The Impact of a Student-Faculty Telehealth Program on Student Education and Patient Care

doi:10.21203/rs.3.rs-3778627/v1

Background and Objectives:

The COVID-19 pandemic has presented many opportunities for health professions students to gain proficiency in telemedicine while supporting patients. We evaluated the pedagogical impact of a diabetes telehealth program on patient and student satisfaction.

Methods

Health professions students were surveyed prior and after serving in a diabetes telemedicine program to assess satisfaction with the intervention and its educational impact. Post-program participant satisfaction was assessed via surveys.

Results

Of 54 students surveyed, there were 26 pre-program respondents and 10 post-program respondents. Post-program, students felt more capable of performing diabetes-focused histories and physicals (audio p = 0.03; video p = 0.01) and discussing blood glucose monitoring (audio p = 0.02; video p = 0.03). Students felt more comfortable counseling patients about lifestyle modification in video but not audio visits (video p = 0.03, audio p = 0.28). Student impressions of telemedicine effectiveness did not change post-program. Challenges student providers noted included continuity of care, technical difficulties, limitations in providing clinical support and decreased ability to develop rapport. Of 60 patients surveyed, 33 respondents noted the convenience of telehealth visits, patient-centeredness of the program and empathy of the student providers as key strengths.

Conclusions

Although student confidence in clinical skills improved and patients were satisfied with telemedicine, students’ satisfaction with telemedicine did not change after involvement. More work is needed to educate students on effective telehealth interventions and improve existing telehealth infrastructure to support patient-centered care.

Medical Education

Interprofessional Education

Telemedicine

Medical Students

Patient-Centered Care

Primary Health Care

During the COVID-19 pandemic, much of healthcare transitioned to a virtual format which, still persists in part today. Accordingly, health professions students need to learn to provide effective virtual care [1, 2]. However, data on virtual visits’ impact on student training is limited. Student-led initiatives throughout the pandemic have effectively managed patient needs virtually, but few assessed educational outcomes and patient satisfaction [3]. Studies have shown that telemedicine education is limited and should be expanded [4, 6].

To investigate virtual visits’ impact on training, we studied students participating in our student-faculty telehealth program for uncontrolled type 2 diabetes mellitus (DM) and social needs. Student run clinics (SRCs) are in a unique position to support patients virtually given their resources, including time for counseling and close follow-up [6, 7].

This study was conducted at Beth Israel Deaconess Medical Center (BIDMC)-Crimson Care Collaborative (CCC), a student-faculty clinic since 2011 at BIDMC’s academic-primary care practice [8]. In 2021, BIDMC-CCC initiated a Diabetes Telehealth Program for patients with uncontrolled DM. Since social determinants of health (SDOH) can impact diabetes control [9], patients were screened for SDOH needs, referred for support when indicated, and offered diabetes management telehealth program enrollment. An interprofessional student-faculty team designed the virtual clinical intervention and student training.

Participants included health professions students and patients. Fifty-one students were volunteers and 3 were completing a formal course. Students were surveyed on their pre- and post-program understanding of and attitudes toward telehealth, and post-program satisfaction. Patient participants were ≥ 18 years with hemoglobin A1c (HbA1c) 8–11%, not on insulin, and English or Spanish speaking. We focused on HbA1c < 11 since patients with poorer control may need more intensive services. Post-program patient satisfaction was assessed with a modified Agency for Healthcare Research Consumer Group-Consumer Assessment of Healthcare Providers and Systems (CAHPS) telephone survey [10].

At the program’s onset, a 45-minute required Zoom student training reviewed curated resources including a diabetes management guide and electronic medical record (EMR) templates and was recorded for those who could not attend. Pre-intervention surveys were distributed at this time. Interprofessional junior and senior clinician student teams then conducted telephone or video visits (video prioritized) with MD or NP preceptor supervision. Students addressed social issues, reviewed blood glucose readings when available, identified and referred for needed diabetes laboratory and screening tests, managed medications and counseled on diabetes management. The interprofessional team discussed and refined plans. Student clinicians included 29 first-year, 10 core clerkship, and 7 post-clerkship medical students, 5 first-year and 2 second-year NP students, and 1 3rd-year dental student.

Pre- and post-program student satisfaction surveys were conducted between 6/2021-4/2022 based on previous CCC surveys containing Likert scale multiple choice questions and were emailed through Qualtrics (Qualtrics, Provo, UT). Post-program, students were asked by email to complete a post-survey and assigned a unique REDCap link to avoid duplicate entries [11]. Seven survey requests were emailed at 1-week intervals. Responses were kept anonymous during data analysis. Patient satisfaction was assessed with a post-intervention survey [10]. All intervention patients were called by trained student volunteers and offered $10 remuneration. Three attempts were made at 1-week intervals.

