ACP Resident/Fellow Member David J. Savage, MD, PhD, was halfway through his residency at the Cleveland Clinic in March 2020 when, suddenly, it was time to learn telemedicine from scratch.
“Up until that point, I had never done a virtual visit at all,” he said. “And I would say, by and large, the faculty members, just a handful of them were doing some form of virtual visits.”
Despite the novelty of telemedicine, internal medicine programs recognized the immense, immediate need to deliver patient care safely from a distance. “We, just like everywhere, had canceled a lot of our ambulatory clinics while we were figuring out what to do with COVID, and … we were scrambling as a program to figure out how we could continue to keep residents seeing patients, since everybody was going to be virtual,” Dr. Savage said.
Across the country, the volume of virtual visits soared. Prepandemic, Johns Hopkins Medicine in Baltimore did 50 to 80 telemedicine visits a month across ambulatory services, said ACP Member Brian Hasselfeld, MD, medical director of digital health and telemedicine, during the C. Wesley Eisele Lecture on the future of telemedicine at Internal Medicine Meeting 2022, held in April in Chicago.
“In March of 2020, obviously, all of that changed, and by April, May, and June, we were nearing 100,000 outpatient telemedicine visits across our footprint—over 1,000 times increase in a period of 60 days,” he said.
The trend remained stable through 2020. During that year, the overall number of Medicare visits conducted through telehealth in the U.S. grew to 52.7 million, a 63-fold increase from about 840,000 televisits in 2019, according to an HHS report published in December 2021.
Since then, telemedicine use has leveled off but still hovers above prepandemic figures. In 2021, about 20% of total ambulatory visits at Johns Hopkins were conducted via telemedicine, according to Dr. Hasselfeld.
As policymakers continue to assess regulatory issues, medical educators and residents continue to refine the best ways to teach and learn telemedicine.
Pros and cons
Prior to the pandemic, telehealth was a blip on the radar in medical education, said ACP Member Ryan Jelinek, DO, during an ACP Telemedicine 201 webinar in January. “[It] never really garnered much significant attention amongst medical educators, given the higher-yield competing priorities that it was up against within such jam-packed curricula,” he said.
Telemedicine appears to be here to stay. However, more than one year into the pandemic, a survey of residents at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs in the Minneapolis/St. Paul, Minn., region found that only 15% reported any formal training around the provision of care via telehealth, according to results published in July 2021 by Telehealth and Medicine Today.
“I suspect that this finding is consistent in many academic medical centers across the country. … Many medical education programs either didn't have the capacity or bandwidth to develop curriculum or have yet to prioritize the creation of strategies to properly train learners in telehealth,” said Dr. Jelinek, coauthor of the study and medical director of telemedicine and access for the department of medicine at Hennepin Healthcare.
A big reason why there has been such limited education on telehealth up to this point relates to a lack of guidance or expectations from governing organizations within academic medicine, he noted. “Without this, many programs did not feel that telehealth education was something that warranted prioritization among the vastness of internal medicine training,” Dr. Jelinek said.
This changed with the 2021 ACGME updates, which incorporate digital health as a milestone for internal medicine, he noted. The milestones state that Level 1 learners should be able to identify the required components for a telehealth visit, Level 2 learners should be able to perform assigned telehealth visits using approved technology, Level 3 learners should be able to identify clinical situations that can be managed through a telehealth visit, Level 4 learners should be able to integrate telehealth effectively into clinical practice for the management of acute and chronic illness, and Level 5 learners should be able to develop and innovate new ways to use emerging technologies to augment telehealth visits.
“With this guidance in place, it's clear that this is a field of medicine that has gained prominence and is worthy of the attention of internal medicine educators,” Dr. Jelinek said.
In addition to following ACGME guidance, he recommended that educators train learners in the importance of telehealth from a patient-centered lens. “Many studies published over the past two years have shown great support and patient satisfaction with these virtual modalities of care delivery,” Dr. Jelinek said. “With this, there is also a growing body of evidence to support the efficacy of virtual care centered around patient outcomes and cost savings.”
Despite telehealth's potential to improve longitudinal care, trainees and educators have faced many challenges with virtual modalities throughout the pandemic. In one study that surveyed 95 internal medicine residents in August 2020 in New York City, only 2% believed the patient received the same level of care when comparing telemedicine visits with in-person visits, according to results published in February 2021 by PLOS One.
The survey showed that 83% of residents preferred in-person visits during their training, 65% thought the telemedicine experience will affect their future career choice, and 67% would prefer to have less than half of their visits be telemedicine in the future. No respondents thought patients were always comfortable discussing their medical conditions over the phone, and 74% agreed that telemedicine visits increase the chance of patients being lost to follow-up.
Lead author and ACP Resident/Fellow Member Chia-Yu Chiu, MD, who was a third-year resident at the time of the study, offered a few potential reasons why residents may not be so keen on having a tall telemedicine workload in the future.
First, he said, since telemedicine curricula are not well established, residents may feel rushed into using the technology or otherwise poorly prepared. “Language barrier is also a problem, and another thing is the lack of physical examination,” Dr. Chiu noted.
