For final-year medical students, the covid-19 pandemic has been the start of their future as doctors, physicians, nurses and surgeons. It has been a dive into the deep end of healthcare and was truly a case of sink or swim.
“All contact teaching and university activities involving face-to-face interaction are postponed.”
This was the bleak message students at the University of the Witwatersrand awoke to on March 16, 2020. The university had issued the urgent statement after the first student tested positive – and it was not alone.
A week later, President Cyril Ramaphosa announced that the country would be entering what became its first (and harshest) lockdown. In those early days of the covid-19 pandemic, uncertainty was quickly becoming the norm.
It was no different for fifth and final-year medicine students, who are always in the hospital but for three weeks over the course of the academic year.
After three long isolating months, the first of the students were summoned back to campus. They were the final-year medical students, and they were being called back to join the front lines of the pandemic response. Two months later, it was the fifth-year students. One such was Nepo Ketso.
“It was very abrupt,’’ says Ketso. ‘‘I remember things happened very quickly and we had to leave campus. Sitting at home for three months was difficult, and it was getting to us. I did not know how to work at home. When we did go back, we were afraid, because there were cases of people our age getting it.”
Ketso and other students were in their fifth year of study when students were recalled in 2020. The reason they were among the first to be recalled? They had to return to their clinical training at academic hospitals such as Charlotte Maxeke and Chris Hani Baragwanath (Bara).
Dr Alex van Blydenstein is a lecturer and specialist physician at Bara. She is involved in the training of medical students in the clinical workspace, operating as one of the consultants.
Van Blydenstein explained that the purpose of clinical training is to ensure that students are prepared for work in the actual medicine workplace. “What you are meant to be learning in the hospital is clinical skills. The theory you can go to your room and learn, but clinical skills are what you need the patients for,” Van Blydenstein said.
Medical students are expected to undergo clinical training, which provides them with exposure to the workplace. At Wits University this begins in the student’s fifth year of study. The work is made up of different departments, from oncology to obstetrics.
As students have different rotations in different hospitals, Ketso has worked at each one during his time of study.
Even before pandemic, it was not easy
“I remember this one time, I slept after 4am because I was asked to help out with a patient. We were doing a C-section and it was kind of complicated. So, we stood there for a long time and then there was another one at 4am. I go there, and my clinical partners are sleeping. But it’s just one of those things,” said Ketso, recalling one of his shifts on the obstetrics ward.
As mass hysteria gripped most of the country, it was medical students who put their hands up first. Students at the University of Cape Town were among the first cohort to request permission to assist at the hospitals where they do their clinics.
The selfless response from students came as a surprise to Van Blydenstein. “It was quite surprising that students, who are not required to, stood up for the calling of medicine. When people were hiding, students who have not really taken an oath and were not required to, stood up. I think that’s a big testament to the calling of medicine.”
Following the move by health science students at other universities, Wits students played their part. After the university closed, the department of children and family called for aid from students of the health faculty. The programme sought to ease pressure on the academic hospitals staff work at. After spending a couple of weeks in limbo, locked up at home, for a final-year student (who asked to remain anonymous), sitting at home and watching was not enough.
Students jumped at the opportunity to help the country’s response to the pandemic.
“We need to learn how to adapt to things,’’ the volunteer student said. ‘‘I thought that by volunteering, we could help people at the forefront of the pandemic. The demand on healthcare workers is insane. I wanted to play my part, as someone who could help lighten that load.’’
Volunteer work consisted of working in departments of the university’s hospitals once to twice a week.
During the country’s covid-19 waves, increased pressure was placed on hospitals as they ran out of beds and hands to care for those who needed it. Student volunteers were one way to help plug the gap. Now medical students were gearing up to enter what was already considered one of the most infectious places you can be — a hospital.
“In the hospital we wear more PPE than people who go to malls and shops, so we are more protected in the hospital. The interesting thing was, people who booked for C-sections were hesitant to come in. So, it was clear that people were afraid to come into the hospital,” the volunteer said.
Clinical work was not going to be the same for the class of 2021. This year’s students had to dive head first into the deep end and survive three covid waves.
“The biggest fear was going home and getting people sick,” said Ketso. Fortunately, Ketso resides in one of the university’s residences but that, too, came with its own limitations and isolation.
“You had to come back from hospital, go get food, eat and then go to your room. Humans are social beings, but now we could not even interact with our brothers. Not being allowed visitors, we understood that, but now I couldn’t have friends, or even my mom, come and visit me,” Ketso said.
Final-year student Dumisa Ntakana echoed Ketso, saying fear was the dominating emotion during that time. In May 2020 the first wave hit. Ntakana returned to the hospital in the middle of it.
“The first one was very interesting; there was a lot of fear generally among everyone. People would wear the heaviest of PPE, even when it wasn’t relevant for the setting. There was a lot of uncertainty in things that were unknown and a lot of hesitancy to touch things and be very active,” said Ntakana.
