key: cord-0709477-3e2fcx9k
authors: Moadel, Renee M.; Zamora, Edgar; Burns, Judah G.; Valdivia, Ana Y.; Love, Charito; Song, Na; Zuckier, Lionel S.
title: Remaining Academically Connected While Socially Distant: Leveraging Technology to Support Dispersed Radiology and Nuclear Medicine Training Programs in the Era of COVID-19
date: 2020-04-15
journal: Acad Radiol
DOI: 10.1016/j.acra.2020.04.005
sha: 8faf8401ada60835dfb60a7d132f0af7e98523d9
doc_id: 709477
cord_uid: 3e2fcx9k

nan

The entity COVID-19, caused by the novel coronavirus SARS-CoV-2, is defined by an array of clinical symptoms such as fever, cough, dyspnea, fatigue, nausea, vomiting, diarrhea, upper respiratory tract symptoms, and can progress to respiratory failure, renal failure, and cardiomyopathy (1) . Infected individuals can be contagious prior to exhibiting symptoms, which has led to an exponential rise in disease prevalence. The Centers for Disease Control recommends that people in the general population maintain a distance of 2 m from others to avoid infection via respiratory droplets, and wash hands frequently to avoid infection via fomites (2) .

In response to this guidance, institutions of higher-learning have almost universally eliminated in-class learning, and moved to online electronic communication platforms to facilitate teacher-student interaction. These initiatives are widespread and effective in the general educational realm, but may be insufficient within graduate medical education. Mentorship and vigilant apprentice-level supervision of patient-care activities are necessary, given ethical concerns and regulatory requirements.

During the current COVID-19 pandemic, we strive to maintain foundational elements of our radiology and nuclear medicine training programs, and to adapt our teacher-learner paradigm. Clinical review at the trainee's workstation presents concerns regarding person-to-person distancing; touching the trainee's keyboard and mouse presents an opportunity for the inadvertent spread of pathogens. Collocation of the trainees and staff in a confined reading room is no longer desirable, as we endeavor to provide physical distance between individuals. Social distancing has further eroded the personal connection in didactic lectures, as teachers must now find ways to connect with dispersed learners both within and outside of a medical center.

To address these concerns, we adapted our existing enterprise-wide communication software (Skype for Business, Microsoft Corporation, Redmond, WA) as a one-stop solution. Because this software is already installed and supported on all enterprise computers, there is minimal technical overhead and no expense. All means of communication (messaging, audio calls, and video calls) are accessed from the workstation and all department members can be quickly reached through a single interface, independent of their location. The dictation handset (Nuance PowerMic, Nuance Communications, Burlington, MA) doubles as a microphone and speaker for telephony. Conferences are presented through the same interface and can be archived using the software, so that trainees can review lectures. As a novel solution to improving didactic review of cases with the trainees, we have made use of the "present desktop" and "request control" capabilities of this communication tool. While viewing a case, either the attending or the resident can share their screen and both physicians can control the mouse, scroll through the images and point out salient findings, while conversing in real time with each other (Fig 1) . As most radiology and nuclear medicine review stations have multiple video monitors, the user can either move images to the shared screen or toggle the "present desktop" to a different monitor. This method is far superior to our previous experience where the trainee and attending physician reviewed the images separately on their workstations while trying to describe findings over the telephone.

One potential challenge regarding this technique relates to image fidelity when using screen share; both users can independently review the case on their workstation, using the communication window in parallel as a teaching tool. During the COVID-19 public health emergency, the US Department of Health & Human Services issued a Notice of Enforcement Discretion where the usual requirements regarding use of noncompliant audio or video communication technology for providing telehealth will not be enforced for nonpublic facing audio or video communication. Our enterprise has business associate agreements with the vendor, ensuring Health Insurance Portability and Accountability Act (HIPAA) compliance, and other vendors that can provide HIPAA-compliant solutions are listed in this notice (3) .

We recommend all training programs to consider and quickly adopt a HIPAA-compliant audio-video communication tool. Until such time that dedicated teacher-learner communication programs are organically built into the imaging workstations, a suite of features may already be present within an institution's enterprise-wide set of software tools. This enables training programs to keep faculty in close contact with residents while maintaining teaching and clinical care paradigms from a safe distance during the COVID-19 epidemic. Screen-capture of a Skype for Business call between trainee and attending physician employing "present desktop" and "request control" features. Image shows the resident's desktop as it dynamically appears on the attending physician's remote computer. The resident has placed software crosshairs on a region of left retroperitoneal disease on the 18 FDG PET-CT scan in this patient with B-cell lymphoma. In addition, the resident is pointing to the lesion in real time, using the mouse arrow (white arrow, right-most fused image). Patient identifiers have been removed for publication but are normally available during screen share to the attending.

Diagnosis and management of COVID-19 disease

COVID-19 related guidance from the U.S. Centers for Disease Control and Prevention

COVID-19 related guidance from the U.S. Department of Health & Human Services. Available at