Medical Students’ Readiness for Virtual Clerkships During the COVID-19 Pandemic.

Background This study aims to qualitatively examine the readiness of medical students to change to virtual clerkship during the pandemic, from both the faculty preceptors and students’ perspectives’. Methods A qualitative study was conducted based on the framework of readiness to change. Focus group discussions with students, and semi-structured interviews with clinical faculty members were done using appropriate online platforms. Transcripts were then analyzed using a qualitative phenomenological approach.


Background
In 2020, the COVID-19 pandemic resulted in a sudden disruption to education worldwide. It had a deep impact on both the medical practice and medical education. Its expansion coincided with the start of the second semester of the academic year in most academic institutions, a time when medical students had only completed a fraction of their clinical training, and hence had only partially acquired the essential clinical competencies they were supposed to gain as the main learning outcome of their training. Regular classes were shifted to online lectures, and hospitals had to prioritize pandemic preparedness. Hence, medical academic programs struggled with nding a solution to avoid compromising the quality of experiential learning that had to be delivered to medical students during that time. They were also trying to balance between the adequate level of teaching social and professional responsibilities and ensuring the physical and psychological well-being of medical students.
Qatar University Health cluster (QU Health) constitutes of the Colleges of Medicine (CMED), Health Sciences, Pharmacy, and Dental Medicine at Qatar University (QU); the national university in the state of Qatar. The Doctor of Medicine (MD) program is six years in length. The program adopts the six domains of competence described by the Accreditation Council of Graduate Medical Education, ACGME [1]. After nishing a foundation year, MD students at CMED complete a pre-clerkship for two and a half years then a clerkship training for another two and a half years. During the COVID-19 pandemic, and like many similar programs around the world, the MD program at CMED was faced with a need for creating safe and appropriate alternatives for onsite clinical training. Thus, clerkships were shifted to online platforms with emphasis on delivery of clinical knowledge and reasoning through means of case discussions. Such online sessions were delivered platforms which are supported by QU like Cisco Webex and Microsoft Teams. This shift was guided by evidence from literature about the bene ts of introducing interactive internet-based learning can offer to medical curricula across different healthcare-related elds, [2][3][4][5]. The MD program at CMED divided the time of the clerkship between online lectures and study sessions, while it differed clinical placements until after the restrictions of clinical attachments were lifted in July 2020.
Meanwhile, the program ensured students were educated about the required clinical knowledge for their clinical placements. This time was also targeted for the completion of in-program assessments such as case reports, case logs, case presentation and work-based assessments. The assessment involved case discussions assessment. Students were asked questions about history and examination ndings of common clinical presentations which were part of their blueprint. Assessment also targeted clinical reasoning, diagnosis, investigation, and treatment across a range of clinical problems. Case discussion were conducted online, but subsequent case discussions were run in the multiple mini interview formats in house. The missing element then was performance-based student assessment such as the Objective-Structured Clinical Exam (OSCE) and workplace-based assessment.
Implementing virtual clerkships VCs demands major changes at various levels. Research on change management has consistently stressed the importance of readiness as a main driver for embracing change (Armenakis & Harris, 2009). A systemic change model by Adelman and Taylor (2007) emphasized the importance of creating and promoting readiness among all stakeholders as an initial step to facilitate the adoption and maintaining the long-term application of the anticipated change.
Earlier literature on change management proposed some models for readiness of change. A model constructed by Armenakis et al [6,7] suggests ve key areas that need to be tackled to communicate and facilitate the change: discrepancy, appropriateness, e cacy, principal support, and valence. This framework of readiness can be applied to understand CMED student readiness for shifting to VC in a context of COVID-19 emergency. By applying this model, these aforementioned ve key areas should be explored upon addressing the change message to medical students and faculty.
