Crossing the Virtual Chasm: Practical Considerations for Rethinking Curriculum, Competency, and Culture in the Virtual Care Era

Virtual Learning and Assessment in Rheumatology Fellowship Training: Objective Structured Clinical Examination Revisited

OBJECTIVE

With the onset of the COVID-19 pandemic, an annual multi-institutional face-to-face rheumatology objective structured clinical examination (ROSCE) was transformed into a virtual format. The educational goals of the virtual ROSCE (vROSCE) were to reproduce the educational value of the previous in-person ROSCE, providing a valuable formative assessment of rheumatology training activities encompassing the 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies for fellows-in-training (FITs). This article describes the novel design, feasibility, and stakeholder value of a vROSCE.

METHODS

Through an established collaboration of 5 rheumatology fellowship training programs, in February 2021, a vROSCE was created and conducted using a Zoom platform. Station development included learning objectives, FIT instructions, faculty proctor instructions, and a checklist by which to provide structured formative feedback. An anonymous, optional web-based survey was sent to FIT participants to evaluate the experience.

RESULTS

Twenty-three rheumatology FITs from 5 institutions successfully rotated through 6 stations in the vROSCE. Immediate feedback was given to each FIT using standardized rubrics structured around ACGME core competencies. A total of 65% of FITs (15 of 23) responded to the survey, and 93% of survey respondents agreed or strongly agreed that the vROSCE was a helpful educational activity and identified individualized opportunities for improvement.

CONCLUSION

A vROSCE is an innovative, feasible, valuable, and well-received educational technology tool. The vROSCE enriched rheumatology FITs' education and offered collaborative learning experiences across institutions.

Incorporating Telemedicine in Rheumatology Fellowship Training Programs: Needs Assessment, Curricular Intervention, and Evaluation

OBJECTIVE

To increase the confidence of rheumatology fellows in training (FITs) in delivering virtual care (VC) and prepare them for independent practice, we developed educational materials addressing gaps in their skills.

METHODS

We identified gaps in telemedicine skills based on FIT performance in a virtual rheumatology objective structured clinical examination (vROSCE) station on VC delivery using video teleconference technology and survey (survey 1) responses. We created educational materials including videos of "mediocre" and "excellent" VC examples, discussion/reflection questions, and a document summarizing key practices. We measured change in the confidence levels of FITs for delivering VC with a post-intervention survey (survey 2).

RESULTS

Thirty-seven FITs (19 first-year, 18 second- plus third-year fellows) from 7 rheumatology fellowship training programs participated in a vROSCE and demonstrated gaps in skills mapping to several Rheumatology Telehealth Competency domains. Confidence levels of FITs improved significantly from survey 1 to survey 2 for 22 of 34 (65%) questions. All participating FITs found the educational materials helpful for learning and reflecting on their own VC practice; 18 FITs (64%) qualified usefulness as "moderately" or "a lot." Through surveying, 17 FITs (61%) reported implementing skills from the instructional videos into VC visits.

CONCLUSION

Continually assessing our learners' needs and creating educational materials addressing gaps in training are requisite. Using a vROSCE station, needs assessments, and targeted learning with videos and discussion-guidance materials enhanced the confidence level of FITs in VC delivery. It is imperative to incorporate VC delivery into fellowship training program curricula to ensure breadth in skills, attitudes, and knowledge of new entrants into the rheumatology workforce.

Exploring Patient Advisors' Perceptions of Virtual Care Across Canada: Qualitative Phenomenological Study

BACKGROUND

While virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care.

OBJECTIVE

This study aimed to understand patient advisors' perceptions related to virtual care and potential impacts on health care quality.

METHODS

We adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen's University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants).

RESULTS

Six themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery.

CONCLUSIONS

Participant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care.

Curriculum Innovations: A Comprehensive Teleneurology Curriculum for Neurology Trainees

Introduction and Problem Statement

As the role of teleneurology expands, it is important to prepare trainees to perform virtual encounters proficiently.

