Leading on a Burning Platform with No Fire Hydrant

Well today's session is titled leaning on a burning platform with no fire hydrant sounds a little bit intimidating this is no doubt something that many of us have encountered over the past year we asked dr chris to present on leading in a crisis situation while not allowing the learning environment to fall by the wayside and dr chris is the ideal person to present on this topic in her roles as vice president of medical staff affairs for carillion clinic an associate dean for clinical sciences for virginia tech carillion school of medicine dr chris would prefer to we hold questions until the end just because the timing of things and if you don't mind just typing them in the chat box i will convey them when she concludes and one final note before we get started please be sure to let us know you attended this session there are two main ways you can do this you can complete the form for cme and or faculty development related to teaching the link to which sandy has and will again post in the chat and at the very least please make sure that your zoom name reflects who you are if your name is currently your phone number your spouse's name your third grader's name generic iphone or anything else that will not allow us to identify you you can easily change this in the participant list by clicking um i think it says more and then selecting rename so i think we all should be looking forward to this conversation regardless of our roles so please join me in virtually welcoming dr tracy chris well well thanks a lot sherry uh dr wicker and i want to say thank you to the teach academy for uh inviting me to make this presentation and also uh right up front i'd like to thank elvira birbick and brian brindle on the tech side as well as sandy hart this morning for helping this to to get going this afternoon so uh as as sherry said leading on a burning platform with no fire hydrant and uh we have quite the story to tell um i i want to go over the learning objectives and they're really uh things to to look at describe four principles when leading in a difficult situation identify the most important thing to do in a crisis and we certainly have learned that identify the players who are going to be working with you in terms of collaborative decision making and collaboration is going to be something i'm going to talk about a lot today and recognize the importance of benchmarking and then recognize the value of temperament or demeanor during a crisis so leadership when it's tough i took these principles from a book called unconventional leadership written by nancy schlichting and nancy schlichten was the ceo at henry ford health system when henry ford and the city of detroit we were emerging from financial crisis and a really difficult situation and and so these are four principles that she talks about and i found them to be uh very important during during this time and still important as this is an ongoing event being a student of leadership learning what you can getting out of your comfort zone they're going to be really uncomfortable decisions to make and you may have to make them without evidence surround yourself with supporters work with people who are helpful work with people who have the same goals as you who want to get to the same place and then keep your eyes on values and you're going to hear me talk about this a lot today because we really kept our eye on on several things and that were of significant value to us and to the students so keep your eyes on values so these four principles are things that we really went by and continue to go by today as this now has become a chronic crisis so the double amc talks about the learning environment as uh playing a key role for for uh in student with students and medical education is dependent upon an inclusive curriculum and an environment designated to promote student learning and maturation and so indeed we we have to make sure that we have a learning environment that's conducive to student learning and is in a student focused we talk about patient-centered care and the learning environment is student focused so hey march 17 2020 we don't have one we got not much okay we don't have a learning environment we have each other and that's a lot we don't have a learning environment we don't have a place to have our students to go to learn at least in the hospital setting so uh we got nothing as people people will say the platform began to burn and we didn't really have a fire hydrant none of us had ever been through something quite like this i mean there was the ebola crisis and uh those of us on the call may remember the uh you know the hiv crisis and we hadn't been through something like this where we really didn't have a hospital in which to teach patients because covet was a significant issue and continues to be so the platform began to burn and we didn't have a fire hydrant so here was the platform we had just finished week four of the six week clerkships and we were we were on we were in the middle of rotation six so there are eight clerkships in the third year to get through the curriculum here at btc som so we were we were uh in week five of kirk ship six so we had significant ways to go we had 14 weeks left in year three and that's a that's a pretty good percentage of the time that's over 25 so we had a lot of the year left uh as far as the enforce at that time we were in a curriculum just like we're in right now this morning i've been precepting in transition residency one and we were in that same curriculum at this time last year when covid emerged the match was that friday how do you have a match when you can't have people in the room together uh epas or entrustable professional activities were being completed and assessed and research day was coming up where a couple hundred people come together in order to uh to attend the research symposium so uh what what do we do there was no fire hydrant we hadn't been through this before we needed to educate students what do we do what's our guidance and who can we ask so these were all questions that we faced that week i come back to number four on that list keep your eyes on values and our compass was that the quality of agitate education must be maintained followed by there must be a workforce to care for patients july 1 2020. and