A number of studies had generally addressed medical students' perspectives for doing their internships virtually during the Covid-19 pandemic [8][9][10][11][12]. However, the majority of published literature on readiness to online education were done in normal situations [2,3,13,14] and may not be able to describe precisely how medical students' readiness to change will look like in the presence of a pandemic, a time when change was by no means a mere choice. Many of the available studies were done to assess medical student perceptions in the context of blended internships [15,16].Thus, there is also scarcity in literature about medical students' readiness to transition to emergency full-scale VC, as happened in the Spring 2020 academic semester. It would therefore be crucial to understand medical students' initial readiness and experiences in such situations in order to ensure better clerkship outcomes. It would also be important to explore how a readiness framework would apply in the context of the externally enforced decision evoked by the Covid-19 pandemic. Hence, the purpose of this qualitative research is to study the readiness of CMED students at QU to change to VC, from their own perspective as well as from the QU clinical faculty perspectives.

Study design
This qualitative study adopted the concepts of readiness for change in an attempt to understand how clinical faculty members and CMED students at QU perceived students' readiness to the shift to VC during the COVID-19 pandemic. It was based on the model of readiness for change that was constructed by Armenakis, Harris, and Mossholder (1993) and Armenakis, Harris, and Field (1999). Using a qualitative phenomenological approach, we aimed to gain understanding of students' experiences during this shift: "how they perceive it, describe it, feel about it, judge it, remember it, make sense of it, and talk about it with others" [17].
The research team were able to develop an interview guide and a focus group guide by reviewing relevant literature discussing its ndings among themselves. The study took place towards the end of the spring 2020 term, around the time when the Covid-19 pandemic was at its peak. It ran in two parallel streams within CMED: 2 focus groups with students and 5 semi-structured one-to-one interviews with QU clinical faculty members. Both streams were run by a trained research team member who was not involved in coordinating nor delivering clinical training for the students, and utilized WebEx and Microsoft-teams online platforms. Another member of the research team was also responsible for taking detailed written notes.

First stream: Students
The study was conducted towards the end of the spring 2020 term, which is the period when the Covid-19 pandemic was at its peak. An email that included a description of the study and an invitation to participate through an online platform was sent out to all CMED students who were registered for clinical training in spring 2020. The invitation also included a consent form, which students were asked to sign before joining the focus group. Students who returned a signed consent form where then emailed regarding the planned date and time of the focus group and received a calendar invitation and a link to the electronic platform. At the beginning of the focus group discussion, the focus group facilitator reiterated the contents of the consent form and explained the rules of conduct in the group ahead of the start of the focus group discussion. Each focus group involved ve to six clerkship students of different rotations and academic levels that is years four and ve. Data Saturation was evident after the second focus groups, where no new themes emerged.

Second stream: Clinical faculty members
Similarly, clinical faculty members from CMED were contacted via an email, which included a description of the study and an invitation to participate in an interview through an online platform. Ten faculty members from both the medical and surgical rotations were invited, however only ve consented and were available for an interview. Faculty members were also asked for permission to record the session,

Data Analysis
Students' focus group discussions were audio recorded and transcribed verbatim. We used the constant comparative method for analysis [18]. Two phases of axial coding took place. The initial phase involved an open-coding process, where the focus group facilitator and the observer used the focus group transcripts and their own notes to identify themes. A third research member who did not take part in the focus group also reviewed the transcript, then the team discussed similarities in the set of identi ed themes. The second phase of axial coding included comparing the themes across focus groups.
Faculty interviews were also audio recorded and transcribed verbatim for the analysis. Inductive qualitative analysis was used to discover themes in the responses, and predetermined themes were also sought (Corbin & Strauss, 2008). Each transcript was coded and new themes were added to the codebook as they emerged. By doing constant comparisons, research members were able to differentiate between similar themes and identify their relevant dimensions. With each addition of new data, themes were added and modi ed as needed. Finally, they combined the resultant themes to produce a coherent textural description of the phenomenon.
Data analysis and its veri cation were done independently by two researcher members. They read through the transcripts, identi ed the common themes separately then came together to discuss the results and reached a consensus regarding the themes and categories.

Results
We conducted two focus group discussions that involved 4 fth-year and 7 fourth-year students of CMED (N=11) and 5 semi structured interviews with 5 CMED clinical faculty members.
Discrepancy (understanding the need for the shift to VC) Theme 1: Perceptions about the university decision and its communication to students Students were generally satis ed with the college decision to shift to VCs. To one of them, the college response was adequate, and he expressed, "College responded well when online learning was implemented the second week of the lockdown".
