A scoping review on adaptations of clinical education for medical students during COVID-19

Published:September 08, 2021DOI:https://doi.org/10.1016/j.pcd.2021.09.004

      Highlights

      • Update teaching & learning methods to maintain clinical programs during COVID-19.
      • Online, telemedicine & VR satisfactory in replacing onsite clinical attachments.
      • Hands-on clinical skills teaching still in need of further development.
      • Telemedicine highlighted as a model for future clinical education programs.

      Abstract

      Rapid advances in clinical education in response to the COVID-19 pandemic are taking place globally. This scoping review updated the educational strategies which could be applied by clinical educators in their practice to effectively maintain clinical attachment programs for medical students amidst public health crises. Almost all elements of clinical teaching were deliverable, whether it was online, onsite, virtual or blended, their educational effectiveness should be further examined. Increase in the number of telemedicine related publications were remarkable, and they could serve as a scalable model for future educational programs to be incorporated into the medical student curricula.

      Abbreviations:

      COVID-19 (coronavirus disease 2019), CT (Computed Tomography), EMR (Electronic Medical Records), ERIC (Education Resources Information Center), ESCI (Emerging Sources Citation Index), ICU (Intensive Care Unit), PRISMA (Prevention and Recovery Information System for Monitoring and Analysis)

      Keywords

      1. Background

      Despite the profound effects from the COVID-19 pandemic, the medical community has fought to maintain high-quality education by flinging open the doors of technology into teaching and patient care [
      • Gordon M.
      • Patricio M.
      • Horne L.
      • Muston A.
      • Alston S.R.
      • Pammi M.
      • Thammasitboon S.
      • Park S.
      • Pawlikowska T.
      • Rees E.L.
      • Doyle A.J.
      • Daniel M.
      Developments in medical education in response to the COVID-19 pandemic: a rapid BEME systematic review: BEME Guide No. 63.
      ]. Recent publications include reviews encompassing the rapid advances in medical education in response to the current pandemic and provided easily accessible summaries to grateful readers [
      • Gordon M.
      • Patricio M.
      • Horne L.
      • Muston A.
      • Alston S.R.
      • Pammi M.
      • Thammasitboon S.
      • Park S.
      • Pawlikowska T.
      • Rees E.L.
      • Doyle A.J.
      • Daniel M.
      Developments in medical education in response to the COVID-19 pandemic: a rapid BEME systematic review: BEME Guide No. 63.
      ,
      • Daniel M.
      • Gordon M.
      • Patricio M.
      • Hider A.
      • Pawlik C.
      • Bhagdev R.
      • Ahmad S.
      • Alston S.
      • Park S.
      • Pawlikowska T.
      • Rees E.
      • Doyle A.J.
      • Pammi M.
      • Thammasitboon S.
      • Haas M.
      • Peterson W.
      • Lew M.
      • Khamees D.
      • Spadafore M.
      • Clarke N.
      • Stojan J.
      An update on developments in medical education in response to the COVID-19 pandemic: a BEME scoping review: BEME Guide No. 64.
      ].
      Previous systematic or scoping reviews up to September 2020 on medical educational responses to COVID-19 have highlighted areas of relative strength, but also parts in need of further development and research such as telemedicine. A rapid systematic review by Gordon et al. [
      • Gordon M.
      • Patricio M.
      • Horne L.
      • Muston A.
      • Alston S.R.
      • Pammi M.
      • Thammasitboon S.
      • Park S.
      • Pawlikowska T.
      • Rees E.L.
      • Doyle A.J.
      • Daniel M.
      Developments in medical education in response to the COVID-19 pandemic: a rapid BEME systematic review: BEME Guide No. 63.
      ] suggested that the range of options deployed offered good guidance for the medical education community despite outcome data mostly being Kirkpatrick’s level 1. Daniel et al.’s [
      • Daniel M.
      • Gordon M.
      • Patricio M.
      • Hider A.
      • Pawlik C.
      • Bhagdev R.
      • Ahmad S.
      • Alston S.
      • Park S.
      • Pawlikowska T.
      • Rees E.
      • Doyle A.J.
      • Pammi M.
      • Thammasitboon S.
      • Haas M.
      • Peterson W.
      • Lew M.
      • Khamees D.
      • Spadafore M.
      • Clarke N.
      • Stojan J.
      An update on developments in medical education in response to the COVID-19 pandemic: a BEME scoping review: BEME Guide No. 64.
      ] scoping review identified publications in telehealth, student admission, and faculty development to teach in remote settings to be areas in urgent need of further research.
      Previous reviews dealt with medical education across the continuum, therefore detailed programs focusing on clinical teaching in undergraduate medical students, when direct patient contact limited due to the COVID-19, have been somewhat lacking. Especially, as clinical teaching is known to be effectively taught and learned through workplace based experiences, concerns exist amongst teachers [
      • Ahmed H.
      • Allaf M.
      • Elghazaly H.
      COVID-19 and medical education.
      ] and students [
      • Guadix S.W.
      • Winston G.M.
      • Chae J.K.
      • Haghdel A.
      • Chen J.
      • Younus I.
      • Radwanski R.
      • Greenfield J.P.
      • Pannullo S.C.
      Medical student concerns relating to neurosurgery education during COVID-19.
      ] on the educational effectiveness of online clinical teaching replacing hands-on experiences in clinical settings. Clinical teachers have been overloaded with the sudden advent of new technologies during COVID-19, having to deliver online or telemedicine clinics at short notice. Clinical educators in both primary/community care and hospitals would benefit from information on practical and efficient ways of adapting their educational programs in such disruptions with easily referenced resources summarizing the available literature. The quality and details of additional developments flooding the literature since the previous reviews are also in need of further analyses.
      The purpose of this scoping review was to summarize the extent and details of clinical teaching adaptation for medical students in response to COVID-19 up to March 2021, which could be readily and easily used by clinicians in both primary care settings and hospitals.

      2. Methods

      Our scoping review applied Arksey and O’Malley’s [
      • Arksey H.
      • O’Malley L.
      Scoping studies: towards a methodological framework.
      ] protocol methodology.

      2.1 Identifying the research question

      The research questions of this study were: (1) what clinical education development has been performed for undergraduate medical students to cope with the limitations on direct patient contact due to COVID-19? (2) What further advancements in educational developments or research have been suggested as areas of improvement since the previous reviews?

      2.2 Identifying relevant studies

      Our scoping review included peer-reviewed publications including primary literature, review editorial, commentary/opinion pieces, but did not include grey literature, and conference proceedings. PubMed, Embase, Scopus, Web of Science (including ESCI) and ERIC were searched with keywords in the title and/or abstract and subject headings (e.g., MeSH, EMTREE) as appropriate.

      2.3 Selecting the studies to be included

      To select studies for inclusion, we used an iterative approach. Two authors (HP and SHS) independently reviewed the titles and/or abstracts of all the articles against an initial set of inclusion and exclusion criteria. Articles without abstracts underwent full-text screening to assess suitability. The two authors met 5 times. On the first meeting the authors worked to create a shared understanding of the criteria, and on the following meetings the selected citations were compared and discussed for any discrepancies. Any coding disagreements were facilitated by author YML. Inter-rater reliability was calculated using Cohen’s Kappa.

      2.3.1 Inclusion criteria

      Published articles on: (1) research or description on clinical teaching programs developed by medical schools, affiliated hospitals or primary care practices; (2) for undergraduate medical students; (3) brought by COVID-19 (4) from 1st March 2020 to 1st March 2021; (5) published in the English language; (6) listed in the MEDLINE and EMBASE databases including case reports, case studies, case control studies, cohort studies and randomised control trials, letters to the editor, commentaries, editorials, perspectives, and any potential reviews or meta-analyses. (7) Any type of study were included such as quantitative, qualitative, and mixed method studies.

      2.3.2 Exclusion criteria

      Articles focusing on (1) postgraduate medicine (e.g. resident, fellow), or (2) other health care professionals bar medical students (e.g. nursing, physio, dentist); (3) on educational theories/concepts or general opinions without actual implementation or adaptations in clinical teaching and; (4) non-clinical education (e.g. anatomy, basic sciences) were excluded.

      2.4 Charting the data

      Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols [
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O’Brien K.K.
      • Colquhoun H.
      • Levac D.
      • Moher D.
      • Peters M.D.J.
      • Horsley T.
      • Weeks L.
      • Hempel S.
      • Akl E.A.
      • Chang C.
      • McGowan J.
      • Stewart L.
      • Hartling L.
      • Aldcroft A.
      • Wilson M.G.
      • Garritty C.
      • Lewin S.
      • Godfrey C.M.
      • Macdonald M.T.
      • Langlois E.V.
      • Soares-Weiser K.
      • Moriarty J.
      • Clifford T.
      • Tunçalp Ö.
      • Straus S.E.
      PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
      ,
      • Peters M.D.J.
      • Godfrey C.M.
      • Khalil H.
      • McInerney P.
      • Parker D.
      • Soares C.B.
      Guidance for conducting systematic scoping reviews.
      ]. Both the PRISMA-ScR checklist and the protocol for scoping review can be found in the appendix section. All three authors independently reviewed and extracted data from all the included articles and any discrepancy was resolved by iterative discussions. YML served to discuss any coding disagreement and as a tiebreaker.

