Current Surgical Trainee Perceptions and Experiences in Telehealth

Introduction

The use of telemedicine within surgical clinics had been steadily growing before 2019, ¹ being safe in both pre- and postoperative settings. ² Broad adoption of telehealth has been limited by the perceived barriers of untrained staff, institutional/provider resistance to change, implementation costs, reimbursement, and patient-level considerations such as age and level of education. ^3,4 The novel coronavirus disease 2019 (COVID-19) pandemic effectively forced providers and institutions to rapidly expand administration of telehealth services in the setting of social distancing and widespread public health measures to mitigate intrahospital disease spread. Relaxation of regulations and payment policies by the Department of Health and Human Services, Office for Civil Rights, and the Centers for Medicare & Medicaid Services allowed for needed economic viability. ⁵ As practitioners and patients experience the benefits of digital encounters, it is expected that a significant portion of care will continue to be provided through telehealth after the pandemic. ⁶

Study of the impact of telehealth on surgical ambulatory care has focused on various stakeholders (providers, systems, payors, and patients), with educational impact on trainees being largely absent from surgical literature. Prior work has demonstrated that teleconferencing can be an effective means to connect multiple hospitals worldwide and exposes trainees to rare and unusual cases. ⁷ Telementoring programs allow for experts to guide less experienced surgeons intraoperatively from remote locations, bypassing geographic and financial constraints of meeting at a common location. ⁸ Although these strategies leverage the use of telecommunication technologies for didactics, they do not investigate the involvement of trainees in the delivery of ambulatory care through telehealth. Due to an anticipated continued expansion of telemedicine services in the aftermath of the COVID-19 pandemic, studies evaluating the trainee telehealth experience are essential.

We sought to assess the current state of trainee experience and perception of telemedicine across the United States through a survey of the American College of Surgeons (ACS) Resident and Associate Society (RAS) and its COVID-19 Resident Task Force, with the aim of identifying deficiencies in effective trainee integration into telemedicine workflows and guiding future progress.

Materials and Methods

The RAS and the ACS Young Fellows Association (YFA) created a COVID-19 Resident Task Force in May 2020 to evaluate the effects of the pandemic on members of RAS. Task force members developed and disseminated a survey centered on resident and early career surgeons' experiences within the following areas: clinical, educational, financial, and personal, the results of which have previously been published by Coleman et al. ⁹ A fifth section to the survey was included (V.C.N.) to allow for further evaluation of resident experiences in telehealth. The survey was sent through SurveyMonkey^® (San Mateo, CA) during July 2020 to the e-mail listservs for RAS and YFA. The survey was administered over a 2-week period. Following the initial dissemination of the survey, two reminders were sent to those who did not respond. Recipients were informed that their response constituted their consent to the study and that individual responses could not be linked back to respondents or their programs.

Initially, respondents were asked whether a telehealth option existed within their institution. An answer of yes brought the respondent to the remainder of the telehealth survey. An answer of no or not sure ended the telehealth portion of the survey. This portion of the survey focused on two attributes: (1) experience with telehealth and (2) opinions on telehealth initiatives. The demographic and telemedicine components of the survey are included in Appendix A1. Descriptive statistics were tabulated for the RAS cohort data and reported as numbers and percentages. Agreement with telehealth initiatives was assessed with the Likert scale and demonstrated in tabular form. Chi-squared testing was used to evaluate differences in responses by respondent demographics. All data were analyzed using SPSS, version 27 (IBM Corp., Armonk, NY). The study protocol was independently reviewed and approved by the Oregon Health & Science University and American Research Institutes Institutional Review Boards.

Results

Discussion

Our survey results demonstrate an increase in surgical trainee integration at all levels into digital health workflows during the COVID-19 pandemic. The majority of respondents believed that trainees should be included in and trained to conduct telemedicine-based patient encounters. Interestingly, there were gender-specific differences in perception of telehealth, with females more likely to support formal training curricula for telehealth encounters and optimization of workflows to integrate trainees. The reason for this difference is not immediately clear. Although provider race has been reported to affect patient satisfaction with telehealth encounters, we found no impact of trainee race or ethnicity on their experience with telehealth. ¹⁰ A significant proportion of residents felt their clinic work hours were negatively impacted by the COVID-19 pandemic. As care transitions to virtual platforms, it is worrying that residents from smaller and nonuniversity-affiliated programs were less likely to report telemedicine options at their institutions. Similarly, it has been shown that these institutions were less likely to adopt telemedicine technologies, highlighting a disparity in telemedicine education and experience for surgical trainees. ¹¹ It remains to be seen whether potential educational deficiencies in administering outpatient care will impact future graduating classes' ability to administer care and is a topic for future study.