and i want to emphasize whenever we communicated with the students we emphasized point one we wanted the students to be clear that the quality of their education was number one in our minds and then we also knew that number two was important as well important for hospitals and important for patients and i'll say several times and this was pounded into my head while this was all going on we must meet the learning objectives either by inpatient care simulation online cases readings we had to focus in on our learning objectives for clerkships and electives and we couldn't we couldn't let that go well communication is important always and it was especially important during this time and again from from uh uh from learning from others there are five main points that that we need to be focused in on uh address vulnerabilities due to the lack of in-person communication you really lose something i mean today i'm speaking on a zoom presentation i this is wonderful i miss seeing people's eyes looking at them as we're communicating so there's something about communicating with people in person attend to emergency communication weaknesses how do we how do we communicate with people never assume assume that an emergency communication is received it may or may not be prepare for before during and after the emergency i mean we have to handle the emergency what are we going to do and then what are we going to do afterwards and then don't overlook the value of staff support in communication so i i i read becker's on a regular basis uh becker's hospital review and i i read a lot and uh i i found this quote from hans vestberg from ceo the ceo of verizon and and you can read it there he talks about transparency and communication uh and he said throughout the pandemic verizon has hosted a daily live webcast for employees to ask questions and stay connected and i was impressed a large company like this would do something like this during this time i i also talked with my own mentor in a fellowship i completed dr jennifer daley and i said you know i feel like i'm communicating on the hospital side in the hospital side in the school side i'm communicating things over and over and i feel like i'm wearing people out and she said you know when you feel like you've gotten to the point where you've worn them out that's probably the time where you've communicated whatever you're communicating just enough so i felt a little bit relieved by that and i've kind of gone by that principle the whole time so back to the platform we had to get our m3s through each of these clerkships and the key component if you remember nothing else from this presentation is must meet the learning objectives our clerkship directors were asked to quickly put a plan together and resources for them included these things that could help create a very positive learning environment specialty specific recommendations from each of their societies and again things were evolving right it wasn't like it was all sitting there ready to go grand rounds here online cases carillion virtual lectures and online simulations an example of that would be dr mark watts from family medicine actually gave out pig's feet through the sim center and he was able to conduct some of his simulations online with the students so people were becoming creative maybe as creative as they've ever been but we we started to put together ideas and how did the students react to this they were wonderful they were wonderful this was disruptive to them it was disruptive to their education are we going to graduate what's going to happen they were wonderful they were and i listed some key words that came to my mind as i put this presentation together they were patient and kind and resilient but they also were tentative and scared but they were understanding they felt some of the things same things we did and we communicated to the students that you know we're we're finding our path as well we're finding a way through this and we're all doing this together and we're all in this together and we're working with you in order to find our way through this so we try to let them know hey we're all human in this but we're all in this together and we're all going to work on this together so what do we do well the m3s completed rotation six and and did some online work and took their exams virtually and then they started rotation seven in what we call four plus two model well what does that really mean you know what how are you going to do any clinical work and and how are we going to make this up so those were all questions on the table so in this four plus two model our course of directors put together four weeks of online work where they could study and learn and prepare for exams and then two weeks we put together a situation where they would would either take an elective or do more research time and an elective would be online uh in res or research and and we quickly put together a lot of online electives and so we put together this four plus two model and i i want to say if you're in the hospital or you're at the school and you see any of these people that i have listed here on this list please say thank you to them they really responded quickly without hesitation and put together curriculum for our students so that this year could continue to move forward and uh they they were wonderful and they're still wonderful and and i like to say that i think we have the best workshop directors in the country um and i and i like to talk about them and and again please be sure to say thank you to any of these people uh that that you see and our dr schmidly here for neurology actually won uh an award through the american association of neurology as the the best teacher in the nation uh this past year so uh thank you to all these people so the plans vary by clerkship our neurology still students took an elective and filled in that time because it's a two week rotation uh radiology became all virtual so we were able to continue in that rotation our core clerkships as i said went online for four weeks and then we had to figure out could we do some telemedicine could we make up some clinical time could we do some of that because what was going to happen was as we went back into the clinical rotations whenever we weren't sure when the time had to be made up we couldn't have people