Nevertheless, they were only partially satis ed in the way this decision was communicated to them, and with the slow response from college upon the start of the outbreak. One student mentioned, "We went to the hospital, we did everything and we didn't hear anything from the college. They only emailed us when we complained. Okay! I'm not sure if we're supposed to complain every time just to get a response." Faculty perceived a similar view as one of them expressed, "During the early phase of the shift, no clear communication with students took place regarding how the clerkships will be handled." "So none of us was ready. Neither the clinicians nor the patients and nor the students so all of them were not prepared for this. It just happened, you know, suddenly." [Clinical Faculty 5] However, all of the faculty members agreed that the college decision to shift to VC was appropriate, quick and reasonable.
"The plan, which has been put to let the students to join again, even for a shorter period of time starting from and taking from all this and grade ve, utilize very reasonable. And it goes with this skewed situation." [Clinical Faculty 3]

Theme 2: A Perceived Lack of clinical experience
Students were disappointed with the sudden change in learning, and felt it will be less bene cial than being in hospital. They realized a huge difference in the way clerkship was being provided, with a total "backward" shift from practice to theory.
"I personally realized a huge part of experience and learning was taken away and with no alternative at the moment. Because at the moment, we're only taking online lectures" [Student 3] "taking us away from the clinical environment it was like taking us a step back to the college………we just got used to the way of history-taking and physical examination. Basically, our serious education was interrupted at that time." [Student 5] More importantly, the vast majority of students emphasized the need for a quick return back to clinical sites. Some students said they were volunteering to compensate for lack of clinical exposure: "I volunteered for the emergency. Therefore, the emergency department volunteering has been really good ", a student expressed.
"We really need to go back, even though it's risky… we would bene t more if we actually go back to the hospital or, for example volunteer or something during this situation. It would be, it would offer a great experience." [Student 5] Students also tried to nd other solutions by suggesting ways to communicate with patients online. Other Ideas included online consultations, WebEx meetings with patients and small training groups.
"We could have WebEx meetings with patients. Yeah, for example, like doctors can nd a good case, they can communicate with the patient, ask him if he wants to participate with us for example and we can see the real patient, we can take history from him". [Student 10] All the interviewed clinical faculty members echoed these views.
"I think we cannot replace it by virtual training. It might be in the future.. This is a stimulus in the future. People can do it, but again, it's called practice of medicine. We cannot give it by books." [Clinical One of them also explained that he was expecting that even in the real setting, education would be affected, as the faculty will be too busy dealing with the pandemic.
"… but we need to look at the bigger picture. Okay! Like, the doctors who are taking care of us in the hospital are actually volunteering or concentrating on the COVID situation..., so we won't have enough staff". [ Student 10] Contrarily, several students perceived that his move to VC might not be necessary because the students could have applied the infection control measures that they got extensively taught, and hence avoided losing the practical training. Clinical Faculty members gave more importance to the issue of maintaining student safety, than the students themselves did. The majority agreed that moving to VC was the best decision to protect students and patients, and to avoid overwhelming the healthcare system. "It's, it's the best why it's the best for their safety is the best for the health care sector as a whole because of the need the need and the demand of the PPEs and for the patients as well." [Clinical Faculty 5] Other faculty members argued that instead of a total shift to VC, students should better maintain at least some limited exposure to clinical settings during the pandemic.
"So, it's a bit di cult situation, but I'm still believing even limited clinical exposure was good idea even in the presence of the epidemic." [Clinical Faculty 4] Yet, some clinical faculty emphasized a need to provide students with more understanding of why such a shift is needed in order to make them embrace such a major change in their learning.
"they are still young and that is the point that we need to address to make sure that students know exactly why we do this new format and make sure that they're always objective." Clinical faculty views were widely concurrent with those of students. They stated that students would better be practicing in hospitals because this would be their duty as future doctors during a pandemic.
"…. how to use The PPE [personal protection equipment], how to limit the chance of getting the infection once you're a doctor, you cannot say no sorry I got kids. Well, everybody got kids. It's our job. We are like soldiers and you cannot say, no I can't ght the enemy because I got kids. The majority of students from CMED explained that they bene tted less from this clerkship compared to being in the hospital, as it did not provide them with the essential clinical skills. One student expressed, "Online lectures, not as useful as hands-on training and the lectures don't work for me… since the pandemic started, I didn't really gain any clinical experience." All students agreed that the VC was mainly theory and knowledge-based, and could never compensate for the actual clinical placement, which is an integral part of their learning.
