Abstract
We have developed a telemedicine elective for fourth-year medical students to learn about the delivery of primary care telemedicine. The goals were to expose medical students to telemedicine as a method for delivery of primary care and to reinforce the importance of doctor-patient communication during the health-care encounter. The elective lasted four weeks. It had three components: two online introductory courses to telemedicine; site visits to near and distant telemedicine sites; and a reflective writing paper. In the first year, seven medical students out of a class of 230 chose the telemedicine elective from a list of 188 alternatives. Evaluation ratings and the students’ written comments, along with end-of-course discussions, indicated that the telemedicine elective was a valuable experience. An elective in the medical school curriculum may be a useful way of providing future physicians with an understanding of telemedicine.
Introduction
Telemedicine can support and enhance team-based care by connecting remote health-care providers, thus fostering collaboration and the exchange of health information. Clearly, advances in information and communication technology have provided new ways of delivering health care. However, the overriding obstacle to the implementation of telemedicine is reported to be a lack of knowledge about it. 1
Introducing new topics into a very full medical school curriculum is extremely difficult, regardless of the need. Electives offered during medical school represent an opportunity where new courses might find a niche. We have established an elective to introduce medical students to telemedicine experiences in a variety of primary care settings. We report here on the first year of the telemedicine elective in which seven 4th-year medical students out of a class of 230 selected this new offering from a list of 188 elective choices.
Elective
The overall goals for the elective were to expose medical students to telemedicine as a method for delivery of primary care and to reinforce the importance of doctor-patient communication during the health-care encounter. The specific objectives were to:
Describe the technology involved in providing telemedicine; Describe the differences and similarities between a face-to-face and a telemedicine encounter; Describe the effect of technology and distance on the doctor-patient relationship; Describe the cost savings for a corporation in having acute care telemedicine services available on-site; Summarize the capabilities and limitations of telemedicine in providing primary care services to patients. Two online introductory courses to telemedicine; Site visits to near and distant telemedicine sites; A reflective writing paper.
The elective lasted four weeks. It had three components:
Students taking the elective met the course directors each week. The first meeting outlined the expectations and the schedule for visiting the telemedicine sites. Log-in details were provided to each student during the orientation for access to two online modules that they were asked to complete before their first site visit. Finally, a discussion of the requirements for the reflective paper, anchored in the student's eventual area of practice, provided a context for the assignment which was expected to be completed by the end of the four-week elective.
Online courses
Each online course took approximately 45 min to complete. The first course covered the basic information about telemedicine and included a detailed guide to planning and starting a telemedicine programme. The topics were:
Telehealth visits – what happens before, during and after telehealth visits?
Responsibilities of the provider and presenter – what kinds of staff are needed on both sides of the camera?
Equipment – what is needed to examine patients via telemedicine?
Successful programmes – what makes them different?
Privacy concerns – what issues are unique to telehealth and to HIPPA compliance?
Reimbursement – what is required to secure reimbursements for telehealth visits?
The second course covered business aspects in the planning process of beginning a telemedicine programme. The topics were:
Potential applications; Legal concerns; Needs assessment; Telemedicine programme proposal; Evaluation process.
Site visits
The students’ first site visit was to a telemedicine operations centre about 3 km from the main university campus. Both the delivery of care, as well as the business aspects of telemedicine, were topics for discussion with the director of the operations centre. Students were then paired with a telemedicine physician/provider in their eventual practice discipline at the centre. Students participated in telemedicine sessions with primary care clinics in adjacent counties, with sites that had contracts for specialist care, or with private business clients who had contracts for telemedicine consultations for their employees.
The first week of experience at a near site was designed to provide students with a provider perspective on telemedicine. Students spent the second and third weeks of the elective visiting three distant sites to gain a patient perspective on telemedicine. All sites were equipped with videoconferencing units and a variety of peripherals. At all three distant sites, mid-level providers assisted with checking the patient in and with physical examination as directed by the distant physician.
Students initially visited two county-run clinics. Both sites are within 60 km of the campus and have contracts for primary care telemedicine. They made at least two visits to each clinic, i.e. a minimum of four visits altogether. The third site was a large private corporation, approximately 3 km from the campus. This is an employee health clinic where the private company perceives sufficient benefit in telemedicine that it covers the insurance co-payment of employees who see their provider at a distance.