complete a clerkship and never see a patient so we were gonna do four weeks of clinical work and the more that we could do through telemedicine in year three the less time we would have to make up in year four because remember we hope to have another year three class coming into the hospital as well so in rotation seven psych and ob were able to put together um a telemedicine for our students and that really helped us once uh it really helped them to stay engaged and help them to have less time uh this this current year to to make up um so we had a rapid development of electives as i mentioned mostly virtual some were not uh some were able to to to work uh together uh inside and i'll i'll go into that in a minute eleven electives were developed of excellent quality and our faculty was phenomenal and here's what that looked like we had basic dermatology which was led by one of our one of our alum alumni and that was dr josh eichenberg in the coven 19 pandemic elective which was led by dr schlupner very and skolnik as busy as they were in history of medicine dr hugh craft hospital infection control pandemic response that was dr bafu bonnie there are some publications coming out of that elective in which he worked with a fourth year medical student wilderness medicine education from dr larue in emergency medicine advanced anatomy pro section with dr carol gilbert and then research or they could study for step two now what i hope you've taken home from this slide and we'll talk more about this as we talk more is everybody stepped up to the plate you heard me say em i am uh peeds um surgery dr gilbert people were stepping up to the plate and uh and that's something to be learned from this slide the collaborative effort we made a mistake in our communication though as we as we place students in electives and i will say i i own this mistake i've apologized to the students and i learned from this uh we placed uh it in in a rush to kind of do some things because time was moving along and we had to have them have credited electives at one point we placed them all in one elective and the students pushed back and good for them they let us know that that they didn't like that they didn't all want to take that elective and uh i i take the blame for missing the vote on communication and we got better in that area and i'll tell you how we got better but uh that was a mistake that we made uh dr very led the establishment of the covid 19 task force and we had representatives on this from each class and we began to meet weekly and we still meet this allowed us time to seek input from the students and to hear their thoughts on what was going on to hear their fears to hear their concerns and to get input on how we could move forward and it's been a very valuable uh addition to what we were doing at that time and has been up and running now for for months uh probably uh eight to ten months so back to our m4s what was going to happen with them because they were in the middle of this ttr one program well we moved our epa's to a virtual format and uh some were some were already virtual and we we canceled uh epa number 12 which was doing an iv i'll point out that today we tested them and assessed them on epa number 12 and we were able to do that in person at the sim center uh on their ability to do a procedure but most of our uh epas moved to an online format and uh and and we had some success with that and it seemed to go pretty well probably not ideal but it worked okay for us um we had the the match as well and uh there's uh dean lehrman and and dr knight and we had a virtual match and our match went very very well and uh and they they led the way on that um collaboration at its finest and i'm going to circle back to the online uh virtual ebas so we had a day uh i i had not to talk about me but i had been in new york city and at three broadway shows just until uh four broadway shows until march 8th just when on march 11th the world kind of blew up with covid and uh so about 14 days into uh what we were doing i i developed severe chills and i was supposed to oversee an epa delivery that morning and i had to then be quarantined for two weeks remember back then we weren't testing everyone uh in the same way that we are now and uh so i was quarantined but able to with collaboration of i.t and doctors fogle and dr watts and dr carp uh participate from home and we were able to do online uh virtual epa's and uh they stepped up to the plate with about 10 minutes notice and i'm not kidding about that it was about 10 minutes notice and they ran that themselves and did a great job uh we get into the idea of as our m4s move along what are we going to do because not all of them had completed icu over at the hospital and icu is a requirement for our students to be able to graduate so uh what we learned from that was we began to query the seven students who had not completed an icu rotation in that m4 year and uh we learned something that on their clerkships and in electives they spend uh you know we don't know where they are every minute they spent a lot more time in the icu than we were aware of and so we had them write a paper about their experiences and what they had learned in the icu and uh and then went through appropriate channels and had that approved as uh their uh in uh meeting that that icu requirement so we were able to to uh utilize uh their skill set in in paper writing and telling their experience in order to meet that graduation requirement and they graduated and there they are uh i think i'll always call them the covid class um there they are and they uh they were resilient and they had a virtual graduation and they had virtual speakers and uh they had a great attitude and and made all kinds of um revisions and adjustments to their schedules and and they graduated and and now they're taking care of patients and so there they are they'll forever at least in my eyes be known as the covet class and how resilient they were so what's the state of mind okay it's like people are getting tired we've been doing this for a couple months and we look back and uh you know jesus we were just a couple months into this thing at this time but you know what do you feel like it's quarantine day again or you know what is your state of mind and i saw something the other day uh on a national presentation