Medical semiology, the study of symptoms, signs, history taking and physical examination, also known as bedside diagnostic examination, is a cornerstone of medical training [1, 2]. When the Coronavirus disease of 2019 (COVID-19) pandemic emerged, the American Association of Medical Colleges (AAMC) released guidance on March 17, 2020, recommending the suspension of medical students’ direct patient interactions. This raised concerns about the future of medical education and clinical training [3]. As for Romania, on March 16th 2020 a state of emergency was established by a national decree, and on May 15th a state of alert, in which it was stipulated that classes in all units and educational institutions were suspended [4, 5]. In order to contain student losses, countries from all over the world switched to an online form of learning, in accordance with the pandemic gravity and local recommendations. However, a struggle was born when it came to adapting clinical practice sessions to online learning. Taking an anamnesis or performing hands-on procedures in the absence of direct interaction with the patients was something unconceivable before COVID-19 and therefore these were much more difficult to fit in [3]. As consequence, it was expected that online teaching would be much more challenging and burdensome for medical students who had passed the preclinical stage of education. In Romania semiology is a subject that takes place over the course of a whole year in Medical Universities – the third year. It represents the first encounter of the students with the clinical learning, standing at the very core of acquiring clinical skills. Therefore, taking all these into account, we aimed to assess the impact that learning semiology offsite had over students, from a psychological, as well as from a practical point of view.
The aim of the study was to evaluate and understand how students experienced facing their first interaction with the clinical environment and developing clinical skills through online classes, together with its impact over them, on the short, as well as on the long term. This is a mandatory process in order to gain a better understanding of that experience, to overcome any gaps in knowledge, and to improve future responses in case of a new pandemic period. A secondary aim of this study was to analyse how online learning is seen by students, and to evaluate if remote education can be applied properly in medical school.
We conducted a phenomenological qualitative study, while using semi-structured in-depth interviews between November 2023 until January 2024. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were used to report the study methodology [6]. Participants were recruited through face-to-face interactions, telephone or e-mail from final-year medical students at “Carol Davila” University, the largest medical university in Romania. We sent them the information form together with the consent form, and afterwards we let them decide if they wanted to enrol in the study. During the COVID-19 pandemic, many university hospitals were transformed in full COVID-19 units or mixed units (dealing with COVID-19 as well as non-COVID-19 patients). Given that in Romania semiology training takes place in various hospitals, it is clear that students’ experiences may have varied according to the place where it was attained. We purposely selected respondents from various hospitals, while using a snowballing technique, in order to achieve a larger overview about students’ experiences. The interviews were conducted by one of the authors (A.M.M), who was an intern at that time (internal medicine resident), without being involved in the process of teaching, in order to increase students’ willingness to enrol in the study, and to open up during the discussions. A.M.M. was previously trained by L.E.M in regard to the process of interactive data collection and verbatim transcription. A.M.M. did not establish a relationship with the students prior to the commencement of the study. The interviews were conducted face-to-face or over the phone, in accordance to students’ preferences. Face-to-face interviews took place in only one hospital. No specific arrangements were done for the interviews conducted over the phone. No one except the interviewer and the participant was present during the dialogue. Each interview consisted in 10 questions, which are further presented in Table 1. The questions were designed in order to evaluate students’ perceptions regarding how they experienced the process of acquiring clinical skills during pandemic times. Through these questions we also aimed to evaluate if online courses could be integrated through medical school, and to identify possible modalities of improving the way in which the internship takes place. In order to assure the obtainment of rich data, the interview was initially piloted on two students, with additional questions being posed when needed. No modifications were made regarding the interview topic guide after piloting the study. Therefore, those two interviews were included in the final analysis. Participants were not involved in the development of research questions or study design.
All the interviews were audio-recorded and transcribed verbatim by the same person after each interview, with the anonymization of the transcript (to each participant a two-digit number was assigned, according to the order in which they enrolled in the study, instead of using his/her name). We decided not to disclose the hospitals and the specific wards where the participants attained the semiology courses, to be sure that the anonymization is fully achieved. Transcripts were not returned to the participants for comments. After the article will be published, the audio-recordings will be destroyed. Volunteers received no remuneration.
