Number of Citations: 0

Submitted: 5 July 2021
Accepted: 13 September 2021
Published online: 5 April, TAPS 2022, 7(2), 6-16
https://doi.org/10.29060/TAPS.2022-7-2/OA2654

Ming-Jung Ho^1,2, Yu-Che Chang^3,4,5 & Steven L. Kanter⁶

¹Center for Innovations and Leadership in Education, Georgetown University Medical Center (CENTILE), Washington, D.C., United States; ²Department of Family Medicine, Georgetown University School of Medicine, Washington D.C., United States; ³Chang Gung Medical Education Research Centre (CG-MERC), Chang Gung Medical Foundation, Taoyuan, Taiwan; ⁴Chang Gung University College of Medicine, Taoyuan, Taiwan; ⁵Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; ⁶Association of Academic Health Centers, Washington, D.C., United States.

Abstract

Introduction: The COVID-19 pandemic forced medical schools worldwide to transition online. While there are ample reports about medical education adaptations to this crisis, there are limited studies evaluating the impact.

Methods: This study includes a case study of how Taiwanese medical school deans maintained in-person education during the COVID-19 pandemic. Additionally, it demonstrates how SWOT analyses can help medical educators reflect on adaptations during the COVID-19 pandemic and future crises.  This study employed two online surveys and a semi-structured interview regarding curricular adaptations. Eligible participants were deans or associate deans of all medical schools in Taiwan.

Results: Through a SWOT analysis, this study identified Strengths as strong leadership, prior experience with SARS, and ability to promptly adapt curriculum; Weaknesses as lack of faculty confidence in online education, limited numbers of administrative staff, and inability to rapidly add new topics; Opportunities as centralised anti-epidemic policies, inter-institutional collaborations, and educational innovations; and Threats as concerns from parents, patients, and teaching hospitals. It is reported that the quality of education was maintained as students’ evaluations of courses, performances in written exams, clerkship supervisors’ assessments, national OSCE, and national board exams remained comparable to pre-COVID times. Strengths and Opportunities such as strong leadership and centralised anti-epidemic policies can overcome Weaknesses and Threats, such as lack of confidence in online education and familial pressure to suspend hospital-based education.

Conclusion: This study recommends that medical school leaders conduct SWOT analyses as early as possible to plan strategies to continue safe and quality medical education during COVID-19 and future crises.

Keywords:           SWOT Analysis, Adaptation, Medical School, COVID-19, Pandemic, National Survey, Medical Education, Taiwan

Practice Highlights

• Medical school deans in Taiwan documented critical observations made during a global pandemic.
• SWOT analysis can help us reflect on medical education adaptations during the pandemic and crises.
• Strong leadership and centralised anti-epidemic policies can aid in overcoming weaknesses/threats.
• Schools can benefit from using SWOT analyses to plan for continuing education during emergent crises.

Table 1. Characteristics of Survey Schools

^aOne medical school had both 6-year program for high school graduates and 4-year program for college graduates.

Table 2. Themes and quotes of curriculum adaptations

Table 3. SWOT Analysis^b

^b This table is created using the blank SWOT form from Topor et al.²¹

A. Curricular Adaptations

1) Pre-clinical curriculum adaptations:

Taiwanese medical schools rapidly adapted their curricula to comply with government policy on social distancing prohibiting indoor gatherings of more than 100 individuals. Whereas a school with a small student body and sufficient classroom capacity did not have to transition online, a school with a large student body and insufficient classroom capacity moved almost all pre-clinical classes online. Some schools went partially online, converting only lectures with more than 100 students to online learning and capping the number of students in the classroom, with live stream available for those not in the classroom. While schools adapted different modalities for lecture-based courses, all schools made efforts to keep laboratory courses face-to-face. Some schools shared how they adjusted laboratory sessions to maintain social distance, including simultaneously using more lab rooms or holding lab sessions in different time slots.

2) Clinical curriculum adaptations:

In contrast to approaches in the United States suspending clinical rotations in spring semester recommended by AAMC (Association of American Medical Colleges, 2021), all medical schools in Taiwan continued clinical rotations while protecting the safety of students. Several strategies were implemented rapidly: Orientation to clinical rotations articulated pandemic prevention and included online modules required by the hospital. Clinical students were provided with surgical masks. In the emergency room, students were given N95 respirators each day. Exposure to suspected and confirmed COVID-19 cases was avoided for students replacing rotations in specialties with high risk of COVID-19 exposure. To prevent cross infection, inter-institutional and overseas exchange programs were cancelled. Students rotated in only one of the affiliated hospitals. Social distancing is also mentioned in clinical rotation adjustments. Several respondents mentioned that the number of students in outpatient clinics, in classrooms, and in conferences was reduced. One school reported an increase of clinical teachers to meet social distancing demands.

