Integrating Telemedicine Training into the Graduate Medical Education Curriculum

Introduction

With the dawn of the COVID-19 pandemic and the need for enhanced social distancing measures, the use of telemedicine has grown significantly in the past year. The Centers for Medicare and Medicaid Services (CMS) made policy changes during the pandemic to allow expanded access to telehealth services. These regulatory changes included improving provider payment for telehealth visits, enabling patients to access telehealth services from home, and allowing providers to offer telehealth consultations to out-of-state patients.¹ With broadened access to telemedicine during the pandemic, the Center for Disease Control and Prevention (CDC) reported a 154% increase in telehealth visits during the last week of March 2020 compared to the same week in March 2019.² As the application of telemedicine becomes more common and relevant, it is essential to educate trainees on how to deliver care through this platform.

While medical schools have started to integrate telemedicine training into their curricula,³ there are few reports of telemedicine training in graduate medical education programs. A recent study found that only 1 out of 104 specialties (Child and Adolescent Psychiatry) listed telehealth in the competency-based milestones by the Accreditation Council for Graduate Medical Education (ACGME).⁴ In 2016, the American Medical Association (AMA) adopted a policy to encourage undergraduate and graduate medical education to incorporate telemedicine training as a core competency.⁵ Formal training in telemedicine is recommended because the virtual patient-physician interaction requires a different skill set compared to the traditional in-person interaction.^6,7 Competencies that are specific to telemedicine encounters include, but are not limited to, the virtual patient-physician relationship, telehealth consent, HIPAA considerations, digital communication and “webside” etiquette, the virtual examination, and familiarity with video-conferencing platforms.

Tele-emergency medicine’s importance is at the forefront in the rural areas of the United States, where limitations both in facilities and physicians can lead to delays in treatment for many throughout the country. A study conducted in 2014 revealed improved care coordination and shorter time to care for emergencies in rural areas when an emergency telemedicine physician was incorporated.⁸ Despite this, and a growing number of emergency departments across the country adopting telemedicine services for psychiatry and neurology,^9,10 emergency resident exposure to telemedicine training is limited. Few studies have been conducted on this training.

In this study, we describe an innovative telesimulation program for emergency medicine residents that utilized standardized patients to simulate telehealth visits. The primary objective of this study was to examine current emergency medicine resident knowledge of telemedicine and analyze the effectiveness of the telemedicine training on completing a successful encounter. We also aimed to analyze the residents’ attitudes towards telemedicine training as a whole and how likely this workshop would have an impact on their future careers.

Methods

The study was conducted at a 3-year EM residency program that matches 7 residents per year. The primary teaching site is a community level II trauma center with an ED volume above 75,000 patients per year. Seventeen emergency medicine residents first underwent a virtual session using standardized patients to complete a simulated telemedicine encounter without any prior training on telemedicine. The Zoom^TM telecommunications application was used to simulate teleconferencing with the patient. The scenarios can be found in the appendix. Each encounter was a maximum of ten minutes. After each encounter, the standardized patients evaluated each resident with regards to competencies in telemedicine. One week after the initial training session, sixteen of those seventeen residents completed asynchronous learning with assigned readings on telemedicine and attended a virtual lecture given by an associate professor of medicine at the University of Central Florida who is also an experienced telemedicine physician. The lecture focused on the fundamentals of a successful telemedicine encounter, including but not limited to: obtaining telehealth consent, virtual physical examination, ensuring privacy through telemedicine. After this intervention, the sixteen residents underwent another virtual telemedicine encounter with standardized patients. Each resident rotated through four different scenarios. Each encounter was a maximum of ten minutes, followed by a ten minute debrief focusing on the fundamental elements of a telemedicine patient encounter. The standardized patients again rated the residents’ ability to complete a successful telemedicine interview. The assessment questions were curated by the director of simulation and the experienced telemedicine physician (Table 1). The responses were scored as follows: “0” for “Not Done”, “1” for “Done Partially”, and “2” for “Done Completely”. Residents also completed a post-workshop survey on their experiences with the training (Table 2). These responses were scored as “Strongly Disagree”, “Somewhat Disagree”, “Neither Agree nor Disagree”, “Somewhat Agree” and “Strongly Agree”.

Results

Standardized patients evaluated 17 emergency residents before telemedicine training, and 16 of those 17 residents after telemedicine training with a 13 question survey focused on aspects of a successful telemedicine interview. Standardized patients scored these questions at “0” for “Not Done”, “1” for “Done Partially”, and “2” for “Done Completely”. The average scores of each question seen in Table 1 are shown in Table 3, as well as the left-tailed Z score and p-value for each question.

Statistically significant increases were noted on the following scoring categories: verifies my name and location, obtains telehealth informed consent, asks about my privacy in my environment, speaks clearly and ensure that I can hear him/her, explains the telehealth examination process and sets expectations, centers him/herself in the center of the screen, and looks directly and the camera and explains if he/she needs to look away. A statistically significant decrease was seen only in: asks if I understand the plan and have any other questions.

Aspects of the encounter that did not have statistically significant differences on pre- and post-test surveys included: introducing him/herself, asks focused questions regarding my condition, pauses to allow me to answer questions, explains his/her assessment of my condition (ie. differentials, diagnosis), and closes the encounter by explaining the care plan (ie. prescriptions, follow-ups).

Fourteen residents responded to a survey after the post-training sessions, with 92.8% of respondents stating that they “strongly agree” that the telemedicine training was helpful to their education. With regards to the question of “I understand how to do a virtual physical exam”, only 28.6% of respondents stated “strongly agree”. The remainder of the resident survey can be found in table 2.

Conclusion

Overall, emergency medicine residents had significant improvement on aspects of an encounter with a standardized patient that were unique to telemedicine after undergoing training from an expert in the field. Resident physicians scored well both before and after training on aspects of the encounter not pertaining specifically to telemedicine, suggesting good clinical overlap between virtual and in-person environments. Residents uniformly felt the training was helpful to their education after completing the training. Participants did feel less confident with the ability to do a physical exam during the encounter, which could be ameliorated with more practice in this environment. Given that a large portion of residency programs across the country are utilizing teleconferencing for weekly didactic sessions, similar training could easily be utilized across the country in emergency medicine residencies. This training could prove to be essential in the future because of the global health crisis of the COVID-19 pandemic, but also has other emergency applications including rural emergency medicine, rapid triaging of patients and virtual medical education.

Ethics approval and Consent to Participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the University of Central Florida Institutional Review Board (Study number 00001861). The requirement for written informed consent was waived as the obtained data was de-identified.