? This plan will disrupt the training pipeline of schools, teachers, and health care facilities who work together to create new doctors as well as diverting and delaying the careers of these future Doctors

It is not as if we have a shortage of bright young people who could do this public service. There are numerous bright, educated people who have applied to Medical School and sadly have not been accepted. Set up a program to offer them a chance to work in this public health capacity in a paid internship position. Offer incentives so the ones who excel will be considered for admission to Medical School or into a Public Health career or graduate school. Don’t derail the career trajectory of future doctors and treat them like they are cogs in a public health wheel.
Authors' Response
Howard Bauchner, MD (1); Josh Sharfstein, MD (2) | (1) JAMA; (2) Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
We appreciate the comments that have been posted, the social media chatter, as well as the emails that we have received directly.

We would like to highlight a few points.

First, to clarify, a national service program would not be compulsory, but rather elective.

Second, although the frame was 1st year medical students, as we stated in the editorial it would be open to public health and nursing students, and certainly individuals from the community.

Third, some have argued these individuals would be over-qualified, others have suggested they would be under-qualified. It obviously depends upon
the individual, but as we suggested all would receive training prior to beginning the work.

We did miss the opportunity to make one other important suggestion. For individuals who participated, there could be an option to graduate medical school in 3 years, which has been suggested in the past. By altering the curriculum and giving up some elective time, although challenging, the 4 years of medical school could be compressed into 3 years. Participating students would accrue less debt, and this would not disrupt whatever they envisioned for the next few years of their lives. This would also reduce the concern about a transient shortage of physicians that this program could contribute to.

For years many have argued that we need to re-invigorate and expand the public health service – the time and need is now. Launching such a program would be challenging, but the cost, given the overwhelming potential benefit, should be seen as minimal.
Targeted Balanced Solutions
Kimberly Lomis, MD | American Medical Association
Bauchner and Sharfstein propose mounting a targeted public health response to the COVID-19 pandemic by suspending all medical education for the medical school class entering in 2020 (1).  Although we agree with their premise - a targeted response capability is needed to allow the country to return to normal activities - we cannot agree with their proposed solution. It ignores three important tenets of modern medical education.

First, to properly respond to anticipated workforce needs, a careful assessment of estimated demands and the roles and competencies necessary to meet them is needed. With that evidence, we can determine who
might best serve. Many of the roles described do not require the level of education of an entering medical student, while others would exceed the capabilities of a rising senior. A meaningful workforce response should be competency-based and inclusive of all our health professions colleagues.

Second, the authors imply that medical education must be delivered in time-based blocks of curriculum. The medical education community has been working for many years to advance competency-based education. (2). This approach supports a degree of flexibility in curricular pathways that would not require pausing for an entire academic year to engage medical students. In addition, the promotion of health systems science curricula has strengthened the connection between education and health systems, positioning medical students to readily step into roles that require an understanding of systems, public health and social determinants of health (3).

Finally, many medical schools have already instituted changes that accomplish the goal of meeting targeted public health needs while working toward educational goals and developing competencies desired of medical students. For example, Heritage College of Osteopathic Medicine in Ohio is requiring all third-year medical students to complete a one-month clinical rotation working in local public health departments to address COVID-related needs (4).

Solutions to the health care work force problems presented by the pandemic must be targeted, nuanced, and grounded in modern educational approaches, meeting both educational goals and the demand for service.

Medical education cannot take a pause. This is not the first pandemic, nor will it be the last. Our health professions education systems must continue to adequately prepare a workforce to meet today’s and tomorrow’s challenges. Interrupting that process now will compromise our ability to respond in the future.

Kimberly D. Lomis, MD
John S. Andrews, MD
Susan E. Skochelak, MD, MPH
American Medical Association Accelerating Change in Medical Education Consortium

