Education Columns

by Sarah Stumbar, MD, MPH, Florida International University; Amy Lee, MD, Deborah Erlich, MD, MMedEd, Tufts University; Lauri Ann Maitland, DO, MPH, Lynchburg Family Medicine Residency; Christine A. Adams, Florida Atlantic University; Dolapo Babalola, MD, Morehouse School of Medicine; John Hayes, MD,Medical College of Wisconsin; Aleksandr Belakovskiy, MD, Elizabeth Jones, MD, University of Michigan; Chivon Brown Stubbs, MD, Morehouse School of Medicine

Background

At the start of the COVID-19 pandemic, medical school clinical rotations were suspended overnight. Many health systems adapted to telemedicine, a safer model of patient care delivery. Telemedicine necessitates new approaches to taking a history, performing a physical exam, and documenting encounters. Given the lasting impact of the pandemic, students continue to need training in all aspects of telemedicine.

Intervention

At the 2021 Society of Teachers of Family Medicine Conference on Medical Student Education, seven schools discussed the integration of telemedicine into their family medicine clerkships during the presentation “Overcoming Challenges in Webside Teaching: Lessons Learned in Medical Student Telehealth Education.” During the session, the approximately 20 attendees completed an interactive Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis via Zoom and facilitated by the use of an interactive document that was visible to all participants. Participants added the strengths, weaknesses, opportunities, and threats related to telemedicine curricular inclusion at their own institution to the shared document in real time; this was reviewed with the group during a discussion moderated by one of the presenters. Here, we offer a summary of the SWOT analysis completed by session participants regarding telemedicine curriculum. 

Results

Strengths

Technology. Students are often more comfortable with telemedicine technologies; this allows them to play a pivotal role in the clinical care team through their facilitation of the technological aspects of telehealth.

Direct Observation. When both the student and faculty are in a telemedicine visit, the physician can turn off the camera and unobtrusively observe the student’s interview, enabling high-quality and specific feedback regarding interview skills.

Social Determinants of Health. Telemedicine allows the student and faculty to see the patient’s home environment. This may promote increased teaching about social determinants of health.

Weaknesses

Limitations to Physical Exam. Telemedicine physical exams are limited, thereby impacting students’ ability to develop these skills.

Less Direct Faculty-Student Contact. If the faculty and student are in two different locations, it can be challenging to find a time to precept, deliver feedback, or have ad hoc mentoring and career discussions.

Technology. The new technologies of telehealth may lead to unclear workflow, including how best to incorporate students. For example, if multiple patients are logged into the platform, communicating the workflow while preserving patient privacy may be difficult.

Limited Patient Visit Types. Telemedicine lends itself to specific visit types such as reviewing lab results and chronic disease follow-up; therefore, limiting students’ exposure to in-office procedures and certain acute visits.  

Opportunities

Review Physical Exam Findings. Given limitations in telemedicine physical exams, faculty and students can discuss classic physical exam findings after the visit. Telemedicine requires keen visual diagnostic skills (eg, skin manifestations) and creativity in eliciting physical exam findings (such as guiding the patient to perform shoulder exam maneuvers).

Population Health. Students can participate in population-based telemedicine by conducting chronic disease follow-up, preventive health reminders, and symptom monitoring.

Continuity of Care. The convenience of telemedicine visits for patients can allow for closer interval follow up and enable students to more directly experience continuity of care.

Technology. Telemedicine exposes students to a new way of delivering healthcare. Learning telemedicine skills presents an opportunity for professional growth for both students and faculty.

Threats

Technology. Some patients—particularly the elderly, nonnative English speakers, or patients without appropriate technology or wifi access—may not be comfortable with or have access to the telehealth platform.

Preceptor Comfort. Preceptors have little telehealth training, which may make them less comfortable incorporating students into these visits. Additionally, some faculty are uncomfortable having students call patients before the patient has expressly consented to the student’s involvement in the visit.

Competing Priorities. Faculty have experienced many personal and professional stressors with COVID-19, which may complicate their commitment to teaching students.

Discussion

The SWOT activity facilitated reflection from participating institutions about the incorporation of students in telehealth visits; there was significant overlap, particularly regarding the theme of technology, in the identified strengths, weaknesses, opportunities, and threats. We hope that our shared experiences help to highlight strategies for incorporating students into telemedicine visits, which will undoubtedly continue to be an integral component of family medicine.