      2.5 Collating, summarizing, and reporting results

      Authors developed a coding sheet in the protocol (Appendix C). The abstracted data was analysed in quantitative and thematic content analysis. Frequency was calculated for: (1) overall characteristics including publication year, curricular phase, institutional setting, educational platform, type of publication, country of papers, medical specialities; (2) papers that reported educational outcomes were classified by Kirkpatrick level. Content analysis was performed in the following categories: (1) telemedicine; (2) online clinical education by curricular phase, patient type, types of clinical skills/procedures, clinical case scenarios discussion; (3) onsite clinical education. Microsoft Excel and SPSS v25 were used for data management and analysis.

      3. Results

      Database searching yielded 1369 records and 11 extra from manual searching. Removing duplicates resulted in 759 articles. After title and abstract screening, 615 records were excluded. 144 underwent full text screening and 87 were excluded. Inter-rater reliability at the screening phase was 0.899 suggesting excellent consistency. Fig. 1 shows the PRISMA flow diagram for article identification.
      Fig. 1
      Fig. 1The PRISMA flow diagram for article identification.
      UGME: Under Graduate Medical Education.
      PGME: Post Graduate Medical Education.

      3.1 Overall characteristics of the reviewed articles

      Table 1 shows the general features of the reviewed papers. Literature on educational developments for clerkship accounted for 84.2% of the papers, 8.8% for preclinical years and four papers (7.0%) included both preclinical and clinical phases. Most articles were university based clinical education programs (84.2%), and online education accounted for the majority (91.2%) of the reported developments, which included 17 papers (29.8%) in telemedicine. Publication types were diverse: which included original research (35.1%), short report (28.1%), letters, perspective opinion, commentaries and reviews. Articles originated from 18 countries and USA accounted for half of the 57 analysed publications (Fig. 2). 16 programs were conducted by medical schools and an array of specialties delivered alternative ways of clinical teaching (Fig. 3). 27 papers reported the educational outcomes of their applied programs, mostly at Kirkpatrick level 1 (77.8%) (Fig. 4).
      Table 1Characteristics of the analysed papers (N = 57).
      Freq%
      Year20203561.4
      20212238.6
      Curricular phaseBoth47.0
      Clinical4884.2
      Preclinical58.8
      Institutional settingBoth11.8
      Community814.0
      University4884.2
      Educational platformTelemedicine1729.8
      Online3256.1
      Onsite58.8
      Online/onsite both35.3
      Type of publicationOriginal article2035.1
      Short report1628.1
      Letter712.3
      Perspective610.5
      Opinion47.0
      Commentary23.5
      Review23.5
      Total Analysed Articles57100.0
      Fig. 3
      Fig. 3Medical specialties that reported clinical education developments.
      # Programs developed by medical schools.
      Fig. 4
      Fig. 4Kirkpatrick Level of programs reporting outcome data n = 27.