Interview topic guide
| 1. What year of study are you in, and which specialty do you wish to choose after the residency examination? |
| 2. How important do you consider semiology to be in your current practice? How about, in general, as you imagine your future practice as a clinician, when it comes to establishing a patient’s diagnosis? |
| 3. What is your opinion about online learning in general? How about learning semiology online? |
| 4. How did your semiology internship take place? |
| 5. How sure on yourself are you when it comes to your semiology knowledge and clinical skills (anamnesis and clinical examination)? |
| 6. Do you consider to be a discrepancy between you and your colleagues when it comes about your semiology notions and skills? |
| 7. What about your colleagues who learned semiology before or after the COVID-19 pandemic? Do you consider that you have been disadvantaged? |
| 8. Do you consider that you managed to overcome your lack of clinical skills or knowledge regarding anamnesis during the following years of university? |
| 9. Do you consider that it is necessary to overcome this lack of practice in the future? How do you intend to do it? (in case they feel uncertain about their current knowledge and clinical skills). |
| 10. In your opinion, how should the semiology internship have taken place? |
The research question we aimed to proceed towards was experiential and exploratory. As consequence, we conducted a primarily experiential form of thematic analysis, while using an inductive, data-driven approach, with a focus not only on a semantic level, but also on a latent one. While performing the analysis, we followed the stages described by Braun and Clarke [7]. L.E.M., which was trained in interviewing, coding and thematic analysis, performed the process of familiarizing with the data and generated the codes. She presented them afterwards to the project supervisor, C.B., together with the audio-recordings and the transcripts. L.E.M. and C.B. matched the codes into themes in nine meetings. Afterwards, the final report was written. We sent our results to two randomly selected participants, in order to perform member checking. All of the selected participants endorsed the draft. We achieved data saturation after 16 interviews. However, besides the codes that recur systematically, we also included in our report codes based on the saliency analysis principle, described by Buetow [8], which stands for the importance of the codes that address real-world problems, no matter the frequency with which they are encountered through the data.
A total of 16 students enrolled in our study, with 3 of them being males. After we analysed and coded the transcripts, we identified four themes: “Acquiring clinical skills during pandemic times”, “Students’ perception about semiology”, “Mapping the role of online learning in medicine”, and “Future perspectives for a better semiology learning”. Four subsequent subthemes were attributed to the first theme. The main themes are defined in Table 2.
Overview of themes
| Themes titles | Themes definitions | Subthemes |
|---|---|---|
| 1. Acquiring clinical skills during pandemic times | This theme focuses on more than one level. It starts with picturing how semiology training took place during the COVID-19 pandemic, while shifting afterwards towards analysing the impact that remote learning had over students, both on the short and on the long terms. Later on, a focus is placed on the measures that students adopted in order to fill in the gaps that appeared due to the lack of practice, as well as on students’ opinions and attitudes in regard to their current level of knowledge. | |
| 2. Students’ perception about semiology | This theme explores the degree of importance that students assign to semiology nowadays, in order to understand the grounds on which the lack of practice during pandemic rooted. | |
| 3. Mapping the role of online learning in medicine | This theme evaluates not only the downsides of remote learning in medical school, but also its pros, in an attempt to examine if online learning may be implemented in a medical academic environment. | |
| 4. Future perspectives for a better semiology learning | This theme explores future directions and actions that may be implemented so that semiology courses and trainings will make students to be more attentive, and also gain better clinical skills. |
The structure of the semiology training varied depending on the hospital's COVID-19 status — whether it was a full COVID unit or a mixed hospital treating both COVID-19 and non-COVID-19 patients. Therefore, there were students that never interacted with any patients during their third year of University “We never went to the hospital, because it was a full-COVID unit (anonymised) at that time, and we didn't have the chance to go there.” (Student 13), as well as there were students that went from time to time at the hospital (more or less): “We went to the hospital three times in one year... we only had contact with two patients” (Student 07) versus “I had the luck to study in a hybrid system, I mean we also went to the hospital, we were going there every week and only the courses were taught in online.” (Student 09).