3) Assessment adaptations:

Eight schools replied that they did not change the assessment of students by written examinations in classrooms but arranged empty seats between students to keep social distance and protected students from airborne droplet transmissions by requiring everyone to wear a mask. Some schools decreased the use of written exams in classrooms by substituting reports, reflections, online exams, online presentations, and other approaches. Some evaluations involving hands-on practices were cancelled or replaced by simulation. One school reported that their admission exams included tests in laboratories. To prevent face-to-face transmission of airborne droplets, transparent acrylic partitions were installed on the benches in front of each student.

B. Impact of curricular adaptations

Medical school deans tried to evaluate the impact of curricular adaptions by comparing student performance in the 2020 spring semester with previous years. Most deans reviewed the passing rate of courses and reported no statistical differences. They also reported monitoring students’ performances in national board exams in July and national OSCE clinical skills exam held before graduation. The deans were relieved to see that the national exam scores were comparable to previous years and felt that curricular adaptations didn’t impact student competencies negatively.

C. Strengths

The strengths of Taiwanese medical schools’ responses to COVID-19 can be summarised into three themes: strong leadership, prior experience with SARS, and ability to rapidly adapt the curriculum.

1) Strong leadership: The key strength most Taiwanese deans cited in their medical schools’ response to COVID-19 is the strong leadership in the early deployment of epidemic prevention measures. The guidelines from the Central Epidemic Command Center were implemented on each campus, including requiring students to wear masks, to maintain social distance, to monitor temperature and symptoms of COVID-19, and to quarantine international students in separate dormitory areas. Communication also was highlighted by respondents as manifesting strong leadership. Furthermore, two deans made videos in collaboration with students to promote anti-epidemic measures (Chang Gung University, 2020; Fu Jen Catholic University, 2020).

2) Prior experience with SARS: Another strength most respondents noted was the experience of SARS. When COVID-19 spread to Taiwan, most clinical teachers had experienced SARS and were able to share critical lessons to face new emerging infectious diseases with the younger generation. The experience of SARS also prepared medical educators to deal with professionalism and ethics issues such as distribution of limited medical resources. Many participants mentioned that SARS had a great impact on the medical education system in Taiwan because it exposed the lack of primary care workforce with medical school graduates entering specialty training directly after medical school. After SARS, a postgraduate year program was established with one year of required general medicine training prior to specialty training programs with the goal of producing more physicians competent in general medicine to respond to emergent infectious diseases.

3) Ability to rapidly adapt the curriculum: All schools reported rapid curricular adaptations when spring semester started one or two weeks later than the scheduled time. Different strategies were employed in pre-clinical and clinical curricula to prevent and control the spread of COVID-19 as described in 3.1 curricular adaptation.

D. Weaknesses

The weaknesses of Taiwanese medical schools’ responses to COVID-19 can be summarised into three themes: lack of faculty confidence in online education, limited number of administrative staff, and inability to rapidly add new topics.

1) Lack of faculty confidence in online education: All respondents mentioned online teaching as challenging to teachers. Many voiced concerns about the effectiveness of online learning and found assessment of online learning challenging. Online learning is also considered challenging to students. Some respondents mentioned that online learning requires self-directed learning, which is not a strength of Taiwanese students since didactic teaching and rote memorisation is the norm of the K-12 education system.

2) Limited number of administrative staff: In response to the question about weaknesses of their medical schools’ responses to the COVID-19 pandemic, administrative challenges were mentioned frequently. Although Taiwan did not experience high burdens of COVID-19, all schools were preparing for large-scale outbreaks with frequent scenario planning, describing these planning activities using the military metaphor of “military sand table planning” and “early deployment.”

3) Inability to rapidly add new topics: The pandemic also revealed the need for medical educators to engage in some topics traditionally not articulated in medical curricula. It was challenging to add new topics in the ongoing 2020 spring semester curricula but respondents suggested to add the following topics in the future: infectious disease control, emergent infectious disease, crisis management and communication, public policy and ethical issues related to pandemics such as distribution of medical resources, and government control and restrictions on human rights vs quarantine policy.

E. Opportunities

Taiwanese medical school deans highlighted three opportunities which enabled them to continue to open medical schools during the COVID-19 pandemic: centralised anti-epidemic policies, collaborations among medical schools, and educational innovations.

1) Centralised anti-epidemic policies: Taiwanese deans all reported that the policies from the central government are helpful in their implementation of anti-epidemic measures. Several deans shared the policy guidelines issued by the Ministry of Education with clear guidelines to follow the principles of infection containment. Although each university has the flexibility to decide how to comply with the guidelines, there was external oversight to ensure compliance. For example, when a teaching hospital had an intra-hospital transmission of COVID-19, the medical school had to work with the Central Epidemic Command Center and Ministry of Education in its response.