      3.2 Clinical education via telemedicine

      Adding to previous reviews, we found reports using telemedicine to overcome the challenges in clinical education amidst the pandemic disruption (Table 2). 17 papers [
      • Dawoud R.A.
      • Philbrick B.
      • McMahon J.T.
      • Douglas J.M.
      • Bhatia N.
      • Faraj R.
      • Greven A.
      • Buster B.
      • Rindler R.S.
      • Laxpati N.G.
      • Gary M.F.
      Letter to the Editor “Virtual Neurosurgery Clerkship for Medical Students”.
      ,
      • Pellegrini W.R.
      • Danis 3rd, D.O.
      • Levi J.R.
      Medical student participation in otolaryngology telemedicine clinic during COVID-19: a hidden opportunity.
      ,
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ,
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ,
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ,
      • Peterseim C.
      • Watson K.H.
      Family medicine telehealth clinic with medical students.
      ,
      • Ruiz Colón G.D.M.M.
      • Mulaney B.
      • Reed R.E.
      • Ha S.K.
      • Yuan V.
      • Liu X.
      • Cao S.
      • Ambati V.S.
      • Hernandez B.
      • Cáceres W.
      • Charon M.
      • Singh B.
      The COVID-19 pandemic as an opportunity for operational innovation at 2 student-run free clinics.
      ,
      • Darnton R.
      • Lopez T.
      • Anil M.
      • Ferdinand J.
      • Jenkins M.
      Medical students consulting from home: a qualitative evaluation of a tool for maintaining student exposure to patients during lockdown.
      ,
      • Paul N.
      • Kohara S.
      • Khera G.K.
      • Gunawardena R.
      Integration of technology in medical education on primary care during the COVID-19 pandemic: students’ viewpoint.
      ,
      • DeVaro S.N.
      • Uner O.E.
      • Khalifa Y.M.
      • Graubart E.B.
      Ophthalmology education in COVID-19: a remote elective for medical students.
      ,
      • Rupley D.
      • Grilo S.A.
      • Kondragunta S.
      • Amiel J.
      • Matseoane-Peterssen D.
      • Catallozzi M.
      • Westhoff C.L.
      Mobilization of health professions students during the COVID-19 pandemic.
      ,
      • Coffey C.S.
      • MacDonald B.V.
      • Shahrvini B.
      • Baxter S.L.
      • Lander L.
      Student perspectives on remote medical education in clinical core clerkships during the COVID-19 pandemic.
      ,
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ,
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ,
      • Lal A.
      • Bell G.
      • Curseen K.
      • Kavalieratos D.
      Teaching telepalliative care: an elective rotation for medical students during the COVID-19 pandemic.
      ,
      • Bhatia R.K.
      • Cooley D.
      • Collins P.B.
      • Caudle J.
      • Coren J.
      Transforming a clerkship with telemedicine.
      ,
      • Hayes J.R.
      • Johnston B.
      • Lundh R.
      Building a successful, socially-distanced family medicine clerkship in the COVID crisis.
      ] described the use of telemedicine as an educational tool mostly for clerkship rotations but three also included pre-clinical year students. Whilst telemedicine was mainly implemented in university hospitals, six programs were also executed in the community. Through the telehealth platform, diverse clinical competencies including history taking, communication skills, information management and diagnostic skills were taught, whilst education on physical examination and clinical procedures were scarce. In addition, professionalism was also learned through patient encounters over telemedicine platforms (Fig. 5). Practice guidelines [
      • Rupley D.
      • Grilo S.A.
      • Kondragunta S.
      • Amiel J.
      • Matseoane-Peterssen D.
      • Catallozzi M.
      • Westhoff C.L.
      Mobilization of health professions students during the COVID-19 pandemic.
      ,
      • Coffey C.S.
      • MacDonald B.V.
      • Shahrvini B.
      • Baxter S.L.
      • Lander L.
      Student perspectives on remote medical education in clinical core clerkships during the COVID-19 pandemic.
      ,
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ,
      • Ruiz Colón G.D.M.M.
      • Mulaney B.
      • Reed R.E.
      • Ha S.K.
      • Yuan V.
      • Liu X.
      • Cao S.
      • Ambati V.S.
      • Hernandez B.
      • Cáceres W.
      • Charon M.
      • Singh B.
      The COVID-19 pandemic as an opportunity for operational innovation at 2 student-run free clinics.
      ] and training for faculty and students were provided [
      • DeVaro S.N.
      • Uner O.E.
      • Khalifa Y.M.
      • Graubart E.B.
      Ophthalmology education in COVID-19: a remote elective for medical students.
      ,
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ,
      • Bhatia R.K.
      • Cooley D.
      • Collins P.B.
      • Caudle J.
      • Coren J.
      Transforming a clerkship with telemedicine.
      ,
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ,
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ,
      • Ruiz Colón G.D.M.M.
      • Mulaney B.
      • Reed R.E.
      • Ha S.K.
      • Yuan V.
      • Liu X.
      • Cao S.
      • Ambati V.S.
      • Hernandez B.
      • Cáceres W.
      • Charon M.
      • Singh B.
      The COVID-19 pandemic as an opportunity for operational innovation at 2 student-run free clinics.
      ,
      • Paul N.
      • Kohara S.
      • Khera G.K.
      • Gunawardena R.
      Integration of technology in medical education on primary care during the COVID-19 pandemic: students’ viewpoint.
      ] prior to encountering patients over the telehealth platform. In-advance informed consent from the patients were obtained and screening took place to ensure patients had the appropriate virtual interfaces [
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ,
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ,
      • Peterseim C.
      • Watson K.H.
      Family medicine telehealth clinic with medical students.
      ].
      Table 2Clinical education development via telemedicine n = 17.
      AuthorKey findingsClinical competenciesSiteSpecialtyCountry
      Dawoud et al. [
      • Dawoud R.A.
      • Philbrick B.
      • McMahon J.T.
      • Douglas J.M.
      • Bhatia N.
      • Faraj R.
      • Greven A.
      • Buster B.
      • Rindler R.S.
      • Laxpati N.G.
      • Gary M.F.
      Letter to the Editor “Virtual Neurosurgery Clerkship for Medical Students”.
      ]
      Students guided through curated surgical video content of select neurosurgical procedures by faculty. Students joined telemedicine clinics observing and participating after prior completion of online telehealth training modules2,3,4,9,11,12UnivSurgeryUS
      Pellegrini et al. [
      • Pellegrini W.R.
      • Danis 3rd, D.O.
      • Levi J.R.
      Medical student participation in otolaryngology telemedicine clinic during COVID-19: a hidden opportunity.
      ]
      1-on-1 attending and 4th yr. med student telemedicine clinic from available exam room. Two computers to access electronic health records.1,2,4,8,10UnivENTUS
      DeVaro et al. [
      • DeVaro S.N.
      • Uner O.E.
      • Khalifa Y.M.
      • Graubart E.B.
      Ophthalmology education in COVID-19: a remote elective for medical students.
      ]
      3-way telehealth clinic with 3rd/4th yr. student, consented patient and ophthalmology attending. History taking and focused ophthalmic exam by student, presentation and feedback.4,5,8UnivOphthalmologyUS
      Rupley et al. [
      • Rupley D.
      • Grilo S.A.
      • Kondragunta S.
      • Amiel J.
      • Matseoane-Peterssen D.
      • Catallozzi M.
      • Westhoff C.L.
      Mobilization of health professions students during the COVID-19 pandemic.
      ]
      Public health, telehealth visit & post-partum outreach teams ran by students. Rapid protocol and practice guideline updates by hospital leadership, EMR education and academic credit reward for student participation.1,2,4,8,9,12UnivOBGYNUS
      Coffey et al. [
      • Coffey C.S.
      • MacDonald B.V.
      • Shahrvini B.
      • Baxter S.L.
      • Lander L.
      Student perspectives on remote medical education in clinical core clerkships during the COVID-19 pandemic.
      ]
      Provision of practice guidelines for telehealth visits. Students joined as observers or participation.2,4,5,7UnivMSUS
      Iancu et al. [
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ]
      Based on experience in applying telemedicine consultation as part of core and elective clerkships, 12 tips were suggested in setting stage, needs assessment, creating tools for student integration into telemedicine1,2,4,5UnivMSUS
      Ho et al. [
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ]
      5 h student shifts on remote tele-ICU patient care, performing real interventions (medication, ventilator adjustment, lab recheck) as part of interdisciplinary care.1,2,3,4,6,8,9UnivMedUS
      Lal et al. [
      • Lal A.
      • Bell G.
      • Curseen K.
      • Kavalieratos D.
      Teaching telepalliative care: an elective rotation for medical students during the COVID-19 pandemic.
      ]
      Flipped classroom over zoom, role-play with faculty assessing symptoms and disclosing prognosis. Outpatient tele-palliative care clinic participation.3,8UnivMedUS
      Bhatia et al. [
      • Bhatia R.K.
      • Cooley D.
      • Collins P.B.
      • Caudle J.
      • Coren J.
      Transforming a clerkship with telemedicine.
      ]
      Students guided patients with varying levels of technological literacy leveraging their communication skills. Switching to a telephone visit if the patient was still unable to connect.1,2,3,4,6,8,9UnivFMUS
      Hayes et al. [
      • Hayes J.R.
      • Johnston B.
      • Lundh R.
      Building a successful, socially-distanced family medicine clerkship in the COVID crisis.
      ]
      20+ telemedicine family medicine patient encounters over 4 weeks. Illness script assignments reviewed by attending & different disease templates shared with students via online drive.1,2,3,4,6,8,9UnivFMUS
      Weber et al. [
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ]
      Both clinical and pre-clinical.
      4-week virtual elective. Prior EMR training and introduction to workflow allowed students to document clinical information after encountering consented patients.2,4,7,8UnivFMUS
      Cain et al. [
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ]
      Patients screened in advance, consented and ensured appropriate virtual interfaces in place. Students able to document the visit in patients' EMR and attested by attending.2.4,5,7CommFMUS
      Carson et al. [
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ]
      Both clinical and pre-clinical.
      Medical students staffed the hotline and assisted the underserved rural populations of northern Nevada; results showed significant improvements in students’ clinical skills including screening patients for COVID19, and triaging patients.1,2,3,4,8,9CommFMUS
      Peterseim and Watson [
      • Peterseim C.
      • Watson K.H.
      Family medicine telehealth clinic with medical students.
      ]
      Telehealth clinic shadowing family medicine attending or student led e-consultation taking history and describing physical exam manoeuvres to patient to perform on themselves.4,6,8,9CommFMUS
      Ruiz Colon et al. [
      • Ruiz Colón G.D.M.M.
      • Mulaney B.
      • Reed R.E.
      • Ha S.K.
      • Yuan V.
      • Liu X.
      • Cao S.
      • Ambati V.S.
      • Hernandez B.
      • Cáceres W.
      • Charon M.
      • Singh B.
      The COVID-19 pandemic as an opportunity for operational innovation at 2 student-run free clinics.
      ]
      Students performed history taking, delivery of patient education and counselling after receiving basic telehealth training.2,4,5CommFMUS
      Darnton et al. [
      • Darnton R.
      • Lopez T.
      • Anil M.
      • Ferdinand J.
      • Jenkins M.
      Medical students consulting from home: a qualitative evaluation of a tool for maintaining student exposure to patients during lockdown.
      ]
      Pre-clinical phase.
      Pre-clinical students already educated in basic clinical communication and exam skills consulted from own home whilst supervised by primary care physician in three-way telemedicine clinic.1,2,4CommFMGB
      Paul et al. [
      • Paul N.
      • Kohara S.
      • Khera G.K.
      • Gunawardena R.
      Integration of technology in medical education on primary care during the COVID-19 pandemic: students’ viewpoint.
      ]
      Community care medicine involved final year students in telemedicine clinics and provided online small group teachings.1,2,4,5,8,9,12CommFMGB
      Clinical Competencies: 1. Professionalism; 2. Communication; 3. Scientific knowledge application; 4. History-taking; 5. Physical and mental examination; 6. Clinical Testing; 7. Clinical Procedures; 8. Information Management; 9. Diagnosis Skill; 10. Treatment, Prevention & Palliation; 11. Prognosis Skill; 12. Care provision in clinical context.
      EMR: Electronic Medical Record.
      Univ: University; Comm: Community.
      ENT: Ear Nose Throat, otorhinolaryngology; FM: Family medicine; Med: medicine; MS: Medical school; OBGYN: Obstetrics and gynaecology.
      US: United States of America; GB: United Kingdom (Great Britain).
      a Pre-clinical phase.
      b Both clinical and pre-clinical.
      Fig. 5
      Fig. 5Clinical competencies taught via telemedicine.
      The categorization of clinical competency was adapted from the AAMC (American Association of Medical Colleges) [
      • AAMC
      Recommendations for Clinical Skills Curricula for Undergraduate Medical Education.
      ].
      At an ophthalmology telemedicine clinic, third and fourth-year students took histories, performed focused ophthalmic examinations, presented the findings to the faculty, and received 5-minute feedback sessions [
      • DeVaro S.N.
      • Uner O.E.
      • Khalifa Y.M.
      • Graubart E.B.
      Ophthalmology education in COVID-19: a remote elective for medical students.
      ]. Pellegrini et al. [
      • Pellegrini W.R.
      • Danis 3rd, D.O.
      • Levi J.R.
      Medical student participation in otolaryngology telemedicine clinic during COVID-19: a hidden opportunity.
      ] described teaching of fourth-year medical students during their otolaryngology telemedicine outpatient clinics. Rupley et al. [
      • Rupley D.
      • Grilo S.A.
      • Kondragunta S.
      • Amiel J.
      • Matseoane-Peterssen D.
      • Catallozzi M.
      • Westhoff C.L.
      Mobilization of health professions students during the COVID-19 pandemic.
      ] implemented three obstetric projects where students provided: (1) public health and access information to vulnerable patients; (2) telehealth outreach to antepartum and post-partum patients scheduled for telehealth visits; and (3) post-partum outreach interdisciplinary efforts. Family medicine departments used telemedicine for communication skills education [
      • Bhatia R.K.
      • Cooley D.
      • Collins P.B.
      • Caudle J.
      • Coren J.
      Transforming a clerkship with telemedicine.
      ]; scripts and disease templates used in telemedicine were shared amongst students to widen their clinical knowledge [
      • Hayes J.R.
      • Johnston B.
      • Lundh R.
      Building a successful, socially-distanced family medicine clerkship in the COVID crisis.
      ]; and prior training in EMR (Electronic Medical Records) allowed students to contribute to telemedicine documentation of consented patients visits [
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ]. Ho et al. [
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ] developed a pilot project integrating medical students into tele-ICU patient care using a 2-way video conferencing platform.
      Telemedicine was also used for clinical teaching in the community health care setting. Carson et al. [
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ] staffed medical students in multicounty telehealth COVID-19 hotlines letting them assist the underserved rural population conducting audio-only exams, screening and triaging patients. Cain et al. [
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ] reported family medicine clerkship students reviewing and documenting on EMR charts later reviewed by the attending. Similar pilot programs were reported by family medicine telehealth clinics at the Medical University of South Carolina [
      • Peterseim C.
      • Watson K.H.
      Family medicine telehealth clinic with medical students.
      ]. A unique program led by Standford University students, called Cardinal Free Clinics, opened immediately after the onset of the pandemic, and changed to a telehealth clinic model when in-person patient clinics were forced to close due to university COVID-19 policies [
      • Ruiz Colón G.D.M.M.
      • Mulaney B.
      • Reed R.E.
      • Ha S.K.
      • Yuan V.
      • Liu X.
      • Cao S.
      • Ambati V.S.
      • Hernandez B.
      • Cáceres W.
      • Charon M.
      • Singh B.
      The COVID-19 pandemic as an opportunity for operational innovation at 2 student-run free clinics.
      ]. In the UK, Darnton et al. [
      • Darnton R.
      • Lopez T.
      • Anil M.
      • Ferdinand J.
      • Jenkins M.
      Medical students consulting from home: a qualitative evaluation of a tool for maintaining student exposure to patients during lockdown.
      ] used telemedicine for teaching pre-clinical medical student in the community. Thirty five second-year students were spread across nine primary care organisations and participated in real-life telemedicine consultations. Final year medical students from Kings College London [
      • Paul N.
      • Kohara S.
      • Khera G.K.
      • Gunawardena R.
      Integration of technology in medical education on primary care during the COVID-19 pandemic: students’ viewpoint.
      ] reported their insights on participating in virtual general practice clinics amidst the pandemic and how their practices as incoming junior doctors would continue.

