key: cord-1014618-vyofha9m
authors: North, Riley; Vitto, Christina; Hickam, Grace; Santen, Sally A.
title: Remote Learning in the Time of COVID‐19
date: 2020-05-21
journal: AEM Educ Train
DOI: 10.1002/aet2.10483
sha: 585ec066720ee673fae9a0be99b3e9438a1af64a
doc_id: 1014618
cord_uid: vyofha9m

With the spread of SARS‐CoV‐2 in the U.S., medical schools across the nation have taken measures to protect the health and safety of their students. Notably, most schools have elected to suspend clinical experiences for medical students as the pandemic evolves. Many schools have demonstrated creativity and adaptability by developing online, non‐clinical electives for their students to engage in.

With the spread of SARS-CoV-2 in the U.S., medical schools across the nation have taken measures to protect the health and safety of their students. Notably, most schools have elected to suspend clinical experiences for medical students as the pandemic evolves. Many schools have demonstrated creativity and adaptability by developing online, non-clinical electives for their students to engage in. Here, we provide an easily implemented opportunity for remote clinical learning in the time of COVID-19 in the Emergency Department.

This process affords students the opportunity to practice history taking, differential diagnosis, clinical reasoning, and patient management skills from a remote setting (Figure 1) . A student will be assigned to a resident or attending and will be available by cellphone, tablet, or other communication device when that physician is working. The resident or attending will contact the student prior to the shift and set a time period when a patient will be identified for the student to interview. Ideally, the student will also have remote access to the electronic medical record for chart review. Low volume or fast-track shifts likely will be most amenable to this scheme.

During the session, the student performs iterative differential diagnosis formulation, as described in other medical education schemes. 1 The Clinical Reasoning and Differential Diagnosis Sheet ( Figure 2 ) is a helpful tool to guide clinical reasoning. Figure 3 demonstrates a completed version based on a remote learning case regarding a 45-year-old healthy male presenting with 2 weeks of lower back pain with bilateral sciatica after an episode of heavy lifting and with a recent history of rollover motor vehicle collision.

At the end of the remote session, the physician and student should review concepts learned during the session and provide feedback. Assessment and teaching of clinical reasoning can be integrated into the case presentation through clinician verbalization of their own thought process. 2 Evaluates patient, asks permission for student to conduct a remote interview, arranges for student to interview the patient (call phone in room, tablet, etc.) and provides the student with the patient's chief complaint, demographics, and vital signs.

1. Receives patient information from the physician and prepares an initial differential diagnosis.

Receives oral case presentation from the student and reviews the Clinical Reasoning and Differential Diagnosis Sheet with the student to guide learning. Time permitting, provides 5-minute teaching on the patient. 4. Writes note, prepares and presents an oral case presentation for the physician.

5. Follows the patient in the electronic medical record for the duration of their care and self-studies the differential and management for the case. Assigns further patients per this scheme. May also assign interesting patients as chart review cases for student self-study outside of this framework.

3. Reviews historical data in the chart (including present-day physical exam) and completes a Clinical Reasoning and Differential Diagnosis Sheet.

2. Prior to reviewing the chart, contacts the patient and conducts a remote interview with subsequent revision of the differential.

As the pandemic continues to evolve, identifying and implementing opportunities to provide some form of clinical continuity and education for medical school learners will be of high value. This simple scheme provides for real-world case practice from a remote setting in the current (and likely recurrent) event that learners are not permitted in the direct clinical environment. In a time demanding adaptability and creativity, we believe this process offers a reasonable model of clinical learning and a valuable engagement for learners. List findings that support this hypothesis 3. List findings that oppose this hypothesis 4. List findings that would be expected if the hypothesis-at-hand were true but which were not encountered in the case 5. Return to your differential list, and reorder the alternative hypotheses if the first hypothesis proved to be incorrect Diagnosis Findings supporting Findings opposing Findings that would be expected but not seen Diagnosis 1: Ask faculty for feedback (i.e., strengths, areas for improvement) -focused on "serious" causes of back pain which are important to rule out; work on also identifying more of the most common causes. What is one concept you learned? These patients benefit from early multi-modal pain control including an NSAID, acetaminophen, and a muscle relaxant. What might you do differently next time? I need to remember to ask for/perform a full lower extremity neuro exam for these patients including reflexes and thorough sensory exam. 

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Can Think Aloud be used to teach and assess clinical reasoning in graduate medical education?

Reflection as a strategy to foster medical students' acquisition of diagnostic competence