ABSTRACT
BACKGROUND: The transition to telemedicine at the onset of the COVID19 pandemic revealed a need for new clinical communication skills. Previous standardized assessments indicate that telehealth requires a distinct skill set that most residents and physicians have not yet mastered. We created a competency-based experiential training program using announced standardized patients (ASPs) to train and assess clinicians in virtual practice. METHODS: From June to October 2021, clinicians participated in a video tele-visit in which an ASP portrayed one of two cases;(A) a 70-year-old man with hearing loss and hypertension or (B) a 60-year-old man with hypertension and financial stress. Following the visit, ASPs provided verbal feedback and completed a behaviorally anchored checklist to rate telemedicine and communication skills, chronic disease management, and use of VA resources. Domain summary scores were calculated as the mean percent of “well done” items and compared using a t-test. Individualized reports and educational resources were shared with participants within a week. Post ASP visit, participants reflected on the feedback they received and their experience. RESULTS: 56 visits (40 residents, 16 attendings) were conducted. There was no significant difference in performance between clinician type and between cases for telemedicine and communication skills. Clinicians performed moderately well in communication skills (information gathering (75% well done), relationship development (68%), education and counseling (73%), and patient satisfaction (86%). They performed less well in telemedicine skills (nonverbal behavior (36%), computer etiquette (36%), optimizing technical aspects of video (26%). Use of clinical resources varied between cases. For case A, only 42% placed referrals for mental health counseling but 88% for audiology. For case B, 60% referred to social work but only 21% to a pharmacist for hypertension management. Participants agreed that the experience was engaging (92%) and a good use of their time (88%). When asked what they would do differently, most clinician responses related to optimizing technology (“be more aware of camera angles,” and “ask about volume on the device”), ensuring patient preparedness (“be clear about time limit,” and “not assuming computer literacy”), and adapting relationship building skills to the video platform (“give time for social conversations,” and “comment on patient's home environment”). CONCLUSIONS: Findings suggest ASPs are an effective and engaging educational methodology to assess clinician practices across multiple domains, including key telemedicine skills. ASP feedback facilitated just-in-time training and commentary from both clinicians and ASPs and identified areas for improvement in future telehealth practice and assessment.
ABSTRACT
BACKGROUND: The COVID-19 pandemic has led to an unprecedented and rapid increase in telemedicine visits. It is unclear how this has affected resident training. This study explores Internal Medicine residents' perceptions of the impact of the transition to telemedicine on their learning experience. METHODS: Three focus groups were held over Zoom with post-graduate year 1 - 3 residents at the New York University Grossman School of Medicine who have their Primary Care continuity experiences at the Manhattan Veterans Affairs Medical Center. Issues explored include relationships with patients, decision-making around clinical issues, use of preceptors, and general impressions of tele-visits. Recordings of the focus groups were transcribed and thematically analyzed. RESULTS: Common themes across the focus groups were categorized into five domains: 1) building patient relationships, 2) using the remote setting, 3) judging appearance and physical examination, 4) confidence with decision making, and 5) interactions with supervisors. Participants felt that they were able to maintain relationships with pre-existing patients, particularly those with chronic conditions for whom tele-visits were an appropriate and even preferable alternative to routine in-person encounters. Participants reported difficulty connecting and building rapport with new patients but suggested the remote setting was helpful for providing additional context (e.g. input from a family member), allowing them to better understand patients' concerns or circumstances. However, some participants expressed hesitancy about asking personal questions because patients were not in private settings. The inability to conduct comprehensive physical exams made it difficult to evaluate physical concerns, and participants were frequently unable to rely on skills that were emphasized in their training, such as assessing overall appearance and frailty. As a result, they had a higher level of uncertainty about diagnosis and management and a lower threshold for making referrals and ordering diagnostic testing. Residents did not ask preceptors for help during a tele-visit - in contrast to in-person clinical visits - which precluded real-time support when participants encountered uncertainty. Due to the awkwardness of asynchronous communication, participants had a higher threshold for asking their preceptors questions and making changes in management plans after televisits were concluded. CONCLUSIONS: In light of the staying power of telemedicine and the overall trend towards virtual care, our findings substantiate the need to identify and address new clinical training competencies. In particular, trainees may need guidance for negotiating clinical decision-making and management when caring for patients remotely;structured preceptor protocols can help to support trainee education and quality patient care.