"we need to communicate with the patients, take the history ourselves. after we do the physical, we can go discuss it with a supervisor and the doctor will comment on what we did, this kind of interaction you cannot replace it with online lectures". [ Student 10] Students negatively perceived the design of the VC. They felt that the VC was less appropriate than on-site training because doctors were busy and were not able to deliver education that optimally matched with the university's program requirements, and one of them expressed, "Doctors are busy, and some have a gap in education based on the college blueprint." Students believed the low number of patients seen during the pandemic deeded a compensation mechanism, such as frequent formative assessment.
"Surgery was the only rotation that I did not observe any patient in it. I feel if we take assessment. Daily assessment, regarding each topic in order to ful l all the gaps regarding surgery, for example for us people who did not attend their rotation". [ Student 2] Students who were through their rst semester in clerkships had to go through medical rotations for ten weeks and a surgical rotation for s similar period. The disruption coincided with the beginning of the second rotation and hence affected the introduction to those rotations. That was perceived by some students as lack of clear goals for the clerkship "The rst four weeks we were lost, because we don't know what is E-value we don't know what we're expected to do. We don't know what are the goals!" [Student 6] On the other hand, students opinions regarding the extent of interaction and engagement during the online sessions were variable. Some students felt that online lectures were missing the interactive component. However, others valued the efforts that clinical faculty exerted towards overcoming this issue. They explained how faculty applied several techniques to enhance the appropriateness of the VC by making the lectures more interactive and engaging.
"After the lecture, some doctors used to put a lot of questions, like, more than ten questions after the lecture to summarize the points that they're raising….
Doctors made us all join with the camera and the Mic, and also he [faculty member] was asking us to participate by the name. So, in this way, it was more engaging". [ Student 2] Clinical faculty members' stressed on the importance of students physical presence in clinical settings and that it is irreplaceable.
"I think this time of training, they need to see patients themselves, they need to put their hands on the patients. And this honestly has been jeopardized...…Again, I think they need to start from the way they sit in that clinic from the way the sit on the chair, introduce themselves to their patients…... It's very di cult.
Because if they read it, they will forget it. It's a practice. They should do it when they sit in the clinic…" [Clinical faculty3] To faculty, the VC created a need to re-structure the standard tests of clinical skills and the Objective Structured Clinical Examination (OSCE) mode of assessment. They expressed that different learning outcomes were expected from different rotations, and such speci c outcomes and objectives should have been better clari ed to students from the beginning in order for them to make realistic expectations from the VC. "In the clinical clerkship, we did the structured case discussion. It went ne, but our expectation did not match what the student have and I think is the major thing, because we cannot, based on assessment, without knowing exactly what the students have gained through their clinical training…, there should be a clear objective and by the end you achieve it." [Clinical Faculty 1] E cacy Theme 6: Belief in own ability to succeed in the VC Only one student felt con dent that students will succeed in this move to VC and expressed, "Being the rst batch we've been through so many changes and we adapted to them… I have faith in the college". However, the majority of students felt discouraged and unsatis ed with the lack of hands-on-training and one of them explained, "Online lectures, not as useful as hands-on training and the lectures don't work for me". Another student added, "It is a little bit discouraging at times, so I nd it a struggle to get back to reading things without knowing I'll ever see those things or experience them in the hospital. " Theme 7: Con dence that VC would reach its goals The vast majority of students felt that the lack of gaining clinical skills along with the lack of staff availability and lack of organization during the pandemic would not help the program achieve its goals.
"making the doctors and the faculty aware that we have a program and these are the goals one, two, three, and these are the expected learning outcomes and the students need to perform one, two, three, four and we may receive assistance from the doctors and the hospital administration for that we are able to do a few things, but in a lot of circumstances, we lose that chance." [Student 6] Conversely, faculty held more positive views about students' e cacy towards taking the VC. They mentioned how a condensed training program was given to students, at least for some rotations (such as the pediatrics rotation), which was an e cient way to make the VC achieve its goals.