The students conducted a short, structured interview with selected patients at the distant telemedicine sites. The intention was to provide an organizing schema for students to discuss communication problems with patients. The topics of access and travel are the usual points of discussion with patients who participate in telemedicine visits. During the elective, however, students attempted to elicit the patient perspective of the doctor-patient relationship as experienced during video mediated communication. This focus on communication was an attempt to reinforce what was learned about good communication skills in the first year of medical school and to reflect on and assess the impact of the medium of distance and technology on doctor-patient communication.
The fourth week of the elective was an opportunity for students to make up any clinic sessions they missed or where patient sessions were cancelled. Students also completed their reflective paper for the course, by integrating both experiential learning with information found in the telemedicine literature about its use in their eventual practice area.
Reflective writing paper
Students were required to address two elements in their reflective paper. The first element was an exploration of how telemedicine would be utilized in their eventual practice area, and how they might consider use of this mode of health-care delivery. The second element was an extended discussion/reflection on the doctor-patient communication that occurs when it is filtered by technology and distance. The suggested length for the reflective paper was 4–5 pages. A discussion of this paper with the course directors occurred at the end of the elective.
Feedback on the elective
We obtained permission from the appropriate ethics committee to assess course outcomes and we obtained permission from the students to reproduce selected passages from their essays. The School of Medicine evaluation ratings and the students’ written comments, along with end-of-course discussions, indicate that the telemedicine elective was a valuable experience.
Elective evaluation form
A standard School of Medicine elective evaluation form was completed by seven students. The evaluation consisted of an online survey with six questions on general education effectiveness, which all seven students completed. The responses were scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The Strongly Agree rating was selected by all seven students for each of the following questions.
Expectations were clear; Expectations were reasonable; The quality of teaching was excellent; The experience proved helpful in focusing on my future career goals; The elective as a whole was a very effectively designed experience; I would recommend this elective to fellow students.
The telemedicine elective provides an opportunity for 4th-year medical students to continue their practice of self-directed, lifelong learning – one of the four overall goals of the medical school curriculum. While we set the expectations for the students and structured the near and distance site activities, the responsibility for learning remains with the students. In reviewing the evaluations and reading the comments (provided below), we noticed a broad approach to learning about and becoming immersed in the telemedicine activities. All students indicated that it was an effective experience and said they would recommend it to their peers.
Comments from the medical students included:
‘The combination of these experiences was very educational and inspiring. In fact, I found telemedicine to be so useful and beneficial to the underserved population that I became interested in making telemedicine part of my career as a pediatric cardiologist.’
‘Exposure has been the best teacher for me over the past four decades of my life. It was an awesome experience to see telemedicine in action, as opposed to the two-minute attraction of passing by it to impress students who are interviewing.’
‘In summary, this course greatly opened my eyes to the vast possibilities that telemedicine has to offer.’
‘These last four weeks have been a unique educational experience for me. I had heard much about telemedicine and its growth, but did not have the opportunity to see it in play, from both the provider and patient perspective. I am especially interested in telemedicine because I wished a part of my time as a health-care provider to be directed toward the underserved population, but am reluctant to live in or commute to a rural clinic.’
‘Following my one-month elective in telemedicine at UTMB, I am excited and look forward to incorporating electronic health into my medical practice.’
‘(This university) is the largest telemedicine provider in the state … but the medical students are not getting any exposure to it. None of our third-year clinical rotations requires us to see even one session of telemedicine, and this should change.’
Reflective paper
The essay assignment encouraged students to explore the telemedicine literature that was relevant to their eventual practice area. The following paragraphs provide examples of student writing (and thinking).