Our respondents indicated reduced in-person clinic volume and increased telehealth clinic volume during the COVID-19 pandemic. Both the Accreditation Council for Graduate Medical Education and American Board of Surgery require surgical trainees to be involved in preoperative and postoperative patient care. ^12,13 As ambulatory care becomes digital, the American Medical Association has recently highlighted the need for medical students and residents to be integrated into telemedicine workflows. ¹⁴ Integration strategies have yet to be explored and evaluated, but our study identified that the majority of residents were involved in synchronous evaluations of patients. Synchrony in telemedicine implies that the patient encounter, medical decision-making, and trainee evaluation are all performed in real time, much like a traditional clinic visit. ¹⁵ Two evaluation strategies have been proposed by groups from the University of Michigan. Iancu et al. demonstrate a workflow that mirrors that of a traditional clinic. ¹⁶ The trainee begins with evaluating a patient and presenting their plan to the supervising faculty. Trainee and faculty return to the patient's virtual room where the trainee observes the patient–faculty interaction, and the plan is finalized. In contrast, Strong et al. developed a strategy that has increased latency between the first and second patient encounters, allowing for a large group of patients to be reviewed before a second patient–faculty meeting. ¹⁷ In both these workflows, faculty and trainees could be in different physical locations, allowing for the use of telecommunication technologies for monitoring patients and supervising trainees. Further work is required to identify the most effective strategies for integrating surgical trainees into telemedicine clinics.

Formalized telemedicine curricula exist, but primarily these come from nonsurgical training programs and medical schools. ¹⁸ One neurology residency program implemented formalized digital health training through lectures and a 2-week telehealth rotation, demonstrating improved knowledge of telehealth technologies and an increased belief that telemedicine provided care at least equal to traditional inpatient visits. After the curriculum, 90.9% of residents believed that telehealth would reduce caregiver burden, as opposed to 54.6% before. ¹⁹ A similar elective was designed for medical students matched to general surgery internships to teach best practices regarding conducting telehealth visits. ²⁰ Participants reported high satisfaction and greater comfort with video visits. Even in programs with established telehealth curricula, there is room for improvement. In the teledermatology clinic, trainees and faculty agree on diagnosis and treatment plan in 53% and 65% of cases, respectively. Concordance for referral to an in-person clinic was 93%. ²¹ Inability to perform typical examinations (e.g., dermatoscopic examination) was cited as a reason for trainee difficulty with the telemedicine assessment, highlighting the need for training in this modality. Studies of this nature demonstrate the need of formalized programs to optimize our telemedicine skill set and more effectively manage patients.

Surgical trainees strongly believe that involvement in telehealth will be beneficial to their training. This study is the first to assess trainee opinions of providing care through telehealth platforms. In nonsurgical literature, multiple studies from the Veterans Affairs health system have explored the educational value of teledermatology consults for residents and medical students. Telemedicine has allowed faster accumulation of a variety of high-yield cases in a teledermatology clinic. ²² Medical students have reported increased engagement and satisfaction in the process. ²³ Once telehealth platforms become better established, specialized clinics or potential training programs could host outside trainees. These virtual rotations would benefit both the host institution and the trainee as knowledge and experience can be exchanged without the geographic and temporal constraints of busy residency programs through the use of telecommunication technologies.

We found that in our sample although the majority of trainees (76%) believe that residents should be involved in video visits, a large portion (24%) disagreed. We posit that the disagreement comes from subpar experiences with telehealth for these trainees. Our survey was distributed during July 2020 as in-person ambulatory care was being transitioned to telehealth platforms at many institutions. At this time, many faculty members were using telehealth for the first time. Telehealth clinic workflows were being constructed on the fly through a patchwork of infrastructure demonstrated by the many different platforms used by our respondents (Table 2). Reported provider satisfaction with telehealth evaluations at this time was also scattered, with providers reporting difficulty in breaking bad news or performing physical examinations. ²⁴ We believe that improving the efficacy of telehealth encounters with staff training will improve its overall utility and perception with patients and providers. Likewise, trainees who first experienced telehealth as an emergency measure during the COVID-19 pandemic may be less likely to appreciate its value in postpandemic ambulatory care or within their own careers.

Our study has certain limitations due to the structure of the survey and the timing of its administration. The COVID-19 pandemic has continued to affect the United States and the rest of the world. Our survey was distributed in July 2020 when certain areas of the United States did not begin to see a spike in cases. Regions where cases were still low may not have had the same shift of in-person clinic visits to video visits. We are encouraged by the heterogeneity of our respondents and believe we captured a representative cross-section of the overall RAS membership. Inherent in this design, our survey results are subject to recall bias and did not capture the opinions of those trainees without telehealth platforms at their institutions. Finally, this survey was focused on trainees and their interactions with telehealth. Although we believe it is important to recognize the contribution of trainees to the future of telehealth, we recognize that health care has many stakeholders. The success of telehealth is dependent on its acceptance by health care institutions, payors, practitioners, and, most importantly, patients.

Conclusions

As the COVID-19 pandemic continues and institutions expand their telemedicine infrastructure, our survey serves as the first description of trainee experience and opinion of this new modality. Trainees recognize its importance and their need to be involved. We suggest that these results be used to support the development of organized workflows and curricula for trainee integration into telehealth.