How do we teach telemedicine in GME?

In the October issue of the GME E-letter, we asked, "How do we train physicians to treat patients via the Internet? What constitutes appropriate oversight? Supervision? What will substitute for direct observation of trainees at the bedside? In the clinic? Will 'bedside manner' become the lost art of medicine? And since this trend will not stop, how do we integrate such experiences into our training programs? Should we be thinking about it now?"

Following are edited versions of the comments received.

As part of the Veterans Health Administration, we are now in our third year of regularly scheduled telemedicine and find that, if properly set up, the system reproduces the interaction, and the comfort and empathy, of an in-person face-to-face encounter. Our psychiatry and psychology patients actually prefer visits via this medium.

The set-up is important. In the case of neurology, almost always the physician who is conducting the interview has visited the remote site and trained an assistant to carry out the examination while the professor observes. It seems to me that observing students and residents performing a physical exam is not much different.

Of course, in a few medical specialties this is a difficult sell—rheumatology, where the "feel" of the joint is so critical, comes to mind—but the majority of medical disciplines are quite amenable to an empathetic, warm encounter, with the same standard of professionalism in the relationship as in traditional face-to-face visits.

In the surgical field, my only knowledge is from reading about the robotic techniques. The literature provides numerous informational reports of techniques using robotic arms that are remotely controlled (sometimes by communication satellites). Clearly these techniques are beginning to come of age - it is the positive feedback that the robot feeds into the gloves used for manipulation that is the effecter. This, too, may well become the method of choice for very remote communities with a scarcity of surgeons.

I agree that telehealth is here to stay, will become the method of choice in patient care for people in reasonably remote communities, and will not cause our patients to suffer from a lack of empathetic and professional care.

We have been providing otolaryngology telemedicine consultations to distant locations since 1997 and performing GME training in this modality for otolaryngology residents since 2000. As for robotic surgery, we have no plans to do this currently.

Each otolaryngology resident provides consultation via telemedicine for 1/2 day a week for 6 months during the GY-3 year. This is the opportunity for 100 percent one-on-one observation and teaching by a staff otolaryngologist in approximately 100 patients. Surgery is generated in approximately 20 percent of consultations. The resident providing the telemedicine consultation has continuity of training by following the patient from initial consultation, through surgery, and then through the post-operative care period.

The otolaryngologist takes a history from the patient using Video Tele-Conferencing (VTC). Concurrently, the consulting provider reviews the chart and enters orders for prescriptions and orders lab work and radiologic testing, as needed.

The exam is accomplished using a Web-accessible computer, a VTC unit with an audio stethoscope, and two cameras (one a 6 cm rigid telescope camera attached to an otoscope head, the other attached to a fiberoptic nasopharyngoscope). The consultant records online photos from these cameras for cosmetic, laryngeal, nasal surgery, tonsil, and sleep surgery cases.

We have evolved through three Telemedicine Medical Record software applications. The latest is Web-based and utilizes Security 180 bit, software-signed reports that are accepted as Standard Form 600 reports, which are placed in the patient's chart as an official part of the record. A CODEC in each computer connects via the respective clinic/hospital computer center through three commercial ISDN lines providing 386KHz resolution.

For more information, see:
"Teleotolaryngology: A retrospective review at a military tertiary treatment facility" Otolaryngology Head and Neck Surgery 130(5): May 2004 511-8

We use telemedicine in our psychiatry program. Supervision is the same as with live cases (eg, if a physician has to be there for the key portion of the exam, that's how it is with telemedicine). On October 21, I took part in a panel on telemedicine, with other child psychiatrists, at a meeting of the American Academy of Child and Adolescent Psychiatry.

We have seen patients via telemedicine for several years now. Our major issue is with reimbursement, but Medicaid just approved increased benefits for telemed consulatations. We see child patients weekly via telemedicine, as well as patients at a juvenile justice center, which is paid through a contract. There is a lot of opportunity to develop other sites as well as educational offerings. We're just limited by manpower.

We use online capabilities for physician-to-physician communication, and essentially none with patients.

I do have a good friend who is a very well thought of internist in our area who does all of his notes on the computer, and I have heard many comments from my friends who are his patients that he spends most of his time with his back to them, typing on the computer.

Telemedicine is not yet mainstream in many of our specialties, with some exceptions (eg, radiology and echocardiology). Other clinical specialties, such as dermatology, are leading the way in entering telemedicine. At our dermatology residency program, we have been doing teledermatology for 3 years with over 9,000 consults. Our research into the peer-reviewed literature has found teledermatology to be equivalent to traditional face-to-face dermatology in terms of diagnostic accuracy—and there are other specialties in which telemedicine is considered clinically effective as well.

The question regarding training is very appropriate and can be addressed by utilizing telemedicine in the residency program and evaluating the residents using this tool. By looking at telemedicine as a tool, we can evaluate how the residents are using it and determine if they are meeting the standard of care. It should be noted that in dermatology, we have always trained with images (kodachromes or digital images), so the transition to telemedicine is not really transformational.

In our dermatology residency (one of the largest in the US), we have a teledermatology program completely integrated into our residency so that the residents see and answer all teledermatology consults. Then, 100 percent of consults are reviewed and evaluated prior to their being sent back to the referring provider. This has allowed us to evaluate our residents using teledermatology as a tool to deliver dermatologic care. In doing so, we are able to determine if they are meeting the standards of care that we apply for traditional face-to-face care.

Clearly we can develop standards for training that are specific to telemedicine, but I would argue that the standards are not all that different from how we train today. We do provide some training and orientation to teledermatology, but I would suggest that additional standards are not necessary. In fact, we have found that using teledermatology has provided us with an additional education tool which is otherwise not available.

In my opinion, there will always be a need for face-to-face dermatology; the goal of telemedicine is not to replace it but rather enhance how we deliver care and improve access. The challenge, as you have well stated, is figuring how to integrate telemedicine into our residency and patient care in such a way that it improves the way we deliver care.

I am the program director at a US Army institution. We have a very active telepathology program with consultations between many overseas pathology departments and one- or two-pathologist departments in the US. They frequently send consults to us for a second opinion or for review of material when patients arrive without their slides from overseas. It saves a great deal of time. We also are linked with AFIP's telepathology sections so we can send over quick consults to departments over there. The residents learn to use the system during surgical pathology rotations, hematopathology rotations, and during a month-long "special studies" rotation, which includes infomatics, digital imaging techniques, traditional photography, and time in the istology, immunohistochemistry, and cytology processing areas. Many use the system after their training when they are in more isolated practices.

Last updated:May 13, 2008
Content provided by: Graduate Medical Education