1.Bauchner H, Sharfstein J. A bold response to the COVID-19 pandemic: medical students, national service and public health. JAMA 2020;323(18).
2.Josiah Macy Jr. Foundation. Achieving competency-based time-variable health professions education; proceedings of a conference chaired by Catherine R Lucey MD. https://macyfoundation.org/assets/reports/publications/macy_monograph_2017_final.pdf. Accessed 4/10/20.
3.Gonzalo JD, Lucey C, Wolpaw T, Chang A. Value-added clinical systems learning roles for medical students that transform education and health: a guide for building partnerships between medical schools and health systems. Acad Med. 2017;92(5):602–607.
4.Heritage College of Osteopathic Medicine. Heritage College students to lend a hand in fighting pandemic. https://www.ohio.edu/medicine/news-center/news/heritage-college-students-lend-hand-fighting-pandemic. Accessed 04/10/20.
CONFLICT OF INTEREST: The authors of this comment work for the American Medical Association and oversee the Accelerating Change in Medical Education innovation consortium and grants programs
Student Response to the Call for National Service
Gillian Christie, DrPH(c), MPhil, MA | Harvard T.H. Chan School of Public Health
We read with interest the Editorial by H. Bauchner and J. Sharfstein (April 8, 2020) regarding deployment of incoming medical students to health agencies in support of the COVID-19 pandemic (1). We agree with the authors in harnessing the enthusiasm and energy of students, though would encourage expansion of the proposed national deployment program beyond medical students. As students in doctor of public health programs, we strongly urge public health schools, in addition to schools of medicine, nursing, and pharmacy, to take the lead in organizing student volunteers to support the COVID-19 response.

Our newly created project, the
Academic Public Health Volunteer Corps (APHVC), is a successful example of leveraging public health students and alumni in the COVID-19 crisis. This collaboration, which was activated at the request of Governor Baker’s administration, includes 11 academic partners, with strong support and participation from the Massachusetts Department of Public Health and the Executive Office of Health and Human Services. We have mobilized more than 500 of the 1,800 public health student volunteers to support 115 local health departments in Massachusetts. Students remotely assist with contact tracing, online communication, and multilingual translation, working with local health departments. We believe this work can be replicated in other states to enable schools of public health, and state and local health departments, to work together to respond quickly and efficiently to the COVID-19 emergency.

Public health students are uniquely trained to partner with local public health leaders and professionals in the fight against COVID-19. The urgency of the COVID-19 crisis makes waiting until medical schools begin in July insufficient. Large-scale contact tracing must begin immediately and culturally appropriate health communications are urgently needed. The large number of students - with more than 20,000 public health students graduating each year and at least as many in schools currently - provide an already activated workforce (2). Public health students have the professional skills to implement and scale rapid response efforts to community transmission. We are also educated at the intersection of health equity and social justice, issues that are sorely reflected in the disproportionate rates of COVID-19 deaths among minority populations (3). It is for these reasons that we believe public health students are an ideal auxiliary workforce for the COVID-19 response to support local public health departments. Only this will ensure more lives are saved (and fewer lives are lost) in public health crises today and in years to come.

Gillian Christie, DrPH(c), MPhil, MA
Cristina Alonso, DrPH(c), MPH, CPM
Eric Coles, DrPH(c), MPA

Harvard T.H. Chan School of Public Health
677 Huntington Ave, Boston, MA 02115

1 Bauchner H, Sharfstein J. A Bold Response to the COVID-19 Pandemic Medical Students, National Service, and Public Health. JAMA. Published online April 8, 2020. doi:10.1001/jama.2020.6166.
2 Leider JP, Plepys CM, Castrucci BC, Burke EM & Blakely CH. Trends in the Conferral of Graduate Public Health Degrees: A Triangulated Approach. Public Health Reports. 133(6):729-737. doi:10.1177/0033354918791542.
3 Osterheldt J. With coronavirus, racism is the underlying condition. Boston Globe. Published online April 10, 2020.
Medical Students Could Support Contact Tracing in Rural Communities
Austin Ritter, B.A. | Lake Erie College of Osteopathic Medicine
I appreciate this editorial thinking seriously about ways medical students and other health professional students could play a more significant role in responding to the Covid-19 pandemic. As many comments on the article point out, delaying the start of first-year medical students may not be the most targeted way to use medical education to synergistically bolster the public health response. However, the overall emphasis on promoting service-learning through the avenue of contact-tracing seems well placed.

A related idea is to shift a larger portion of clinical experiences for third and fourth-year medical students to rural community hospitals and clinics,
making a portion of these students available (on a rotating schedule) to assist with contact tracing in these communities.

The ability of medical schools to restart in-person clinical experiences for students will likely correlate with the ability to relax social distancing measures in a particular area. If rigorous contact tracing can be performed, it will be safer to relax distancing protocols and allow medical students some degree of "hands-on" patient experience.

