Ripple effects of COVID-19 lockdown pertaining to clinical skills among undergraduate medical students of Karachi

Objective: To determine the outcomes of coronavirus disease-2019 lockdown pertaining to clinical skills among undergraduate medical students. Method: The cross-sectional questionnaire-based study was conducted after approval from the Jinnah Sindh Medical University, Karachi, at 6 public and private medical education institutions in Karachi from July 3 to August 3, 2021, and comprised undergraduate students from the 3rd, 4th and final academic years. Data was collected using a pre-designed questionnaire. Data was analysed using SPSS 20. Results: Of the 383 subjects, 260(67.9%) were females and 123(32.1%) were males. The overall age range was 20-25 years. There were 145(37.9%) students from the 3rd year, 154(40.2%) from 4th and 84(21.9%) from the final year. Among them, 251(84.2%) accepted having decreased eﬃciency in clinical skills because they were not being able to train in person, 157(41%) claimed that certain topics related to clinical study were given in exams even though they were not taught, and 164(72.6%) faced diﬃculty in exams related to clinical skills. Conclusion: Coronavirus disease-2019 caused disruption in routine life, and medical education was not an exception. E-learning modality was found to be insuﬃcient, and patient exposure elevates confidence, eliminates hesitation, and improves clinical skills.


Introduction
The pneumonia outbreak amid normal life in the Wuhan city of China in late December of 2019 was scrutinised and later confirmed by the Centres for Disease Control and Prevention (CDC) as having been caused by novel coronavirus.The new variant was called the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the resultant disease, called the coronavirus disease-2019 (COVID- 19), was declared a pandemic on March 11, 2020. 1 Many precautions were taken to restrain people from contracting the highly communicable, contagious disease.One measure that ultimately impeded every work, each person's routine, and bound people to the home was the lockdown.This seemed necessary to restrain people from contracting the virus.The impact of lockdowns and social distancing was remarkably significant on medical education with regard to hands-on procedures, historytaking, clinical examinations, case presentations, hospital visits, and patient exposure, etc.These skills are grasped inch by inch in the last three academic years. 2 Tele-learning looks good enough broadly, but when it comes to medical education at the undergraduate level, it can never replace clinical skills that are learnt through patient exposure.Psychomotor skills in terms of clinical practice are least attainable via e-learning.Declined selfassurance, low level of confidence and professional competency to cope up with the actuality of professional life can be an acute outcome among future doctors if no measures are taken to cement the gap generated by COVID-19 lockdowns on clinical skills of undergraduate medical students.Surgical ward rotation in the final three years plays a remarkable role in hand-picking a surgical career.The halt in surgical rotations can tail off the fascination towards surgery as a career choice. 3dical students have showcased concern about inadequate clinical skills during COVID-19 lockdowns around the globe. 4The current study was planned to determine the impact of COVID-19 lockdowns on the clinical skills of undergraduate medical students.
Karachi, and comprised undergraduate students from the 3rd, 4th and final academic years.Students of the 1st and 2nd years as well as non-medical undergraduates were excluded.Data was collected using a predesigned 19-item questionnaire.
The sample size was calculated via OpenEpi 2 with confidence level 95%, and hypothesized frequency of outcome factor in population (p) 46.4%.Absolute precision value (d) was 5%.Non-probability convenience sampling technique was employed.
The online questionnaire was generated via Google Forms and was distributed to the participating institutions using various messaging applications.A pilot study was done to check the efficacy of the questionnaire which resulted in Cronbach's alpha value of 0.785, indicating its reliability.The questionnaire included an informed consent form which was signed by all the subjects.Participation was voluntary and it hardly took 15-20 minutes to fill the questionnaire.For maintaining anonymity, no personal questions, like participants' name, institution, were asked.
The question types included multiple choices that were answered on a six-point Likert scale, as well as open-ended questions.The questionnaire gathered demographic data, like gender, age, year of study and the public or private orientation of the institution, and students' perception about the impact of COVID-19 on their education both in terms of theoretical and clinical skills (Annexure).

