The previous Editorial [¹] introduced the issue of the impact and repercussion that the COVID-19 health crisis will have on the medical training process. This second editorial aims to reflect on and explore in greater detail the effect that COVID-19 has had, and will certainly continue to have, on undergraduate training. In this reflection, we turn our attention to several aspects: on the one hand, the contents and the way they are delivered and, on the other, clinical practices and, of course, evaluation.

With regard to content, the current health crisis has brought to the fore an issue that we often forget, i.e. the need to constantly review the contents taught in the curricula. This makes it possible to resize many of the contents we currently teach in both basic and clinical subjects, some of which have become ’inflated’ and unnecessary for a general practitioner – something which the degree course is responsible for. It also allows the introduction or further development of new aspects that are barely present in our current curricula, such as public health, epidemiology in a globalised world, clinical management, bioethics, digital medicine, individual and collective protection of the health of professionals or the professional values that this pandemic has brought abruptly to our attention. But we should also be able to foresee what kind of knowledge may be useful for our students in a future where they will certainly have to adapt to unpredictable collective health issues. That is to say, we have to think ahead.

The second point is the way the contents are delivered. Up until now, in our medical schools, teaching has been carried out mainly within the context of on-site universities, that is, on a face-to-face basis. The abrupt and unexpected appearance of this crisis has made it necessary to change, or at least to try to change, the setting and the way in which knowledge is transmitted/taught. Finally, emphasis should be placed on something that is as obvious as it is neglected, namely, members of teaching staff have little or no preparation enabling them to implement the changes. Teaching teachers to teach is undoubtedly the first step.

For a long time, the contents of the courses have been made available to students in different formats and this has led to face-to-face classes losing some of their appeal and, as a result, a reduction in the number of students who attend them. Not attending classes is not an obstacle preventing knowledge from being acquired properly. The ICTs allow knowledge to be imparted at a distance by means of different platforms (Zoom, Collaborate, streaming, etc.), which the virtual classrooms of the medical school either already included or have incorporated during the months of lockdown. These technologies allow online, synchronous and effective contact to be maintained with the student. In addition, they make it possible to address teaching strategies such as the flipped classroom, group work or webinars. In short, we can say that we have before us an opportunity to engage in more personalised teaching, tutoring and monitoring of students and, above all, a different way of communicating with them.

If the new methodologies allow us to approach students in such a close and profound manner, we might ask ourselves: Should we abandon face-to-face classes altogether? The answer to this obviously rhetorical question is of course no. Distance and face-to-face training are not in competition – in fact they complement each other. The idea is to combine face-to-face activities, devoted primarily to assignments carried out in small groups, discussion of practical cases or problems and seminars, which allow an adequate social distancing to be observed, with distance training, which should focus mainly, but not exclusively, on more comprehensive teaching activities aimed at larger groups. This new perspective makes it necessary to enhance and reinforce the technological resources of the medical schools’ computer platforms along with the increased commitment of their technicians to providing teaching support, which means that the contact between lecturers and technicians must become much closer than it has been up until now. It is quite apparent that the situation created by COVID-19 implies a series of measures to ensure social distancing, but it is important to bear in mind that most of the proposed changes have positive effects on learning, whether or not there exists a complicated health situation.

A second relevant, complex and irreplaceable aspect is clinical practice. When the health contingency was declared, universities were suddenly closed and students stopped attending their clinical activities. On the one hand, this was a result of the enormous pressure on healthcare personnel (many of whom were clinical teachers), which made it impossible to follow the training process in an appropriate manner. And on the other hand, it was due to the restrictions that the new health policies imposed, for safety reasons, on all citizens, including the students themselves. Faced with this panorama, we must think about the future, and not just the immediate one, by evaluating alternatives that serve not only for the next academic year but can also to improve teaching/learning, bearing in mind that inequality between students should always be avoided so that everyone has the same chances to learn.

Clinical training alongside patients and contact with them are an essential part of learning in the clinical sciences. Learning alongside the patient is the ideal situation. It is clear that this contact has been reduced by COVID-19 but it could also be reduced in other situations. There is (on the internet) a large amount of material available for clinical training, but above all, and as the first and main option, we must place the emphasis on simulation. Simulation is an effective and efficient methodology that makes it possible to learn, within a safe setting for both students and patients, not only technical procedures but also aspects such as clinical reasoning, the acquisition of communication skills, teamwork and professional values, among others. Designing appropriate clinical scenarios in a simulated setting or the use of simulated patients should be methodologies that are routinely used in medical schools. Simulation is the teaching methodology that allows the closest approximation to real practice with patients. It is true that nowadays many medical schools have developed different types of simulations to complement or anticipate clinical practice. There is no doubt that this methodology needs to be further developed and extended. Medical schools should try to cover the maximum number of competences in the curriculum through simulations and ensure that they have lecturers who are experts in the application of this methodology.