Objectives

We created a comprehensive multimodality teleneurology curriculum for residents to teach key aspects of telehealth encounters including the virtual examination and skill development across several environments.

Methods and Curriculum Description

We developed and implemented a teleneurology curriculum focused on teaching the virtual neurologic examination, measuring teleneurology competency, and providing opportunities for trainees to perform telehealth encounters in multiple settings. Residents (N = 22) were first surveyed on what methods would be most helpful to learn teleneurology. Trainees observed a faculty member conducting a teleneurology visit with another faculty member playing a patient. Residents then practiced a teleneurology encounter during a 10-minute objective structured clinical examination (OSCE) at a simulation center. After positive feedback from the fall of 2020, we adapted the OSCE to be completely remote in the spring of 2021 for senior residents. Trainees then performed teleneurology visits during their continuity clinics and subspecialty clinic rotations.

Results and Assessment Data

All neurology residents from adult and child neurology and neuropsychiatry programs at New York University Grossman School of Medicine participated in the curriculum. Residents identified a variety of teaching modalities that would help them learn teleneurology: didactics with slides (25%), live demonstration (25%), simulated experience (23%), starting with live patients (23%), and articles/reading material (4%). To date, 68 trainees participated in the OSCE. Trainees who completed on-site and remote simulations reported increased comfort (p < 0.05) and interest in teleneurology (p < 0.05) and requested more access to simulations during training. Sensorimotor assessment and adequate visualization of the affected limb were identified as areas for improvement.

Discussion and Lessons Learned

Our multimodal 3-year teleneurology curriculum provides opportunities for residents to learn and apply teleneurology. Survey tools helped strengthen the curriculum to optimize educational potential. We implemented a teleneurology simulation with and without the use of a simulation center. We plan to expand our teleneurology clinical and simulation experiences to trainees based on our data and further developments in teleneurology and to track the progress of teleneurology skills as residents advance through training.

Feasibility and Acceptability of a US National Telemedicine Curriculum for Medical Students and Residents: Multi-institutional Cross-sectional Study

BACKGROUND

Telemedicine use increased as a response to health care delivery changes necessitated by the COVID-19 pandemic. However, lack of standardized curricular content creates gaps and inconsistencies in effectively integrating telemedicine training at both the undergraduate medical education and graduate medical education levels.

OBJECTIVE

This study evaluated the feasibility and acceptability of a web-based national telemedicine curriculum developed by the Society of Teachers of Family Medicine for medical students and family medicine (FM) residents. Based on the Association of American Medical Colleges telehealth competencies, the asynchronous curriculum featured 5 self-paced modules; covered topics include evidence-based telehealth uses, best practices in communication and remote physical examinations, technology requirements and documentation, access and equity in telehealth delivery, and the promise and potential perils of emerging technologies.

METHODS

A total of 17 medical schools and 17 FM residency programs implemented the curriculum between September 1 and December 31, 2021. Participating sites represented 25 states in all 4 US census regions with balanced urban, suburban, and rural settings. A total of 1203 learners, including 844 (70%) medical students and 359 (30%) FM residents, participated. Outcomes were measured through self-reported 5-point Likert scale responses.

RESULTS

A total of 92% (1101/1203) of learners completed the entire curriculum. Across the modules, 78% (SD 3%) of participants agreed or strongly agreed that they gained new knowledge, skills, or attitudes that will help them in their training or career; 87% (SD 4%) reported that the information presented was at the right level for them; 80% (SD 2%) reported that the structure of the modules was effective; and 78% (SD 3%) agreed or strongly agreed that they were satisfied. Overall experience using the national telemedicine curriculum did not differ significantly between medical students and FM residents on binary analysis. No consistent statistically significant relationships were found between participants' responses and their institution's geographic region, setting, or previous experience with a telemedicine curriculum.

CONCLUSIONS

Both undergraduate medical education and graduate medical education learners, represented by diverse geographic regions and institutions, indicated that the curriculum was broadly acceptable and effective.