      3.3 Online clinical education

      3.3.1 Pre-clinical & across all years

      Some studies reported online delivery of clinical education for preclinical students [
      • Darnton R.
      • Lopez T.
      • Anil M.
      • Ferdinand J.
      • Jenkins M.
      Medical students consulting from home: a qualitative evaluation of a tool for maintaining student exposure to patients during lockdown.
      ,
      • Afonso N.
      • Kelekar A.
      • Alangaden A.
      “I Have a Cough”: an interactive virtual respiratory case-based module.
      ,
      • Elengickal J.A.
      • Delgado A.M.
      • Jain S.P.
      • Diller E.R.
      • Valli C.E.
      • Dhillon K.K.
      • Lee H.K.
      • Baskar R.
      • MacArthur R.D.
      Adapting education at the medical college of georgia at Augusta university in response to the COVID-19 pandemic: the pandemic medicine elective.
      ,
      • Knie K.
      • Schwarz L.
      • Frehle C.
      • Schulte H.
      • Taetz-Harrer A.
      • Kiessling C.
      To zoom or not to zoom - the training of communicative competencies in times of Covid 19 at Witten/Herdecke University illustrated by the example of “sharing information”.
      ,
      • Shah N.G.
      • Patel D.M.
      • Retener N.F.
      • Dittmar P.C.
      • Lacap C.
      • Thom K.A.
      • Martinez J.
      Beginning a new medical school curriculum amidst a global pandemic.
      ]. Knie et al. [
      • Knie K.
      • Schwarz L.
      • Frehle C.
      • Schulte H.
      • Taetz-Harrer A.
      • Kiessling C.
      To zoom or not to zoom - the training of communicative competencies in times of Covid 19 at Witten/Herdecke University illustrated by the example of “sharing information”.
      ] implemented communication skills by interviewing simulated patients over Zoom, resulting in higher satisfaction levels than role-playing amongst themselves. Elengickal et al. [
      • Elengickal J.A.
      • Delgado A.M.
      • Jain S.P.
      • Diller E.R.
      • Valli C.E.
      • Dhillon K.K.
      • Lee H.K.
      • Baskar R.
      • MacArthur R.D.
      Adapting education at the medical college of georgia at Augusta university in response to the COVID-19 pandemic: the pandemic medicine elective.
      ] reported online critical community-based projects through an interdisciplinary approach and Shah et al. [
      • Shah N.G.
      • Patel D.M.
      • Retener N.F.
      • Dittmar P.C.
      • Lacap C.
      • Thom K.A.
      • Martinez J.
      Beginning a new medical school curriculum amidst a global pandemic.
      ] described maximizing active and collaborative learning over online platforms.
      Four medical schools described clinical educational programs across all curricular stages, including pre-clinical and clinical phase students [
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ,
      • Furlan R.
      • Gatti M.
      • Menè R.
      • Shiffer D.
      • Marchiori C.
      • Levra A.G.
      • Saturnino V.
      • Brunetta E.
      • Dipaola F.
      A natural language processing-based virtual patient simulator and intelligent tutoring system for the clinical diagnostic process: simulator development and case study.
      ,
      • Kunisch R.
      • Zimmermann P.
      • Berges N.
      • Nitzschke M.
      • Schweiger F.
      • Seidl M.
      • Weidenbusch M.
      Learning in peer teaching of patient relations and communication skills at the “Anamnesegruppen” munich – proof-of-concept and lessons learned.
      ,
      • Ludwig C.
      • Stoevesandt D.
      • Ludwig C.
      • Fritsche V.
      Telephone-based communication training in the era of COVID-19.
      ]. A half century old course in Germany on ethics and professionalism involving real patients was successfully digitalised [
      • Kunisch R.
      • Zimmermann P.
      • Berges N.
      • Nitzschke M.
      • Schweiger F.
      • Seidl M.
      • Weidenbusch M.
      Learning in peer teaching of patient relations and communication skills at the “Anamnesegruppen” munich – proof-of-concept and lessons learned.
      ] and diagnostic reasoning and diagnosis training were delivered to medical students via an artificial intelligence–based virtual patient simulator developed by a medical school in Italy [
      • Furlan R.
      • Gatti M.
      • Menè R.
      • Shiffer D.
      • Marchiori C.
      • Levra A.G.
      • Saturnino V.
      • Brunetta E.
      • Dipaola F.
      A natural language processing-based virtual patient simulator and intelligent tutoring system for the clinical diagnostic process: simulator development and case study.
      ].

      3.3.2 Patient seen in hospital

      Most papers with real patient involvement were in the realms of outpatient telemedicine, but Pennell et al. [
      • Pennell C.E.
      • Kluckow H.
      • Chen S.Q.
      • Wisely K.M.
      • Walker B.L.L.D.
      Live-streamed ward rounds: a tool for clinical teaching during the COVID-19 pandemic.
      ] described live-streaming inpatient ward rounds as a clerkship educational tool. Medical students were engaged securely via mobile phone to participate in the ward round, including discussion before and after a patient visit. Sukumar et al. shared internal medicine clerkship experiences at a university hospital [
      • Sukumar S.
      • Zakaria A.
      • Lai C.J.
      • Sakumoto M.
      • Khanna R.
      • Choi N.
      Designing and implementing a novel virtual rounds curriculum for medical students’ internal medicine clerkship during the COVID-19 pandemic.
      ] in three steps; students pre-rounded an assigned hospitalised patient by remotely accessing their electronic health records, then calling into hospital rounds virtually, followed by oral presentation to their small group of instructors and fellow students. Kopp et al. [
      • Kopp A.R.
      • Rikin S.
      • Cassese T.
      • Berger M.A.
      • Raff A.C.
      • Gendlina I.
      Medical student remote eConsult participation during the COVID-19 pandemic.
      ] provided third-year medical students an opportunity to join inpatient medicine e-Consult teams which included COVID-19 patients. The orthopaedic department at the Chinese University of Hong Kong [
      • Ong A.M.-L.
      Impact of COVID-19 on medical education and resident burnout in a postgraduate programme.
      ] set up a live-feed camera that allowed students to interact with consented patients in the online clinic and an attending physician demonstrated physical examinations techniques.

      3.3.3 Teaching clinical skills or procedures

      To compensate restricted real patient physical examination, tutors played the role of standardised patients and taught via video conferencing [
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ]. Schleicher et al. [
      • Schleicher I.
      • Davids L.
      • Latta N.
      • Kreiß A.F.
      • Kreuder J.
      Training of physical examination techniques in video conferences.
      ] taught musculoskeletal and neurological system examinations using models as well as demonstrating physical examinations on a second tutor via live video link. Student demonstration also took place in reverse with live feedback. In Jiang et al.’s [
      • Jiang Z.
      • Wu H.
      • Cheng H.
      • Wang W.
      • Xie A.A.
      • Fitzgerald S.R.
      Twelve tips for teaching medical students online under COVID-19.
      ] program, instructors played children’s parents’ roles and the students were able to take histories and propose necessary physical examinations via video link. Torres et al. [
      • Torres A.
      • Domańska-Glonek E.
      • Dzikowski W.
      • Korulczyk J.
      • Torres K.
      Transition to online is possible: solution for simulation-based teaching during the COVID-19 pandemic.
      ] reported online clinical skills education by ‘borrowing’ the hand of a technician during medical simulation over zoom, where students guided the technician through a clinical examination on a fully articulating patient simulator. In a surgical skills study in Hong Kong, a synthetic skin and suture set was sent to each final year student, and 30 students per group joined an interactive tutorial. The students’ hands-on practice was monitored and assessed by the surgical tutor online [
      • Co M.
      • Chu K.-M.
      Distant surgical teaching during COVID-19 – a pilot study on final year medical students.
      ].
      Final year Italian students [
      • De Ponti R.
      • Marazzato J.
      • Maresca A.M.
      • Rovera F.
      • Carcano G.
      • Ferrario M.M.
      Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students’ perception.
      ] underwent virtual reality online platform training with simulated clinical scenarios. Body Interact™ is one of the increasing virtual patient platforms that allows students to interact with virtual patients, to collect histories, perform physical examinations, request and view vital signs and laboratory images, administer medications and decide on interventions.

