COVID-19 and Medical Education in Ghana: Assessing the Impact

Medical education in Ghana has been affected in many ways by the onslaught of the COVID-19 pandemic. Though the pandemic has affected both preclinical and clinical segments of medical education, the effect has been felt more at the clinical stage. Medical students on vacation who started their clinical training abroad could not return to their destination of study to complete their programme because of COVID-19 linked travel restrictions. This qualitative study examined how COVID-19 impacted on teaching and learning at a public higher education institution offering clinical medical education in Ghana for over 200 medical students. These medical students were from three different higher education institutions with varied curriculum outcomes. Thus, for them to be considered as a single group required innovativeness on the part of administrators. Open-ended interviews were held with administrators and the outcome indicated that salient aspects of the clinical training process had been impacted. These included administration of clinical education, curriculum, student learning, student assessment and code of practice. As a result of the pandemic, student learning shifted from traditional face to face interaction to online learning at the beginning. Some of the administrative challenges that ensued included the need for reduced number of students per tutor and introduction of afternoon sessions with a limited budget. The paper concludes that COVID-19 has been disruptive to traditional medical education in Ghana. However, the novel learning processes may provide opportunities to increase access to medical education using a phased system of learning. The findings from this study should have implications for policy and contribute to the discourse on blended learning in medical education in Ghana while ensuring that quality is maintained in all instances.

student learning shifted from traditional face to face interaction to online learning at the 23 beginning. Some of the administrative challenges that ensued included the need for reduced 24 number of students per tutor and introduction of afternoon sessions with a limited budget. 25 The paper concludes that COVID-19 has been disruptive to traditional medical education in 26 Ghana. However, the novel learning processes may provide opportunities to increase access 27 to medical education using a phased system of learning. The findings from this study should 28 have implications for policy and contribute to the discourse on blended learning in medical 29 education in Ghana while ensuring that quality is maintained in all instances. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021.

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COVID-19 pandemic has precipitated a number of transformations in the education sector 32 globally and the medical education unit has not been spared [1]. Clinical and practical 33 components of medical education that had been handled on a face-to-face basis for decades 34 had to be suddenly revised and transformed into a blend of online and limited face-to-face 35 programmes while ensuring that COVID-19 protocols were observed to guarantee faculty and 36 student safety. Suffice it to say that in the Sub-Saharan African country of Ghana, the global 37 COVID-19 pandemic has disrupted the traditional model of medical education which, over a 38 long period of time has been very conservative in its structure and function [2]. 39 Overall, the COVID-19 pandemic has caused an overhaul of medical school orthodoxy that 40 whilst disruptive, may serve to expose institutions to novel means of teaching and assessment 41 which may ultimately improve medical education in the future [3]. In Ghana, COVID-19 has 42 interrupted the clinical aspect of medical education in many ways. During a three-week is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint 3 maintenance of social distance. Faculty members and administrators also had to be creative in 55 their clinical supervision of students. 56 In line with safety protocols, there were fewer number of cases for teaching the clinical 57 component in Ghana's higher education institutions. In addition to merging some of the 58 lessons, administrators ensured that class sizes were reduced to prevent infection while e-59 learning was rapidly deployed as a means of teaching. Research indicate that the beginning of 60 the pandemic led to a suspension of didactic teaching to be replaced by live-stream 61 synchronous or recorded lectures which negatively impacted collaborative experiences and 62 communication skills of students [ 5,4,6].  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Notably, the transition to a blend of both online and limited face-to-face contact was not 80 without its challenges as students needed this fusion to enable the efficient practical 81 application of theories learnt [5,4,6]. 82 Invariably, the COVID-19 pandemic has obliged administrators of higher education 83 institutions to be innovative in their ability to replicate some of the face-to-face clinical 84 contact and engagement into a virtual environment. Thus, this paper aims to describe and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint 5 unstructured open-ended interview protocol. The objective of the interview method was to 105 obtain salient information from the administrators regarding the processes that had gone into 106 the provision of blended learning to medical students undergoing clinical training in the era 107 of COVID-19. Interviewing is an effective means to gain insights into experiences and 108 perspectives of administrators in a higher education institution [9]. Similarly, according to 109 Rubin and Rubin [10] interviews are very beneficial because they enable the researcher to  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint In this study, all six participants were recruited by the lead researcher in October 2020 from 137 the departments that constitute the undergraduate unit. Telephone and face-to-face interviews 138 as the situation demanded were conducted while obeying all the COVID-19 safety protocols. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint 7 for repeating ideas that were relevant to the research questions among others. Each interview 155 transcript was read at least three times to acquaint the researchers with the themes that would 156 emerge from the coding process. The researchers also undertook open coding of the 157 transcripts to be followed by axial coding by developing categories. The researchers 158 examined themes that emerged from the interviews both deductively and inductively and 159 looked for linkages and patterns among themes. Descriptive categories were identified and 160 copies of the interview transcripts and emergent themes were sent to participants by email. 161 The participants acknowledged that the interpretation of the data was accurate after reviewing 162 the transcripts. To further ensure reliability and validity of data analysed, there was member 163 checking thus, a peer reviewer reviewed all the codes to eliminate possible research bias.