Ramaphosa announced the relaxation of lockdown regulations on September 21, 2020, before the start of the second wave.
“The second wave was much different,’’ said Ntakana. ‘‘People wore less PPE and were much more relaxed. We were more knowledgeable on how the virus presents itself, and how to assess and screen people that would possibly be high risk.”
Data from the National Institute for Communicable Diseases showed the third wave of covid was the harshest. It recorded a new daily peak infection of more than 24 270 new cases in July 2021. Despite this statistic, for students, working in the hospital became less “strict”. Having spent two waves in the hospital, an acceptance of the reality of the pandemic overcame them.
On the third wave, Ntakana said, “It was essentially normal and absolutely nothing had changed. I don’t know if that’s because it’s the two waves we’ve gone through, or things in the hospital had become the new normal. Covid is probably going nowhere, and we’ve adjusted. We’re actively involved in the assessment, investigation and management of patients.”
Opportunities missed because of covid
While students were accepting the new normal in the clinical space, they also faced changes in their regular curriculum. A report by Unicef stated that 75% to 100% of the academic year was lost due to covid in 2020, and for Wits medical students it was no different.
“We’ve had a much more online (virtual) meeting outside of the wards, and theoretical discussions about the patients. And actually, what you want to come to the hospital and do is put your hands on patients and experience disease,” said Van Blydenstein.
To adhere to covid regulations and limit students’ interaction with covid, there had to be a restructuring of the course. According to Van Blydenstein, the virus has shifted the way medicine is being taught, which may leave students at a disadvantage.
This restructuring included restrictions on contact between students and patients. There was a change in the dynamic of how tutorials and practicals were done. For students, the effects of this meant a limitation on certain departments of the course.
“I remember after I came back, I was doing orthopaedics. After that I did ophthalmology, which has to do with the eyes. To do that you have to get close to a person and look into their eyes, but you can’t really do that because they don’t want us to get covid,” said Ketso.
Further north, at the University of Pretoria, the situation was no different; 454 final-year medicine students were recalled to their clinical training on May 12, 2020.
One among them was Mulanga, a fifth-year student completing her undergraduate degree in medicine and surgery. The difficulties of navigating the curriculum during the pandemic have been her biggest issue.
“To some extent I feel robbed. Especially last year, we couldn’t see specific things such as trauma, which I did in the second block. Usually, the main contributor to trauma is alcohol, and there was an alcohol ban. Now you are not even learning how to treat a stab wound, for example,” said Mulanga.
There is an incredible amount of pressure placed on healthcare workers. Even at a medical school level, there is little time for rest.
Ntakana said: “From 7am to 1am the following day, you are basically assessing, investigating and managing patients. One of the biggest eye openers was where you essentially go to family hospitals and manage patients at the GP from beginning to end, including births.”
While in this environment, it can be very easy for people to reach their breaking point.
A 2012 study by L van Niekerk surveyed 874 medical students from around the country. It found there was a 6.2% prevalence of suicide attempts and 32% reported suicidal ideation. And there are plenty of examples to choose from when looking at individual universities. In 2018 a second-year oral health sciences student committed suicide at Wits. Three years later, there was a master’s student studying pharmacy who took their own life.
Mental health has been a talking point in the health community, specifically burnout. Burnout has been defined as “a syndrome of emotional exhaustion, depersonalisation and a sense of low personal accomplishment that leads to decreased effectiveness at work”.
According to a study by Van der Merwe et al, more than 80% of medical students at five universities in South Africa have reported academic stress linked to medical training. Students juggle clinics, course work and their lives outside of medicine school, which contributes to burnout.
The nature of the competitive environment is echoed by Ntakana who, outside of school, works. “We have to integrate a massive amount of knowledge, show up for work, get people their scans and then come home and consume this massive amount of information. We go through 18-hour calls, sometimes 12 or eight hours.”
However, Ntakana said it is something students are required to come to grips with. “Each time it (burnout) happens, your tolerance goes up.”
Another study by Van der Walt et al looked at the rates of depression and anxiety among health sciences students at UCT in 2018. At undergraduate level, it found that students experience a greater amount of mental health symptoms in their clinical years. The increased difficulty of the course in the fifth and sixth years of study, coupled with the clinical work, are cited as contributors.
An anonymous final-year student recalled something a professor said to their class. “The way we are being taught is, if you are able to stand the mental toughness of the degree, then you are ready to be a doctor. It really resonated with me, ‘Can you stand the pressure?’ versus being a good doctor. But it’s like we are always withstanding pressure the whole year,” the student said. “You have to dig it up within yourself, because that’s just the way it is. It’s either make it or break it.”
FEATURED IMAGE: Final year medicine students walking down the halls of Helen Joseph Hospital. Photo: Zanolwazi Kunene