key: cord-0845005-nvmhqfio authors: Frankl, Susan E.; Joshi, Ashwini; Onorato, Sarah; Jawahir, Gilianne L.; Pelletier, Stephen R.; Dalrymple, John L.; Schwartz, Andrea W. title: Preparing Future Doctors for Telemedicine: An Asynchronous Curriculum for Medical Students Implemented During the COVID-19 Pandemic date: 2021-07-27 journal: Acad Med DOI: 10.1097/acm.0000000000004260 sha: 1aab649de9b836347da41fbcb188819333083f18 doc_id: 845005 cord_uid: nvmhqfio PROBLEM: The COVID-19 pandemic led to changes in both the clinical environment and medical education. The abrupt shift to telemedicine in March 2020, coupled with the recommendation that medical students pause in-person clinical rotations, highlighted the need for student training in telemedicine. APPROACH: To maintain students’ ability to participate in clinical encounters and continue learning in the new virtual environment, a telemedicine curriculum for clinical students was rapidly developed at Harvard Medical School (HMS) focusing on the knowledge and skills needed to conduct live video encounters. Curriculum leads created an interactive, flexible curriculum to teach students clinical skills, regulatory issues, professionalism, and innovations in telemedicine. This 5-module curriculum was delivered using various primarily asynchronous modalities including webinar-style presentations, prerecorded videos of physical exams from different disciplines, shadowing a synchronous telemedicine visit, peer discussions in small groups, and quizzes with both multiple-choice and open-ended questions. OUTCOMES: During May 2020, 252 clerkship and postclerkship medical students at HMS completed the telemedicine curriculum. All students completed a precourse survey and 216 (85.7%) completed the postcourse survey. Students’ self-rated knowledge of telemedicine increased, on average, from 38 (15.1%) reporting being fairly/very knowledgeable over 4 domains before the course to 182 (84.3%) afterward (P < .001). The course was highly rated, with 176/205 (85.9%) students reporting that it met their learning needs and 167/205 (81.5%) finding the delivery methods to be effective. Of 101 (45.3%) students who answered an open-ended postcourse survey question, 91 (90.1%) reported asynchronous learning to be a positive experience. NEXT STEPS: As telemedicine becomes increasingly and likely permanently integrated into the health care system, providing medical students with robust training in conducting care virtually will be essential. This curriculum provides a promising and feasible framework upon which other schools can apply these emerging competencies to design their own telemedicine curricula. The COVID-19 pandemic led to changes in both the clinical environment and medical education. The abrupt shift to telemedicine in March 2020, coupled with the recommendation that medical students pause in-person clinical rotations, highlighted the need for student training in telemedicine. To maintain students' ability to participate in clinical encounters and continue learning in the new virtual environment, a telemedicine curriculum for clinical students was rapidly developed at Harvard Medical School (HMS) focusing on the knowledge and skills needed to conduct live video encounters. Curriculum leads created an interactive, flexible curriculum to teach students clinical skills, regulatory issues, professionalism, and innovations in telemedicine. This 5-module curriculum was delivered using various primarily asynchronous modalities including webinar-style presentations, prerecorded videos of physical exams from different disciplines, shadowing a synchronous telemedicine visit, peer discussions in small groups, and quizzes with both multiple-choice and openended questions. During May 2020, 252 clerkship and postclerkship medical students at HMS completed the telemedicine curriculum. All students completed a precourse survey and 216 (85.7%) completed the postcourse survey. Students' self-rated knowledge of telemedicine increased, on average, from 38 (15.1%) reporting being fairly/very knowledgeable over 4 domains before the course to 182 (84.3%) afterward (P < .001). The course was highly rated, with 176/205 (85.9%) students reporting that it met their learning needs and 167/205 (81.5%) finding the delivery methods to be effective. Of 101 (45.3%) students who answered an open-ended postcourse survey question, 91 (90.1%) reported asynchronous learning to be a positive experience. As telemedicine becomes increasingly and likely permanently integrated into the health care system, providing medical students with robust training in conducting care virtually will be essential. This curriculum provides a promising and feasible framework upon which other schools can apply these emerging competencies to design their own telemedicine curricula. The COVID-19 pandemic prompted many clinicians to begin conducting synchronous telephone or video visits. Including medical students in synchronous ambulatory telemedicine visits has become an essential modality for their clinical learning. Given the high degree of patient satisfaction and convenience associated with virtual visits, 1 this model of care is likely to become increasingly integrated into the health care delivery system, necessitating teaching telemedicine skills at all levels of medical training. Association recommendation for telemedicine instruction at all levels of physician education, 2 many U.S. medical schools offer neither preclinical or clinical training in telemedicine. 