      3.3.4 Clinical case scenarios discussion

      Sixteen papers from an array of countries described the use of online clinical case scenarios to remedy the disruption in clinical clerkships for clinical year students [
      • Biermann M.
      • Kanoun S.
      • Davidsen T.
      • Gray R.
      An open source solution for “Hands-on” teaching of PET/CT to medical students under the COVID-19 pandemic.
      ,
      • Boulger J.G.
      • Onello E.
      Transforming rural family medicine curriculum from experiential to virtual: a response to COVID-19 limitations.
      ,
      • Nnamani Silva O.N.
      • Hernandez S.
      • Kim E.H.
      • Kim A.S.
      • Gosnell J.
      • Roman S.A.
      • Lin M.Y.C.C.
      Surgery clerkship curriculum changes at an academic institution during the COVID-19 pandemic.
      ,
      • Wagner-Menghin M.
      • Szenes V.
      • Scharitzer M.
      • Pokieser P.
      Designing virtual patient based self-study quizzes covering learning goals in clinical diagnostic sciences for undergraduate medical students – the radiology example.
      ,
      • Wickemeyer J.L.
      • Yu J.
      A model for undergraduate medical student education in otolaryngology during the post–COVID-19 era.
      ,
      • Zeinali M.
      • Almasi-Doghaee M.
      • Haghi-Ashtiani B.
      Facing COVID-19, jumping from in- person training to virtual learning: a reviewoneducational and clinical activities in a neurology department.
      ,
      • Zottmann J.M.
      • Horrer A.
      • Chouchane A.
      • Huber J.
      • Heuser S.
      • Iwaki L.
      • Kowalski C.
      • Gartmeier M.
      • Berberat P.O.
      • Fischer M.R.
      • Weidenbusch M.
      Isn’t here just there without a “t” - to what extent can digital Clinical Case Discussions compensate for the absence of face-to-face teaching?.
      ,
      • Roskvist R.
      • Eggleton K.
      • Goodyear-Smith F.
      Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down.
      ,
      • Nic Dhonncha E.
      • Murphy M.
      Learning new ways of teaching and assessment: the impact of COVID-19 on undergraduate dermatology education.
      ,
      • Deng J.W.
      • Zhou F.W.
      • Hou W.T.
      • Silver Z.
      • Wong C.Y.
      • Chang O.
      • Drakos A.
      • Zuo Q.K.
      • Huang E.
      The prevalence of depressive symptoms, anxiety symptoms and sleep disturbance in higher education students during the COVID-19 pandemic: a systematic review and meta-analysis.
      ,
      • Geha R.
      • Dhaliwal G.
      Pilot virtual clerkship curriculum during a pandemic: podcasts, peers, and problem-solving.
      ,
      • Kaliyadan F.
      • ElZorkany K.
      • Al Wadani F.
      An online dermatology teaching module for undergraduate medical students amidst the COVID-19 Pandemic: an experience and suggestions for the future.
      ,
      • Khalil R.
      • Mansour A.E.
      • Fadda W.A.
      • Almisnid K.
      • Aldamegh M.
      • Al-Nafeesah A.
      • Alkhalifah A.
      • Al-Wutayd O.
      The sudden transition to synchronized online learning during the COVID-19 pandemic in Saudi Arabia: a qualitative study exploring medical students’ perspectives.
      ,
      • Kuo M.
      • Poirier M.V.
      • Pettitt-Schieber B.
      • Pujari A.
      • Pettitt B.
      • Alabi O.
      • Rajani R.
      Efficacy of vascular virtual medical student education during the coronavirus disease 2019 pandemic.
      ,
      • Ochsendorf F.
      • Kollewe T.
      • Kaufmann R.
      Corona pandemic: teachings for dermatological teaching.
      ,
      • Rüllmann N.
      • Lee U.
      • Klein K.
      • Malzkorn B.
      • Mayatepek E.
      • Schneider M.
      • Döing C.
      Virtual auscultation course for medical students via video chat in times of covid-19.
      ]. The University of Bergen’s radiology department [
      • Biermann M.
      • Kanoun S.
      • Davidsen T.
      • Gray R.
      An open source solution for “Hands-on” teaching of PET/CT to medical students under the COVID-19 pandemic.
      ] allowed fifth-year students to download the multiplatform image viewer on their personal computers and taught online practical skills on how to read and interpret CT examinations.
      Online case discussions at a university hospital [
      • Nnamani Silva O.N.
      • Hernandez S.
      • Kim E.H.
      • Kim A.S.
      • Gosnell J.
      • Roman S.A.
      • Lin M.Y.C.C.
      Surgery clerkship curriculum changes at an academic institution during the COVID-19 pandemic.
      ] was performed by students and residents together: third-year students produced a preliminary list of differential diagnoses; fourth-year students helped arrive their junior to the correct answer; and surgical residents provided examples of real-life experiences and evidence-based best practices to contextualize and enrich the patient presentations. An otolaryngology department [
      • Wickemeyer J.L.
      • Yu J.
      A model for undergraduate medical student education in otolaryngology during the post–COVID-19 era.
      ] provided students online cases in response to the markedly reduced outpatient and surgical volume due to COVID-19. Not only video media, but auscultation of cardiac murmurs were incorporated into an interactive case-based online course [
      • Rüllmann N.
      • Lee U.
      • Klein K.
      • Malzkorn B.
      • Mayatepek E.
      • Schneider M.
      • Döing C.
      Virtual auscultation course for medical students via video chat in times of covid-19.
      ]. To prevent disengagement during online clinical case discussions, Zottmann et al. [
      • Zottmann J.M.
      • Horrer A.
      • Chouchane A.
      • Huber J.
      • Heuser S.
      • Iwaki L.
      • Kowalski C.
      • Gartmeier M.
      • Berberat P.O.
      • Fischer M.R.
      • Weidenbusch M.
      Isn’t here just there without a “t” - to what extent can digital Clinical Case Discussions compensate for the absence of face-to-face teaching?.
      ] formally trained selective students in didactics of higher education encouraging fellow students during virtual teachings. At a general practice program, rural family physician preceptors led online education sessions on rural hospice and end-of-life care, obstetrical services and maternity care, approaches to opioid use disorder and medication-assisted treatment, and COVID-19 rural disaster preparedness and response [
      • Boulger J.G.
      • Onello E.
      Transforming rural family medicine curriculum from experiential to virtual: a response to COVID-19 limitations.
      ].

      3.4 Onsite clinical education

      Whilst onsite modified clinical clerkships continued in parts of the world [
      • Cowley S.
      • White G.
      Healthcare support worker assistantships should form a mandatory part of medical school curricula: a perspective from UK medical students.
      ,
      • Halbert J.A.
      • Jones A.
      • Ramsey L.P.
      Clinical placements for medical students in the time of COVID-19.
      ,
      • Lavender D.M.
      • Dekker A.P.
      • Tambe A.A.
      Rising to the challenge: medical students as Doctors’ Assistants; an evaluation of a new clinical role.
      ,
      • Lee Y.M.
      • Park K.D.
      • Seo J.H.
      New paradigm of pediatric clinical clerkship during the epidemic of COVID-19.
      ,
      • Stout R.C.
      • Roberts S.
      • Maxwell-Scott H.
      • Gothard P.
      Necessity is the mother of invention: how the COVID-19 pandemic could change medical student placements for the better.
      ], in others it was combined with online teaching [
      • Shah N.G.
      • Patel D.M.
      • Retener N.F.
      • Dittmar P.C.
      • Lacap C.
      • Thom K.A.
      • Martinez J.
      Beginning a new medical school curriculum amidst a global pandemic.
      ,
      • Adeleke O.A.
      • Cawe B.
      • Yogeswaran P.
      Opportunity for change: undergraduate training in family medicine.
      ,
      • Kasai H.
      • Shikino K.
      • Saito G.
      • Tsukamoto T.
      • Takahashi Y.
      • Kuriyama A.
      • Tanaka K.
      • Onodera M.
      • Yokoh H.
      • Tatusmi K.
      • Yoshino I.
      • Ikusaka M.
      • Sakao S.
      • Ito S.
      Alternative approaches for clinical clerkship during the COVID-19 pandemic: online simulated clinical practice for inpatients and outpatients-A mixed method.
      ]. Thomas von Lengerke et al. [
      • von Lengerke T.
      • Afshar K.
      • Just I.
      • Lange K.
      Classroom teaching with simulated patients during COVID-19: the communication skills course in the second year of the model medical curriculum HannibaL.
      ] described communication skills teaching for preclinical students using simulated patients in a classroom setting under social distancing and infection control guidelines. Lee et al. [
      • Lee Y.M.
      • Park K.D.
      • Seo J.H.
      New paradigm of pediatric clinical clerkship during the epidemic of COVID-19.
      ] reported a modified paediatric clerkship in response to reduced patient volume and parents’ reluctancy to be seen by medical students. The University College London infectious diseases team [
      • Stout R.C.
      • Roberts S.
      • Maxwell-Scott H.
      • Gothard P.
      Necessity is the mother of invention: how the COVID-19 pandemic could change medical student placements for the better.
      ] trialled an 8-week ‘COVID-19 apprenticeship’ for the graduating students to work as Doctors’ Assistants or Healthcare support worker assistants. The Doctors’ Assistant program was also positively reported by Lavender et al. [
      • Lavender D.M.
      • Dekker A.P.
      • Tambe A.A.
      Rising to the challenge: medical students as Doctors’ Assistants; an evaluation of a new clinical role.
      ] and Cowley and White [
      • Cowley S.
      • White G.
      Healthcare support worker assistantships should form a mandatory part of medical school curricula: a perspective from UK medical students.
      ] who reported the assistantships to form part of the mandatory medical school as successfully piloted in the UK.