In the end, according to their reactions at that situation, there were two types of students: the ones that benefited from a fair enough amount of contact with the patients (at least), which allowed them to form an opinion regarding the semiology training and to identify pros and cons, while on the other side there were the students that did not make the most of it or did not benefit at all from any bedside teaching. Therefore, the latter ones did not have any comparator or standard of reference regarding the way it should have been, and they rather developed a form of desperation and anxiety when realising that the normal process of learning was entirely disrupted.
“For two hours we really benefited from bedside teaching...but the downside was that unfortunately, semiology is not taught in wards that are 100% of internal medicine, where you can see patients with various diseases, involving different organs and systems.”
“We had both, the courses and the practical part, online (...) my teacher tried playing roles with us in order to substitute bedside teaching – someone pretended to be the patient, while somebody else was pretending to be the doctor, in order to practice our anamnesis, he (the teacher) was also playing the role of the patient…but again, it was not the same thing.”
“We tried to auscultate on each other, to percuss on each other, to...but we were healthy and we were only observing what was normal, we couldn’t see how it was…an abnormal heart sound, or an abnormal dullness(...).”
However, even though students were affected by the altered process of learning, they understood that given the situation, everyone tried to make the best out of it “ Honestly, it was fair how the internship took place, I mean yes, I would have like to go to the hospital every time, but at the same time I consider that everything that was possible was done at that time.” (Student 09), considering the well-being of the patients, and taking into account their risk of contaminating with SARS-CoV-2: “I mean, ok, you bring the students to the hospital and they get ill...but the patients will get ill too, and therefore they didn’t have what to do. (…)” (Student 10)
On the short term, depending on the students’ psychological pattern, SARS-CoV-2 pandemic and acquiring clinical skills off-site had a major psychological impact. Some of them managed to get over it, while others did not. Maybe the feeling that they cannot accumulate the information as they should or would desire was in part due to the anxiety generated by the fear of the unknown, and the perception of futile medical learning, given the imminence of death that was hovering at that point, as it is illustrated below.
“(…) I wasn’t really interested in medical school at that time because I was only thinking that the world will end. Honestly, it was such a terror back then…in the air (…) it made me change completely…it made me live my life, that is all, yes (…) No, I couldn’t do it, I didn’t manage to learn. I was only thinking at COVID and at my parents.”
“Clearly, there were…there were people, both students and teachers, that were more afraid than others. But me, personally, I wasn’t afraid of this pandemic.”
On the long term, the most striking effect of acquiring clinical skills during the pandemic state consisted in experiencing one of the most undesired antitheses of the medical school: being a doctor and the fear of touching patients. So, when the time to interact with real patients came, later than supposed to, students realised that they were afraid to touch them, while performing the anamnesis and the clinical examination was far from feeling natural to them, as it is illustrated below.
“…he said (the teacher): «What does he has? Did you touch him?» And we were like: «no, how could we have touched him?». And he was like: «What? What is wrong with you?». I mean, for us, to touch the patients was something odd; it was like…you shouldn’t do it. Nobody taught us how to touch them, and we were in our fourth year, no, in the fifth year. We were in our fifth year and we still didn’t…had it imprinted in our routine, like it was something normal.”
Moreover, students experienced a form of anxiety when it came to the process of learning and the thought of practicing their future profession. They realised they were already in medical school, with no easy way out and without knowing how to deal with the patients. The fear of having direct physical interaction with them, like it was something wrong or unnatural, originated in learning remote semiology during pandemic times. It persisted during the following trainings, which only deepened their state of disorientation and anxiety.
“The first anamnesis that I have ever done was only at the end of the fourth year of medical school, even though semiology was during the third year (…) In the first place, we were very clumsy, very fearful, we didn’t know how to begin, or who should do it. Aaa, not to mention that performing the clinical examination was something unconceivable, to touch the patient and to perform on him some manoeuvres that we only did on ourselves or not at all... (…) I mean the first time we ever had contact with a patient was during our cardiology internship and we didn’t even know how to handle the stethoscope, we didn’t know how to do anything, it was very brutal. I mean for us really…from my point of view, online semiology really had an enormous impact on us.”