3 Among the subset of medical schools offering telemedicine training, few have publicly accessible information about their curricula or methodological effectiveness. 4 An urgent need exists to expand telemedicine education, supported by significant medical student interest in formal training to obtain skills necessary to conduct these visits. 5 On March 17, 2020, the Association of American Medical Colleges released its first set of guidelines strongly supporting a pause on all medical student clinical rotations to ensure the safety of both students and patients. Due to these changes in medical education, as well as the rapid adoption of telemedicine use during the COVID-19 pandemic, including students in synchronous ambulatory telemedicine visits has become an essential modality for students' clinical learning. This gap, combined with a lack of medical education experience in teaching synchronous video visit skills, necessitated the rapid development of a clinically relevant, timely telemedicine curriculum for students. Given the urgent need to train all clerkship and clinical elective students in telemedicine visits, on April 13, 2020, we began developing a curriculum focused on knowledge and skills 6 , was used to rapidly deploy a curriculum that could be implemented asynchronously, thus reaching students at different levels of training who were simultaneously also engaged in coursework and clinical rotations in a wide variety of specialties. The innovative use of embedded reflection questions, quizzes, and novel videos with faculty demonstrating telemedicine skills created active student engagement. Consistent with adult learning theory in medical education, objectives and assignments targeted learning behaviors associated with increasingly higher levels of Bloom's taxonomy 7 as students progressed through the modules (Table 1) . We consulted with local clinical and academic telemedicine experts as well as HMS curriculum faculty leaders to develop the learning objectives, which were used to create a curricular map (Table 1 ). In addition, 3 students served as advisors to the faculty course director, providing the student perspective on important learning goals. To our knowledge, before COVID-19, the literature on telemedicine teaching strategies reported few details of curricular efforts in this domain, 3 despite a recent increase of relevant work. The curriculum was presented in 5 separate modules to allow students flexibility to proceed through materials at their own pace while engaged in other remote coursework. The overarching curricular goal was to provide all medical students engaged in clinical learning with the foundational knowledge required to successfully engage with their faculty and patients, to continue developing their clinical skills using remote encounters. The first 2 modules introduced telemedicine and its role during the pandemic, as well as best practices for setting up a telemedicine visit with a patient. Module 3 focused on history-taking and physical exam skills through interactive recordings of standardized patient telemedicine visits across different specialties that addressed several key clinical questions ( Table 2) . Given the wide range of learners from early clerkship to advanced elective levels, links for supplemental clinical were placed in small groups to share their observation experiences with peers who observed different specialties. Each group collectively authored a 3-page paper addressing potential solutions to 1 of 5 current challenges in providing care through synchronous telemedicine visits (Table 1) . At the start of the course, each student was required to complete a precourse survey, administered online via the course platform immediately before the course. Eight questions in the presurvey gathered demographic information and evaluated self-assessed baseline knowledge and self-efficacy in telemedicine. The 12 anonymized postcourse survey questions were administered immediately at course completion and also accessed through the online course platform. These questions were designed to align closely with the learning objectives (Table 1 ) and enable assessment of any change in students' self-efficacy and knowledge in conducting telemedicine visits as well as engagement in each module ( Table 3 . The learning objectives of Modules 1-3 were assessed by querying student self-rated agreement with several statements (see Table 3 ). • How can one effectively convey empathy in a virtual video visit? Pediatrics: 2-year-old child with a cough and accompanied by mother • What are the benefits and challenges of video visits from a parent or caregiver perspective? • How can one build rapport over video with a parent? With a child? • What is the role of observation of the child and history-taking from the child during a pediatrics virtual visit? Orthopedics: 47-year-old man with shoulder pain after a fall • How can one perform a shoulder examination over video? • How might a virtual visit impact the clinician-patient relationship? • When is it necessary to