2) Inter-institutional collaborations: Collaborations among medical schools through the Taiwan Association of Medical Education (TAME) also helped Taiwanese medical school deans to adapt to COVID-19. For instance, the deans worked together at TAME to ensure that final-year students graduated on time. Every year, TAME organises a national OSCE examination required for graduation for final year Taiwanese medical students. Medical schools and teaching hospitals collaborated to administer these exams at OSCE centers in selected teaching hospitals with infection mitigating measures.

3) Educational innovations: All respondents mentioned that the COVID-19 pandemic provided opportunities to engage in innovations in medical education, especially online education.  Online education was quickly implemented in some schools because access to internet is prevalent in Taiwan and they utilised the technology developed before the pandemic. One school reported an innovation using the Interactive Response System (IRS) developed three years ago and is now applied to enhance online teaching amid COVID-19. Another school adapted communication software instead of face-to-face counseling meetings. One school reported using “LINE” (a messaging app widely used in Taiwan) for a group chat for students to reduce student anxiety related to COVID-19. 

F. Threats

Three themes were identified during the COVID-19 pandemic as threats to medical education, but external to medical schools: parental pressure to remove students from clinical settings, decrease in patient volume, and hospital infection control measures limited educational opportunities.

1) Parental pressure to remove students from clinical settings:  Several deans mentioned that students’ parents reached out to them, pressuring them to discontinue clinical rotations. One respondent stated, “Parents are more worried than teachers and students. They are concerned that clinical rotations in the hospitals are risky for students. However, parents accepted our explanation that clinical rotations will not proceed unless there is adequate PPE and infection control measures.”

2) Decrease in patient volume: Another threat commonly mentioned was the decrease in patient volume. A participant explained, “Our hospital experienced a 30% decrease in patient volume. It is inconvenient for patients to come to the hospital due to tightened entrance control. The restriction on patients’ family visits is another factor. We are not letting students rotate on wards with suspected COVID-19 patients.” The limited patient encounters are perceived as potential threat to students’ clinical competence.

3) Hospital infection control measures limited educational opportunities: Finally, another threat reported was associated with infection control measures by the teaching hospitals. Deans expressed concerns that students’ clinical learning opportunities were compromised during the pandemic due to cancelled bedside teaching in high-risk specialties, cancelled presentations in conferences, cancelled interdepartmental grand rounds, and suspension of exchange programs both domestically and internationally. Some mentioned that reduced clinical exposures might result in less role modeling.

IV. DISCUSSION

During this historical event, medical schools around the world are challenged to navigate a path forward to meet missions of education, research, and patient care during an ongoing pandemic. As many countries are loosening or tightening restrictions after their curves of infection have flattened or resurged, medical schools globally are at various stages of deliberating when and how to resume campus-based and hospital-based medical education (Blaaza et al., 2020; Cleland et al., 2020; Tolsgaard et al., 2020). A systematic rapid review of published reports of medical educational developments in response to the COVID-19 pandemic concluded that most papers lacked evaluation data and focused on transitioning online and removing students from the clinical contexts (Gordon et al., 2020). The review suggested that medical schools learn from a few postgraduate papers reporting how face-to-face patient contact could be maintained while mitigating risk using PPE and social distancing (G. Choi et al., 2020; Hanel et al., 2020; Kang et al., 2020). Our study of medical school deans in Taiwan on how they continued in-person medical education throughout the COVID-19 pandemic offers lessons for the medical education community to engage medical students in campus-based and workplace-based learning with evaluation of impacts.

This study offers a conceptual advance by demonstrating how SWOT analysis can help us reflect on medical education adaptations to COVID-19 pandemic and future crises. Our analysis of the strengths, weaknesses, opportunities and threats in Taiwanese medical school adaptations to COVID-19 highlights certain strategies to leverage strengths and opportunities to overcome weaknesses and threats. A critical factor in the decision to continue face-to-face medical education, clearly identified by the opportunity-strength strategy in Table 3, was the early deployment of epidemic prevention measures under centralised government policies and strong medical school leadership. Epidemic prevention measures were deployed at all levels of schools in Taiwan as students returned to campus for spring semester in February 2020. To enact anti-epidemic policies in different contexts, this study presented various preventive measures to keep the recommended social distance in classrooms, laboratories, and teaching hospitals. To implement these measures, transparent communication and administrative support from medical school leadership are essential.

