Telemedicine Teaching for Everyone? Comparing Responses of Medical Students and Residents with a Shared Curriculum

Introduction

The COVID-19 pandemic forced health care systems to evolve rapidly. Telemedicine (clinical) and telehealth (both clinical and non-clinical) were used as physicians, and their patients sought to safely participate in medical care. ¹ In a 2021 American Medical Association survey, 85% of physicians self-reported current telemedicine use. ² Studies show high patient satisfaction with telemedicine visits.^3–5 Patients have indicated a preference for continued access to telemedicine services post pandemic. ⁶

With the rapid rise in telehealth, undergraduate and graduate medical education leaders have recognized the need for training in its appropriate, effective, and efficient use. ⁷ In Association of American Medical Colleges (AAMC) surveys of medical schools in the years prior to the pandemic, less than half included telehealth in their curriculum (2015–2017 academic years). This escalated to over 80% in academic year 2020. ⁸ The Family Medicine (FM) Residency Review Committee’s 2023 update on core competencies now includes several references to the use of telehealth. FM residency practices must have telehealth modalities available, and residents must show competence in telehealth use by graduation. ⁹

Telemedicine’s necessarily rapid uptake occurred without significant consideration of clinical education needs. ¹⁰ Clinical education leaders quickly realized the need for teaching its use to residents and medical students.^7,8,11,12 Early surveys indicated the utilization of didactic sessions and clinical experience for teaching medical students about telemedicine. ¹⁰ Educational efforts were complicated by availability of minimal educational materials and limited faculty expertise.^7,8,11,12 The Society of Teachers of Family Medicine (STFM) Telemedicine Task Force developed a national curriculum focused on best practices and foundations in telemedicine. This curriculum was specifically aimed at medical students and FM residents and was based on the AAMC telehealth competencies. Additional competencies were added based on committee consensus. Importantly, the curriculum was designed to be provided asynchronously via an interactive virtual platform. ⁷ This design, therefore, differs from the previously described didactic or clinical settings for education. ¹⁰ The curriculum was piloted at medical schools and FM residencies throughout North America and noted to be broadly effective. The curriculum consisted of five modules: 1—Intro to telehealth; 2—The telehealth encounter; 3—Requirements for telehealth; 4—Access and equity in telehealth; and 5—Future of telehealth. ⁷ This study looks at a subset of the pilot evaluation outcomes for medical students and FM residents within a single institution to assess for efficacy in both groups of learners while minimizing variability in institutional differences in education, experience, and practice patterns.

Materials and Methods

The STFM Telemedicine Task Force spent 1 year developing a telehealth curriculum utilizing the AAMC telehealth competencies and development group expertise. A detailed description of the process and curriculum has been previously published. ⁷ The five modules applied Bloom’s taxonomy levels of apply, analyze, and synthesize and involve interactive exercises and case-based decision-making. ¹³ Seventeen medical schools and 17 FM residency programs piloted the curriculum. Only one institution had both the medical school and a residency program selected, Western Michigan University Homer Stryker M.D. School of Medicine (WMed). The AAFP Institutional Review Board determined this study to be exempt and not human subjects’ research.

Results

Comparative analyses of student and resident evaluations of the modules were significantly different in just two areas (Table 3). Student assessment of the level of knowledge gained in Module 1 was significantly greater than resident assessment (p = 0.0292). There was no significant difference in ratings on the level of knowledge gained between students and residents for the four remaining modules. There was a significant difference in student and resident open-ended comments on Module 4, with more residents than students commenting that the module was right on target. There was no significant difference in student and resident responses to categorical questions on knowledge gained and the level of the module.

Discussion

Medical students and residents have had limited exposure to telemedicine teaching. ¹⁴ This pilot of a shared STFM curriculum in medical students and FM residents at a single institution demonstrated a significantly greater knowledge, skill, or attitude acquisition in medical students versus FM residents in Module 1. There was no significant difference between medical student and resident knowledge, skill, or attitude acquisition in any of the other modules. This is in contrast to national data that observed significantly greater agreement with knowledge, skill, or attitude acquisition of medical students versus FM residents in Modules 2, 3, 4, and 5, but not on Module 1, where there was no difference between the two groups.

Many of the WMed FM residents participated in rapid uptake of telemedicine early in the pandemic, in advance of most medical student exposure and prior to curricular exposure. Given their first-hand experience with telemedicine, Module 1, which focuses on appropriate uses of telemedicine along with its benefits and limitations, was likely already intuitive to the resident group.

Our expectation is that over the next several years, most residents will have received teaching on the basics of telemedicine as part of their undergraduate curriculum, leading to less need for introductory education in residency. WMed FM residents received little explicit instruction in the performance of telemedicine visits (Module 2), technological requirements and legal considerations of telemedicine (Module 3), the impact of telemedicine on health care access and equity (Module 4), and the future of telemedicine (Module 5) prior to its clinical use. Therefore, within the WMed institution, Modules 2, 3, 4, and 5 represented new information to both FM residents and medical students. Additionally, WMed FM resident interest in these modules may have been positively affected by their ongoing participation in telemedicine visits with resulting need and desire to improve skills in its use. With expanded teaching and utilization of telemedicine in undergraduate education, we may see a decline in resident satisfaction of the knowledge gained. This would be more similar to the national data, though it is unclear whether national data indicate increased knowledge or a lower perception of utility in FM residents versus medical students in Modules 2–5.

Medical education is a continuum from an inexperienced learner to a master clinician. ¹⁵ This pilot suggests that in relatively novel areas of medical education, curriculum can be developed and used for multiple levels of learners. Intentional use by learners allows the opportunity for learning in a spiral manner, with participant’s ability to revisit areas of weakness. With continued use of telehealth, expansion of telemedicine education to include higher-level competencies, such as incorporation of physical exam, is needed.

While this study was limited by location within a single site, this limitation was leveraged to control for outside variables, allowing for consistency in the analysis between the two learner groups. Evaluation was limited to acquisition in knowledge, skill, and attitude, as well as the level of instruction. In future studies, we would include a faculty group as part of the learning continuum.

Knowledge of efficacy of a shared curriculum for both residents and medical students is a critical message for faculty looking to deploy innovative practices. We postulate that curriculum development can focus less on the stage of the learner and more on previous exposure.