General Internal Medicine (GIM) faculty and third-year medical students at an academic medical center were included.
In March 2020, the University of California, San Diego (UCSD) began planning for widespread community transmission of COVID-19. Anticipating a greater need for TM, an institution-wide command center staffed with electronic medical record (EMR) and TM-trained personnel was instituted. TM training protocols were developed and distributed to providers and patients. Clinic schedulers converted templates to accommodate TM visits, conducting patient outreach and education on visit logistics. TM was provided using the EMR patient web-portal, allowing for consent, documentation and billing. Prior to March, less than 1% of all UCSD GIM faculty visits used video. Between March 16th and 20th, all GIM faculty received TM training, and by the week’s end, nearly 80% of all patient visits were by video.4
The VA San Diego Healthcare System (VASDHC) had existing TM capability within primary care using the VA Video Connect (VVC) application which was not extensively used prior to COVID-19. Scheduling staff converted most appointments to video or telephone, educating patients about VVC technology via phone calls and test-appointments. Between February 2020 to April 2020, the percentage of primary care providers conducting at least one video visit increased from 66.8% to 88.5%, while total number of video TM appointments among all specialties increased from 1,093 to 4,448.5
Third-year medical students on the internal medicine clerkship volunteered to test potential workflow models for optimizing TM virtual education. Paired with GIM faculty, these trainees helped develop a framework for TM video encounters, facilitating the creation of both trainee- facing and preceptor-oriented protocols. A construct consisting of four distinct phases (pre- implementation, preparatory, active, and debriefing) emerged from these efforts (Table 1).
In the pre-implementation phase, students gain access to and learn how to use the necessary technological platforms, orient to TM best practices such as appropriate setting, consideration of device positioning, and review of proper “webside manner”.6
During the preparatory phase, students are paired with TM-practicing GIM faculty and contact their preceptor to coordinate details of the virtual clinic session. The preceptor selects 1-3 patients for the student to evaluate. Students review patient data in the EMR or via notes provided over secure email in advance of the visit. The student and preceptor discuss pertinent medical and psychosocial information that should be addressed for each patient. The preceptor and student plan the agenda and workflow for the visits.
For the active phase, the student is encouraged to log onto the video platform prior to the first encounter. At the start of the visit, the student and preceptor join the encounter synchronously to perform patient safety and technology pauses and student introduction. The student then executes the agreed-upon workflow of the visit.
In the debriefing phase, the preceptor and student discuss the encounter, documentation, and questions that arose during the visit. Faculty provides feedback to the student about history- taking technique and TM principles. Debriefing occurs between patients or at the end of the session.
Early pilots of video visits allowed clinician-educators and learners to evaluate the feasibility of such encounters in an under-developed TM environment, starting with the functionality of technological platforms and support of existing infrastructure (e.g. information technology bandwidth). During the first two weeks of TM implementation in March 2020, four highly engaged third-year students were matched with GIM faculty to test educational workflows, providing detailed feedback (Table 2) that enabled the development of the above framework for TM video encounters. Students found participation in video visits to be an overall positive experience, appreciating the opportunity to engage with patients during COVID-19 and refine their clinical skills. Benefits included increased opportunities for direct observation and feedback, while learning a new skill in TM. Drawbacks included limited ability to practice the physical exam, technological difficulties, and adjusting to the virtual workflow (Table 2). Learner-facing and preceptor-oriented protocols were incrementally rolled-out to additional clinician-educators and trainees (Appendix A,B).
Two distinct workflow models arose from our pilot. In the first, preceptors chose to observe trainees throughout the entire TM video visit. While the learner interviewed the patient, the preceptor provided a supporting role, conducting chart review, documentation, and order entry. Additionally, the preceptor could offer suggestions to the learner or pose questions directly to the patient. In the second, the learner conducted the history and physical in the virtual care room independently, presenting to the supervisor who would join the TM visit at a later time.
The former appeared to be favored by providers new to TM video encounters, those that had not yet formed a working relationship with their learners, and learners that were earlier in their training. This workflow model allowed the preceptor to directly observe the learner, develop trust, and provide real-time feedback on the history-taking and assessment. The supervisor could also document and enter orders during the encounter. Disadvantages included the total amount of time required by the preceptor, inability to see other patients during the student’s encounter, limited focus on learner clinical reasoning and presentations, and the potential for the trainee to perceive they have less autonomy in the care of the patient.
The latter model was preferred for more advanced medical students. Preceptors who have formed longitudinal relationships with learners or who oversee multiple learners simultaneously may also benefit in using this approach. This model can also be extended to practices with residents and fellows, as it permitted a more autonomous level of function. Within this model, the trainee can either present to the preceptor “live” in front of the patient (similar to a bedside presentation), or the preceptor and trainee can leave the virtual room to discuss the plan before returning to review with the patient. While there are several advantages to “live” presentations including opportunities for the patient to clarify the history and increased patient satisfaction related to involvement in the care plan,7 inherent challenges include balancing the correction of trainee errors without undermining patient confidence in the learner and difficulty in broaching sensitive topics. Disadvantages include more limited observation of learner interactions with the patient, additional complexity in coordinating learner and attending join and discussion times, decreased opportunities to teach by modeling, and potential delays while awaiting preceptor availability to join the TM visit.
Both workflow models were conducive to the preceptor and trainee leaving the virtual exam room and connecting elsewhere to discuss the care plan. While mechanisms to leave the virtual exam room with the trainee have not been optimized, approaches may include calling the trainee on the phone or using a video telecommunication application (e.g. FaceTime, Skype). Both have limitations including additional time, clicks, and other technical barriers, potential to lose the connection with the patient, and possible patient confidentiality issues. Having an open line of communication between provider and trainee during the encounter (e.g. via virtual chat or alternative communication devices) is critical in order to share information that could facilitate workflow.
Additionally, educators should consider the need for a contingency plan should a patient not show up to a virtual visit or if there are technical challenges in conducting the TM encounter. One solution is to attempt to convert the video visit to a 3-way telephone call between patient, attending, and trainee. Disadvantages with telephone visits include privacy issues in protecting personal phone numbers, depersonalization compared to video encounters, the need for the preceptor to be present for the entire visit in order to satisfy certain billing requirements, and lower rates of reimbursement compared to video visits. Given the current COVID-19 national emergency, the Office for Civil Rights at the Department of the Health and Human Services has relaxed restrictions on the use of commercially available video communication applications, such as FaceTime,8 which may provide alternate options for educators facing technological difficulties.