SWOT analysis on opportunity-weakness and threat-weakness strategies offers lessons on how to overcome the weakness of lack of faculty confidence in online education. Although online education is an important curricular adaptation to maintain social distance in campus-based medical education, our survey shows that respondents found online teaching challenging to faculty and are concerned about the effectiveness of online education. Strategies identified to overcome this weakness is to take advantage of the educational technology readily available and to transform the threats from hospital infection control to suspend hospital-based education into opportunities for integrating innovative online education. It is important to leverage innovative online education in workplace learning in the context of reduced patient case exposures before the pandemic subsides (B. Choi et al., 2020; Lo et al., 2020). There is sufficient evidence in the education literature that well-designed online education is as effective as traditional classroom teaching and shows equivalent or better learning outcomes (George et al., 2014; Jung & Rha, 2000; Khalil et al., 2020). We hope that the evaluations reported in the fall semester survey showing equivalent outcomes of online adaptations during COVID-19 would encourage medical educators to take advantage of innovations reported by this study, existing literature on online education in general, and the growing literature about innovative online medical education (Ahmed et al., 2020; Medical Education, 2020).

This study highlighted that another enabling factor for Taiwanese medical educators to continue face-to-face medical education was the experience of SARS. The Taiwanese population became accustomed to anti-epidemic measures, including wearing masks after SARS, which facilitated the implementation of anti-epidemic measures in schools during COVID-19. Taiwanese health providers were severely challenged during the 2003 SARS epidemic. 103 of 318 confirmed cases  (Centers for Disease Control and Prevention, 2003) and 11 of 60 deaths (including two first-year residents) (Taiwan Centers for Disease Control, 2013) were healthcare workers. Medical education leaders had a difficult decision to make regarding the final year students who were working as interns in hospitals (Lai, 2020). Following closures of clinics and resignation of healthcare providers, there were heated debates about physician duties to treat patients while being at risk of exposure to a deadly infectious disease and of being stigmatised by society (Lee, 2003). After SARS, not only were curricula on ethics and infection control strengthened, but the medical education system was reformed to convert the final-year of medical school to a formal post-graduate year program (Ho et al., 2017). In addition, as articulated by the respondents of the survey, SARS prepared Taiwanese medical educators and clinical teachers to be confident and competent to perform their educational and clinical duties in the time of COVID-19.

Although this study has many lessons to offer both conceptually and practically, there are some limitations to be considered. We conducted the survey with open-ended questions to explore diverse perspectives. The reported theme frequencies should be considered with caution since some respondents record more comprehensive answers than others. While the most frequently mentioned themes might be most important to the respondents, the least frequently given answer might be valuable due to its innovative nature. Another limitation of an open-ended questionnaire is that respondents might not have the time to enter answers in detail. To overcome this limitation, we invited the respondents to participate in a follow-up interview. However, only about one-third of deans were available to be interviewed during the study period. The four interviews conducted nonetheless enriched the study with more context and details. Finally, this study only surveyed medical school deans. It would be interesting to conduct further studies comparing these results to the perspectives of students and faculty members.

V. CONCLUSION

This nationwide study of all medical schools in Taiwan documents critical observations of top medical school leaders during an active pandemic. This case study demonstrated that strengths and opportunities such as strong leadership and centralised anti-epidemic policies can overcome weaknesses and threats such as faculty lack of confidence in online education and parental pressure to stop hospital-based education. We recommend that medical school leaders conduct SWOT analyses as early as possible to plan strategies to continue safe and quality medical education during COVID-19 and forthcoming emergencies. Similar to the impact of SARS, which led to reform of the Taiwanese postgraduate training system, there is hope that thoughtful reflection on medical education adaptations to the COVID-19 pandemic will improve medical education in general and lead to better preparation for future crises.

Notes on Contributors

MH contributed to the conception, acquisition and analysis of data, drafted the article, and approved the final version; YC contributed to the design, acquisition and analysis of data, drafted the article, and approved the final version; SK contributed to analysis and interpretation of data, revised the article critically, and approved the final version.

Ethical Approval

This study was approved as exempt by the Georgetown University Institutional Review Board (STUDY00002812). Since the study poses no greater than minimal risk to subjects, a waiver of written consent was granted. . We emailed invitations with information about study purpose, data confidentiality, and a weblink to the online survey. A verbal consent was obtained before data collection began. Participation was voluntary without incentives offered. All methods were carried out in accordance with relevant guidelines and regulations.

Data Availability

It is not possible to share data since we did not get consent from participants to share all data collected. They agreed to have results reported in a summary format with selected quotes.

Acknowledgement

The authors wish to thank survey respondents and interviewees for providing insights on the research topic. Fred Hafferty and Carrie Chen provided useful feedback to improve the manuscript.

Funding

This study did not receive any funding.

Declaration of Interest

The authors declare that they have no competing interests.

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*Yu-Che Chang
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