The Challenges of Visualisation During Delivery and Assessment of Clinical Teaching Under COVID-19: A Reflective Account of Problem Solving.

Whilst the in-person clinical immersion of students in their final years of medical programmes was relatively protected from the impact of COVID-19, the ability to deliver in-person clinical teaching was restricted or heavily altered for early-year students. Our challenge as a 3-year BSc (Hons) in Medicine programme at the University of St Andrew's School of Medicine was to continue to immerse and engage students in their clinical training when in-person access to the authentic environment was impossible, restricted, or completely altered from the original image held by students.In this chapter, we aim to discuss the problems faced, the solutions considered within the contextual restraints and then reflect on the successes and failures of the approaches we took in aiding students to visualise themselves in the clinical environment, or when using altered delivery modes that introduced radically different optics on the learning experience.Whilst there were some limits on what could be practically achieved (specifically remote learning of "hands-on" clinical skills requiring specialist models or equipment), either sole- or hybrid-use of virtual platforms to provide both real-time and student-led mixed-media visualisations provided effective means to ensure appropriate delivery and assessment throughout varying levels of restrictions. In some cases, this mirrored adaptations in the clinical environment (e.g. virtual consultations).Whilst online delivery of teaching and assessment provided some mitigation of COVID-19 impact upon teaching, given the nature of a medical curriculum these cannot offset the lack of hands-on practical experience students require. However, some adaptations made by necessity (e.g. teleconsultations) have mirrored the advances in patient care and have arguably better-equipped students. The full positive and negative impacts of the pandemic on medical education remain to be seen.

Telehealth in South Africa: A guide for healthcare practitioners in primary care.

The use of telehealth is becoming a prevalent feature in clinical practice worldwide, partly because of advances in medical and telecommunications technology. The coronavirus disease 2019 (COVID-19) pandemic has been a key driver in justifying the accelerated use of telehealth, leading to healthcare practitioners (HCPs) utilising virtual consultations more avidly. Although challenges remain, recent data have shown that remote consultations are feasible, safe and effective in South Africa (SA) and that HCPs should become proficient in conducting telehealth, virtual or remote consultations. These guidelines are based on the revised Health Professions Council of South Africa (HPCSA) General Ethical Guidelines for Good Practice in Telehealth (Booklet 10) and guidelines on remote or video consultations from the University of Oxford, the Royal Australian College of General Practitioners and the Royal College of Psychiatrists. These guidelines aim to equip HCPs with the basic knowledge and skills pertaining to medicolegal, communication and practical aspects of telehealth and how to practise telehealth safely and effectively in primary care settings in SA during the COVID-19 pandemic and beyond.

Global Impact of the COVID-19 Pandemic on Orthopedics and the Implications of Telemedicine: A Systematic Review of the Literature.

This study aimed to systematically review the literature on the impact of the coronavirus disease (COVID-19) pandemic on the orthopedics field by focusing on multiple aspects, including orthopedic training and application, performance, work loading, change of practice, research work, and other psychological factors. Published articles were searched using the PubMed database. Articles were selected in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 58 studies published between 1 January 2020 and 1 October 2021, 57 peer-reviewed original articles were included. Nearly 90% of students experienced an impact of the pandemic on application. The impact on training stemmed from redeployment rates of 20.9-23.1%. The rate of emergency or outpatient visits decreased from 18% to 58.6%. The rates of all surgeries or emergency surgeries decreased by 15.6-49.4%, while the rates of elective surgeries decreased by 43.5-100%. The rate of work loading ranged from 33% to 66%. Approximately 50-100% of surgeons had a change of practice. A total of 40.5% of orthopedic surgeons experienced mild psychological pressure. Approximately 64% had stopped research participant recruitment. Most of the included studies were conducted in Europe, followed by Asia and North America. It is suggested orthopedic surgeons prepare more sufficient, flexible, and reservable staffing measures, proper preventive strategies and surgical scheduling algorithms, and set up dedicated venues and equipment for routine telemedicine with staff training for virtual teaching or consultations in case of future impacts on orthopedics.

Patients' and physicians' experiences with remote consultations in primary care during the COVID-19 pandemic: a multi-method rapid review of the literature.