To compare pre- and post-data, unpaired two-tailed Welch’s unequal variances t-tests identified differences in Likert scale averages with P-value < 0.05 as the threshold for significance. For free response questions, two researchers (BB, AZ) conducted independent thematic analyses which were reviewed by AW and the research team to resolve discrepancies. Statistical analyses were performed in Python 3.10.7 with SciPy version 1.9.1 and reviewed by our statistician. This study was deemed exempt by the BIDMC Institutional Review Board (protocols 2021P000011, 2021P000845).

Twenty-six of 54 students completed the pre-program survey (14 pre-summer term, 12 pre-fall term). Since we found no differences across terms, the data were combined. Pre-program, 69% (n = 18) of student respondents had provided telemedicine services. Students felt informed about telemedicine (mean 4.3/5-point Likert scale, strongly disagree/disagree/neutral/agree/strongly agree, standard deviation = 0.71). Ten students completed the post-program survey.

Students’ comfort with telemedicine clinical skills increased post-intervention, particularly with regards to performing a diabetes-focused history and physical and discussing blood glucose monitoring (Figure). Students felt more comfortable counseling about lifestyle modification during video visits. After program participation, student attitudes towards telemedicine were unchanged. Post-intervention, 70% of students surveyed (n = 10) were satisfied or highly satisfied with telehealth visit quality. Of 9 students who answered, although 89% noted telehealth was less effective or neutral compared to in-person, 78% felt telehealth was valuable for patient care. The most effective telehealth aspects students noted were frequent follow-up visits (56%), integration with SDOH screening (22%), and lifestyle counseling (22%). 8/8 reported audio was less effective than video.

Thematic analysis of student provider free text responses identified three major themes as challenges to virtual care: 1) Clinician support: students wished they could provide more detailed counseling on lifestyle modification and resources, and noted challenges responding to patient concerns regarding medications, challenges connecting with other clinicians on the interprofessional team, and the need for greater access to SDOH resources; 2) Patient contact: students noted that telehealth limited their ability to establish rapport, perform a physical exam, and pick up on non-verbal cues as well as resulted in privacy concerns; 3) Technical issues: students noted challenges with connectivity, scheduling and accessing interpreter services. Despite these challenges, students found that this telehealth experience provided valuable training. Of 9 post-program respondents, 33% were more interested in primary care, while 56% experienced no change. 89% felt that the telehealth program was valuable or highly valuable for their education. 67% felt that telehealth teaching was at least as effective as in-person diabetes management education.

Fifty-five percent (n = 33/60) of patients participated in the patient survey. Thematic analysis of open-ended responses revealed high patient satisfaction and many strengths including high student attentiveness and empathy, virtual visit convenience, and emphasis on patient-centered care and patient education (Table). Areas for improvement included provider communication and student experience.

Overall, students felt more comfortable caring for patients with diabetes after telehealth program participation. Patients were satisfied with student-faculty telehealth visits, noting several strengths: convenience, patient-centeredness and student empathy. Thus, this study demonstrates that a virtual visit program is an effective means of educating students while providing care.

This study builds upon a limited body of literature [12–15]. Our students noted advancement of their telehealth skills after participating in our program, which is aligned with prior data demonstrating low telehealth physical exam self-efficacy in early medical students [2]. Our data, including students’ perceiving telehealth’s advantage of allowing them to better provide patient-centered care, support the telehealth education framework outlined in the literature [3], including improving patients’ health, extending the ability to provide care and increasing experiential learning opportunities.

This work provides important insights for telehealth curricula development, emphasizing the importance of video over audio platforms, and providing longitudinal care and frequent follow-up to optimize learning and support the student provider-patient relationship. A particularly interesting finding is that patients valued the same telehealth experiences more than student clinicians. Thus, it will be important to effectively train and engage students in telemedicine to support this patient-centered care model.

Our analysis was limited by a small sample size, likely due to our small group size and lower responses due to this work being remote. It may be difficult to isolate the program’s impact on learning when similar skills were taught in students’ courses. However, the lack of differences at different points in training suggests that students were not heavily influenced by their concurrent learning.

Overall, we saw student confidence in clinical skills significantly improve, but no change in student satisfaction with telemedicine and several student concerns. Looking forward, more research is required on telehealth in student education and how to address associated barriers. Especially given patients’ high satisfaction, additional work is needed to improve student comfort and attitudes toward telemedicine as an effective means of providing patient-centered care.

Competing Interests:

All authors declare no conflicts of interest.