Rural communities have lower population density such that near-complete contact tracing may be more feasible in these areas. However, these communities do not necessarily have the personnel or lab capacity to perform this level of contact tracing. Medical students could fill these personnel needs, and larger hospitals in cities, where many students traditionally rotate, could provide the lab capacity.

Rural communities would benefit from improved contact tracing ability. Students would benefit from continuing to gain in-person clinical experiences amidst the challenging pandemic environment. And medical schools would benefit from being able to continue providing a quality educational experience for their students, while also better-preparing students for their residency programs.

Medical students need in-person clinical experiences to gain confidence before starting residency. Obtaining these experiences in a way that protects students and the communities they are working in may be more feasible in areas with lower population densities. There are certainly challenges that can occur for many students living in rural communities. However, as a third-year medical student who has completed most of their core rotations at a rural community hospital, I have personally experienced the excellent quality of medical education that can take place outside of city centers.
Worth Considering Various Stakeholders
Saahil Jumkhawala, BS | Tufts University School of Medicine
In their recent Editorial, Drs. Bauchner and Sharfstein describe innovative ways medical students can address ongoing challenges posed by the novel coronavirus (COVID-19) pandemic. The authors describe a national service program for public health, through which entering students can help implement advanced testing modalities, enhance protection of high-risk populations, and staff ancillary service centers. While a creative suggestion, the potential benefits of integrating trainees into the workflow must be weighed against consequential disruptions to medical education and the physician workforce.

As medical students, we believe that several weeks of online courses would not sufficiently prepare students to contribute significantly
within state and local public health agencies. Students at minimum require foundational knowledge in microbiology, immunology, and epidemiology to effectively assist with telemedicine and contact tracing efforts. Without firm foundations in these disciplines, which students typically develop over years of rigorous medical education, students have limited use as responders against the global pandemic.

Suspending one year of medical training for up to 20,000 students would not only result in financial losses to academic institutions, but would result in a sizeable shortage of medical interns in 2024. Though expediting medical school graduation may address this, most schools are not prepared to implement three-year curriculums, which would require a substantial overhaul. At our own institution, adopting a systems-based curriculum was a several-year undertaking. While we acknowledge the authors’ suggestion that the program would be elective, medical students may feel coerced to participate despite insufficient training, fearing that deferral would represent shirking responsibility.

Instead, we propose enlisting International medical graduates (IMGs) and graduates of social science programs, who may be better suited to address the pandemic. Many IMGs who apply to US residency programs go unmatched, with 2,685 IMG applicants failing to secure US residency positions in the 2020 application cycle. Instead of assuming unpaid research positions to bolster their residency applications, IMGs may be willing to participate in financially compensated efforts against the global pandemic. Graduates of social science programs, who receive extensive training in epidemiology, public health, and biostatistics, have the required skillsets to address the challenges of evaluating and implementing policy reform. Social science researchers have the statistical background to conduct epidemiological and cross-sectional studies that can have large-scale impact.

We have been continually inspired by our colleagues’ enthusiasm and creativity to become involved in COVID-19 efforts. We hope that continued discussion engages various stakeholders to explore solutions to safely and strategically tackle the challenges at hand.

Saahil A Jumkhawala, BA
MD/MBA Candidate, Tufts University School of Medicine

Sheena Desai, BS
MD/MBA Candidate, Tufts University School of Medicine
What “Going Bold” Looks Like, Part 1: A Student’s Perspective
Catherine Raney, MD anticipated 2021 | Perelman School of Medicine at the University of Pennsylvania
In their article, “A Bold Response to the COVID-19 Pandemic”, Dr. Howard Bauchner and Dr. Joshua Sharfstein outline a plan for medical students to become key players in our nation’s public health response. Much of what they describe—including programs led by medical students that protect vulnerable groups and help COVID-19+ patients quarantine—is already happening at my medical school, and ought to be implemented across the country.

Drs. Bauchner and Sharfstein aptly point out that an effective public health response must include programs designed to meet the unique needs of vulnerable groups, like nursing home residents and incarcerated individuals. While the
article proposes mobilizing incoming students, third- and fourth-year medical students are already well positioned to do this work. Not only do we have several years of medical training, we are also available and eager to help. (In March, the AMA recommended that medical students be pulled from in-person clinical work.) 

