A Practical Framework for Conducting Video Telemedicine Visits with Trainees


 Background:Due to COVID-19, traditional clinical education for senior medical students has largely halted. In response to social distancing, many outpatient practices have transitioned to Telemedicine (TM). While TM has been integrated into undergraduate medical education curricula at many institutions, a published roadmap for incorporating learners into TM is not readily available.Aim:To describe one healthcare system’s transition to TM and propose a framework for including learners in video TM visitsSetting:Primary care clinics at an academic medical centerParticipants:Medical students, facultyProgram Description:Training protocols were distributed to providers and students. Multi-provider video visits were enabled for distance teaching. Students tested potential workflow models and provided feedback, facilitating creation of a 4-phase construct to guide inclusion of learners in video TM encounters.Program Evaluation:We employed a rapid feedback cycle to improve workflow process and to modify trainee and preceptor instructions. We analyzed student comments for narrative themes to plan for future evaluation of video TM encounters.Discussion:TM will be increasingly used in the provision of medical care. Clinician-educators will need to innovate in order to meet patient and learner expectations. TM will be an integral teaching tool and may enhance the educational experience.


Introduction
The COVID-19 pandemic has upended medical education. While pre-clinical curricula has transitioned to online learning, in-person clinical education for senior medical students has largely ground to a halt as student access to patient encounters have been broadly restricted.1 While many institutions are utilizing teleteaching and online virtual case repositories, these curricula are designed to supplement but not replace actual patient interactions.
Telemedicine (TM), the remote delivery of medical care, is becoming a fundamental component of American health care delivery.2 With the mandate for social distancing in the COVID-19 era, primary care practices have been forced to rapidly transition scheduled o ce visits to TM encounters to continue delivering care to patients. With institutions modifying their technological infrastructure, a unique opportunity exists to incorporate trainees into this virtual practice environment. However, intrinsic challenges exist, including differences in practice between traditional clinical encounters and telemedicine, unfamiliarity and discomfort with TM visits, and lack of a structured TM educational framework to conduct patient encounters.2 While many institutions have incorporated TM into undergraduate medical education (UME) curricula,3 a review of the literature did not reveal any published protocols guiding educators on how to incorporate trainees into video TM encounters. Recognizing that others may be facing similar challenges at their own institutions, we describe our local process of transitioning to TM and propose a framework for conducting multi-provider TM video visits.

Setting And Participants
General Internal Medicine (GIM) faculty and third-year medical students at an academic medical center were included.

Program Description
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 work ow 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 debrie ng) 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 work ow for the visits.
For the active phase, the student is encouraged to log onto the video platform prior to the rst 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 work ow of the visit.
In the debrie ng 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. Debrie ng occurs between patients or at the end of the session.

Program Evaluation
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 rst two weeks of TM implementation in March 2020, four highly engaged third-year students were matched with GIM faculty to test educational work ows, 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 re ne their clinical skills. Bene ts 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 di culties, and adjusting to the virtual work ow ( Table 2). Learner-facing and preceptor-oriented protocols were incrementally rolled-out to additional clinician-educators and trainees (Appendix A,B).
Two distinct work ow models arose from our pilot. In the rst, 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 work ow 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 bene t 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 con dence in the learner and di culty 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 work ow 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 con dentiality 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 work ow.
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 O ce 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 di culties.

Discussion
The COVID-19 pandemic has accelerated the rapid adoption of TM in primary care practices, fundamentally altering the way medicine is delivered.9 Virtual visits have the potential to increase access to care for some of society's most vulnerable patients including those who are homeless, cannot afford transportation or time off work to attend clinic for a visit, and/or have signi cant mobility limitations.
Recognizing COVID-19's continued impact on societal norms (e.g. social distancing) coupled with the increasing utilization of TM moving forward, educators must swiftly adapt to a "new normal" and consider novel strategies to preserve the educational experience of learners. Despite our institution's relative inexperience with TM prior to COVID-19, we were able to rapidly implement a TM educational experience that was deemed effective by faculty and learners.
Narrative comments from students in our pilot mirror those in other studies in recognizing TM as a valuable educational tool, not only for development of medical knowledge but also for its potential to improve their ability to deliver patient care.2,3 Adding TM to already over owing UME curricula is an ongoing challenge; however amidst the ongoing pandemic, it may be a necessary step towards preserving clinical education as medical schools contemplate when and how to safely re-integrate students back into the clinical realm. Institutions and professional organizations have taken steps to mitigate some of the barriers that had previously limited the widespread adoption of TM, including improvement of technological infrastructure and dissemination of TM resources to providers. We hope that our framework targeting clinician-educators will reduce additional hindrances to incorporating learners in the provision of TM.
There are several limitations with our study, the foremost being that this is a single institution pilot that was implemented with a small number of learners within a single specialty. While our narrative analysis shows that the virtual TM experience was generally accepted by trainees participating in our pilot, additional outcome data is necessary.
Future research is needed to compare and contrast our model of TM encounters to in-person clinical encounters. Student surveys should include average number of patients seen per clinic; amount of time spent preparing for clinic, coordinating with faculty, and completing documentation after the visit; amount of time faculty spent on student teaching during clinic; and quality of teaching and feedback. We plan to survey faculty to assess barriers and facilitators of clinical teaching through TM, amount of time spent in direct observation of students, and the impact of TM on engagement in medical education.
Finally, we will solicit feedback from patients regarding their experiences incorporating trainees into multiprovider TM visits.

Conclusion
TM provides an acceptable alternative when in-person visits aren't desirable, feasible or safe. Learners, clinician-educators, and patients need to prepare for TM becoming more common and learn how to use it e ciently and effectively. We offer a practical framework for rapid and effective implementation of TM in ambulatory practices.