“(…) many of us are still afraid to touch the patients, even now, in our sixth year of medical school, from what I heard from my colleagues, because they missed this interaction.”
It appears that in post pandemic times, some of the teachers did not change their perception regarding the semiology notions considered to be mandatory for students by that time. This may be because they did not acknowledge that medical scholars learnt this subject offsite, with no or not enough bedside teaching. For students, this lack of understanding was difficult to take on, as it made them more susceptible to feel like outsiders, like they were not where they were supposed to be. As consequence, depending on their type of behaviour, some of them might have abandoned the fight, while others might have worked even harder in order to fill in the gaps.
“(…) after that, in our fourth year, every teacher scolded us, throwing it in our face«Why didn’t you learn? You didn’t do anything?». They were making it look like it was our fault that we didn’t learn anything and I was feeling very guilty and it was like a responsibility aaa that we didn’t learn by that time (…).”
“And every time…during every internship we had…they were asking us where did we do semiology and we said «anonymised», and they asked us how, and we said online, and after that silence was following…and yes, we felt judged for a situation that we didn’t chose.”
In students’ opinion teachers’ post pandemic reactions were inadequate. Most of them felt misunderstood and judged for something that they did not consider to be responsible for. However, others experienced a feeling of mediocrity, considering that the gaps in knowledge were their fault, as it is illustrated above. Therefore, performing a patient’s clinical examination represented a psychological barrier for many students, sometimes hard to overcome.
When it comes about choosing their specialty, it appears that for some students COVID-19 pandemic had a certain sway. When they realised that they cannot accumulate clinical skills in accordance to their desired level, some of them gave up and preferred to choose a specialty where they will need to overcome the lack of clinical skills no more, as it is pointed below:
“(…) there are people who, somehow, when they saw that the lessons will take place in online and realised that to opt for a paraclinical specialty is a better choice, they detached very much from the clinical examination of the patient, and therefore they did not accumulate semiotics notions as they should, because they were not interested in it.”
However, others were not influenced at all, once again, most probably depending on their behavioural pattern:
“Yes, it didn’t have an influence over me, it really didn’t (…) I have colleagues that slowly moved from wanting something…from wanting a medical specialty to wishing radiology for example. I don’t know exactly what is their reason, why they changed their mind, and why they don’t want to have contact with the patients anymore, but for me nothing changed.”
When the process of learning took place away from the patients’ bedside, gaps in knowledge appeared. Still and all, the information and the clinical skills are not entirely irretrievable, and in accordance with every student’s level of interest and commission, some of these blanks were filled in. However, many hours of active learning and practice were needed in order to build up the clinical skills that should have been acquired through bedside teaching. Students considered that their teacher had an important role in order to achieve this. They needed to be supervised during anamnesis and clinical examination, the lack of any feedback whatsoever preventing them from improving their act.
“Aaa, in theory I knew the steps, but it was difficult to apply them while examining the patient, because there is a difference between the theory and the practice. Even the stethoscope…I didn’t know how to hold it, if to press harder or lighter, some of the patients weren’t…they didn’t have the same constitution, they were overweight or obese…it was difficult, it was difficult.”
“I believe that it is important, especially during third year, at semiology, to have the teacher by your side in order to guide your anamnesis; if you stay every day at the patients’ bedside but you are not supervised, I don’t know if you can improve your medical act or, I don’t know, your medical examination, or how to ask your questions. I mean I believe that you will repeat the same mistakes over and over again.”
In order to enhance the ongoing process of learning and fill in the gaps, some of them began with some basic steps, like watching content rich materials or explanations on YouTube, and reading more books regarding semiotics. Others spent important amounts of their summer vacations in the hospital, in order to benefit from having contact with the patients, which they missed so much during the pandemic period. In spite of the fear that governed those moments, there were students that even dared to volunteer in COVID-19 wards, in order to gain a larger frame regarding the semiology notions that they learnt or were learning off-site at that time.