His study is one of the first to document telemedicine from an internal medicine trainee perspective, said Dr. Chiu, now a second-year infectious diseases fellow at the University of Texas Health Science Center at Houston. (Jacob Quinton, MD, MPH, FACP, Chair of the ACP Council of Resident/Fellow Members from 2020 to 2021, led a survey study on resident and fellow perspectives on COVID-19's impact last year, although it doesn't principally address telemedicine; results are pending publication.)
“My study's conclusion is that we are not ready for telemedicine,” Dr. Chiu said. “We need more supervision, and we need to have a good protocol.”
Working out the kinks
Educators and trainees may have been unprepared for telemedicine visits when the COVID-19 pandemic hit, but more recently, programs have made inroads in designing effective curricula.
One model is the four quadrants of telehealth teaching, developed by Ben Li, MD, MBA, and Julian Genkins, MD, ACP Resident/Fellow Member. These include facilitating learning, optimizing logistics, building skills, and innovating, explained Pamela Vohra-Khullar, MD, FACP, during the ACP webinar.
To facilitate learning as an educator, promote learner engagement by explaining the benefits of telemedicine, and encourage independent problem solving, as telemedicine requires creativity, she said. As with teaching in general, it helps to be kind and understanding and to admit your own weaknesses, since telemedicine is new for everyone, Dr. Vohra-Khullar said.
Optimizing logistics, on the other hand, can be a more complicated matter. “I probably spent the first few months of the pandemic just working on this part to try and perfect some things,” said Dr. Vohra-Khullar, who is an assistant professor of general internal medicine at Emory University in Atlanta.
She recommended meeting in person with trainees if possible, exchanging cell phone numbers, and identifying colocation procedures (e.g., the learner and preceptor are colocated in person, with the patient remote). While the level of supervision will vary based on the learner and the preceptor's comfort level, be sure the learner knows how to ask for help during a virtual visit (e.g., secure messaging, texting, muting the call and speaking by phone), Dr. Vohra-Khullar recommended.
Building skills is the “real crux of the teaching,” she said. Teaching after a telephone visit should focus on proper phone communication skills (i.e., empathetic, no jargon), triage skills, and counseling patients about self-management, while teaching after a video visit should review webside manner (i.e., working with others who are virtually present, setting up the camera), the virtual physical exam, and counseling about COVID-19 public health measures, Dr. Vohra-Khullar noted.
Innovation, the final quadrant, can include repurposing highly effective tools for in-person learning for virtual formats, such as simulation labs, said Dr. Jelinek. “Training learners on how to tackle some of the more common connectivity issues the patient might have in a simulated environment is a great way to help improve efficiency and comfort around these types of issues that most learners have never received any training for in the past,” he said.
Indeed, medical educators should test their virtual visit platform out first, according to the “T” in the TELEMEDS framework, presented in a March 2021 article published by JMIR Medical Education. The rest of the mnemonic recommends that medical educators evaluate their schedule, lay out an agenda, establish visit rules, modify their speech, encourage patient engagement, demonstrate positive nonverbal communication, and summarize next steps.
But back in March 2020, such frameworks weren't readily available to scrambling internal medicine residency programs. As the Cleveland Clinic tried to figure out how to properly train its residents in virtual visits, program leaders tapped the three residents in the Clinician Educator Track for help.
“They said, ‘Is this something you can help us with? Because we need to come up with something pretty quick,’” said Dr. Savage, who was a second-year resident in the track at the time and is now a second-year hematology/oncology fellow at Scripps Health in San Diego.
Word had gotten out that the residents had started thinking about creating a telemedicine curriculum just one month prior to the pandemic. “At the time, we didn't have a whole lot; we just had a lot of brainstorming, and so that's what really spurred us to start working hard on it,” he said.
The team finalized the curriculum in five weeks. It included introducing a formal training program for residents, creating a resource guide for different video communication tools, and training preceptors to supervise care. The majority of residents who responded to a preparticipation survey had no prior telemedicine experience and expressed only slight comfort with the modality. In a span of 10 weeks, residents performed more than 2,000 virtual visits; 64.9% of those who responded to a postparticipation survey said they had acquired new knowledge as a result.
Dr. Savage said that he initially envisioned doing a capstone project during residency, not designing a telemedicine curriculum during a pandemic. “But it ultimately turned into this, and this was the most impactful, meaningful thing that I never could have imagined coming in,” he said.
Soon after designing the curriculum, Dr. Savage moved with his spouse across the country and started his third year of residency in August 2020 at the University of California, San Diego. He was surprised to see similar progress in telehealth at a different residency program.
“Everybody was doing exactly what we had talked about at a brainstorming session six months prior, where it seemed like, ‘Well, maybe in five years we could be doing this,” Dr. Savage said.
He attributed that innovation solely to the pandemic, noting that newer trainees seem to be much better prepared for telemedicine visits due to exposure in medical school.
“It felt so new and so abrupt and so futuristic to be doing it in real time as the pandemic started, but now, people are getting exposure further down in the education pipeline. They come into residency or fellowship, and it's just kind of part of their standard workflow,” Dr. Savage said. “I feel like [the pandemic] just catapulted the way we do ambulatory health care forward by years.”