it's become march 97th every day and that's kind of what it felt like so it's quarantine day again but we were doing the best that we could so what's going to happen are we going to be able to get our students into the hospital when we get into july and we're going to have an orientation or you know things were really uncertain and as i've interviewed people and physicians in the hospital and and people i know across the country and and read things i think uncertainty has been one of the big stressors for people across the country uh in healthcare uncertainty of when this when is a surge going to come when are we going to need more covert units how many are going to die uh am i going to have ptsd and so i think uncertainty was a big big issue and and there were four things we really needed to consider to get students back into the classroom but here's one thing you need to know about when this paper came out from a collaborative group in july we didn't know these things at this time we were making these up ourselves as we decided how are we going to work through and get our students into a clinical learning environment this came out in july we were already in the process of figuring out what we were going to do if we were going to have a clinical learning environment we had to have a capacity for clinical education we had to have ppe would there be enough we hadn't had a big surge here yet would there be enough screening and testing of students and evaluating the clinical learning environment and then looking a little deeper into that capacity for clinical education these were things we needed to think about and we were thinking about all of this and this this may be on one or two slides this is a couple months worth of work when we think about the learning environment and how are we going to have our students in a learning environment our students had to to meet learning objectives i've come back to that several times it was as a dean my seniors were were pounding into my head they must meet the learning objectives and and they must have the clinical experiences uh who's going to supervise them what happens if the attendants get coveted or they're quarantined for a long time period what what would we do uh what do we do can they seek overpatients can they see patients under investigation or pus if we as we call them what what can we do in terms of rounds uh what are what if they do virtual rounds what if we use an ipad is that compliant is it hippa compliant uh what are we going to do if our students get sick what if they're quarantined you know what if there's foes and they're quarantined do we bring them all in at once do we bring them in at some other time two months later a month later two weeks later i mean what are we going to do can they see standardized patients our standardized patients are typically 65 70 or older not all of them but some of them are they going to want to come over here and be with young people what what are we going to do how are we going to monitor our students what about a waze can they do a race what what if they want to go see their grandma in indianapolis indiana and they want to fly there what are we going to do with these things uh and how are our students going to report safety concerns and what kind of documents do we need to do all this with i hope i've conveyed conveyed what we were facing and the amount of work that was going to go into this to make sure that our students could be successful so you know when we think about re-entry into the clinical setting i collaboration i'm going to say this word multiple times it's such an important word collaboration collaboration collaboration and we really had collaboration at its finest uh our chairs who we have been talking with all along our id team led by dr skolik and dr bethubani and and and dr gardner gardner calling them uh the korean clinic c-suite supporting us and being very supportive of the school uh our deans and the double amc and then benchmarking from virginia allopathic schools uh these were the three schools that we uh collaborated with and we we've benchmarked with and we started that early on uh uh vcu and evms and we met regularly with them and we still meet with them in fact we met with them just this past weekend to talk about their their entry for for this next year uva's already started their their uh next academic year uh with their third years and so we we talked with them this weekend about how they did that and just benchmarking i think in anything we do in the hospital or on clerkships uh it's good to benchmark and see what other people are are doing uh so we had to make a big decision how are we if we could get our students how are we going to get them back into the hospital and we decided to do a four plus two model um a little different from what we talked about earlier that four plus two model had four weeks of online this was going to be four weeks of in in-person clinical learning if korean clinic allowed that and then a four plus two model where they would do two weeks of online online learning um and uh so and those weren't going to be necessarily six weeks that were consecutive in other words a student may do four weeks of peds uh clinical and then four weeks of medicine and then maybe two weeks of online ob and then four weeks of psychiatry and essentially and we can kind of smile when we talk about this now uh dr knight did a wonderful job of setting up the schedule and we were trying to out guess coven we were thinking if we have a search in the winter time that we want to make sure that we have had most of our clinical work done and then maybe we can get them back in the hospital we were thinking we were going to be removed from the hospital again because the covid would be so bad here so we were trying to outguess covet um so this slide here it says five things this right here this slide represents two months of work um we had to think about ppe and and tom hill materials management at carillion uh our standard operating procedures who was going to write them and dr harrington took the lead role on that and it took us a while to to produce those and and then we continued to update them today uh and in terms of of these things you know ppe how are we going to get it to the students uh are we going to have enough are the pa people taking