send a patient for radiologic imaging following a telemedicine video visit for a trauma-related injury? Neurology: 42-year-old woman with vertigo • What components of a neurologic examination can be conducted during a virtual video visit? What are the best strategies to instruct patients to perform complex special exam maneuvers virtually? • How could evaluation of a patient be impacted by technical difficulty? • In what ways might language barriers influence care delivered through telemedicine, particularly for non-English speaking patients? Psychiatry: 32-year-old woman with increasing anxiety • In what ways does a psychiatry telemedicine visit with an attending clinician, student, and patient differ from an in-person session? • How does precepting during a telemedicine visit affect the attending clinician-student relationship? Geriatrics: Video recorded lecture • What strategies are available to provide care to a patient with hearing or visual impairment during a virtual visit? • How can one perform standardized assessments of cognitive function during a virtual video visit? • How can one assess a patient's mood during a virtual visit? weaknesses, and 91 (90.1%) made positive comments; for instance, "The videos of the simulated visits were fantastic. It was great to have faculty in different areas of medicine run visits for their particular specialty. " Support for the course's efficacy was further demonstrated in comments such as, "I will definitely be using some of the lessons from these videos moving forward. " Students also indicated enjoying other innovative aspects of the course such as the asynchronous format, which allowed self-paced and self-directed work plus flexible scheduling. Another student wrote, "I think that the most useful things were the observation of a telemedicine visit and then being able to discuss those as we all had different experiences and could learn from each other. " When asked for suggestions about course improvement, one student noted, This item was scored on a 5-point Likert scale: less confident, a little less confident, about the same, more confident, and much more confident with more confident and much more confident responses collapsed into a single point. their observed preceptor's specialty. These were 119/234 (50.9%) from adult primary care, 26/234 (11.1%) from internal medicine specialties, 23/234 (9.8%) from pediatrics, 23/234 (9.8%) from neurology, 16/234 (6.8%) from surgery, and the remaining 27/234 (11.5%) from other specialties. A total of 209 individual faculty precepted telemedicine visit observations. These data demonstrate that faculty from a wide variety of disciplines volunteered to teach in this online telemedicine curriculum. The high level of student self-reported learning and satisfaction reported above indicates student satisfaction with multidisciplinary faculty participation. These observations support the conclusion that faculty across specialties may serve as effective telemedicine preceptors and that the medium and the content are applicable to the major clinical disciplines. Students were divided into 64 groups of 3 or 4 for Module 5. Each group worked collaboratively to write the final reflection paper on a topic chosen from 5 potential prompts (Table 1) . All 64 groups (100%) completed this assignment. Although all topics were chosen, the most popular topic was "health disparities in telemedicine, " selected by 21/64 (32.8%) of the groups. These students applied concepts of geographic and socioeconomic disparities to telemedicine, exploring the potential to address problems or to worsen gaps in care delivery. Groups presented innovative solutions to address the potential impacts of telemedicine in each of the topic domains (see student responses in Supplemental Digital Appendix 2, at http://links.lww.com/ACADMED/B149). This innovative course demonstrates that an asynchronous telemedicine curriculum offers a promising and scalable approach to rapidly teach medical students key aspects of telemedicine, a skill now critical for all physicians. Although designed and implemented at a single medical school, it offers a generalizable mechanism for disseminating telemedicine knowledge and skills to medical students learning remotely or for learners pursuing an elective independently. Key lessons include the ability to cover a wide breadth of skills-based material with practical video recordings, as well as the flexibility of an online asynchronous modality conducive for students with competing academic demands. Providing a sequenced and logical approach to telemedicine added to students' selfreported learning, allowing immediate application of new concepts to an authentic clinical learning environment. Next steps for this curriculum include potential improvements for future iterations of the course and anticipated applications for future students and faculty. For instance, students could conduct the virtual visit with faculty supervision and feedback and solicit reflections from others involved in the encounter, including patients, caregivers, or other members of the care team. In addition, the creation of virtual telemedicine objective structured clinical examinations (OSCEs) may serve as a formal assessment tool to objectively evaluate curricular effectiveness