Excerpt 1
‘As for me personally, I will begin a Pathology residency program … so I see it fitting to address telepathology and how it will affect my practice in the future… There are also applications of telepathology for the autopsy specialist. If I embark on an anatomic pathology career in performing autopsies, I may not be fully trained to perform a difficult fetal autopsy. This would require 3D images to be taken of the representative subject and sent for consultation, ultimately via telepathology. An important pitfall with remote processing of images to pathologists is that the image being viewed is only a computerized representation of reality and therefore the eye should be trained to look at these types of images before making a diagnosis. Overall, as you can surmise from the details above, the advantages of telemedicine to the field of pathology in particular far outweigh any disadvantages; thus I am confident I will be utilizing this technology in my future pathology career.’
Excerpt 2
‘As a graduating 4th year medical student … I have been underexposed to methods of providing indigent care outside of the major university clinics. My experiences interacting with the telemedicine physicians, nurses and patients has opened my eyes to a method of health-care delivery that is not typically taught to medical students. I will be starting a residency in Physical Medicine and Rehabilitation in the near future. Challenges in this particular field include the chronicity of injuries, the expense and labor involved in caring for this subset of patients, the lack of self-sufficiency that many of the patients have, and the broad scope of patients and patients’ issues that are dealt with. The scope of patients can include everything from workers compensation cases, to geriatric health, to severe brain injury. All of these particular challenges can be addressed effectively through telehealth. Telemedicine can allow a provider to perform follow-up examinations and routine follow-up care from a distance. In this patient population, it is especially difficult for the patient to commute to the physician's office…. From my experiences in the clinics, patients appreciate the accessibility of the provider, as well as the reassurance that everything is going well.’
Discussion
The telemedicine elective was organized to meet the objective of our training grant in family medicine. The objective was to provide an opportunity for students to learn about the delivery of primary care to underserved populations through telecommunication technology. During the elective, medical students observed and interacted with both patients and health-care providers at near and distant sites, and reflected on their experiences and the potential for use of telemedicine in their eventual clinical practice. The elective was highly rated using the standard evaluation form and medical students provided reflections on their experiences at near and distant sites. Students also explored ideas on the potential use of telemedicine and supported greater use of telemedicine in the School of Medicine curriculum.
Although elective courses at our medical school are simply graded as pass or fail, the elective students invested considerable time in completing their essays in a comprehensive manner. However, students selecting the telemedicine elective were a small and self-selected group, and this is a limitation of any conclusions that might be drawn from the enthusiasm they expressed. Nonetheless, the preliminary feedback of this first group of students was unanimously positive. We will continue the structure of this elective in future years. In subsequent classes, however, we will ask students in advance of starting the elective about their choice of eventual clinical practice area with the intention of better matching student choices with telemedicine practitioners at the central telemedicine site. While the distant sites will continue to be focused on delivery of primary care at a distance, the assigned telemedicine practitioner in the student's eventual clinical practice area can provide insights and background on other uses of telemedicine. We will also integrate a logbook into the elective experience. Our discussions with students at the conclusion of the elective revealed that they generally need some structure in recording the experiences for later reflection.
Further applications
Like medical students, residents have a very full training programme. It would be possible to match a resident in paediatrics, internal medicine or family medicine with a physician in a rural practice. If supervised appropriately, senior residents could be exposed through telemedicine to a wide range of presenting problems from a rural area. Conversely, a senior resident sent out to a rural site might be supervised by someone on campus while the rural physician was away from the office on vacation or out sick. However, the Requirements for Residency Education in Family Medicine would need to be met before telemedicine could be used for supervision. 2
Including the principles and practices of telemedicine in the curriculum for both medical students and residents, and providing opportunities to experience delivery of services at a distance, may be important for ensuring growth of the field in the future.
Telemedicine services are being increasingly utilized by patients, clinicians and institutions. The Agency for Healthcare Research and Quality (AHRQ) reported that there are 455 telemedicine programmes, representing 30 medical specialties and serving many diverse populations. 3 The number of telemedicine encounters has increased steadily. However, despite the impressive growth of telemedicine in various settings and across diverse disciplines, information about this mode of health-care delivery remains noticeably absent from the medical school curriculum. An elective in the medical school curriculum may be a useful way of providing future physicians with an understanding of telemedicine.
Footnotes
Acknowledgements
Funding was provided by a Health Resources and Services Administration (HRSA) Predoctoral Training Grant (D14 HP00035-2).