SUBMIT
Data was analysed using SPSS 20.Chi-square test was used for inferential analysis, and the potential association between independent and dependent variables was explored.
Overall, 343(89.6 %) students agreed that medical education relies heavily on good theoretical concepts as well as clinical skills, 363(94.6%)had their clinical rotation suspended during the pandemic, and 256(66.8%)were worried about being exposed to COVID-19.253 (66.1%) students had their clinical posting for 15-30 days before the pandemic, which was reduced to 10-15 days during the pandemic.
Regarding the students' perception of whether clinical skills could be taught online, 328(85.6 %) believed that it cannot be done, 251(84.2%)accepted having decreased efficiency in clinical skills because they were not being able to train in person, 157(41%) claimed that certain topics related to clinical study were given in exams even though they were not taught, and 164(72.6%)faced difficulty in exams related to clinical skills.Only 39(10.2%)students participated in any elective during the lockdown phase.

Discussion
The COVID-19 pandemic and subsequent lockdowns affected people from all walks of life. 5While a major crisis in the health sector was taking place, different steps were taken in order to make sure that the disruption of normal routine life was minimal.One such measure was the shifting of education from physical to online classes. 6While this played a major role in decreasing the loss of precious time, it was still a new concept in lare parts of the globe, including Pakistan, and took a lengthy phase of trial and error as it seemed unrealistic to teach practical skills through online lectures. 7Comprehending the conveyed content emerged as a challenge in e-learning. 8e current study found that during the pandemic and subsequent lockdowns a vast majority of students had their clinical rotations suspended, and the days of their rotations thereby got significantly reduced. 9Cognitive content has been lessened in terms of grasping skills. 10tudents were also markedly worried about being exposed to COVID-19 during their clinical training. 11e current study also explored students' opinions towards major challenges they faced during the experience of learning online and if such clinical skills could be taught online.A large majority disagreed.Students also admitted of facing difficulty in their last appeared exams in relation to clinical skills.Internet access also emerged as a significant hurdle.Most of the students agreed that the pandemic resulted in a decreased confidence in terms of clinical skills.[14] The results also showed that most students were moderately confident in their basic clinical skills, but there was decreased confidence in specialised clinical skills. 15pple effects of COVID-19 lockdown pertaining to clinical skills among undergraduate …..They also showed less interest in surgery, due to suspended surgical postings.Remote education of surgical procedures seems just about impossible. 16,17Undergraduate medical students suffered a lot due to lockdowns.They had no interaction with peers, no clearing of doubts, and were not being provided with adequate learning material as the elearning modality was new to students as well as to the teachers. 18tient interaction is the core of the medical profession.All clinical examinations are best acquired when attained via tactile method. 19It is crucial to gain experience and implement theoretical knowledge. 20By reading medical books only, a medical student can never become an efficient doctor. 21Patient exposure gives crystal clear picture of clinical scenarios and is important to build rapport.Patient exposure and practice of clinical skills leads to stronger concepts and better learning. 22In ward postings, students get to know that how a patient perceives the symptoms related to a disease.Medical students should know all the measures of infection control and for this they need ward exposure. 23The interpersonal skills and social intelligence get enhanced when a medical student is acquainted with the environment and learn how to approach a patient in a proper manner, and this is essential to establish a high-quality healthcare system. 24n exam based on inspection, palpation, percussion and auscultation can never be mastered via e-learning.Without going to the ward on a daily basis, a doctor cannot be competent enough to deal with the actuality of professional life.Patient exposure elevates confidence, eliminates hesitation, and improves clinical skills. 25VID-19 restrictions created problems in the current study's data collection process as well.This was the reason that the study had to be conducted online.
In the light of the findings, it is recommended that efforts should be made by educational institutions to solve the issues faced by the students.This can be done by ensuring clinical exposure along with standard operating procedures (SOPs), making vaccination mandatory, holding workshops on clinical skills and interactive sessions with teachers after regular academic hours to mitigate the loss of learning, and modifying the timings of ward posting and calling fewer students at a time.Besides, no final examination should be conducted until and unless the clinical skills of that year have been taught to the relevant students.

Conclusion
COVID-19 caused disruption in routine life, and medical education was not an exception.E-learning modality was found to be insufficient, and patient exposure elevates confidence, eliminates hesitation, and improves clinical skills.