and as a means to ensure students are evaluated systematically in developing telemedicine competencies. A pilot of such a virtual OSCE shows promising results 8 in which students could successfully demonstrate telemedicine skills within a simulated setting. Where telemedicine instruction is best positioned across a 4-year medical school curriculum in relation to a pandemic is a key question. Ideally, students will learn telemedicine skills in step with foundational clinical skills, building proficiency and facility with virtual care delivery as they move through their education. At HMS, our curriculum committee plans to integrate telemedicine instruction across the 4-year course of study. Future courses should build on telemedicine's advantages for student learning: fostering longitudinal relationships with patients, building skills in motivational interviewing and patient counseling, and close follow-up and in-home care for chronic disease management. As the popularity and novelty of this course reached the larger HMS education community, faculty requested information on how best to integrate students into their telemedicine visits. We have developed virtual faculty development sessions (e.g., "Making the Most of Telemedicine Visits with Students") and widely disseminated a teaching tips sheet and checklist. 9 Pairing these faculty development efforts with student education fills critical gaps and provides best practices to enable meaningful student engagement in telemedicine visits and optimize clinical instruction in virtual settings. Ultimately, acquisition of novel telemedicine clinical skills needed to ensure readiness of future physicians to care for patients in evolving clinical environments requires innovative approaches to curriculum, assessment, and faculty development. Eracism Every Brown-skinned physician can tell countless tales of being asked, "Where are you really from?" or "Where did you learn how to speak English?" Regardless of being American or an immigrant, regardless of having a Boston or Tennessee accent-we have all heard it. At one point in my training, I was on rotation in a wealthy suburb of a metropolitan area, working with an attending in his clinic. I went to see a follow-up patient with a chief complaint of intermittent shortness of breath. I was unable to get through even a few questions without the patient interrupting with effusive praise of my attending. "He is the best doctor I have ever known.... When will he be coming in?.... I trust him with my life. " I obtained a history and performed a physical, and then prepped the patient's nose for a laryngoscopy. I told the patient that I would return with the attending to perform the procedure and exited the clinic room. As I stood outside of the room waiting to present the patient's case to my attending, I discovered that the clinic door was not soundproof. The patient and his wife (both White) were discussing whether or not they could trust me, and whether I should be involved in the laryngoscopy. "She seemed nice. But I don't know if I want a foreign doctor doing my scope. Her English was pretty decent, and at least I could understand her accent. " I quietly chuckled to myself, as I was born in the United States and have lived here my whole life. My English is more than pretty decent. And my accent is American. Despite the fact that I had performed hundreds of laryngoscopies, I understood their concern-I was unfamiliar to them and was fully willing to concede performing the procedure. Though I may have been exactly what they thought they wanted on paper, they made a snap judgment based on the color of my skin. The attending with whom I was working was a phenomenal physician, not only in terms of diagnostic and surgical skills but also in the compassionate way he cared for patients. He was born in the Middle East. English was his second language. He had an accent. The irony was not lost on me. The patient doubted my ability solely based on the color of my skin, incorrectly believed me to be a foreigner, and discriminatingly judged me as inferior and incapable. Yet he also had full faith and confidence in his doctor, who just so happened to be from another country and had an accent. I choose to view this not as a story of bias against me, but instead of my attending's patience and perseverance. His uncompromising kindness made the patient blind to his own preconceived notions. I have marveled at this encounter time and again, and keep my attending's behavior in mind whenever I find myself in similar situations. I try to be a role model for my own residents the way that he was for me. There is no doubt that racism is a pervasive disease in medicine. When that racism is on the part of a patient, providers are forced to work harder to prove themselves worthy and capable of their jobs. Patients are often under intense stress from illness and uncertainty, which amplifies any conscious or subconscious bias they may have. And sometimes, it can be unbearable for the recipient. Sometimes we have to walk out of the room and transfer the patient to another provider. Other times we persist, refocus the conversation, and show compassion by caring for the sick, regardless of their misjudgments. 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