care of patients going to have enough will there be enough for the students and i mentioned our sops and then boarding passes those of us who work at at korean clinic know and even here at the school we know that you have to have boarding passes every day to to get into the hospital and uh those are different for students because they don't have a kronos number like we do and so we work with a team in hr and it to make sure that our students would do the same thing as what is done at korean clinic every day and we checked the dashboard out and made sure that they were completing these and checking off if they were symptomatic or asymptomatic so that was a process in and of itself and did it work of course you have to do test runs and with quarantine and testing we relied heavily upon uh our id team to guide us on that uh and to to guide us what do we need to do and put together a plan of where our students whether they were third year or fourth year would quarantine for 14 days before they could come back into the hospital and before they could come even for orientation and then they would all have to be tested before they could enter the clinical setting so that was a plan and we worked with virginia tech on that and the health department and so that that all had to be set up and then m3 orientation we were able to have some of that in person we did some of that virtually it was interesting the part some of the parts that we did virtually the uh evaluations of those were down from prior years so uh we're going back uh uh well i'll tell you uh i think we're gonna go back to in person this year um but this this this slide here represented a couple couple months of work and these are people who participated in this i won't read the list but um i i i want to mention the word temperament here that was in our learning objectives and we're dealing with a lot of people uh emotions were running high we were unsure of what was going to happen and you know some people are here some people were at the hospital some people are in the c-suite some people are um you know in various places at virginia tech and we had to call people we had to call people a lot and you know text people call people and everyone's busy and uh the word temperament i do want to emphasize that word temperament and demeanor and i do want to give an example um but one night as we were trying to prepare our students to come back in the year three it's a friday night i still remember this it was a friday night i was pulling into my driveway and it was 8 30 and um dr mafubani called me and uh he was still at work and he wanted to walk through uh with us and infection control how we were going to uh get the students into the korean system and tested and then if they had questions after they came into the hospital who would they call and you know the covet hotline and those kind of things and i remember you know it's 8 30 at night and surely he's tired or he's had a long day or and he was so nice and i just emphasized the word temperament because it meant a lot as we work together in teams and collaborative efforts that people uh were able to maintain their cool and and be helpful because that that meant a lot that we were able to all work together so what's the state of mind well at this point we're real really feeling better because uh we think we're going to get our students back in the hospital uh and uh this is my favorite quote uh henry david thoreau uh it works well i'm also a psychiatrist so it works well for me in my clinical practice um it's you can read it um i think it gives people hope and uh it offers hope when maybe people don't have much but it's really how we how we uh how we see things and uh it's a beautiful quote and uh i've thought of it often in the past year so for n3 orientation uh we did do some of that virtual as i mentioned some was in person our m4 students were supportive and helped us out with our m3s we were able to hold an ultrasound procedures workshop at the sim center with ppe appropriate ppe uh and uh our students didn't get to meet their courtship director we usually have a luncheon with about 80 people in the room we weren't able to do that we cancelled some activities so they went into the hospital with no hospital tour and uh having never met their first clerkship director uh which was a little uneasy for them uh for our m4s uh there were uh this was uh occurring on the national level uh there were not going to be any away in person electives unless the elective here did not lead to a potential residency program so for us those were the students who were in vascular surgery or pathology or radiology or orthopedics would be another example we don't have those residencies here so our students who were going into those programs were allowed to do one away and this was recommended on a national level by the national experts double amc and others and it was recommended that they could do one away and um so it's kind of the honor system right that all schools are abiding by the rules because students uh really go away to try to see if they like the place impress the faculty there impress the residents and then maybe it's a rule out maybe they realize they don't like it so it goes it's it's bi-directional but our students were allowed to do one away elective in in some particular fields as i've mentioned that also meant things for us here at home that meant that more of our invoice were going to be here doing electives that meant a lot that meant budgetary issues right i mean that that meant a lot of things to us so it also meant that we got to see them more uh which was nice but there were uh the only ones that were allowed to go away were the ones that i had mentioned so the effects on the learning environment we did have earlier on in this academic year some anecdotal reports of students not getting to participate as much as m3s because there would be an m4 on the service and this would be an example uh a student who had to make up say two weeks of peace or had to make up two weeks of whatever rotation uh maybe would get first shot at doing something as opposed to the m3 and we we didn't hear this often but we did hear that and we have been aware of that and didn't hear it much but we wanted to everyone to have a good experience uh the learning environment has to be equitable