Escobar, Ana Maria de Ulhôa

Gomes, Filumena Maria da Silva

Grisi, Sandra Josefina Ferraz Ellero

Tannuri, Ana Cristina Aoun

Tannuri, Uenis

English

Cadernos Espinosanos (E-Journal)

Lessons learned about teaching and medical care atthe Instituto da Criança e do Adolescente do Hospitaldas Clı́nicas da Faculdade de Medicina da USP duringthe COVID-19 pandemicAna Cristina Aoun Tannuri0000-0000-0000-0000 , Ana Maria de Ulhôa Escobar, Filumena Maria da Silva Gomes,Uenis Tannuri0000-0000-0000-0000 ,* Sandra Josefina Ferraz Ellero GrisiDepartamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, SP, BR.Tannuri ACA, Escobar AMU, Gomes FMS, Tannuri U, Grisi SJFE. Lessons learned about teaching and medical care at the Instituto da Criança e doAdolescente do Hospital das Clı́nicas da Faculdade de Medicina da USP during the COVID-19 pandemic. Clinics (Sao Paulo). 2021;76:e3579*Corresponding author. E-mail: uenist@usp.brThe restrictive measures imposed on the world to controlthe coronavirus disease 2019 (COVID-19) pandemic had asignificant impact on all spheres of society (economic, social,and behavioral). In particular, education had to undergo aseries of adaptations in an attempt to reduce the lossesarising from the lack of contact and face-to-face relationships.Never has it been so difficult to practice this famous quote byMalcolm Knowles: ‘‘We will learn no matter what! Learningis as natural as rest or play. With or without books, inspiringtrainers, or classrooms, we will manage to learn’’ (1). Fromelementary to graduate school, different forms of distantinteraction had to be implemented on an emergency basis.The first resource used for teaching at all levels duringthe pandemic was online teaching, the challenges of whichimpact both those who teach and those who learn. Teachersoften do not adequately deal with the diverse meetingplatforms available, particularly those teachers who have tolearn how to use such technology in adulthood and adapt tothe routine of administering online tasks. Simultaneously,students also struggle with their own issues, such assustaining attention for a long period, absorbing the contentdelivered in a new fashion, and spending multiple hours infront of the computer. Technical challenges such as problemswith audio and video, downloading or streaming errors,login problems, poor internet quality, and security issuesmust be considered. However, it is also known that onlineteaching encourages student autonomy and protagonism.Medical education in undergraduate and graduate pro-grams deserves special attention. The unique integrationof the theoretical framework with the practice of anamnesisand physical examination of the patient, associated with thediversity of presentations of each clinical case, makes thepractice of medicine, as well as its teaching, particularlycomplex. Thus, one of the challenges posed by the pandemicwas the need to maintain the training of students andphysicians in this context.The medical course curriculum of Faculdade de Medicinada Universidade de São Paulo (FMUSP) underwent exten-sive restructuring seven years ago, aiming at the integrationand better contextualization of the taught subjects. Inpediatric teaching, interdepartmental classes were imple-mented in the form of curricular units such as Life Cycle I, II,and III, and Integration of Major Pediatric Diseases andSituations, and no longer in departmental subjects. Theore-tical classes also incorporated practicals in the teaching ofclinical pediatrics. The course exams were in person, butonline, with laptops in the classroom. Due to this recentchange, adaptation to the online teaching environment waseven more difficult as the institution was still transitioningto this new curriculum. A good solution was the interactionof two main formats of activities: asynchronous distanceeducation, such as recorded videos and podcasts, andsynchronous (live) distance education (SDE), such as videoconferences and virtual classrooms. The undeniable advan-tages of recorded classes are noticeable for both the facultyand student body. For the former, there are considerablesavings in time and resources because once the lesson isrecorded, it can be made available several times to differentclasses without prejudice to its content. For the students, thepossibility of watching the recorded lessons more than once,pausing whenever necessary, and accessing the lessons at themost convenient time are important advantages. However,there is a consensus that such activities should not last morethan 40 to 50 minutes.The SDE format, in which teachers and students connectat the same time on the virtual meeting platform, allows forgreater interaction, student participation, and elaborationof questions and answers. Such activities, mainly discus-sions of clinical cases in small groups, allow the strengthen-ing of the knowledge previously learned in recorded classesas well as the exercising of clinical reasoning and clarifica-tion of any doubts. Such meetings also allow teachers tocontrol student attendance and performance in both thepre- and posttests.DOI: 10.6061/clinics/2021/e3579Copyright & 2021 CLINICS – This is an Open Access article distributed under theterms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in anymedium or format, provided the original work is properly cited.No potential conflict of interest was reported.1COMMENTSAn additional challenge was the application of tests orother forms of measuring skills and acquired knowledge.Different mechanisms were developed to achieve a relativelyfair way to assess students’ learning, such as blocking otherwebsites during tests, defining a specific duration forcompletion, and designing questions based on clinicalreasoning rather than mere content memorization.Practical teaching during the hospital internship for the 5thand 6th year students became unviable in the first months ofthe pandemic, in which Hospital das Clínicas was comple-tely restructured for the care of patients with COVID-19 fromall over the state. However, the impact of the pandemic onpediatrics, and consequently, in the teaching of students, wassomewhat different. Symptoms of SARS-CoV-2 infection inchildren are mostly mild (2). In addition, isolation measuresalso caused a significant decrease in the incidence ofcontagious respiratory diseases, which are highly prevalentin the pediatric age group, especially during fall and winter.Thus, there was a drastic decrease in Emergency Room visitsand hospital admissions for children.Despite this, the Pediatric Department at the HospitalUniversitário (HU) and the Instituto da Criança (ICr) madesignificant efforts to overcome possible gaps in studentlearning through additional activities and online discussions.Students were