      4. Discussion

      Authors of this scoping review aimed to provide practical information to help teachers effectively maintain clinical attachment programs for medical students when patient contact or clinical attachment become restricted due to public health crises. Our research has amalgamated knowledge on assorted online and onsite methods of clinical teaching over various delivery platforms adding to the body of evidence from previous reviews [
      • Gordon M.
      • Patricio M.
      • Horne L.
      • Muston A.
      • Alston S.R.
      • Pammi M.
      • Thammasitboon S.
      • Park S.
      • Pawlikowska T.
      • Rees E.L.
      • Doyle A.J.
      • Daniel M.
      Developments in medical education in response to the COVID-19 pandemic: a rapid BEME systematic review: BEME Guide No. 63.
      ,
      • Daniel M.
      • Gordon M.
      • Patricio M.
      • Hider A.
      • Pawlik C.
      • Bhagdev R.
      • Ahmad S.
      • Alston S.
      • Park S.
      • Pawlikowska T.
      • Rees E.
      • Doyle A.J.
      • Pammi M.
      • Thammasitboon S.
      • Haas M.
      • Peterson W.
      • Lew M.
      • Khamees D.
      • Spadafore M.
      • Clarke N.
      • Stojan J.
      An update on developments in medical education in response to the COVID-19 pandemic: a BEME scoping review: BEME Guide No. 64.
      ].
      COVID-19 has been the spark that accelerated the implementation of already existing technology in medicine. Students being excluded from the clinical space led to many novel ideas from clinical teachers who used the available technology to facilitate real patient contact in the ward or outpatient setting [
      • Furlan R.
      • Gatti M.
      • Menè R.
      • Shiffer D.
      • Marchiori C.
      • Levra A.G.
      • Saturnino V.
      • Brunetta E.
      • Dipaola F.
      A natural language processing-based virtual patient simulator and intelligent tutoring system for the clinical diagnostic process: simulator development and case study.
      ,
      • Torres A.
      • Domańska-Glonek E.
      • Dzikowski W.
      • Korulczyk J.
      • Torres K.
      Transition to online is possible: solution for simulation-based teaching during the COVID-19 pandemic.
      ,
      • Halbert J.A.
      • Jones A.
      • Ramsey L.P.
      Clinical placements for medical students in the time of COVID-19.
      ,
      • Lee Y.M.
      • Park K.D.
      • Seo J.H.
      New paradigm of pediatric clinical clerkship during the epidemic of COVID-19.
      ,
      • Stout R.C.
      • Roberts S.
      • Maxwell-Scott H.
      • Gothard P.
      Necessity is the mother of invention: how the COVID-19 pandemic could change medical student placements for the better.
      ,
      • Adeleke O.A.
      • Cawe B.
      • Yogeswaran P.
      Opportunity for change: undergraduate training in family medicine.
      ,
      • Sideris M.
      • Emin E.I.
      • Hanrahan J.G.
      • Odejinmi F.
      • Mallick R.
      • Nicolaides M.
      • Velmahos G.
      • Athanasiou T.
      • Papalois V.
      • Papalois A.
      ABC of surgical teaching: time to consider a global blueprint for holistic education.
      ]. Even without real patients, the passion of clinical teachers has led them to become simulated patient themselves [
      • Schleicher I.
      • Davids L.
      • Latta N.
      • Kreiß A.F.
      • Kreuder J.
      Training of physical examination techniques in video conferences.
      ,
      • Jiang Z.
      • Wu H.
      • Cheng H.
      • Wang W.
      • Xie A.A.
      • Fitzgerald S.R.
      Twelve tips for teaching medical students online under COVID-19.
      ] and taught using clinical case scenarios allowing access to real patient imaging and EMR [
      • Weber A.M.
      • Dua A.
      • Chang K.
      • Jupalli H.
      • Rizwan F.
      • Chouthai A.
      • Chen C.
      An outpatient telehealth elective for displaced clinical learners during the COVID-19 pandemic.
      ,
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ]. Albeit fewer in number, there were attempts at teaching clinical skills such as suturing, demonstrating that with advance preparations, basic technology and willingness, such education was possible over online platforms.
      We identified telemedicine as an area of additional publication from previous reviews. Despite the exponential growth in telemedicine in the last decade, its enactment has been lukewarm until social distancing rules created the opportunity for its expansion in medical student education [
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ]. Iancu et al. [
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ] highlighted telemedicine education as an important aspect of future medical student training, especially in augmenting traditional in-person clinical experiences. Telemedicine engaged students and patients in diverse clinical settings providing a platform to teach wide range of clinical skills including clinical reasoning, professionalism, and communication skills during a pandemic [
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ,
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ] with high satisfaction levels [
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ,
      • Sukumar S.
      • Zakaria A.
      • Lai C.J.
      • Sakumoto M.
      • Khanna R.
      • Choi N.
      Designing and implementing a novel virtual rounds curriculum for medical students’ internal medicine clerkship during the COVID-19 pandemic.
      ]. The publications reporting clinical teaching via telemedicine during the COVID-19 could serve as a scalable model for future educational programs to be incorporated into the medical student curricula [
      • Peterseim C.
      • Watson K.H.
      Family medicine telehealth clinic with medical students.
      ] and expanded into outreach programs, especially in underserved rural communities [
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ].
      Although the papers showed that most clinical competencies could be learned online or in the virtual setting, concerns as per their effectiveness on clinical skills learning are abound. There is also a need for further outcome data collection in regards to the benefits or adverse effects of the new approaches in clinical teaching as our review has shown that reported educational outcomes stagnated at Kirkpatrick level 1 assessing only participants’ reactions or satisfaction to the educational programs.

      4.1 Limitations

      Our scoping review confined peer reviewed published papers in English, but grey literatures or conference proceedings were not included. These restrictions may affect the whole picture of mapping clinical teaching adaptations for medical students due to COVID-19, despite the widespread educational developments attempted to counteract the pandemic disruption across the globe. Evidence for substituting or effectively teaching physical examination online or virtual platforms could not be identified.

      4.2 Strengths

      Our analysis included papers up to March 2021 filling the gap in the literature and updating previous published reviews with the focus on clinical teaching for medical students. We have especially updated clinical educational developments in telemedicine, an area highlighted in a previous scoping review to be in urgent need for further research and development.

      4.3 Conclusion

      The new educational developments brought by the pandemic are still fraught with challenges and there is still lack of evidence in their educational effectiveness. However, this scoping review updated the educational strategies which could be applied by clinical educators in their practice to effectively maintain clinical attachment programs for medical students amidst public health crises. In particular, the increase in telemedicine related publications were remarkable, which may serve as a scalable model for future educational programs to be incorporated into the medical student curricula.

      Conflict of interest

      The authors declare that they have no conflict of interest.

      Funding

      There are no funding sources to declare.

      CRediT authorship contribution statement

      Hyunmi Park: Methodology, Validation, Formal analysis, Data curation, Visualization, Writing - original draft, Writing - review & editing. Sunhee Shim: Validation, Data curation, Formal analysis, Visualization, Writing - review & editing. Young-Mee Lee: Conceptualization, Methodology, Validation, Investigation, Data curation, Writing - original draft, Writing - review & editing, Supervision, Project administration.