to all involved has to be equitable and and we didn't hear this much but we're definitely aware of it and watch for any concerns about that so this is what we've been waiting for uh you know um if we have any korean clinic physicians on the phone they know that we were going to have a surge we thought according to the national models in april then it was going to be may and it got pushed back pushback and you know september august september when the tech and radford students came back that's when our numbers of korean i'm sorry of positive tests really started to go up so we started to see an uptick here uh and especially in september um and so we we started to to have uh you know more uh more concern here about covid and uh and keep that in mind because something else is coming later um and so we really began to know that at this point our students are going back into the hospital and uh they're in the hospital and we we're we're in a long-term crisis at this point um this is no longer an acute crisis this is a long-term crisis and so uh i attended a national conference for a couple hours virtually a couple weeks ago and uh pam scaliarano co at yale presented this uh topic uh and had this in her slide set and i i it really struck me because we think about leadership in a long-term crisis so you have to have a structure and we had a structure at this point and you have to make decisions even rapidly at times but you want to try to have some evidence-based decision making and we did by this time flexibility and a structure and you know sometimes you have to fill the gaps in if you don't have evidence-based information you have to fill the gaps in and uh empower individuals and teams to generate ideas and action and and listen listen to what people are saying uh respect what they're saying be open-minded and realize that maybe even your own assumptions about things are incorrect but listen to those around us and see what they say express empathy in we found ourselves doing this with the students uh every call i can say every call that we had with our coveted response task force we at some point on that call said to our students that we we realize that this is stressful and we we want you to know that we we get that and uh and we appreciate your resilience and your understanding and we would express that to the students and let them know that we were concerned and then you have to be present you know you have to be present and ready to make decisions um so moving forward through early december uh this is where we were in our clinical learning environment um there was no participation at all in the care of cover 19 patients and that continues even now or puis until november um we did decide that on peds we we felt like our clinical learning environment was being compromised there were so many pui's on that service think about it a page patient they're admitted they have diarrhea respiratory symptoms i mean they all look like a coveted patient and so we did allow our students with full ppe the proper ppe just like faculty was wearing uh to participate in the care of pui patients under investigation and if those patients then were deemed not to have covet we allowed our students i'm sorry we're deemed to have coveted we allowed our students to still participate in care but they couldn't enter the room but they could certainly attend walking rounds uh no participation in our nicu until november 2020 um as our coven numbers went up we had a change of teaching attendings on im because the hospital began to have more of a need for coveted beds coveted rooms coveted icus and so uh what was eight south a normal teaching service for us became a coveted unit and so our students uh we we um had to then include our hospitalists as teaching uh attendings and i'm i'm just so pleased to say and heartwarmed to say that we asked for a couple to help out 15 volunteered uh we we had to turn folks down who wanted to help out so kudos to the hospitalists who don't normally teach our students but they really rose to the occasion and uh and have done a super job for us and uh our students uh were beginning to be exposed and uh they many have been exposed and they were utilizing the korean clinic 19 hotline which by the way operated officially they would get back with our students within an hour or two so that worked very well uh i'm going to show this slide quickly i don't elvira birbik put this in here and i almost took this out i leave it on my own picture and hopefully you focus on adrian for one reason um and that is last week i um at night i was watching news and two newscasts came on and i was really stricken by something that they said and that was um if you're a physician you need to you need to model for other people you need to tell your patients that you were that you received a vaccine you need to inform people that you've had the vaccine so that hopefully if if they trust you you can convince others that the vaccine is okay every patient i see in my clinic every person whether virtually or in person i asked them do they have a vaccine yet if they're over 65 and i emphasize to them the importance and i answer any questions that they have so i feel strongly about that that we have to be in healthcare we have to model and uh make others aware of the importance of doing this to save lives and get back to some sense of normalcy because mental health issues are also becoming an issue as well and uh so anyway that's why i have this slide in here i want to say thank you the other reason is i want to say thank you to our id team and human resources our uh uh they've watched out for us to the point of including our students and even even checking as we began to run low on vaccine checking with us to make sure that we had enough uh vaccine for our students and uh and having us queried them and uh so i appreciate that dr skullnick and team reached out to us about that and really took care of our students here's what we were worried about here's the slide that you've been waiting on if you want to hear about his surge um our search came and as you can see it came later than the national model showed way a year ago so here we are and in january was when we peaked out and uh so this is a mean of where we were but this is what was coming and you're going to see how this affected uh even