vaccinated against SARS-CoV-2 and per-formed internships in emergency rooms and infirmaries,with rotations in small groups.Theoretical classes were performed remotely, synchro-nously, and were available in the classroom. Situationsinvolving telesimulation were implemented, and a definedperiod was given for students to solve tasks. Team-basedlearning (TBL) is a structured form of small-group learningthat emphasizes student preparation out of class and theapplication of knowledge in class. Students were organizedstrategically into diverse teams of five to seven that worktogether throughout the class. Platforms that allow the mainstudent group to be broken down into smaller groups weresuccessfully used to enable online TBL. Even essentiallypractical activities such as Objective Structured ClinicalExamination could be transferred to the virtual environment.With the decrease in the number of consultations in theEmergency Room (mainly in HU), and in the number ofhospitalized children, the skills laboratories at the HU andICr started to be used.However, the internships in neonatology at HU and ICr(which include emergency care and rear wards) could bemaintained with excellent structure and the same dutyschedule as both the number of births in HU and theemergency care of children in ICr (where most patientspresent comorbidities) could be maintained despite thepandemic.In ICr, professionals were shifted, and the physical spacewas readjusted to care for children suspected andunsuspected of COVID-19 infection. Thus, screening anddifferential input flows, collection structure, and beds(infirmary and intensive care unit) were installed forchildren with or without flu symptoms. All newbornsfrom the neonatal intensive care unit of the CentralInstitute as well as the equipment and professionals ofthis unit were transferred to the HU. The tele-assistancesystem was implemented to re-evaluate patients afterdischarge from the Emergency Room and in all specialtyclinics (more than a thousand teleconsultations have beenconducted since then).During 2020, this restructuring allowed 145,391 outpatientconsultations, 8,041 Emergency Room visits, and 6,817hospitalizations to be performed at the ICr.The pediatric surgery and liver transplantation divisionsare characterized by a diversity of pathologies, ranging fromlow complexity cases to major surgeries, such as correctionof severe congenital digestive and respiratory diseases,resections of large tumors, and a robust liver transplantationprogram. Initially, it was decided to suspend all electiveprocedures, including liver transplants due to chronicdiseases. However, the treatment of a large number ofchildren with complicated surgical and oncological condi-tions was considered critical and therefore could not beinterrupted.After the first two months of the pandemic, with a betterunderstanding of the transmission route and with thepossibility of a more adequate control of COVID-19, wereturned to performing liver transplantation with cadavericdonors and semi-elective surgeries. We then returned toperforming living donor liver transplants, strictly followingall safety protocols to avoid contagion of the recipient and,above all, of the living donors. No increased morbidity orcomplications were observed in comparison with previousperiods.In the period between the onset of the pandemic in Brazil(February 2020) and the present time (September 2021), 82liver transplants were performed in the institution, 58 ofwhich were from living related donors and 24 were fromcadaveric donors, with a survival of 76 patients to date(92.7%). There were no cases of COVID-19 in the periopera-tive period, either in living donors or recipients (3).Currently, with vaccinations evolving at a faster pace,there have been glimpses of good prospects. The extensiveclinical observation and the results of some scientific studiesalready allow us to trust the efficacy of vaccines as pro-tecting, if not against contagion, then at least against theprogression to severe forms of the disease, even with theemergence of new variants of viral strains. With this, we canschedule a gradual and conscientious return of didacticactivities in person. Initially, a mixture of distance theoreticalclasses with face-to-face practical activities will be designed,with emphasis on student contact with patients, as well asactivities of an essentially practical nature.Certainly, some of the behavioral and social changesimposed by the pandemic will certainly remain, even whenthe pandemic ceases to exist. Currently, within the scope ofthe FMUSP post-graduation program, qualification examsand thesis defenses are clear examples of how the adaptationto the online learning environment can have lasting positiveimpacts. Such activities fit perfectly in this format and allowmembers of these examining boards, from other cities andstates (even countries), to participate without the financialcost and time required for their travel. The number ofstudents enrolled in online postgraduate courses at thePediatric Department has increased considerably, and thishas increased exchange with the students and faculties ofother disciplines, such as psychology and physical education.In the end, we can also presume that many graduationprograms (including ours) will assume a hybrid aspect,combining ‘‘online’’ activities, such as theoretical classes,with face-to-face practical activities. Even though in-personinteraction is paramount in medical training, the road aheadwill be paved with hybrid formats that include onlineresources.2Teaching and medical careTannuri ACA et al.CLINICS 2021;76:e3579’ REFERENCES1. Knowles MS. The Modern Practice of Adult Education: From Pedagogy toAndragogy. 1980. Englewood Cliffs: Prentice Hall/Cambridge.2. Tannuri U, Tannuri ACA, Cordon MNA, Miyatani HT. Low incidence ofCOVID-19 in children and adolescent post-liver transplant at a LatinAmerican reference center. Clinics (Sao Paulo) 2020;75:e1986. https://doi.org/10.6061/clinics/2020/e19863. Carlotti APCP, de Carvalho WB, Johnston C, Gilio AE, de Sousa MarquesHH, Ferranti JF, et al. Update on the diagnosis and management ofCOVID-19 in pediatric patients. Clinics (Sao Paulo) 2020;75:e2353.https://doi.org/10.6061/clinics/2020/e23533CLINICS 2021;76:e3579 Teaching and medical careTannuri ACA et al.

Lessons learned about teaching and medical care at the Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da USP during the COVID-19 pandemic

https://www.revistas.usp.br/clinics/article/download/213220/195208

Lessons learned about teaching and medical care at the Instituto da Criança e do Adolescente do Hospital das Clínicas da Faculdade de Medicina da USP during the COVID-19 pandemic

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