      Appendix A. Search strategy algorithm

      (COVID-19[tw] OR COVID19[tw] OR severe acute respiratory syndrome coronavirus 2[tw] OR SARS-CoV-2[tw] OR coronavirus disease 2019[tw] OR novel coronavirus[tw] OR 2019-nCoV[tw] OR 2019nCoV[tw] OR coronavirus 2019[tw] OR SARS-CoV2[tw] OR SARS coronavirus 2[tw] OR corona virus disease 2019[tw] OR COVID-2019[tw] OR novel corona virus[tw] OR COVID2019[tw] OR novel 2019 coronavirus[tw] OR nCoV 2019[tw] OR SARS-CoV-19[tw] OR nCoV2019[tw] OR corona virus 2019[tw] OR HCoV-19[tw] OR NCOVID-19[tw] OR 2019 new coronavirus[tw] OR human coronavirus 2019[tw]) AND
      Education, Medical[mh:noexp] OR Clinical Competence[mh] OR (medical[tiab] OR clinical[tiab] OR preclinical[tiab]) AND (education*[tiab] OR curricula[tiab] OR curriculum[tiab] OR program*[tiab] OR teach*[tiab] OR train*[tiab] OR learn*[tiab] OR skill*[tiab] OR competenc*[tiab]) AND undergraduate*[tiab] OR (college*[tiab] OR universit*[tiab] OR school*[tiab]) AND student*[tiab]
      NOT: (Education, Medical, Graduate[mh] OR Education, Medical, Continuing[mh] OR postgraduate*[tiab] OR residency[tiab] OR resident[tiab] OR residents[tiab] OR fellow[tiab] OR fellows[tiab] OR fellowship[tiab] OR specialt*[tiab] OR anatomy[tiab] OR lecture*[tiab]).

      Appendix B. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist

      Tabled 1
      SectionItemPRISMA-ScR checklist itemReported on page #
      Title
       Title1Identify the report as a scoping review.1
      Abstract
       Structured summary2Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.1
      Introduction
       Rationale3Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.2
       Objectives4Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.2
      Methods
       Protocol and registration5Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.3
       Eligibility criteria6Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.4
       Information sources7Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.4
       Search8Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.24
       Selection of sources of evidence9State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.4
       Data charting process10Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.4
       Data items11List and define all variables for which data were sought and any assumptions and simplifications made.5
       Critical appraisal of individual sources of evidence12If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).5
       Synthesis of results13Describe the methods of handling and summarizing the data that were charted.5
      Results
       Selection of sources of evidence14Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.5
       Characteristics of sources of evidence15For each source of evidence, present characteristics for which data were charted and provide the citations.5
       Critical appraisal within sources of evidence16If done, present data on critical appraisal of included sources of evidence (see item 12).5−10
       Results of individual sources of evidence17For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.5−10
       Synthesis of results18Summarize and/or present the charting results as they relate to the review questions and objectives.5−10
      Discussion
       Summary of evidence19Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.10
       Limitations20Discuss the limitations of the scoping review process.12
       Conclusions21Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.12
      Funding
       Funding22Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.1
      From: Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMAScR): Checklist and Explanation. Ann Intern Med. 2018;169:467–473. doi: https://doi.org/10.7326/M18-0850.

      Appendix C. Protocol for a Scoping Review on clinical education development for medical students during COVID-19

       Stage 1: Identifying the research question

      Through consultation with the research team (HP SHS YML) and editor in chief of the Primary Care Diabetes journal, the overall main research question developed is defined as: ‘What are the clinical education development for medical students during COVID-19.’

       Stage 2: Identifying relevant studies

      Identification of studies relevant to this review will be achieved by searching electronic databases of the published literature which will include: PubMed, Embase, Scopus, Web of Science (including ESCI) and ERIC. (The proposed search strategy is shown in Appendix A) We will also hand search all reference lists of included studies to identify additional studies of relevance. Search terms will be determined with input from the research team. The search strategy will be developed by an experienced research librarian and co-author (HP), and will be revised pending input from stakeholders. Database and other searches will combine terms from COVID-19 and Medical Education. Terms will be searched as both keywords in the title and/or abstract and subject headings (eg, MeSH, EMTREE) as appropriate. Language was limited to English and date limits from 1st March 2020 to 1st March 2021 were applied.

       Stage 3: Study selection

      The review process will consist of two levels of screening: (1) a title and abstract review and (2) full-text review. For the first level of screening, two investigators will independently screen the title and abstract of all retrieved citations for inclusion against a set of minimum inclusion criteria. Any articles that are deemed relevant by either or both of the reviewers will be included in the full-text review. In the second step, the two investigators will then each independently assess the full-text articles to determine if they meet the inclusion/exclusion criteria. To determine inter-rater agreement, Cohen’s κ statistic will be calculated at both the title and abstract review stage and at the full article review stage. Any discordant full-text articles will be reviewed a second time and further disagreements about study eligibility at the full-text review stage will be resolved through discussion with a third investigator until full consensus is obtained. Relevant studies will be included if they describe the concept of Medical Education during COVID-19.
      Studies included can be on any of (a) development; (b) implementation; (c) evaluation; or (d) comparative validation of medical education interventions. Any type of study design (eg, randomised control trials, case–control study, prospective or retrospective cohort study, quasi-experimental, qualitative) will be included. Studies will be excluded if they do not describe an intervention but is a personal opinion only.

       Stage 4: Data collection

      Study characteristics to be extracted will include, but not be limited to: Author, Title, Country, Year, Pre-clinical/clinical, University/Community, Specialty, Online / onsite, Patient type, Teaching methods, Clinical skills, Participant number, Study design, Kirkpatrick level, Data collection methods, Conclusion/suggestion, Limitations and Strengths. This form will be reviewed by the research team and pretested by all reviewers before implementation to ensure that the form is capturing the information accurately. Data abstraction will be conducted in duplicate with two reviewers independently extracting data from all included studies. To ensure accurate data collection, each reviewer’s independent abstracted data will be compared and any discrepancies will be further discussed to ensure consistency between the reviewers. The data will be compiled in a single literature review software program, Mendeley, and then downloaded into a single excel spreadsheet in Microsoft Excel software for validation and coding.

       Stage 5: Data summary and synthesis of results

      Since a scoping review can be used to map the concepts underpinning a research area and the main sources and types of evidence available, the aggregated findings provide an overview of the research rather than an assessment of the quality of individual studies.