“I went as a volunteer at COVID. I went to the emergency ward, and it was clear that I gained more notions than those…those that I have learnt from the semiology clerkship.”
“I watched videos on YouTube many times, and I tried to listen to recordings of auscultations, yes, and every time that I had the occasion, I tried to talk with the patients (…)”
“I did more than possible, every month of summer I was on and on at the hospital, more than this you couldn’t have done, three out of three months of summer I was at the hospital, so no…”
However, there are also students that did not manage to gain the missing information, mostly due to their lack of interest, and what it is more worrisome is the fact that some of those are not even realising the major problem that this pose:
“there are colleagues that are very well prepared (…) I don’t know from where they managed to gain their notions, but I believe that they are well trained, and there are very few of those. The rest, in my opinion, are very poorly prepared, and what I consider to be even more worrisome is the fact that they don’t even seem to care.”
As it would be expected, differences clearly existed, even between students that benefited from the same process of learning (out of site or mixed). This is in fact a proof that students’ involvement will always represent a key role in learning and overcoming any sort of difficulties encountered in schooling. Ultimately, a mix between the dedication of the tutor, seen as a mentor, and the students’ desire of learning is what will lead to a proper shaping of the medical mind.
“There are indeed different grades of how good we are in everything that means semiology, anamnesis and clinical examination.”
However, not all the students acknowledged the presence of differences. In some cases, those were overlooked, maybe as a mechanism of coping. This may be especially true when taking into account the fact that the pandemic context cannot be changed – it was easier to ignore the differences between them and the others at any given time point, in order to try to fill in the gaps without feeling a supplementary pressure. Therefore, when students had almost completed their academic education process, their opinions regarding their knowledge status were quite different, ranging from not perceiving any difference “I believe that we are all at the same level.” (Student 15) to noticing an important dissimilarity between classmates “When it comes to students outside of our series, yes, for example the ones that learnt at X (anonymised) hospital are far better than us.” (Student 09).
Moreover, the same mixed opinions were noticed regarding the process of filling in the gaps. Most of them considered that in time, they managed to overcome their lack of knowledge and clinical skills, entirely or partially. However, some still felt there were things that could be improved, as it is illustrated below.
“It could be noticed that we knew…that us, who learned semiology at X Hospital (anonymised) where we couldn’t go at all, it could be noticed that we knew less, but somehow, as time went by, we filled in the gaps and the situation was homogeneous (…).”
“I don’t feel sure about myself, I feel that there are many notions that I still don’t manage to master (…) I don’t feel that I master it.”
As so, even though most of the students noticed the presence of different shortcomings, many of them also tended to see the half full of the glass, while trying to detach from the negative thoughts. Keeping their morale helped many of them to overcome this difficult period and to pursue their dreams. Therefore, they look at the future with great hope, considering that residency is the place that will allow them to define their knowledge and clinical skills.
“I mostly have an idea, but I am sure that during residency I will get the experience I need, and all will take place involuntarily; I mean at this point it is all only a luggage of mixed information.”
Semiology is seen by most of the students as a cornerstone in medicine, no matter the specialty, considering it a fundamental subject, the basis on which the information encountered during the next three years of learning should be built in:
“I don’t think that you can manage it without having a basic vocabulary in medicine, to say it so...It is... the first step, the base!”
The degree of importance they assign to semiology comes from the fact that in their opinion, having solid clinical skills is useful not only during the first interaction with every patient, but also later on, by judging cautiously the laboratory tests which they will order, especially in low-income areas, where less tests are available. As consequence, they feel more confident and more secure. In their opinion, paraclinical investigations represent an extension of anamnesis and clinical examination, and only by applying these steps in order, they can see the logic beneath and resolve the puzzle represented by the final diagnosis, as it is illustrated below.
