In the month of all new beginnings, we took stock of the last semester with those who directly intervened in the process of implementing a new communication and distance learning structure. We shared the greatest challenges and anxieties of those who were on that other front, seeking to ensure the best possible training conditions, despite the constraints they faced. Now we look to the future in a new year that now begins still in the shadow of the pandemic and the risk that is as real as life itself.
Recalling the “exceptional behaviour” of the entire FMUL academic community in the second half of last year, Professor Joaquim Ferreira stressed “everyone’s” adaptability and agility, from coordinators of the various academic years to lecturers and non-teaching staff, in search of a solution to respond, as efficiently as possible, to an exceptional situation. “We were able to put together a curricular programme in hours and we were consistent with the design we outlined. Obviously, we cannot comment on whether it was highly successful or unsuccessful from a pedagogical point of view, but we had the merit of having a programme designed and outlined, which was implemented rigorously and, compared to other medical schools and even other colleges in other areas, certainly with a level of organization that makes me very proud”, said the President of the Pedagogical Council.
Finding a way to evaluate students remotely was a huge challenge and Joaquim Ferreira recognizes that, although the ideal assessment model was not the one that was implemented in the previous school year, “if we stick to the way it went and the actual results, they leave us relatively calm in relation to what was done”. He said that “calm does not mean that there were no mistakes, no problems and, even no situations of injustice that makes us concerned, but, looking back, it would be very difficult to do things differently”.
In the perspective of Joaquim Ferreira, who wanted to send a message to students who may have felt affected in some way, if one has to blame anything, in this specific case, the pandemic is to blame. “It is not the person who takes the exams, nor the coordinator. The culprit is the pandemic, which generated a situation that made us uncomfortable”, he stresses, establishing “a parallelism with situations that we live in our clinical practice, in which we have a serious disease, we have a patient who is getting worse and we have a family that is angry about the context of the disease, and we often tend to blame doctors, nurses or health professionals. I always say that we must not forget that it is the disease that we have to blame, because it generates that discomfort situation, and this is a little bit what happened in the last semester in relation to assessment and to what may have gone less well. I think that the pandemic should be blamed for generating a very complex situation”.
Confessing his exhaustion, not only in the first person, but in the name of a “collective” that responded “very well” to an unprecedented situation, Joaquim Ferreira understands that the pandemic exposed the only and greatest disadvantage of studying or working on a campus hospital. “We are privileged because we have a Faculty of Medicine based on a campus that includes the largest hospital in the country, which is a university hospital, and the biomedical research institute.
And having students in a hospital is a privilege, unless there is a pandemic, adding that “this is the type of situation where having a medical school where at least part of the activities would be conducted in a physical space outside a hospital campus would have been easier. Thus, what in normal circumstances is a privilege, which I do not do without, in the context when it is necessary to have students taking classes, living in a hospital physical space, obviously caused major limitations and brought additional difficulties, even compared with other medical schools”. He said that this same difficulty was found when planning the new academic year.
In retrospect, Joaquim Ferreira considers that “surely there were losses”, because “nothing substitutes learning with a patient and with a lecturer in a clinical and hospital area”, emphasizing the steps taken in order to “with organization, effort, and, to mimic as much as possible a learning process that results from the physical presence of students and lecturers in a hospital”.
For Miguel Bernardino, a student who is going to start year 4 of the Integrated Master Degree in Medicine (IMDM) and Head of the 17-23 Course Committee, one of the main lessons to retain from the experience of the last semester of the previous year “is that all elements of the Faculty - whether they are lecturers, students or employees of the technical and administrative services – have great capacity for adaptation”, a competence demonstrated “by the implementation of a distance learning model in 24 hours”, he recalls, sharing those he believes to have been “advantages and some inconveniences which, when evaluated, allow us to conclude that it (distance learning) is better adapted to some Disciplinary Areas and to certain types of classes than to others”.
Miguel Bernardino used “two paradigmatic examples” to justify his view. “I believe that the teaching of Imageology significantly improved from the first to the second semester. The remote classes allowed students to better follow the lecturer's explanations during class (the images had high quality and the resources available to the lecturers allowed them to circumscribe the specific area of the image they were referring to at a given moment more accurately)”. In addition, “the recording and availability of classes proved to be a very relevant study element in the preparation of the exam, and the reformulation of the method for theoretical and practical teaching led to a better pedagogical strategy (the students kept their active role in the preparation of clinical cases, but the presentation was done by the lecturers, which made it more useful)”, he stressed.
