How the telehealth boom is changing physician training

Brendan Murphy , Senior News Writer

How to teach and assess competence in telehealth has been a topic of import in medical education for years. The COVID-19 pandemic, however, has transformed care to more digital media. How has medical education responded?

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That question was broached in a recent episode of the “AMA COVID-19 Update.”

Prior to the pandemic, training on telehealth was limited. That made sense—very few physician-patient interactions took place outside of an office. Now that has changed, and educators are working on a response.

“Before COVID, nationally, telehealth was used for about less than 1% of total encounters in volume,” said Vimal Mishra, MD, medical director of telehealth and informatics at Virginia Commonwealth University Health (VCU). “If you think about this and then boom, mid-March you're seeing about 60 to 70% of the visits delivered through telehealth. And of course, there's been lot of challenges.”



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One principal challenge has been that physicians are not skilled enough in telehealth to work with medical students and residents.

“A lot of people focus on ‘How do I use telehealth technology?’ but the real question is ‘How do I integrate it into my practice?’” said Richard Van Eck, MA, PhD, associate dean for teaching and learning at the University of North Dakota School of Medicine & Health Sciences, one of 37 member schools of the AMA Accelerating Change in Medical Education Consortium. “And that's not just health care, it's also now teaching students in that same process.

“So, when clinicians are learning this process and this technology for the first time and students don't know what to expect, a lot of students get relegated to that observational role,” Van  Eck said. “We know we have to build our training around those things.”

The challenges extended beyond medical school to residency training. “It was a real shock to our system,” said Brian Garibaldi, MD, associate professor of medicine at Johns Hopkins University School of Medicine. “We had not had a lot of prep time in terms of ramping up telehealth, particularly amongst our residency programs for internal medicine. And back in March and April—when clinical care essentially shut down outside of COVID care for several months—telehealth is really the only way that our residents were able to keep up their continuity clinics and to maintain contact with patients.”

“And there's a huge institutional-wide effort to get the technology working, obviously. But once we had the technology and the capability we realized: Wow, we have a whole generation of clinicians who haven't used telehealth, who are now in charge of training others to use telehealth during their own training.”

When the pandemic hit, with students initially pulled from clinical rotations, VCU worked swiftly to create a telehealth elective. “We had an M4 elective before this whole thing started, and it was more of an elective,” said Dr. Mishra. “These students would say: All right, yes, I think telehealth is something, it was in parallel with traditional health care delivery. Now it was more of a need. We quickly ramped up and created M3 curriculum and try to teach them. The good part of this is the students, they learn so quickly. They actually helped attending physician to navigate with the technology as well. Telehealth isn’t going anywhere after the pandemic, and that does offer some advantages to both patients and educators. One significant difference telehealth offers is that faculty members have the ability to observe, from a distance, in real time.

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“We're able to actually watch our learners go through these encounters in real time and then provide them real time feedback on things that they might want to incorporate into their next encounter,” said Dr. Garibaldi. “So, the next time they see someone with shortness of breath or problems with ambulation or problems with sensory loss, they actually know: What can I accomplish over telehealth? And I think equally importantly, when do I need to say: You know what, I'm not going to be able to get the answer through telehealth. This is someone I need to prioritize for an in-person visit or another evaluation.’”

For more detailed tips on engaging learners in telemedicine visits, watch the webinar from the Accelerating Change in Medical Education Consortium in June 2020.

The AMA has curated a selection of resources to help residents, medical students and faculty during the COVID-19 pandemic manage the shifting timelines, cancellations and adjustments to testing, rotations and other events at this time.