“I believe that it is essential, it is essential to have good knowledge of semiology, because you avoid to make unnecessary or expensive investigations (…) Aaa I mean, I don’t want to remain in Bucharest, I want to go back to my hometown (anonymised) after residency, where I don’t think that I would have that much freedom to order plain radiographs, computerized tomography, magnetic resonance imaging, and I believe that it is good to have solid notions of semiology, to avoid prescribing useless and expensive drugs and tests…”
The feelings of confidence and security that we previously mentioned are further nourished by the fact that having solid semiology notions will allow them not to miss abnormalities outside of their specialty field. Ultimately, this will lead to a proper patient management.
“It is important that us, as physicians, to…at least to draw an alarm if we notice something that may be the sign of a disease and to inform our colleagues, to redirect him or at least to ask for an advice.”
However, at the opposite spectrum lies the students that tend to overspecialize from the University benches. Students that do not wish to pursue a clinical specialty apparently tend to prematurely detach from having contact with the patient, considering that for establishing the diagnosis it is enough to analyse some images or other probes.
“I have some colleagues who refuse to talk with the patients, saying that they will never choose a clinical specialty and therefore they do not participate (referring to active participation during trainings), they are only present with their bodies.”
Online learning presented several challenges, particularly for bedside teaching. Students struggled to integrate theoretical knowledge with sensory experiences — seeing, feeling, and interpreting clinical signs — leading to a superficial learning process.
“We really had a handicap, if I can name it so, after the pandemic time and after learning semiology in online (…) it was noticeable the fact that we had many gaps, especially aaa practical ones.”
Some students believed that minimal interaction with instructors and a lack of active supervision led to decreased engagement and diminished recognition of the importance of their academic activities. As for, it was not uncommon for students to shut down their camera after presence was made, in order to perform other activities during courses, as it is illustrated below.
“The ones who wanted to be present were writing their name while the presence was being made, and afterwards they were shutting down the speaker and the camera and they were seeing their own business.”
However, one cannot assume that online learning is entirely useless, and if we take a look from a different point of view, it may even represent a more favourable option. Therefore, there were students considering that engaging properly during the course depends on every students’ level of interest, being possible to prove a low level of interest no matter how the courses are being held:
“I can go at the University for the course and sleep there, as well as I can stay at home and sleep, I mean you cannot say that if you are in the amphitheatre you are more attentive, who wants to learn, learns from home and learns from the University, too.”
Students believe that holding the courses online is useful to save precious time which would otherwise be spent in public transportation, while trying to reach the place where various courses are being held, or waiting for the many breaks between two different courses to come to an end. They could use that specific time window to learn, which would lead to an enhanced productivity, as it is illustrated bellow.
“A positive thing consists in the fact that during my second year, I mostly stayed at home, and I personally, had more time to implement more stuff from the preclinical subjects, which helped me in the following years of study, because I had enough time to stay home and learn, to watch movies (medical) on the internet.”
Besides, some of them believe that there may be a place for online learning when it comes to the practical part of various subjects that involve no contact with the patient; however, this was a debatable point of view between students.
“I believe that there are some subjects that can be learned in online, it is not as bad as I…was expecting to. I mean, for example, radiology was very well done in online, I considered it to be an advantage, because it was much easier to zoom in, to better see some images(…)the electrocardiogram(ECG) part was also very well done in online(…)We could zoom in the ECG, we could see all those small squares.”
Students emphasized the importance of diverse clinical exposure for effective semiology training. They suggested that examining patients with a variety of pathologies would help integrate theoretical knowledge with clinical practice.
“I believe that what I would change a little would be…the hospital rotations, maybe on different wards, so that the students could see complex cases of internal medicine and to aaa…practice clinical examination and anamnesis on more aaa…on various pathologies, on various patients, so that they could see many positive signs, many heart murmurs (…)”
Many students highlighted the importance of strong mentorship in semiology training. They believed that active guidance and supervision from instructors were crucial for skill development and confidence building, as it is illustrated below.
“In the first place, I believe that it is useful to have the teacher next to the students and to show them, for the first times, how anamnesis and clinical examinations are correctly performed and why we do those things, why we ask those questions, what do we want to find out, I believe that this is the most important thing.”