On the other hand, the biggest disadvantage was reflected in the teaching of Introduction to Clinical Practice, which, in the opinion of Miguel Bernardino, “was impaired from the first to the second semester.” “Although remote methods could adequately replace theoretical classes and, eventually, theoretical-practical classes, the quality of practical teaching was undoubtedly affected. This statement is justified in the following events which, unfortunately, were inevitable: the training of the procedures in the models was not feasible, it was not possible to practice the protocols under the supervision and guidance of the assistants and the small clinical gestures course had to be suspended”.
Regarding the academic year that is now beginning, Professor Joaquim Ferreira reveals that the plans to anticipate the preparation of an academic year, which from the beginning was foreseen atypical, started in May, when “the Faculty Directorate and the Pedagogical Council began to meet, in order to outline the general guidelines of the following year. A specific working group was created, which I coordinated, to suggest what would be the implementation guidelines for this new year, and a set of structural decisions were made that were the basis of everything that happened.” These guidelines established “a set of scenarios, some more likely, others more hypothetical. For all of them there is a plan, explained the Professor, giving details of the teaching structure that was designed for the start of this new school year. “What is planned is that all theoretical classes and seminars will be given by videoconference, taking advantage of all the learning that teaching gained using these formats. At the outset, we managed to take students away from the hospital physical area and create classes that most easily adapt to this type of format”, which also allows freeing some physical spaces necessary for the adaptation of teaching in its most practical aspect. “Basically, the year is planned so that some theoretical-practical classes are face-to-face, others taught remotely, depending on the adequacy of the subjects to this type of format”.
In Miguel Bernardino’s view, considering the learning of the past semester is a key step for Coordinators to better plan the adaptations that will be introduced in their specific Disciplinary Areas in response to this new epidemiological situation”.
Despite the pandemic context being different in the two semesters, Miguel Bernardino believes that “what happened at the end of the last academic year allowed us to obtain important concrete knowledge of the classes that must continue to be taught face-to-face and of those that best adapt to remote models.”
As for practical classes, "which are most difficult, whether clinical practical classes or laboratory practical classes", says Professor Joaquim Ferreira, the face-to-face model will be privileged. “What is planned is that the number of students per class and the time of exposure to the practical context will be reduced, so what will happen is that we will have smaller classes and an alternation between students that are in a practical hospital context, in the ward or in the laboratory, and the students who are in another physical area taking face-to-face classes, which we hope will be most interactive, simulating the practical context as much as possible”, he explains, stressing that such a strategy allows the number of students exposed to a higher risk situation is lower and in a format that is obviously more dynamic and more agile.
Regarding the assessment system, which “is not yet fully defined”, Joaquim Ferreira said that “the format will tend to be face-to-face, probably using the same type of technologies”. “The idea is that students use existing technological systems, namely the computer application Quizz One. In relation to the written exams, it is intended that they answer the test using a computer or laptop, but in person at the faculty, obviously distributed over wide physical spaces. Instead of being at home, they are here, benefiting from the technology that we implemented a little hastily because we had no other alternative, but which now we benefit from”.
The President of the Pedagogical Council believes that such a model has the added value of having supervision done by the faculty, “which is also an additional factor of justice”. He stresses the advantage: “when using this type of systems, we believe that the quality of the questions will improve, because this application requires the fulfilment of a set of rules in the preparation of the questions that is positive from a pedagogical point of view to improve the quality of the tests”. He explains that the application“ allows generating a set of questions and assessing their quality", and also a "set of aspects to improve the pedagogical quality of the assessment, which may result from maintaining, in part, what we started doing last semester, but ideally with the students in person in the physical space of the faculty”.
The physical presence of the students generates, in turn, “additional difficulties” and requires taking care of some logistical details to ensure the essential conditions to fulfil the plan. “Having a student with a laptop computer in an amphitheatre taking an exam implies that there is risk that the computer will run out of battery, thus rendering the student unable to take the exam. It implies starting to think about how we are going to ensure that those aspects, which we sometimes don't remember, are guaranteed so that what we believe will eventually occur in practice”.