more our clinical learning environment but here it is and we had waited for this and um we had to make some changes uh but but there we are in our surge and now we're we're our numbers are down and uh had we seen this kind of numbers in october we said wow that's really high but now they're they've plateaued out and that's still an issue for us we'd like to see them come down in the hospital but they're plateauing out so we we all still have work to do mask and whatnot we have work left to do uh but in january we had to make more changes uh our eighth and ninth floors then be all became coven um and as our students returned we actually didn't have enough space for some of our students to take the internal medicine corps ship so we had to switch students out of that onto more online work and um and then we will have them take i am this spring but we had to make more changes because we didn't have a clinical learning environment at that platform it didn't look as bad as it did in one of those first few slides not near as badly i can tell you that but we had to make some switches and our students uh reacted quite well to that they were wonderful january 26th we made uh more changes in ob gyn our students can at that point can see gyne elective surgery patients if they're greater than 21 days what we call rpcs recently positive covet and now they're out of the period of where they can infect others also on ob our students for the first time this year began to be allowed to go into stage two labor um if the patients were greater than 21 day uh recently positive covered patients and our students were 14 days posts their second vaccination so they had to be fully vaccinated and in internal medicine our students can now see patients greater than 21 days rpcs but they can't go to what we call aerosolizing generating procedures with them so our changes have been ongoing and they may continue to be ongoing but things are still changing i i wanted to show you some slides so you can see our numbers um blue is our is our clinical learning environment the whole hospital the way they look at things with organization blue is 2019-20 academic year red is 2020 21. and these are just rotations one to five because rotations one to five were normal in 2019-20 and as you recall was in rotation six when we pulled the students off so we compared that to rotations one to five of this year um you know not statistically significant differences again much credit to our corporate directors and directors and our faculty and our students um our learning environment not a statistical statistically significant difference our clinical experience not statistically significantly different and then our student assessment did they think they were assessed fairly did they like their web-based online learning learning materials so no statistical significant difference is the point for all these slides so now we have a platform with a fire hydrant things are better our students are on track to graduate in both the m3 and the m4 class and we're planning for a i have a regular year three and a somewhat regular year for next year we know the aways are going to be limited uh but we we have a somewhat regular year coming up we hope uh we're we're planning for that and i i wanted to end with this and i won't read it i i would like to have a 15 second moment of silence for those who have lost their lives during covet and allow you to read this slide and recognize the beauties of collaboration and teamwork and the work that our nurses and faculty and teachers have done and these are my references excellent thank you i'm going to put this slide back up because it's i've it it's very mean very powerful i think absolutely i'm happy to take questions and again thank you for asking me to participate today absolutely thank you for sharing so much about the amazing approaches that we have all taken through vtcsom and caroline clinic to lead throughout this past year while doing as much as we could to avoid additional learner learner struggles it's not always obvious all of the work that goes on behind the scenes and there are many key points from your presentation that i really think that we can extrapolate to benefit all of our learning environments as we continue to navigate our current situation and beyond so i heard collaborate collaborate with people and organizations with whom and in ways you may not have done so before overly communicate communicate important messages until you feel as if your learners think you've done too much remember not everyone receives communication well in the same way so use a variety of approach approaches embrace being creative and innovative whoever would have imagined that we would be doing procedures with pig feet virtually stick to a structure and apply evidence-based practice decision making as much as you can but be flexible within that structure when the structure just won't work empower other individuals to help and consider others perspectives express empathy we're all doing our best um regardless of what you think or which uh at which point you're you have different priorities from others we are all trying to do our best so i think that was expressed throughout dr chris's wonderful presentation i see lots of comments in the chat that uh expressing appreciation for your review of these um these wonderful things we've all done so excellent presentation wonderful thank you so much for a wonderful um impressive response and outcome uh thank you your leadership over the past year has been spectacular and your reflections on lessons learned was filled with pearls for the future absolutely thanks tracy wonderful presentation great overview of a challenging year curling clinic and virginia tech heroine school of medicine are lucky to have such great leaders thank you so much tracy does anybody have any questions they would like to ask dr chris before we close this session for the afternoon i know we've focused a lot on the students but these techniques and strategies can really be extrapolated to all types of learners and i know that dr chris is more than happy to advise provide additional advice um or guidance and any of the individuals that she has mentioned um are fabulous resources for um strategizing for how to incorporate this within different learning environments as well.