In addition, students consider that more contact with patients is necessary in order to improve clinical skills, because much time is needed to improve the logic beneath the anamnesis’ questions, and to get familiarised with the clinical examination, as it is further shown below. Therefore, they consider that crowdedness interferes with the quality of the learning process, and see the chance of having less students allotted to every teacher as highly beneficial.
“(…) if you would have the chance to have your own patient, to see him, I think that the students would be more stimulated to be interested in semiology and with everything that speaking with the patient represents.”
Besides all these, students emphasised the fact that it would be important for the information to be more concise, and presented in a more clinical and practical fashion. They consider that theoretical courses have a high amount of information, which sometimes it is difficult to engulf if no connection with the clinical practice can be made, as it is shown below.
“aaaa… at semiology it was a little bit harder because there were lots of information that were explained to us all at once and we didn’t know how to make the difference, we had to learn those theoretical notions very much and to make time for them.”
Even though the human kind experienced several outbreaks in recent times, none of them had the impact of the COVID-19 pandemic. As consequence, no predetermined plan existed regarding the process of learning in case of mandatory social isolation. The teaching process was severely influenced by the transition from onsite to offsite. When online learning was imposed, teachers tried to adapt themselves and to update their courses, while struggling with the exercise of donning and doffing, as well as the thought of having to take care of patients contaminated with a new virus that may be lethal [9]. The most burdensome was to adapt clinical subjects, and especially the semiology training, which is intended to lead students from having no contact with patients to developing solid clinical skills.
Our findings indicate that limited patient interaction and concerns about inadequate clinical skills development had a profound impact on students. Many developed a fear of patient contact, which poses a significant challenge, as clinical diagnosis relies heavily on anamnesis and physical examination. Until now, there are multiple qualitative, as well as quantitative studies evaluating COVID-19 impact over medical students’ well-being and professional growth. It was reported that the lack of training was a detrimental factor, while experiencing chronic academic pressure and feelings of comparison, competition and unproductiveness [10,11,12]. However, as far as we know, no previous paper reported that the lack of interaction with patients had such a strong impact that it led to experiencing a paralyzing fear when it comes to addressing a patient in real life. Even though most of the students reported that during the following years of academic preparation they managed to overcome this fear, it is important to draw attention towards this sensitive subject. It is essential to address this psychological distress and potential lack of clinical skills, especially during residency, through semiology teaching programs conducted by resilient and patient tutors. An additional argument that stands for this is represented by the fact that there were students reporting to feel judged by their teachers over their lack of clinical skills training, for which they did not feel responsible, considering it the pandemic’s fault. A previous web-based cross-sectional study among 300 students, reported that 81% of them considered that COVID-19 pandemic decreased their control over their development as students and future physicians; more important, as much as 32% of them had second thoughts about pursuing a career in medicine [13]. Our findings are in partially agreement with these ones. Some students were influenced by the lack of practice when it comes to choosing their future specialty, showing an apprehension towards paraclinical specialties, while others were not. COVID-19 pandemic’s inconsistent impact in this area may be explained by students’ experiences through clinical placements, not only during the breakout, but also after resuming onsite learning, when spending as much extra time as possible at the hospital was essential in order to make the transition from theory to practice. Besides, all of them considered that having a good teacher was essential in order to develop and improve their learning and clinical skills. A process of supervised active learning by a supportive teacher who makes you feel comfortable, is the most efficient mean of accumulating information and skills, which is in accordance with other studies’ findings [14,15,16,17].