The plan is outlined and expectations are in favour of the effectiveness of this strategy. However, according to the Professor, “once again, we have to be prepared to adapt in a short period of time, readjust and redefine. In the end, it will require on the part of everyone, whether teaching staff or students, great generosity in terms of behaviour, common sense and prudence”.
As responsible for the Year 4 Course Committee, Miguel Bernardino had the opportunity to follow the preparations for the new academic year more closely. He believes that “the Faculty is perfectly aware of the fundamental importance of classroom teaching - and of clinical contact in particular - in the training of future doctors”. Therefore, "the planning of the new academic year will seek to provide students with this essential practical face-to-face contact, while not neglecting the fundamental security measures to avoid the spread of the SARS-CoV-2 virus as much as possible", he stresses.
Considering that the “transition from the preclinical cycle to the clinical cycle is an occasion strongly desired by most students since the first day of classes in the medical degree”, referring to students who move from year 3 to year 4, Miguel Bernardino says that the pandemic “introduced a certain degree of uncertainty as to the possibility of actually realizing these long-awaited opportunities for clinical contact.” Accordingly, "it seems natural that year 4 students will feel some apprehension (a feeling that is not exclusive to them, shared globally by all colleagues of the various years)".
When we look at this constraint that has a determining weight in the path of our students, it is almost inevitable to discuss the concept of justice. A vain discussion, certainly, because in times as adverse as the ones we now live in, what we can take for granted is only the uncertainty of what cannot be predicted. But we have confidence in concerted action, in order to minimize the damage caused by the pandemic.
For Joaquim Ferreira “there are several situations of potential injustice when we move to a format of remote classes. It depends on whether people have access to them, depends on technology, and not all students have the same ideal circumstances to access this type of information". He argues that "those who live in places where the quality of Internet access is worse, who do not have the same quality of technological support, are automatically at a disadvantage". He points out that, “the fact that we are unable to find better solutions or that we had to make decisions hastily did not always generate the circumstances to guard against all these scenarios. However, this does not mean that we are not concerned with these students. That is why I say that many of the decisions that we make are almost cruel decisions, because they define the various scenarios and we know that there are some students that can potentially be at a loss".
The institution is not indifferent to this situation, guarantees the Professor, recognizing the difficult challenge of making urgent global decisions, aware that the benefit of the majority has certainly placed others in a more disadvantaged position. “Assessment itself is a context where it is almost impossible to guarantee that in this second semester the scenarios and assessment mimicked exactly what had happened in the first semester. Obviously, many students had different subjects and, therefore, there are differences between those who had these subjects in the first semester and those who were assessed in the second semester. And again, in some circumstances, corrective measures have been taken, but there are no ideal corrective measures. However, all of this was thought out, discussed and planned. The decisions were not taken lightly. Some, surely, will have reason to feel affected in some way, but the context is so aggressive and difficult that it is impossible to consider all situations, all students and to implement corrections that would guarantee comfort for all”. The Professor added that when referring to justice, it means “access to education that is not the same for everyone, and even less in this context, because people are not here in person and the assessment methodology used was the one that was possible”.
Miguel Bernardino is confident about the start of the new academic year, saying that “the main expectation is that the teaching process can proceed as smoothly as possible, provided that the necessary security conditions to combat COVID-19 are guaranteed”. He also expresses “the hope that the mixed teaching regime in place will have the capacity to take advantage of the potential of remote education and, at the same time, to make up for its gaps”. He hopes “to be able to have enough clinical contact opportunities so the quality of my medical training suffers as little as possible from the calamity that threatens the world, and that the rules established for such contact are effective to the point of guaranteeing the safety of patients and all professionals and students who attend the hospital”.