"I am con dent in what they [students] had in terms of information by the end of the rotation and actually, see the difference between the rst week of rotation and the last week of the rotation and it shows while they are doing the oral presentations" [Clinical Faculty 2] Faculty also had con dence in student's abilities to carry the VC based on their positive attitude and attributes. According to them, students built the needed knowledge, were motivated to learn and were highly adaptable.
"…The attitude is very important that I think because we could make sure that students are motivated enough, and they are working towards and proceeding their rotation, make sure they have a clear objective". [Clinical Faculty 1] "Overall. They were good. Some of them were very enthusiastic about learning …They are con dent, they are very good". [Clinical Faculty 2] They also valued how this millennial generation of students accommodated the shift to virtual learning, since they possessed high computer and technological skills.
"I think the students also, I was astonished, the way the absorb the... how they understood the system and they had no problem about the online teaching at all" HCP4 Valence Theme 8: New enhanced learning approaches Almost all students appreciated some short-term bene ts from VC that were not feasible in the context of on-site trainings. They explained how they were offered extra sessions and revisions and how the clinical staff were always approachable to answer questions over the phone. It is worth indicating that attempts to standardize clinical lecture across different remote clinical sites wasn't possible due to the lack of IT infrastructure in place. That lead to the same lectures prepared and provided by different faculty each in their own hospital which was always a source of students dissatisfaction before the pandemic. Once these lectures moved online during the pandemic, students started receiving each lecture by a single faculty regardless of the location of their clinical placement, which they appreciated and considered as an enhanced in learning approaches in addition to the fact that faculty started including case-based learning in some online sessions. One of the students mentioned: "The online lectures. It's much better compared to the lectures that we take in hospital… I feel that our lectures in hospital can be replaced with online lectures to be much better even if we can take it evenings, or even at night". [ Student 9] "Doctors would give us the lecture then give us like, cases and we resolve questions. So, it's kind of like seeing a patient and discussing." [Student 1] The majority of students also agreed that the VC helped them allocate more time for studying and revising patient cases.
".. It was really di cult to study after a whole day of the training, which is from seven to three. You are very tired, you're not motivated to study or do anything for ve days, it's only the weekend when you have the opportunity to the study or to revise what you saw at the hospital. " [Student 9] Faculty members' views coincided with views of students.
"we believe now that we can do a lot of things without presence physically. And one of the things that you are doing your job now, even from other places, I think we become more accessible to our students by this telecommunications…" [Clinical Faculty 3] Theme 9: Acquired skills During the VC, students developed some skills like adaptability and problem-solving, which are very important skills.
"They teach us how to adapt to situations quickly even the college everyone had to adapt to the situation thrown at them very quickly, nd solutions to every problem. So, everyone had to look, think quickly and change". [Student 8] Theme 10: Preparing students for new types of practice in the future Faculty members perceived that the VC as an opportunity with long-term bene ts for students, such as preparing them for virtual teaching and practicing telehealth in the future.
"…. the online teaching, there will be a, it has a lot of future. So, they can use it in the future themselves to teach somebody else we can give lectures online." [Clinical Faculty 4] "I think this will be a major change in the healthcare system, the appointments and the frequency of the appointments, and having the virtual evening clinics will be a great change". [Clinical Facutly 5] Principal Support Theme 11: Academic support and communication with faculty and college Students were satis ed with the positive attitude of faculty, their availability and willingness to help at any time. "The [clerkship] director is always approachable", one student described. "The attitude of the professors and of the doctors have been really good. They've been really friendly. They're really keen on teaching us", another student explained.
"I feel like we had a lot of support from them. The staff are willing to give extra sessions and revision sessions and willing to take questions at any time. They have given us their contact numbers as well."

[Student 4]
On the other hand, a few students felt uncomfortable with the level of communication and they asked for clearer and more frequent communication about academic issues from the college. These students asked for better organization and more collaboration within the program in a way that facilitates better and e cient communication regarding assessments, curriculum and resources available during the VC.
One student explained how this would also allow more depth while studying a speci c topic. "So when I'm studying, I want to know how much in depth should I go so I can read a su cient amount on it. If you say abdominal pain, there could be a lot of topics under that. So having a speci c depth you want….that's the issue I'm facing with the blueprints at the moment". [Student 8] Students also expressed that they did not receive su cient guidance nor regular feedback on their performance and thus demanded more frequent assessments. They also asked for more support from college by assigning staff from the college as student mentors.