Recognizing both the importance of meeting the growing needs of at-risk patients and the power of partnering with senior medical students, Dr. Jaya Aysola, Executive Director of Penn Medicine’s Center for Health Equity Advancement, created the COVID-19 Social Needs Response Team. Our team, made up of nearly thirty medical students and five social workers, assists patients experiencing distress or with safety concerns or that have immediate unmet social needs. We are connected with these patients by way of a shared electronic medical record “pool”, which we are able to access remotely. Currently, referrals come from numerous sources including telemedicine visits, triage call centers, and community-facing websites. Before contacting patients, we were provided with screening questions, suggested scripting, escalation protocols, and information about community resources. Now, with the support of social workers, we are gaining hands-on experience performing a thorough needs assessment of at-risk patients and linking them to local resources.

On my first shift, a provider referred a COVID+ patient to the pool. She explained that he was experiencing homelessness, and that she was unable to contact him. Our team, with the support of employees at the department of health and local homeless shelters, as well as street outreach coordinators, was able to contact the patient, share his results, and find him housing in a local hotel. For the first time since this pandemic began, I felt like I was using my skills to meaningfully contribute to our nation’s public health response: with my help, this individual was able to quarantine instead of spreading COVID-19 to many other vulnerable individuals.

Since the Social Needs Response Team’s rollout, the benefits of the program are undeniable. I am learning skills that will enable me to better care for my future patients individually and will help me better advocate for effective public health interventions moving forward. More importantly, we are providing important services, including connecting undocumented immigrants to local resources and COVID-19 positive patients with housing so they can quarantine. It’s time that every medical school adopt a similar program, and quickly. Our nation’s ability to recover from this pandemic depends on it.
What Going Bold Looks Like: A Faculty Perspective
Jaya Aysola, MD, DTMH, MPH | University of Pennsylvania
This call to action resonated with our efforts to identify new synergies between service and educational missions and develop programs that benefit both patients and students. Drawing on my experiences building an integrative behavioral health and primary care clinic for vulnerable families in the wake of Hurricane Katrina that also served as a continuity care site for residents, we created the COVID-19 Social Needs Response Team. The program empowers medical students to work alongside social workers to assist patients experiencing distress or safety concerns, or that have immediate unmet social needs.

We see medical students as
essential partners, in many ways best equipped to navigate this virtual landscape and assist vulnerable populations. Together with the Department of Case Management and Social Work, we prepared students to conduct and document patient calls with detailed screening questions and suggested scripting, workflows and escalation protocols, and training in crisis intervention theory, empathetic inquiry, and cultural humility. Now, virtual teams of two to three students and one social work supervisor per shift answer referrals from across the health system. These referrals come from ambulatory providers, triage call centers, community-facing websites, as well as COVID-19 teams involved in reporting test results and contact tracing.

The Department of Case Management and Social Work was essential in creating and staffing this response team, and the Department of Psychiatry helped define protocols to effectively triage patients experiencing mental health concerns. In addition, through our Center for Public Health Initiatives, we have established strong community ties and public health partnerships, which allow our team to provide daily updates on the existing resources available to address patient needs in real time. Virtual chat platforms enable team members to communicate with each other during and between shifts. Weekly virtual huddles with the entire team allow for case discussions, operational updates, and workflow improvements.

Working alongside social workers, medical students have found housing for COVID-19 positive patients experiencing homelessness, helped arrange for food delivery to households, and assisted those experiencing distress. Students have been grateful for the learning experience and the health system grateful for the service. We are grateful to provide these meaningful learning opportunities, while helping those most in need; however, we are equally humbled by this unprecedented crisis and believe models such as this may offer not just relief during this time but also ways by which we can operate in the future.
Incoming Medical Student Involvement in a Pandemic: A Student’s Perspective
Vignesh Ramachandran, MD | Baylor College of Medicine
Bauchner and Sharfstein propose utilizing incoming medical students during this pandemic, thereby delaying their start of medical school [1]. While well-intentioned to address provider shortages from COVID-19, it foregoes an important perspective: medical students’. Anecdotally, I discussed the article with a few dozen colleagues (MS1-MS4) at nearly 10 institutions. The vast majority were both opposed to the program and would hypothetically opt-out even if implemented.

First, the proposal overlooks medical trainees’ vulnerabilities in our hierarchical structure. We must be careful to not implicitly coerce students. Even 36% of healthcare workers themselves would not work in an influenza
pandemic [2]. Trainees do not have that option as they pursue board certification. There is an undeniable difference in power dynamic and independence compared to physicians. This is only magnified for incoming medical students, who are at the bottom of the totem pole. They may feel obligated to opt-in to not tarnish their reputations at their new institutions.