When we talk about medical education that the pandemic determined would take place remotely, completely breaking the paradigm of what we understand to be the practical training of a future doctor, we discuss the difficulties and ways of overcoming the challenges that year 6 faced, “one of more difficult years”, according to Joaquim Ferreira, because it takes place in a context “where real clinical practice is simulated”. “For these students, at least half a year of year 6 was not fulfilled in the format it is supposed to happen. Unlike other institutions, we implemented a distance learning programme even for year 6, whereby every day students had 4 hours of classes by videoconference, covering all the clinical areas we thought were more relevant, from the point of view of their learning preparation for the exam. We tried that these classes simulated a context of clinical decision, diagnosis decision and therapeutic decision as much as possible”, said the Professor. The decision was the one that was “possible to implement”, but that “does not replace this training time”, emphasizes Joaquim Ferreira, addressing the other possible alternative, which was, in fact, an option taken by some educational institutions, which consisted of postponing the conclusion of medical training. “It would have been perfectly legitimate, which is to say: the curriculum has not been fulfilled, so that when it is possible to fulfil the curriculum as outlined initially, they will complete the degree. In this case, they will be doctors later. That was not the decision. The decision was, despite these difficulties, to validate this period even if the teaching format was different. I fully supported that decision, even though it is a difficult one” agreed by all Medical Schools in Portugal.
Postponing the conclusion, in Joaquim Ferreira's opinion, causes “an additional uncertainty: no one can say exactly how long it will be postponed for, it can be 6 months, 1 year, 2 years, 3 years… Clearly, year 6 was one of the most difficult years and it will be one of the most difficult years this year again, because in practice we are asking students to integrate themselves from the point of view of behaviour and rules in the institutions that will host them. We are asking for an effort from both sides here. What we are asking everyone to do is to behave like a young doctor in the structures of the hospital or health units that will welcome them and, basically, respect the rules, have exactly the same type of attitude. We are asking them to be real doctors sooner from the point of view of complying with the rules, although they are obviously in the last year of medical training at our faculty”.
A “request for help and an additional effort” in the face of a scenario with few alternatives, which Joaquim Ferreira thinks will translate into a “more medical” attitude, “in the most noble sense of the word”. "If there is an adjective or qualification that I think is good for a doctor, it is generosity from the point of view of behaviour. And that is what I ask of them, to be generous, both inside and outside hospital structures", pointing out some “good examples”, namely the fact that they can follow patients who are deprived of the visit of family members. "What's harder? Should a patient be hospitalized and not have a family member’s visit, or ask a college student to be as strict as possible in these prudent gestures? I think it is more difficult for the patient, so despite everything we are still in an advantageous situation compared with many others who are sick and without much alternative. They are deprived of the basic things, which is contact with their close family members in an environment where they are fragile, where they are sick and deprived of much more than we are.”
When asked about the implications of the lack of the normal internship period in the career of future young doctors who finished their academic training in the middle of a pandemic, Joaquim Ferreira admits to believing that “from the point of view of basic clinical training, there is no loss of skills”. However, “there will be some loss, even for a reason that is easy to understand, as many of the future decisions regarding the areas to which people will connect result from the passage through some places. I am a neurologist, because at a certain moment I was attracted to neurology, resulting from the classes I had in neurology. If I am not exposed to a certain context or situation, or have contact with an older colleague who makes a certain area appealing to me, I will not follow that path. Many of the options we take are a result of our own path and these students’ path has changed. Thus, that will limit their options as young doctors, hopefully not for the worse.
On the other hand, the Professor looks at it from another angle and focuses on the “enormous experience” which is “being a student at a medical school in a pandemic period”. “It is certainly a unique experience that will shape our students in a way we do not yet know very well, but I hope it will be a good one! Because it requires, in fact, a training of generosity and availability that in an easier and more normal context would not happen”.
Today, Joaquim Ferreira believes it was “impossible to do better” and considers that “we must feel very proud of the level of organization that was possible to implement”, remembering that the last few months were “heavy from the point of view of attention, care and effort”, requiring adaptation to a new normal and a future that is promising for everyone, at all levels. "The pandemic was democratic regarding who it affected, but it is not democratic in the sense of who can best adapt, and this applies to the institutions and to each of us individually".
The learning, not only of new forms of communication, but also of new ways of being in life, which confronted us with such a disparate and unnatural normality for the human being, will remain in future. It required, and continues to demand from everyone, the confidence, courage, generosity and adaptation necessary to be the best version of ourselves. Doing more, doing better, each new day.
Sofia Tavares
Editorial Team