Quality Frameworks for Virtual Care: Expert Panel Recommendations

Given the significant advance of virtual care in the past year and half, it seems timely to focus on quality frameworks and how they have evolved collaboratively across health care organizations. Massachusetts General Hospital's (MGH) Center for TeleHealth and Mass General Brigham's (MGB) Virtual Care Program are committed to hosting annual symposia on key topics related to virtual care. Subject matter experts across the country, health care organizations, and academic medical centers are invited to participate. The inaugural MGH/MGB Virtual Care Symposium, which focused on rethinking curriculum, competency, and culture in the virtual care era, was held on September 2, 2020. The second MGH/MGB Virtual Care Symposium was held on November 2, 2021, and focused on virtual care quality frameworks. Resultant topics were (1) guiding principles necessary for the future of virtual care measurement; (2) best practices deployed to measure quality of virtual care and how they compare and align with in-person frameworks; (3) evolution of quality frameworks over time; (4) how increased adoption of virtual care has impacted patient access and experience and how it has been measured; (5) the pitfalls and barriers which have been encountered by organizations in developing virtual care quality frameworks; and (6) examples of how quality frameworks have been applied in various use cases. Common elements of a quality framework for virtual care programs among symposium participants included improving the patient and provider experience, a focus on achieving health equity, monitoring success rates and uptime of the technical elements of virtual care, financial stewardship, and clinical outcomes. Virtual care represents an evolution in the access to care paradigm that helps keep health care aligned with other modern industries in digital technology and systems adoption. With advances in health care delivery models, it is vitally important that the quality measurement systems be adapted to include virtual care encounters. New methods may be necessary for asynchronous transactions, but synchronous virtual visits and consults can likely be accommodated in traditional quality frameworks with minimal adjustments. Ultimately, quality frameworks for health care will adapt to hybrid in-person and virtual care practices.

Telemedicine to Expand Access to Critical Care Around the World

This multiauthored communication gives a state-of-the-art global perspective on the increasing adoption of tele-critical care. Exponentially increasing sophistication in the deployment of Computers, Information, and Communication Technology has ensured extending the reach of limited intensivists virtually and reaching the unreached. Natural disasters, COVID-19 pandemic, and wars have made tele-intensive care a reality. Concerns and regulatory issues are being sorted out, cross-border cost-effective tele-critical care is steadily increasing Components to set up a tele-intensive care unit, and overcoming barriers is discussed. Importance of developing best practice guidelines and retraining is emphasized.

Telemedicine-based new patient consultations for hernia repair and advanced abdominal wall reconstruction

Purpose

Telemedicine has emerged as a viable option to in-person visits for the evaluation and management of surgical patients. Increased integration of telemedicine has allowed for greater access to care for specific patient populations but relative outcomes are unstudied. Given these limitations, we sought to evaluate the efficacy of telemedicine-based new patient preoperative encounters in comparison to in-person encounters.

Methods

We performed a retrospective analysis of adult patients undergoing new patient evaluations from April 2020 to October 2021. Telemedicine visits consist of both video and telephone-based encounters. Visit types, patient demographics, preoperative diagnosis, travel time to the hospital, and prior imaging availability were reviewed.

Results

A total of 276 new patient encounters were conducted (n = 108, 39% telemedicine). Indications for evaluation included inguinal hernia (n = 81, 30%), ventral hernia (n = 149, 54%) and groin or abdominal pain (n = 30, 11%). Patients undergoing telehealth evaluations were more likely to have greater travel distance to the hospital (91 km vs 29 km, p = 0.002) and have CT image-confirmed diagnoses at the initial visit (73 vs 47%, p < 0.001). Patients who were evaluated for a recurrent or incisional hernia were more likely to be seen through a telemedicine encounter (69 vs 45%, p < 0.001).

Conclusions

We report the efficacy of telemedicine-based consultations for new patient preoperative evaluations related to hernia repair and abdominal wall reconstruction. Telemedicine is a useful modality for preoperative evaluation of new patients with hernia and advanced abdominal wall reconstruction needs. Understanding this patient population will allow us to optimize telemedicine encounters for new patients and improve access to care for patients in remote locations.