Although simulations are used in the form of face-to-face activities, they allow better control over interpersonal safety conditions because they are carried out in small groups and also because of the specific characteristics of the facilities where the simulation takes place. But, in addition, the simulation methodology can also potentially do away with the need for on-site sessions. Thus, several education centres have developed their own teaching material with videos of simulated situations, with ad hoc video games, and also with the possibility of students attending the laboratory individually in order to repeat actions guided by video tutorials prepared by their lecturers. Students can use their mobile phone to record themselves in a simulated action, send it to their lecturers and get feedback from them, and can even be assessed on it. Medical schools must make simulation centres/laboratories the core element of medical training. No other department can offer this potential for teaching innovation, whether face-to-face or otherwise. Once again we must insist on the need to implement teacher training strategies in general, and more particularly so in the case of simulation methodologies. Moreover, once the competences in the curriculum have been defined, each course/discipline/subject will know which competences can be taught/learned through simulation. A considerable proportion the clinical practice of today’s and tomorrow’s students will involve telemedicine. The online relationship/contact with patients must be among the competences included in the curriculum, and should therefore be taught as a modality of professional practice.

An interesting survey on clinical practices was conducted by medical students at the University of Barcelona during the current pandemic. The survey showed that a high percentage of students (88%) want their practices in clinical settings to be maintained as far as possible, taking into account all the necessary safety measures, but assuming the risk of contagion. Moreover, about 70% of students considered that the best alternative to on-site clinical practice was simulation-based practice.

The current health crisis has underscored the relevance of primary care. This is a setting that should be enhanced, among other reasons, to facilitate students’ practical training. The medical schools have included primary care in their rotations, but have been sparing in providing teaching posts to cover it, granting access to university teaching resources or involving it in their teaching and research projects. It is therefore time to move towards greater integration of primary care in undergraduate training.

The last, but by no means the least important, aspect to be commented on is that of evaluation. Undoubtedly this aspect, which already played a key but poorly resolved role, will continue to be essential and with an added difficulty, namely, social distancing. Most of our usual forms of assessment (classroom tests, ECOEs – Objective Structured Clinical Examinations, assessment with simulated or real patients, etc.) will not be suitable for large cohorts and they will be affected and hampered.

Evaluation of knowledge and how it is applied can be carried out remotely. One of the main concerns of teachers in distance learning tests is the possibility of students using non-legal media and information. In addition, teachers are faced with the technological challenge of ensuring that access to the web – so as to be able to conduct the tests – is secure, easy, feasible and equitable. The lockdown has shown that we have a secure and reliable internet connection network and that, despite the high usage, it has not suffered any disconnections for university and teaching activities in general. In addition, we have numerous computer programs to detect and prevent different types of fraud. Technological improvement is undoubtedly a challenge in which universities must invest greater efforts. We can see that the profile of a professional with expertise in technology will become more and more necessary in universities, and especially in evaluation processes. These technological profiles will have to work side by side with the clinical teaching staff to put forward new proposals that are safe, discriminating and effective.

We should not rule out the possibility that evaluation may continue to be carried out on a face-to-face basis. Medical schools must have computer rooms or rooms with good Wi-Fi access that allow secure evaluations (smaller numbers of participants, safety measures, etc.). An example of this possibility is the case of the USMLE (United States Medical Licensing Examination), which must be sat by medical graduates from other countries who want to practise in the USA. These exams include knowledge questions based on both basic and clinical vignettes, clinical case simulations, imaging, functional tests, etc. In addition, an important number of students take the exam with an adequate level of security.

With regard to the evaluation of clinical skills, we should not dismiss the possibility of doing so through ECOEs, or Mini-Cex, the latter carried out at the patient’s bedside, with appropriate safety measures. The Mini-Cex can be recorded, which allows later feedback to be provided on the basis of the video recording. Several pilot projects have also been implemented with ECOEs carried out online. But, again, the role of simulation must be underlined, both in the evaluation of procedures and in the evaluation of clinical skills with simulated patients. Furthermore, the key competences (communication skills, empathy, professional values, etc.) can also be evaluated from the simulation setting. The pandemic has boosted the daily use of telemedicine and evaluating students in online interviews with simulated patients has become an alternative that many lecturers and students have experienced.

In this context, students are a fundamental element. For them, the current situation has also involved difficulties in adapting, as well as concerns about how the course would end or how it would be carried out. Lecturers must therefore take flexible steps to facilitate learning. In the case of evaluation, the participation of students is also fundamental in order to get round some of the difficulties mentioned. As has been made clearly evident in the most critical moments of the pandemic, students have displayed a high degree of responsibility by successfully collaborating in different tasks. Since clinical training and evaluation are one of the most critical points in the learning process, we must again appeal to the responsibility of our students to ensure that their behaviour regarding these processes is governed by the rule of the strictest honesty in accordance with medical professionalism.

Implementing all or some of the above issues is not easy and cannot be accomplished in one day. Medical schools must activate both human and financial resources to put all the above issues in operation and must be aware that the first step in the whole process is the development of their teaching staff. Lecturers are not used to distance teaching and applying technology to address these challenges.

However, despite all the difficulties, a progressive plan must be followed to put all or some of these measures into practice. The proposed changes are not a transitional stage to be implemented until the pandemic is resolved or it improves. The aim of these changes is to improve the teaching/learning processes. If the COVID health emergency has had any positive impact at all, it has been the swift implementation within a short period of time of a series of changes that should have been put into practice long ago. Hence, we must not squander what we have learnt during lockdown.