Teaching Clinical Medicine During the Pandemic: Experiences and Insights

The Covid pandemic nearly brought our lives into a different dimension beyond our imagination. Measures to ensure the safety of everyone have never been stricter. The education system had to deal with similar restrictions. Everyone shifted to online virtual classes, which has never been easy to both the teachers and students. Not only are we concerned of our responsibilities as educators but responsive to the needs of students and patients as well during these times of uncertainties. This article briefly describes my personal insight on teaching medicine and how patients continue to take part in the learning process of students despite restrictions.


INTRODUCTION
Teaching clinical medicine starts in Medicine I where an in-depth history of the patient's illness and physical examination skills is taught. This task impresses upon the students the importance of listening to the patient's journey, asking the right questions, and outlining the chronology of how events unfold. The critical thinking process ensues in Medicine II and III from the available medical information. Students start formulating clinical impression and plausible differential diagnoses through the integration of concepts and principles learned from Medicine I, II and III, and proceed thereafter to draw diagnostic and treatment plans. The role of the faculty who practice clinical medicine is to inculcate in the minds of students how best to analyze each patient's condition and offer treatment in a holistic manner as a general care practitioner, further knowing when to refer to specialists.

INESCAPABLE CHALLENGES WHEN "LIFE MUST GO ON"
Following the imposition of worldwide lockdown due to the Covid-19 pandemic, everything went into standstill. With very limited knowledge on how to defeat the virus, "classroom" learning needed to continue with a similar objective in mind -to produce compassionate, committed Thomasian doctors competent to make sound decisions in each clinical situation, including the readiness to serve as frontliners in challenging situations. Universities and colleges have drawn up curriculum in a matter of days to weeks to be conducted in virtual learning platforms. Everyone worked from home. Not only did students and faculties need major adjustments from the daily rigors of onsite to online classes, various learning methods and teaching strategies were developed on how students and faculty could engage productively through blackboard course site. [1] Certainly, it should resonate amongst us that virtual teaching and learning has its own opportunities in today's remote learning environments[2] -a different learning experience that should be individualized and at the same time find ways of integrating virtual learning as a pedagogical approach in the new teaching norm.
While students continued on the path of virtual learning, most patients, on the other hand, felt helpless on how to access medical care, finding Emergency departments flooded with patients in distress. Telemedicine via zoom platform and other ways of "communication" became popular with a lot of limitations nonetheless. A thorough physical examination is not complete without palpation, percussion and auscultation. Accepting this constraint became part of the steep learning curve which both faculty and students had to reckon with. Frustrations on when the world will go back to normalcy resonated daily in our minds.

ADAPTATION STRATEGIES
As experts slowly found medical solutions to curtail the havoc created by this pandemic, faculty leaders and administrators needed to find effective ways on how to bring real-world clinical medicine to students online. The scope of rheumatology education spans from taking focused history and supplemented by an adept physical exam. Virtual classes in Medicine II continued on the patient partners program conducted pre-covid in the class. As most rheumatic diseases like gout, osteoarthritis, rheumatoid arthritis and systemic lupus erythematosus are treated in an "ambulatory" setting/clinic, patient partners were invited for a virtual medical consult online based on their underlying rheumatic disease to represent an important spectrum of disease relevant to nonspecialists in clinical practice. Protocols on ensuring patient data privacy simulating outpatient clinic consults were followed. These patients were adept in collaborating with students, exuded a positive outlook despite their disabilities and difficulties, and most importantly, proved able to teach and motivate the students to do well in their studies with the goal of rendering medical care to their own future patients in preparation for integration into the universal healthcare program. Physicians continually learn from their patients, gain new insights and perspectives that influence largely their clinical practice, other than everything being evidencebased. A paradigm shift in medical education is to encourage and empower patients to take a more active new role in medical education. [3] The virtual "Patient Partners" program of the UST Rheumatology compensates for the inability to render human touch and conduct face-toface encounters with patients. In this innovative educational program, real-life stories are shared through the use of available digital platforms. These patients with chronic rheumatoid arthritis have undergone training and certification to teach systematic musculoskeletal examination to medical students for the past 15 years. During the virtual learning process, patients with systemic sclerosis, systemic lupus erythematosus, chronic tophaceous gout, systemic vasculitis, ankylosing spondylitis and psoriatic arthritis were also invited to join the patient partners educational program. The dictum that "no two (2) patients of the same diagnosis are ever the same in all aspects including treatment response" is emphasized all throughout the program. As mentors in a specialty of few rheumatologists, we empower patients to monitor their own disease progress and be keen to recognize inflammatory symptoms that warrant immediate consultation with primary care physicians if specialists are not available. Students in Medicine III, postgraduate interns, residents and fellows in training as well as trainees from other disciplines were also involved in a discussion of actual patient cases to get a semblance of real-life clinical bedside medicine. As education is constantly evolving, we seek ways to improve the curriculum of our students guided by regular feedback from students.

REFLECTIONS FROM STUDENTS
The patient partner program has evolved from a faceto-face encounter with students to virtually meeting up in various social media platforms, ie, Zoom, Google meet, Facebook, messenger and Viber. This activity obtained an encouraging feedback from the Medicine III students who experienced intimate exchange of conversations with real patients, albeit briefly. They were able to "visualize" the course of rheumatic diseases from patients themselves, the similarities and differences in the manifestations of one patient to another of the same condition. All of these are clearer to the students than what are read and described in textbooks or journals. Some students even shared how they find Rheumatology intimidating during their Med II course. Interacting and listening intently to patients' stories allow students to understand the concept and importance of "quality of life" more than just writing down and handing out a prescription. Students express profound empathy for their rheumatic condition. These lifelong diseases afflicting the lives and dreams of such young and productive individuals of society truly leave on the students a lasting impression of how resilient and inspiring these patients are, defying all adversities that come along their way, despite the mounting healthcare expenses that they have to deal with daily, embracing what life has to offer, they still possess and exude the positive attitude of giving back by getting involved in student education. This program also served as an avenue where patients recognize their self-worth while accepting the unpredictability of their condition as well as possible long-term complications of disease and the effects of treatment. Most importantly, the program gives everyone a sense of hope -to patients hoping there will come a day where autoimmune inflammatory conditions will have a permanent cure, and to students that this pandemic comes to an end or the least is back to normalcy where students can come to interact with everyone in school face-to-face and proceed with little restrictions.

KEY LEARNINGS AND FUTURE DIRECTIONS
While we continue to adapt in this period of uncertainty, creativity, resourcefulness and resiliency are crucial fundamentals that both educators and learners should possess as everyone shifts from faceto-face to simulated learning. As we ensure a safe and healthy learning environment while we continue striving to attain learning goals, we need to be cognizant of our personal strengths and weaknesses as we help each other cope, learn and surpass this health crisis together.

Acknowledgments
The insights reflected in this write-up is dedicated to all the UST Faculty of Medicine and Surgery faculty staff personnel and medical students who continue to be an inspiration to the institution for decades. Special thanks to my mentor, Prof Sandra V. Navarra, MD.
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