BACKGROUND: During the COVID-19 pandemic, many countries implemented remote consultations in primary care to protect patients and staff from infection. AIM: The aim of this review was to synthesise the literature exploring patients' and physicians' experiences with remote consultations in primary care during the pandemic, with the further aim of informing their future delivery. DESIGN & SETTING: Rapid literature review. METHOD: PubMed and PsychInfo were searched for studies that explored patients' and physicians' experiences with remote consultations in primary care. To determine the eligibility of studies, their titles and abstracts were reviewed, before the full article. Qualitative and quantitative data were then extracted from those that were eligible, and the data synthesised using thematic and descriptive synthesis. RESULTS: A total of 24 studies were eligible for inclusion in the review. Most were performed in the US (n = 6, 25%) or Europe (n = 7, 29%). Patient and physician experiences were categorised into perceived 'advantages' and 'issues'. Key advantages experienced by patients and physicians included 'reduced risk of COVID-19' and 'increased convenience', while key issues included 'a lack of confidence in or access to required technology' and a 'loss of non-verbal communication' which degraded clinical decision-making. CONCLUSION: This review identified a number of advantages and issues experienced by patients and physicians using remote consultations in primary care. The results suggest that, while remote consultations are more convenient and protect patients and staff against COVID-19, they result in the loss of valuable non-verbal communication, and are not accessible to all.

A Solution Focused Approach of Delivering Virtual Paediatric Diabetes Consultations During the COVID-19 Pandemic.

The onset of the COVID-19 global pandemic rapidly accelerated the use of virtual consultations into everyday practice. A solution focused approach (SFA) has been established in paediatric diabetes care, resulting in positive clinical outcomes and communication. The aim of this study was to assess feedback from paediatric diabetes patients and their parents or carers regarding virtual consultations, using a solution focused approach, in a hospital setting. An electronic survey was sent to patients following their virtual consultation. Of those surveyed, 86% recommended video consultations to be part of their diabetes care. Qualitative data showed reduced travel time, comfort, reduced need for parking and convenience as the highest areas improved through video consultations. Clinical care was shown to be positive and addressed patients concerns, the majority of respondents (84%) reported that the appointment was about what they wanted it to be about. Using the solution focused model helped overcome the challenges faced with virtual consultations particularly with concerns surrounding safeguarding issues, confidentiality, audio/video difficulties and also helped to support the patient journey.

Implementing digital technology during the pandemic: impact on stoma nursing services at a tertiary referral centre.

The COVID-19 pandemic has been one of the greatest challenges to the NHS, creating turmoil in the public health workforce and for all of those who use its services. Its immediate impact was a rapid change in how care in the NHS is planned, delivered and accessed, with no concession for stoma care services. Investment in global resources detailing COVID-19 recovery plans and the steady increase in national data related to the transmission and treatment of the virus has allowed stoma care nurses to better understand the long-term effects of the pandemic and mitigate future risk to specialist nursing services. This article describes how this crisis has provided an opportunity to radically change systems and processes in stoma care through the use of digital technology to continue interaction with patients, communicate with the multidisciplinary team and collaborate with relatives or carers, and as a platform to enhance personal development, training and education.

Clinicians' Feedback on Patient/Carer Experience After Switching of Growth Hormone Treatment in Pediatric Patients During COVID-19.

PURPOSE: This study investigated why some clinicians switched growth hormone (GH) brands in pediatric patients with GH-related disorders to Norditropin® since the start of the COVID-19 pandemic, the clinicians' perceptions of the results, and whether observations from this period of disruption could inform clinical practice in the future. PATIENTS AND METHODS: Clinicians (N=106) from the UK, France, Italy, and Japan who had switched at least one patient to Norditropin® from a GH therapy manufactured by a different pharmaceutical company between February and November 2020 participated. They completed an online survey and submitted patient report forms for up to three switched patients. RESULTS: Since the start of COVID-19, 39-54% of the reported consultations were virtual (ie, via telephone or online means) in the UK, France, and Italy. Overall, 17% of patients seen by respondents in the survey were switched to a different GH brand; approximately two-thirds of switches were to Norditropin®. Clinicians' top considerations in choosing a GH brand were patient/carer feedback, patient support programs, and the need for easy-to-use therapies in the context of virtual consultations. The top reasons for switching patients to Norditropin® included ease of use, device features and benefits, better patient/carer feedback, and ease of training in device use via virtual consultations. Norditropin® was considered suitable for use in virtual or in-person consultations or a mixture of both. Based on patient/carer feedback, 66% of clinicians believed that patients preferred Norditropin® to their previous therapy in terms of overall satisfaction. CONCLUSION: In this survey, key considerations in prescribing GH therapy were ease of use and acceptability to patients and carers. If virtual consultations increasingly replace in-person ones, ease in training patients/carers in device use will be particularly important. A majority of clinicians considered that their patients preferred Norditropin® to their previous therapy.

Resumption of Cosmetic Surgery During COVID - Experience of a Specialised Cosmetic Surgery Day-case Hospital.