"We need motivation, guidance and kind of follow up, which is actually the role of mentors… So, if we had, for example, mentors from the college, this would be much better." In concordance with students' views, clinical faculty members' demanded more administrative support from college.. Clinical faculty members indicated that some disorganization and insu cient communication existed, and were mainly caused by the lack of administrative and technical support from training sites.
"We do need admin support, because I can describe how much we struggled with that at Sidra/ Hamad. Because I am working with two groups here and there, it is like, I do not know, print the schedule. I like to print the schedule sitting in my o ce. So I can allocate which student is rotating where or whatever phone I get. I know where they are. We have beautiful schedules made by XXXX colorful and last month, when I asked the nurse to print this paper for me, she said no colored printers." [Clinical Faculty2] "I think quite possibly build the station in the medical education where the faculty can go to, full prepared studio, good mike for example, with more advanced computers in order to make sure that we deliver the best possible medical education." [Clinical Faculty1] Theme 12: Psychological support to students Faculty members perceived a need to provide students with more specialized psychological support to lessen the anxiety that student might have in relation to the pandemic and its impact on their education. They indicated that faculty communicated well with students about this issue. The college also assigned a student representative board, but no student counsellors, to work closely with students, help them understand the need to change the nature of their trainings.
"Having these representatives of students, provided psychological support to the students that we are listening to. We are there… having a very close communication between the students and the college at this critical situation… the more the communication, the more students have trust and con dence towards the faculty and the college…" [Clinical Faculty 5] "I would suggest, in terms of coping strategies and coping mechanisms, that the university provides a counselor on the phone, or WebEx, or some hotline...not because of the COVID alone, but to this age group." [Clinical Faculty2]

Discussion
The objective of this study was to explore the readiness and experiences of CMED student at QU towards shifting to full scale VC during the COVID-19 pandemic. By applying the theoretical framework of readiness for change, we were able to nd that CMED students were not fully ready for the shift to VCs, and held some negative perceptions towards such a change. Results from this study show that medical students experienced a high sense of uncertainty during the shift to VC in such an emergent situation, and that students expected clearer and more prompt communication from the college about theirdecisions and the changes they applied..
Students also perceived that shifting to VC was not appropriate. Most of the students felt that having a theory-based training instead of an experiential one was discouraging. They were disappointed with not being offered any hands-on experience during the VC, as the latter could only be gained through collaboration and peer-review [19,20]. These perceptions coincided well with what students reported in similar studies done in other parts of the world during the pandemic [8, 12,[21][22][23][24]. Moreover, all CMED students and faculty who participated in this study believed that the VC could never compensate for the lost clinical experience, which are normally the most important aim from rotations. Such a nding is consistent with the literature about the importance of interaction with patients and other healthcare providers during clinical trainings as the corner stone for shaping up scienti cally grounded and clinically competent physicians [19]. In spite of the several advantages of videoconferencing technology used in medical education, literature suggests that it can constrain dialogue and does not allow for teaching psychomotor skills. [4], and students may struggle with clinical skills later [4,11].
Consequently, students were skeptical about their own ability to succeed in the VC, and whether the VC would reach its experiential learning goals. For example, medical students felt uncomfortable with the level of organization and collaboration across departments. They also asked for clearer and more frequent communication from the college in order to allow for more e cient planning of their studying schedule. Insu cient communication with educators can be a major obstacle to building con dence and capability to undertake new challenges and changes [25][26][27][28][29]. However, clinical faculty felt that students had great ability to navigate through their virtual learning experience based on their adaptability and willingness to learn. They also possessed high technological skills. This result is similar to ndings those of another study from Nepal [12] but discordant with results from 2 others studies in KSA and [8,9].