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The outcomes of the study are reported under the following thematic areas namely: is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint For very valid reasons, participants indicated that they had to find ways of balancing the need 187 to complete the academic calendar despite the substantial time lost because of the pandemic, 188 while incorporating social distance into the programmes. Student groups had to be reduced 189 from an average of 10 per tutor to five for clerkship rotation. Afternoon sessions which were 190 not the norm, were introduced to accommodate the increased student groups created as a 191 result of the pandemic. Another administrative concern that had to be addressed was  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021.  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint The COVID-19 protocols that had to be adhered to included social distancing rules and the  In the pre-COVID era, students were to elicit their own findings based on lessons taught in 242 the classroom that encouraged a more hands-on process while the tutor corrects mistakes. The  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint curriculum delivery and student assessment in the UK, noted that many of the written In most instances about a quarter of the proposed programme had to be omitted according to   is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint 14 determined the effect of these practical sessions on the ability of trainees to perform these 334 examinations and make interpretations appropriately. 335 The elimination of some aspects of clinical education as a consequence of COVID-19 led to a 336 feeling of vulnerability among students as they could not be of immediate assistance to their 337 faculty members in the discharge of their clinical duties. The students did not partake in 338 frontline service provision perhaps from the fear of contracting COVID-19. However, the 339 students found ingenious ways of assisting medical personnel and were not directly involved 340 in the frontline service provision. In Singapore, medical students were involved in the design 341 of workflows for patient management [7]. Findley [4] also indicates that when students 342 returned to clinical rotation eventually, all didactic teaching have evolved to online formats.   is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint Nonetheless, Jaideep [6] is of the view that though teaching online during the pandemic is is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Thus they had to run three different curricula simultaneously in a midst of a global pandemic.

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The study further indicated that student learning changed from a face to face didactic to do more with bandwidth issues, reliable and stable internet for online classes rather than 395 skill. Participants further noted that the regular class sizes also had to be reduced to ensure 396 that COVID-19 safety protocols such as social distancing and wearing of personal protective 397 equipment were adhered to. The reduction in class sizes however, came with faculty fatigue 398 as they had to do more sessions than they were previously accustomed to.

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Emergency cases were also reduced in clinical training and this impacted on the collaborative 400 learning skills of students [5,4,6]. The adaption in practice where students have to appear in 401 protective equipment and scrubs aggregating around a patient was new to our sociocultural 402 practices. The absence of emergency cases for clinical education needs to be studied further 403 to determine its impact on performance in practice. This study highlights the need for a  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint Student assessment also shifted from the traditional long case assessment to the Objective 408 Structured Clinical Examination (OSCE). This was a rapid paradigm shift that students, 409 faculty members and administrators adapted to. The data suggests that though administrators 410 were ill prepared in terms of resources and training to undertake the OSCE but were able to 411 achieve the desired objective. OSCE is an expensive method for clinical assessment and the 412 cost must be adjusted in medical education funding. The use of OSCE as an assessment tool 413 is suitable in times of emergencies and provides a practical method in the absence of patients.

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Findings from the study also indicate opportunities and challenges that participants had to is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint  is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.11.21253306 doi: medRxiv preprint were not without challenges, the incorporation of technology greatly enhanced the training 459 process and aided in completion and graduation while taking cognizance of student 460 assessment, curriculum and administration among others. As students, faculty members and 461 administrators adapt during this pandemic, technology continues to be leveraged and novel 462 initiatives improved on while quality is not sacrificed. This paper has shown that COVID-19 463 has been disruptive to traditional medical education in Ghana. However, the innovative 464 learning processes may provide the opportunity to increase access to medical education 465 through the introduction of a phased system of learning. An alternative to foreign medical 466 training will also have to be evaluated if part of training can be undertaken in-country. The  The data used to support the findings of this study are included in the article.

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The authors declare they have no conflict of interest.