The novel coronavirus outbreak (COVID-19) in 2019 resulted in the suspension of all elective hospital procedures during the height of the pandemic in the UK. The Clinic in London is one of the first day-case hospitals to resume cosmetic surgery in a post-COVID-19 clinical environment, whilst also employing the use of virtual consultations. Details of the protocol implemented by the Clinic to allow the safe resumption of cosmetic surgery are stated in this paper. The volume of procedures at the Clinic saw a significant increase post-lockdown; reasons as to why this occurred are also explored in this paper. The disruption of cosmetic practice during lockdown can be said to have resulted in a backlog of procedures once lockdown restrictions began to ease. Whilst this may be true, we believe that there are other confounding factors regarding what may have influenced the rise in cosmetic surgery during the pandemic, including the privacy of working from home and the increased exposure to video conferencing software.

A qualitative investigation into the results of a discrete choice experiment and the impact of COVID-19 on patient preferences for virtual consultations.

OBJECTIVES: To conduct a qualitative investigation on a subset of participants from a previously completed Discrete Choice Experiment (DCE) to understand why factors identified from the DCE are important, how they influenced preference for virtual consultations (VC) and how COVID-19 has influenced preference for VC. METHODS: A quota sample was recruited from participants who participated in our DCE. We specifically targeted participants who were strongly in favour of face-to-face consultations (F2F - defined as choosing all or mostly F2F in the DCE) or strongly in favour of virtual consultations (VC - defined as choosing all or mostly VC consultations in the DCE) to elicit a range of views. Interviews were conducted via telephone or videoconference, audio recorded, transcribed verbatim and uploaded into NVIVO software. A directed content analysis of transcripts was undertaken in accordance with a coding framework based on the results of the DCE and the impact of COVID-19 on preference. RESULTS: Eight F2F and 5 VC participants were included. Shorter appointments were less 'worth' travelling in for than a longer appointment and rush hour travel had an effect on whether travelling was acceptable, particularly when patients experienced pain as a result of extended journeys. Socioeconomic factors such as cost of travel, paid time off work, access to equipment and support in its use was important. Physical examinations were preferable in the clinic whereas talking therapies were acceptable over VC. Several participants commented on how VC interferes with the patient-clinician relationship. VC during COVID-19 has provided patients with the opportunity to access their care virtually without the need for travel. For some, this was extremely positive. CONCLUSIONS: This study investigated the results of a previously completed DCE and the impact of COVID-19 on patient preferences for VC. Theoretically informative insights were gained to explain the results of the DCE. The use of VC during the COVID-19 pandemic provided opportunities to access care without the need for face-to-face social interactions. Many felt that VC would become more commonplace after the pandemic, whereas others were keen to return to F2F consultations as much as possible. This qualitative study provides additional context to the results of a previously completed DCE.

How Effective Are Telephone and Video Consultations in Shoulder and Elbow Clinics? Analysis Using an Objective Scoring Tool.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic resulted in disruptions of clinical services, which saw more clinics being conducted as telephone and videos. The study aimed to assess and compare the effectiveness of consultations, that is, telephone, video, and face-to-face (F2F) in a shoulder and elbow clinic. METHODS: A total of 84 clinic letters from a shoulder and elbow clinic at a district general hospital were analysed using the Ashford Clinic Letter Scoring System. Of these, 30 were F2F, 30 were telephone, and 24 were video consultations. The letters were analysed and scored based on four parameters, that is, whether a working diagnosis was formulated, relevant investigations were requested or available, a clear management plan was formulated, and whether the consultation was deemed valuable by both the clinician and patient. RESULTS: The mean score (out of a total possible of eight) for F2F was 7.967, 7.667 for video, and 7.333 for telephone consultations. Amongst new referrals, F2F performed the best, followed by video with telephone consultations scoring the lowest. With follow-up referrals, the performance of telephone and video consultations was similar but more inferior compared to F2F. Videos performed nearly as well as F2F when it came to formulating treatment plans for patients.  Conclusion: F2F consultations remain the gold standard in a shoulder and elbow clinic; however, careful stratification of patients into video, telephone, and F2F clinics can help in optimal delivery of care. These findings can be applied to other surgical specialties and medicine in general. Virtual clinics are viable and potentially cost-effective options to the traditional F2F.

Patient experience of virtual consultations in Oral Medicine during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic resulted in a rapid shift to the use of virtual consultations in both primary and secondary care. The aim of this study was to assess patient experience of virtual consultations (telephone and video) in the Oral Medicine department during the first wave of the COVID-19 pandemic. METHODS: A validated survey was developed with the Patient Experience Team in Guy's and St Thomas' NHS Foundation Trust. A combination of previously validated questions and newly validated psychometric questions were used to design the patient feedback questionnaire. The survey was administered to all patients following their virtual (telephone or video) consultation. Data were synthesised and electronically analysed. Qualitative data were thematically analysed. RESULTS: A total of 115 surveys were completed. Over 82% rated their experience as good or very good and 69% preferred a virtual consultation for their next consultation. Thematic analysis of individual comments identified positive themes including convenience and positive/helpful clinical experience. Areas for development identified from thematic analysis included accessibility and clinical limitations in not undertaking a physical examination. CONCLUSION: Overall, the patient experience of virtual consultations in Oral Medicine was positive.