In some areas more modern techniques like the implementation of wearable camera-based technologies that facilitated off-site interaction with the patients was a useful approach [3, 18]. However, in our study, students felt that in most cases their teachers did their best to provide them with as much support as possible when it comes to the process of learning, giving the pandemic context. Even more interesting, it was reported that the examination scores did not change for students who were prepared through electronic education means, when compared to in-person learning [19]. In a mixed-methods study which evaluated rapid adaptations in clinical skills learning, it appears that COVID-19 students demonstrated significantly higher scores than their previous generation when it came to clinical reasoning skills; the only subject where they were overtaken by their non-pandemic fellows was the Venipuncture station, which involves ongoing direct practice [20]. These findings may be due to the fact that COVID-19 students may have dedicated to a greater extent their free time for studying, having as major drivers for this the lack of practice and its inherent anxiety. In addition, this may also suggest the fact that remote learning may be beneficial in some cases. Therefore, as pointed out in our study, in agreement with previous findings, the online environment presents advantages in some specific cases, one of its main benefits being represented by the possibility of saving time, which can be further used for supplementary study [20, 21]. Moreover, as we previously showed, it is also particularly useful when it comes to subjects that involve zooming out images, like ECGs and plain radiographs, while in the study of Saad et al., it is mentioned that remote development of certain skills, like ECGs, is useful in helping students to prepare for Telehealth format [20]. However, teaching through online platforms also has its downsides, like technical barriers consisting of unstable internet access, teachers' lack of experience with online platforms, or underdeveloped curricula [20, 21]. Nevertheless, these technical difficulties are not permanent and may be overcome in time. Therefore, electronic education may be adequate for preparing students not only in time of crisis, but also may be more suitable for certain subjects, in order to facilitate image analysis and improve students’ timetable.
However, even though technology has its place in the medicine field and the learning process, attention should be paid in order to avoid overlooking the importance of clinical examination while shifting towards an indiscriminate use of modern means of diagnosis. This leads not only to increased costs and over diagnosis, but also to a degradation of the patient-physician relationship, together with a loss in clinical skills [1, 2, 22]. In agreement with these observations, in our study most of the students attributed a high degree of importance to semiology. However, some of them tended to prematurely detach from those basic notions, advocating the fact that they wish to pursue a career that involves none or less contact with the patients.
Therefore, in order to keep students’ interest in traditional methods and improve their clinical skills, it is important to assess the quality of the teaching process when it comes to semiology, from a theoretical, as well as from a practical point of view. It was reported in the literature that this proceeding is inadequate in medical schools [23, 24]. Supporting these findings, students enrolling in our study considered that presenting the information in a more practical and interactive fashion would be advisable. They considered the amount of theoretical information presented through courses to be difficult to memorise and understand. This was also pointed out in another study aiming to analyse how much is too much reading for medical students, in which it was mentioned that faculty members should take into account the amount of data that undergraduates could reasonably read and comprehend. In a preclinical basic curriculum, they had to spend between 28 and 41 hours respectively, each week, in order to complete the pages they were assigned to read. Moreover, it appears that at least at the beginning of medical training, students may not be able to identify by themselves the information deemed important by a faculty member [25]. Therefore, teachers should carefully identify concise learning objectives that should be presented to students while trying to match the information they went through to clinical practice. As for, it is necessary to revise the way in which semiology is thought. The curriculum should be adapted to the actual context, in order to merge the traditional part of it to the modern one, aiming for all students to develop solid clinical skills, that will last.
The main limitation of this study consists in the fact that it was undertaken almost three years after students had their semiology rotation. Some of the key emotions and experiences they lived at that point may have been forgotten, or at least characterized by a lessened intensity, as time went by. However, on the other side, this also represents a strength, because it allowed us to evaluate the pandemic impact over students not only on the short term, but also on the long one, which helped us to understand the difficulties they encountered later on in future clinical rotations, and how they managed to overcame the secondary gaps in knowledge. Given the fact that no remuneration was offered to the participants, one other limitation may consist in a selection bias, while having enrolled in the study mostly students that see the importance of semiology. This may have led to an augmentation of the importance that nowadays undergraduates assign to this subject.
The COVID-19 pandemic significantly impacted medical students, resulting in both a lack of clinical skills and psychological barriers to patient interaction. Addressing these deficiencies is crucial for improving future pandemic responses. Implementing structured semiology training programs during residency could help students overcome these challenges, enhancing both their professional growth and well-being. Moreover, a particular attention should be paid to amending the semiology curriculum. Concise learning objectives should be identified. Also, students’ involvement in the process of learning through variate means like case reports and problem-based learning should be enhanced, aiming for all students to develop solid clinical skills that will last.