Second, the article does not comment on long-term financial impact on students. Since 1985, university tuition has risen >500% [3], saddling incoming students with debt exacerbated by exorbitant costs of medical education. A year of lost attending-level salary is not insignificant. Theoretical pay for incoming students would foreseeably be less than residents’, who have already voiced displeasure with lack of economic hardship pay or disability insurance [4]. Incoming students, like residents, are just in considering the financial ramifications of working during a pandemic.

Third, personal protective equipment shortages and increasing healthy young healthcare workers dying of COVID-19 (including residents) highlight the risk of this program to our field’s future: our youngest, most inexperienced colleagues. Some proposed ways to integrate them are notably unsafe, such as at high-risk outbreak sites and performing nasopharyngeal testing, the latter also being technically challenging. Other modes are of uncertain value, such as manning call centers (can use non-medical workers/volunteers).

This unprecedented time calls for novel solutions. Alternatives to increase the workforce could include: redistributing physicians to urban and underserved areas with disproportionally high COVID-19 deaths; allow final-year medical and allied health students to graduate early; tap into >20,000 annual MPH graduates for public health roles; suggest MD research faculty clinically participate; integrate outpatient providers to inpatient settings; and recruit non-medical volunteers (e.g. call centers). No matter the solution, it unsettles my peers and I to think incoming medical students could be asked to delay their training and get involved, potentially risking everything.

1. Bauchner H, Sharfstein J. A Bold Response to the COVID-19 Pandemic: Medical Students, National Service, and Public Health [published online April 8, 2020]. JAMA.
2. Wicker S, Rabenau HF, Gottschalk R. [Influenza pandemic: Would healthcare workers come to work? An analysis of the ability and willingness to report to duty]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2009 Aug;52(8):862-869.
3. U.S. Department of Education, National Center for Education Statistics. Digest of Education Statistics, 2017. https://nces.ed.gov/programs/digest/d17/index.asp. Accessed April 8, 2020.
4. Reddit. Residency subreddit. https://www.reddit.com/r/Residency/. Accessed April 8, 2020.
An Impractical Solution to the COVID-19 Pandemic
Syed Kaleem, B.S. | Drexel University College of Medicine
While I commend the authors for starting the conversation about how to tackle the important issues related to the COVID-19 pandemic, the authors provide an impractical response to the problem. There are certainly more holes and questions here than tangible solutions.

1) Why focus on incoming medical students? What about new MPH graduates, many of whom have trouble finding jobs, who actually have the necessary knowledge, education, and career aspirations to contribute to these solutions in the long term instead of for only one year? Or what about people looking for something meaningful to do in their gap years
that can give them relevant experience? Why instead are we choosing people who were already accepted to medical school, who are waiting for school to start?

2) The vast majority of medical students start school without any interest in public health – the majority just want to become surgeons or subspecialized doctors and make six-figure salaries as soon as possible. Additionally, medical students who are interested in public health from the start have likely already finished one or two gap years of some job related to public health and are entering medical school already having had that experience. Do the authors really believe that these medical students are interested in delaying their degrees for yet another year of their lives?

3) Medical students would be learning skills that are not ultimately necessary for them to know for their future professions. Yes, knowledge of disease tracking and pandemic outbreaks is useful information for a doctor to know - but it is something we can easily add to the biostatistics/epidemiology curriculum that medical schools already have without having medical students use an entire year of their lives unnecessarily. Even with the urgency of COVID-19, most students would not elect to take another year off for this anyway, given that they are entering a long road ahead, maybe even after having a past career. So while it is a necessary role to fill, and some students may likely take this offer, the vast majority will not elect to do this & we would have missed a golden opportunity to recruit from gap year or MPH students, who might actually find the skills they learn to be helpful in their job searches and in their careers.

4) Finally, the authors suggest that medical schools should receive extra government funding for the upcoming academic year, since their incoming medical students would not be paying tuition. Is that really a responsible use of tax dollars? This is not at all a small consideration to be laid out in no detail in this piece and is a completely unreasonable take on such an important issue. It probably plays well politically, but it is not actually efficient or even beneficial for public health.

Honestly, it seems that the authors are unable to provide a realistic solution, either because they are completely lost in their excessive admiration of medical students or because they believe too strongly in their ability to take advantage of anxious medical students in this difficult time.