A major nding from our study was the students' motivation to remain on-site. Although the study was conducted around the time were the pandemic was at its peak, personal safety at training sites was not much of a concern to most of the students. The majority of students believed they could have applied the infection control and safety measures while maintaining their training. Moreover, they believed that, being future medical professionals, taking part in the ght against the pandemic was a professional obligation. They were disappointed with not being part of the medical team and demanded an urgent need to return to training sites. Literature has demonstrated various student views about this issue. Our ndings are concordant with those from Singapore [30], which assessed the medical students' preference and showed higher levels of preference for returning to the clinical setting during the COVID-19 pandemic, and attributed this preference to a high level of internal motivation, professional responsibility of students and the little fear that they would pose risk to patients and to the healthcare system [30]. From a similar perspective, some institutions were concerned about the type of message that moving to VC would send to medical students regarding a medical doctor's obligation to treat all patients [31,32]. Furthermore, other medical schools recruited students, medical residents and promoted nal year medical students in order meet the high demand of doctors during the pandemic [32][33][34]. Looking back at literature in 2003, during the height of the SARS outbreak in Singapore, we can see that medical students were assigned to help with temperature screenings [35]. Student perceptions regarding onsite trainings were in our study seemed different compared to ndings in other studies [36,37]. For example, and in contrary to what students in our study expressed, the majority of medical students in Brazil had negative perceptions towards being at training sites during the pandemic and many medical schools prioritized maintaining student safety, patient safety and preservation of Personal Protective Equipment (PPE) [37]. Another study called for a need for paradigm shift in medical education traditions and curriculum, to empower students and make them ready to face emergent health crisis, and concluded that no further expectations should be set for students until such measures become in place [38] The most positive student perceptions in this study were expressed towards the short term and the longterm bene ts that they gained from this VC experience. There was an agreement among all students that the VC offered several new enhanced learning approaches. They expressed high satisfaction with the case-based learning that was offered to them, and valued the opportunity they had by being introduced to telehealth, which constitutes a very important asset to their future practice [4,39]. Students also appreciated being able to allocate more time for studying and revising patient cases. They also developed some skills like adaptability and problem solving. Such student perceptions are consistent with what was reported in KSA [8,24].
Students were generally satis ed with the positive attitude and academic support of faculty members in terms of their availability and willingness to help students during the VC. Nevertheless, students were not satis ed with the extent of college communication, guidance and feedback. They also demanded more support from the college by assigning mentors, and asked for more e cient feedback on their performance by having more frequent and timely formative assessments. For instance, a systematic review by Peechapol et al consistently listed instructor feedback among the main factors that in uence students' self-e cacy in online learning [27,31].
Additionally, students reported that they received suboptimal psychological support from the college during the VC. A student representative board, but no student counsellors, were assigned by the college to work closely with students in order provide psychological support and lessen the fears they had regarding the impact that the pandemic would have on their education. There is a clear evidence from literature that medical students are subject to academic stress which in turn makes them at risk of poor mental health status and suicidal ideation [40,41]. This also goes along with existing literature regarding a deep need for improving medical students' preparedness in order for them to face challenges and threats imposed by COVID-19 on their education, as well as by the health consequences of the pandemic itself [38].
Findings of this study may be limited to participant's interpretation of experiences and perceptions may have been subject to researcher's personal biases [42]. Results from this study may not re ect the views and experiences of students and clinical faculty members of other medical schools in Qatar. No validation of the themes by study participants was done due to time constraints.

Conclusions
This is the rst study in the Arab region to ever explore medical students' readiness to shift to full scale VC during the COVID-19 pandemic. Student perceptions re ected how they are more than just learners, and that they were willing to serve some value-added roles in the provision of care during an emerging health crisis. It would be hence important to include them in the decision making and ensure proper communication with them about the need to shift to VC and about future plans for better incorporation of such major changes in their learning [31]. Efforts should be made in order to ensure medical students' safety and that of the patients without compromising the quality of clinical trainings and recognizing potential contributions that medical students can offer during a health crisis. Thus, more focus should also be done on improving medical student preparedness as one mediator for their readiness to undertake VC [38]. Medical curricula need to create channels to accommodate more in-depth learning approaches in the presence of the COVID-19 pandemic. Therefore, it would be bene cial to assist remote learning by virtual simulations and computer-based models [4,5,8,39,43]. Finally, this study can aid in understanding medical students' current experiences in order to prepare competent medical doctors who will essentially advance healthcare outcomes and ful ll the healthcare needs of Qatar.