What is the content of virtually delivered pain management programmes for people with persistent musculoskeletal pain? A systematic review.

INTRODUCTION: Virtual consultations (VC) have been embraced by healthcare organisations during the COVID-19 pandemic. VC allows continuation of patient care while adhering to government advised restrictions and social distancing measures. Multidisciplinary pain management programmes (PMPs) are a core element of many pain services and utilising virtual methods to deliver PMPs has allowed them to continue to provide care. This systematic review aimed to explore the content of existing virtually delivered PMPs and discuss if and how these findings can be used to guide clinical delivery. METHODS: Eligible studies included adults (aged ⩾18 years) with persistent musculoskeletal pain and any virtually delivered intervention that was described as a PMP or that had components of PMPs. Databases were searched from inception until July 2020. We performed a content analysis comparing existing interventions with established evidence-based clinical guidelines published by the British Pain Society (BPS). Intervention reporting quality was assessed using the Template for Intervention Description and Replication (TIDieR) checklist: an established checklist developed to improve the completeness of the reporting of interventions. RESULTS: Eight studies were included. One intervention included six of the seven components recommended by the BPS; none included all seven. 'Skills training and activity management' was present in all eight interventions; 'education' and 'cognitive therapy methods' were present in six interventions; 'graded activation' and 'methods to enhance acceptance, mindfulness and psychological flexibility' were present in four interventions; 'physical exercise' was present in two interventions and 'graded exposure' was present in one intervention. None of the studies described all 12 items of the TIDieR checklist adequately enough for replication. CONCLUSION: Published virtual PMPs partially meet established clinical guidelines. Future virtual PMPs should be based on evidence-based clinical guidelines, and more research is needed to explore the effectiveness of virtually delivered PMPs and each recommended component.

Tele-Gastroenterology Midst COVID-19 Pandemic: Patients' Perspective.

Objective The aim of this study was to assess patient satisfaction and experiences of teleconsultation in gastroenterology. Methodology Patients who had telephone consultations for gastroenterology and hepatology conditions were contacted, and their responses to questions in a structured questionnaire were recorded. The survey responses were compiled into a Microsoft Excel spreadsheet (2016 version) and formatted using qualitative representation. Results A total of 98 patients participated in this survey. The majority of the survey participants were less than 70 years of age (n=69) and more males than females (51 versus 47). Of the patients, 76 (77.5%) were satisfied with their consultations. The positive experiences, as perceived by the participants, were cost, avoidance of travel time and not having to take time off work. The negative experience perceived by the patients was lack of information regarding their condition. Conclusion Our study discovered that our patients perceived telemedicine as an effective way of catering for their healthcare needs with good satisfaction rates. This can be used as an adjunct to the traditional face-to-face appointment system to provide uninterrupted healthcare to gastroenterology and hepatology patients during and after the COVID-19 pandemic.

Orthopedic Surgery and Telemedicine in Times of COVID-19 and Beyond: a Review.

PURPOSE OF REVIEW: This review article presents the current knowledge on the use of telemedicine and summarizes the literature highlighting the advantages and limitations of this technology in the field of orthopedic surgery during the COVID-19 pandemic and beyond. RECENT FINDINGS: Orthopedic surgery is the surgical specialty that has seen the highest proportion of its procedures cancelled due to the pandemic. In this context and onward, telemedicine seems to be a reasonable option for the orthopedic surgeon. Multiple studies have described its safety and a similar patient satisfaction compared to in-person consultations. It has a potential to increase productivity and decrease wait times by providing easier access to the clinician and by decreasing travel-associated limitations and costs. Authors have described the possibility to conduct a reliable virtual assessment of the patient range of motion. Some of the limitations to the use of this technology are technological literacy and access to virtual consultation platforms, the inability to conduct a complete physical examination, potential reduction in identification of intimate and child abuse victims, and limited knowledge about the legal implications of this technology. Telemedicine in orthopedic surgery has a potential to increase productivity, reduce costs, and increase the access to healthcare. Identified limitations include risk of misdiagnosis, required technologic literacy, unknown legal implications, and failure to identify victims of abuse. In order to use this technology judiciously, the clinician must take into consideration the patient's condition and his technological literacy and be aware of the advantages and disadvantages.