Funding:

This work was supported by a BIDMC Center for Healthcare Delivery Science Innovation Grant.

Author Contribution:

AW and GK made substantial contributions to the design of the work and the interpretation of the data; BB, AZ, BT, PB, KS, AC worked on the acquisition, analysis, and interpretation of data. BB and AZ drafted the manuscript. AW, GK, BT, PB, KS, AC reviewed the manuscript critically for important intellectual content. All authors agreed on the final version of the manuscript.

Acknowledgements:

The authors would like to thank Oluwatobi,Ariyo, Marya Cohen, Tenzin Dechen, Jonathan Li, Sienna Li, Howard Libman, Sammer M. Marzouk^, Annie Miall, Ashley L. O’Donoghue, Barbara Rosato, Claire C. Rushin, Katherine Wrenn, the BIDMC Center for Healthcare Delivery Science and the Crimson Care Collaborative students for their support of this work.

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Table. Patient Satisfaction with the Telehealth Program

Theme	Details	Representative Quotes
Strengths
Student providers	Empathy	“They listened to me and everything I had to say - they explained to me. Sometimes I think student doctors are better than the actual doctors - I guess because they are learning and they ask a lot of questions. They seem so interested in what is going on.” “For me, it was a better connection. They seem like they care; not just as doctor to patient, [but] they seemed like they treated a family member. I really enjoyed it.”
Student providers	Attentiveness	“Very attentive, the provider did a great job listening.” “They were very thoughtful, respectful, very patient.” “[The student providers] listened to anything I had to say. They...talked back what they heard me say to make sure that they were hearing the correct information I was sharing.”
Virtual visits	Convenience	“Very convenient to do the call from [my] home office.”
Patient centered care	Personal-ization	“They showed me what I needed to do and how to get better. They were very encouraging, informative, and helped me keep track of my blood sugar.” “They give you a lot of information. They give help when it is needed and they answer questions that you might have. They are terrific.”
Patient centered care	Reduced isolation	“Sometimes when you see the same person, you become stagnated so having somebody new and fresh talking to me and seeming to care and put a lot of interest did help me” “When you're given a diabetes diagnosis, it’s pretty scary. You can feel isolated dealing with this problem on your own. It is nice to have a team interested in your health and wanting you to improve it.”
Patient Education	Improved diet	The program “woke me up to doing my blood sugars [and] woke me up to when I'm hungry about what to eat.” The program “helped me manage my diabetes and what I eat. I don't eat sugar anymore.”
	Improved motivation	“On some levels, such as goal-setting, [the program] helped me make changes, more so than the model where I meet 2–3 times a year with a doctor or NP.” “I don’t do any organized exercise but they encouraged me to walk more which I do all the time - that was a plus.” “The program is informative and helpful. Even if people know what they are doing they need encouragement along the way.”
	Diabetes knowledge	“It feels like talking to somebody in the program is useful to talk about certain side effects of the drugs I am taking.” The student providers “taught me how to take different insulin, how to take it without it being painful. I was having a lot of trouble taking it. They were very courteous.”
Areas for Improvement
Communi-cation	Scheduling	“Appointments always get postponed or changed. The follow-through never met what the initial promise was, but it was never such a long time to where it was a problem.”
	Follow through	“The program might have more success if there was some type of 5 minute phone call every 2 weeks, like a check-in, rather than every 4 weeks.” I “was referred to a nutritionist and housing specialist but no one has contacted [me] yet.”
	Commun-ication with PCP	“…very upset that the CCC doctors stopped the Trulicity medication after putting me on it. I recently went to see the PCP to get another prescription. Before this prescription stopped, it was perfect.” “Only slight issue…was a service snag in that there was a lack of communication between the student team and my diabetes physician such that I felt that the advice was not vetted by my diabetes doctor.”
Student providers	Inexperience	“Information that was provided wasn't geared toward people with different amounts of experience with diabetes. It felt like it was set up going through a checklist, rather than personalized.” “There was a bit of a misunderstanding over certain areas because there was a student who was somewhat confused about some aspect of my care that he had to speak with a physician at the practice about.”
Virtual visits	Missing in person visit elements	“The best visit would probably be in person with an A1c test but they were doing the best they could over the phone. They were very polite and fine.”

No competing interests reported.

The Impact of a Student-Faculty Telehealth Program on Student Education and Patient Care

Status:

Version 1

Abstract

Background and Objectives:

Methods

Results

Conclusions

Figures

Background

Activity

Results and Discussion

Declarations

Competing Interests:

Funding:

Author Contribution:

Acknowledgements:

References

Table

Additional Declarations

Status:

Version 1