      Appendix D. Table charting all the key information for all 57 papers

      Tabled 1
      AuthorTitleJournalCountryYearClinical/pre-clinicalUniv/CommSpecialtyOnline/onsitePatient typeTeaching methodsKPType of publicationStudy design & data collection
      Adeleke et al. [
      • Adeleke O.A.
      • Cawe B.
      • Yogeswaran P.
      Opportunity for change: undergraduate training in family medicine.
      ]
      Opportunity for change: Undergraduate training in family medicineS Afr Fam PractZA2020ClinicalUnivMSBothRealOnline self-directed learning, ward roundsNAOpinionNA
      Afonso et al. [
      • Afonso N.
      • Kelekar A.
      • Alangaden A.
      “I Have a Cough”: an interactive virtual respiratory case-based module.
      ]
      "I Have a Cough": An Interactive Virtual Respiratory Case-Based ModuleMedEdPORTALUS2020Pre-clinicalUnivMedOnlineStand /simDemonstration of percussion and auscultation, SP patient encounter SP for communication skills and “web-side” manner, faculty feedback, clinical reasoning and case discussion sessionNAOriginal articleNA
      Bhatia et al. [
      • Bhatia R.K.
      • Cooley D.
      • Collins P.B.
      • Caudle J.
      • Coren J.
      Transforming a clerkship with telemedicine.
      ]
      Transforming a clerkship with telemedicineJ Am Osteopath AssocUS2021ClinicalUnivFMOnline™RealClinical case discussion, clinical skill teaching, lecture, patient interviewNAReviewNA
      Biermann et al. [
      • Biermann M.
      • Kanoun S.
      • Davidsen T.
      • Gray R.
      An open source solution for “Hands-on” teaching of PET/CT to medical students under the COVID-19 pandemic.
      ]
      An Open Source Solution for “Hands-on” teaching of PET/CTNuklearmedizinNO2020ClinicalUnivMedOnlineClinical scenOnline software for PET/CT teaching, e-lectures, diagnostic nuclear medicine viewing system, face to face seminar via Zoom1Original articleCross-sectional; survey
      Boulger and Onello [
      • Boulger J.G.
      • Onello E.
      Transforming rural family medicine curriculum from experiential to virtual: a response to COVID-19 limitations.
      ]
      Transforming Rural Family Medicine Curriculum From Experiential to Virtual: A Response to COVID-19 LimitationsPRiMERUS2020ClinicalComFMOnlineClinical scenCase discussion, journal presentation, panel discussion, lecture1Original articleCross-sectional; survey
      Cain et al. [
      • Cain R.
      • Shafer Klink D.
      • Yunus S.
      Telemedicine implementation in family medicine: undergraduate clerkship during COVID-19 pandemic.
      ]
      Telemedicine implementation in family medicine: Undergraduate clerkship during COVID-19 pandemicMed EducUS2020ClinicalComFMOnline™RealStudents able to document the telemedicine clinic visit in patients' EMR and attested by attending1LetterCross-sectional; survey
      Carson et al. [
      • Carson S.
      • Peraza L.R.
      • Pucci M.
      • Huynh J.
      Student hotline improves remote clinical skills and access to rural care.
      ]
      Student Hotline Improves Remote Clinical Skills and Access to Rural CarePRiMERUS2020BothComFMOnline™RealOnline education sessions on rural hospice, end-of-life care, obstetrical services and maternity care. Education on COVID-19 rural disaster preparedness and response.1Original articleCross-sectional; survey
      Co and Chu [
      • Co M.
      • Chu K.-M.
      Distant surgical teaching during COVID-19 – a pilot study on final year medical students.
      ]
      Distant surgical teaching during COVID-19 - A pilot study on final year medical studentsSurg PractHK2020ClinicalUnivSurgOnlineStand /simSuture skills1Original articleCross-sectional; survey
      Coffey et al. [
      • Coffey C.S.
      • MacDonald B.V.
      • Shahrvini B.
      • Baxter S.L.
      • Lander L.
      Student perspectives on remote medical education in clinical core clerkships during the COVID-19 pandemic.
      ]
      Student Perspectives on Remote Medical Education in Clinical Core Clerkships During the COVID-19 PandemicMed Sci EducUS2020ClinicalUnivMSOnline™RealSynchronous case conference, dictating lecture, evaluation & progress review, telehealth experience1Original articleCross-sectional; survey
      Cowley and White [
      • Cowley S.
      • White G.
      Healthcare support worker assistantships should form a mandatory part of medical school curricula: a perspective from UK medical students.
      ]
      Healthcare support worker assistantships should form a mandatory part of medical school curricula: A perspective from UK medical studentsMed TeachGB2020ClinicalUnivMedOnsiteRealWorking as Healthcare support worker assistantsNAOpinionNA
      Darnton et al. [
      • Darnton R.
      • Lopez T.
      • Anil M.
      • Ferdinand J.
      • Jenkins M.
      Medical students consulting from home: a qualitative evaluation of a tool for maintaining student exposure to patients during lockdown.
      ]
      Medical students consulting from home: A qualitative evaluation of a tool for maintaining student exposure to patients during lockdownMed TeachGB2020Pre-clinicalComFMOnline™RealClinical communication and exam skills consulted from own home whilst supervised by primary care physician in three-way telemedicine clinic1Original articleQualitative
      Dawoud et al. [
      • Dawoud R.A.
      • Philbrick B.
      • McMahon J.T.
      • Douglas J.M.
      • Bhatia N.
      • Faraj R.
      • Greven A.
      • Buster B.
      • Rindler R.S.
      • Laxpati N.G.
      • Gary M.F.
      Letter to the Editor “Virtual Neurosurgery Clerkship for Medical Students”.
      ]
      Letter to the Editor “Virtual Neurosurgery Clerkship for Medical Students”World NeurosurgUS2020ClinicalUnivSurgOnline™RealCurated surgical video content on select neurosurgical procedures, Students joined telemedicine clinics observing and participatingNALetterNA
      De Ponti et al. [
      • De Ponti R.
      • Marazzato J.
      • Maresca A.M.
      • Rovera F.
      • Carcano G.
      • Ferrario M.M.
      Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students’ perception.
      ]
      Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students' perceptionBMC Med EducIT2020ClinicalUnivMedOnlineVirtual patientCase based scenarios1Original articleCross-sectional; survey
      DeVaro et al. [
      • DeVaro S.N.
      • Uner O.E.
      • Khalifa Y.M.
      • Graubart E.B.
      Ophthalmology education in COVID-19: a remote elective for medical students.
      ]
      Ophthalmology Education in COVID-19: A Remote Elective for Medical StudentsJ Acad OphthalmolUS2020ClinicalUnivMedOnline™RealOnline self-directed learning, virtual patients, telemedicine clinics, case-based discussions2aOriginal articleMixed method; survey; knowledge test
      Dong et al. [
      • Dong A.
      • Simpson F.
      • Qu W.
      • Javidfar J.
      Clinical medical education: cardiothoracic surgery in the era of COVID-19.
      ]
      Clinical medical education: Cardiothoracic surgery in the era of COVID-19J Card SurgUS2021ClinicalUnivSurgOnlineClinical scenSmall group teaching discussions after lecturesNALetterNA
      Elengickal et al. [
      • Elengickal J.A.
      • Delgado A.M.
      • Jain S.P.
      • Diller E.R.
      • Valli C.E.
      • Dhillon K.K.
      • Lee H.K.
      • Baskar R.
      • MacArthur R.D.
      Adapting education at the medical college of georgia at Augusta university in response to the COVID-19 pandemic: the pandemic medicine elective.
      ]
      Adapting Education at the Medical College of Georgia at Augusta University in Response to the COVID-19 Pandemic: the Pandemic Medicine ElectiveMed Sci EducUS2021Pre-clinicalUnivMSOnlineClinical scenLecture, Service learning, online community-based projects1Short reportCross-sectional; survey
      Furlan et al. [
      • Furlan R.
      • Gatti M.
      • Menè R.
      • Shiffer D.
      • Marchiori C.
      • Levra A.G.
      • Saturnino V.
      • Brunetta E.
      • Dipaola F.
      A natural language processing-based virtual patient simulator and intelligent tutoring system for the clinical diagnostic process: simulator development and case study.
      ]
      A Natural Language Processing–Based Virtual Patient Simulator and Intelligent Tutoring System for the Clinical Diagnostic ProcessJMIR Med InformIT2021BothUnivMSOnlineVirtual patientComputer programsimulating real-life clinical scenarios using Natural language processing2bOriginal articlePre/post comparision; perf test(MCQ)
      Geha and Dhaliwal [
      • Geha R.
      • Dhaliwal G.
      Pilot virtual clerkship curriculum during a pandemic: podcasts, peers, and problem-solving.
      ]
      Pilot virtual clerkship curriculum during the COVID-19 pandemic: Podcasts, peers and problem-solvingMed EducUS2020ClinicalUnivMedOnlineClinical scenInteractive videoconferences, resident-level case conferences, conversation-style medical podcasts1Short reportCross-sectional; survey
      Halbert et al. [
      • Halbert J.A.
      • Jones A.
      • Ramsey L.P.
      Clinical placements for medical students in the time of COVID-19.
      ]
      Clinical placements for medical students in the time of COVID-19Med J AustAU2020ClinicalUnivMSOnsiteRealClinical clerkship was continued for the final 2 yearsNAOpinionNA
      Hayes et al. [
      • Hayes J.R.
      • Johnston B.
      • Lundh R.
      Building a successful, socially-distanced family medicine clerkship in the COVID crisis.
      ]
      Building a Successful, Socially-Distanced Family Medicine Clerkship in the COVID CrisisPRiMERUS2020ClinicalUnivFMOnline™RealTelemedicine family medicine clerkship clinical encounters. Illness script assignments reviewed by attending & different disease templates shared with students via online drive1Short reportCross-sectional; survey
      Ho et al. [
      • Ho J.
      • Susser P.
      • Christian C.
      • DeLisser H.
      • Scott M.J.
      • Pauls L.A.
      • Huffenberger A.M.
      • Hanson 3rd, C.W.
      • Chandler J.M.
      • Fleisher L.A.
      • Laudanski K.
      Developing the eMedical student (eMS)-A pilot project integrating medical students into the Tele-ICU during the COVID-19 pandemic and beyond.
      ]
      Developing the eMedical Student (eMS)-A Pilot Project Integrating Medical Students into the Tele-ICU during the COVID-19 Pandemic and beyondHealthcareUS2021ClinicalUnivMedOnline™RealStudent shifts on remote tele-ICU patient care, performing real interventions (medication, ventilator adjustment, lab recheck) as part of interdisciplinary care.1, 2bOriginal articleCross-sectional; survey
      Iancu et al. [
      • Iancu A.M.
      • Kemp M.T.
      • Gribbin W.
      • Liesman D.R.
      • Nevarez J.
      • Pinsky A.
      • Pumiglia L.
      • Andino J.J.
      • Alam H.B.
      • Stojan J.N.
      • Walford E.
      • Schiller J.H.
      Twelve tips for the integration of medical students into telemedicine visits.
      ]
      Twelve tips for the integration of medical students into telemedicine visitsMed TeachUS2020ClinicalUnivMSOnline™Real12 tips: set stage, lay out expectations, assess & provide software, hardware & workflow to all. Pilot system, share information and educate faculty & students, collect feedback.NAPerspectiveNA
      Jiang et al. [
      • Jiang Z.
      • Wu H.
      • Cheng H.
      • Wang W.
      • Xie A.A.
      • Fitzgerald S.R.
      Twelve tips for teaching medical students online under COVID-19.
      ]
      Twelve tips for teaching medical students online under COVID-19Med EducCN2021ClinicalUnivMSOnlineStand /simClinical case discussion, clinical skill teaching. Patient interviewNAReviewNA
      Kaliyadan et al. [
      • Kaliyadan F.
      • ElZorkany K.
      • Al Wadani F.
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      ]
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      Countries: AT: Austria; AU: Australia; CN: China; DE: Germany; GB: United Kingdom; HK: Hong Kong; IE: Ireland; IN: India; IR: Iran; IT: Italy; JP: Japan; KR: Korea; NO: Norway; NZ: New Zealand; PL: Poland; SA: Saudi Arabia; US: United States of America; ZA: South Africa.
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