Clinical closures during the COVID-19 pandemic forced organizations to quickly maneuver towards virtual care models in the ambulatory setting. In recognition of the need for telemedicine during this health crisis, the American Medical Association (AMA) encouraged telemedicine training for learners1 and the Accreditation Council for Graduate Medical Education (ACGME) encouraged resident-patient interactions via video visits. The ACGME also announced digital health as an updated milestone, with a focus on identifying and utilizing telehealth technology, triaging, and disease management.2 While asynchronous telemedicine activities, such as MyChart messaging and remote chronic disease monitoring, were already underway at some teaching hospitals, the shift to video visits presented new challenges for residency programs inasmuch as it required skills-based training during a highly stressful time. Recently published studies of cross-sectional surveys of internal medicine programs have shown a need for telehealth curricula in the era of COVID-19, unfortunately there are few published articles about successful interventions.3
Mount Sinai Hospital is an urban, academic hospital in New York City. Our internal medicine residency program consists of 150 residents practicing at one ambulatory care site for two weeks every two months (6+2 model). The curriculum was presented to internal medicine (IM) PGY2 and PGY3 residents, who had one video visit session on each outpatient block every eight weeks, for a total of four clinical sessions in a six-month period. In order to onboard our residents for video visit practice, we delivered a zoom-based telehealth curriculum consisting of four sessions: 1. introduction to telemedicine and technical practice; 2. telemedicine triaging; 3. communication and physical exam skills via telemedicine, and 4. video visit ambulatory morning report. The first two sessions were delivered prior to any resident video visit encounters, the last two sessions were delivered after residents had at least one clinical video visit session.
The first session was an introduction to telemedicine and technical practice that covered synchronous and asynchronous telehealth practices. We began the session by outlining a brief overview of the history of telemedicine and some of the strengths and challenges of this patient care modality.4 We then reinforced the asynchronous models of telemedicine already in place in our residency practice, including electronic medical record (EMR) direct-patient messaging, telephone triage, and remote monitoring of patient’s blood pressure and diabetes management. Then, a mock patient was created within our telemedicine platform to practice video visit log-in logistics from both the provider and patient perspective. Documentation basics, such as pre-visit patient messaging and visit templates and highlighting comparison with in-person encounters, were reviewed.
During the second session, we focused on the types of patient encounters best served for video visit management, such as diabetes management, hypertension control, hospital discharge appointments, and medication reconciliation visits. Utilizing Cochrane review data, case-based clinical presentations that were appropriate for a video visit were presented, including heart failure and diabetes management.
During the third session, telehealth communication and physical exam skills were taught. We discussed the feasibility of triaging patient acuity via a general exam using a mock patient video. Then, using breakout rooms, residents updated a live online document that outlined physical exam findings that are feasible via video for each body system.5 Using this model, we highlighted the physical exam portions that are amenable to video visit (such as mental status examination, dermatologic examination, and patient abdominal self-examination), and the portions that are more challenging (such as cardiopulmonary examination). For body systems that have limited examination via video visits, we reiterated the importance of triaging by measurement of basic vital signs such as heart rate and respiratory rate.
During the final session, residents were asked to submit a video visit case for ambulatory morning report. These cases allowed us to review common primary care concerns that may present via video visits, such as urinary tract infections, upper respiratory infections, and abdominal pain. We highlighted the literature supporting the use of telehealth for diagnostic and treatment strategies.
Residents were surveyed immediately before the first zoom-based session in July 2020 and six months later in February 2021. Based on prior work on perceived attitudes towards telemedicine, residents were asked about familiarity and comfort with patient care via telemedicine, perceived barriers to patient care in the telemedicine setting, and prior telemedicine experience.
Eighty-one residents received the curriculum, with 66 residents completing the survey immediately before the first curricular session in July 2020 and 61 responded to six-month post-curricular survey in February 2021, for an overall response rate of 78%. Only 7.5% reported they had sufficient training in telemedicine during residency or medical school prior to the initial curricular session. There was considerable baseline interest, with 97% agreeing that they wanted to learn more about telemedicine.
After our curricular intervention, residents were significantly more confident in an array of telemedicine-related skills. On the pre-test, residents were significantly more likely to report feeling confident in determining a treatment plan for a patient with a physical exam and labs than without; on the post-test, there was no difference in confidence in determining a treatment plan with or without labs perhaps highlighting the impact of careful history taking or appropriate triaging cases for video visits. Additionally, residents reported significant improvement in agreement that telemedicine improves the quality of care for patients and that telemedicine improves outcomes for chronic diseases. Overall, residents reported fewer perceived barriers to video visits after our educational intervention.
Unfortunately, there was no significant change in resident belief that telemedicine is a way to address health disparities in medicine. Further, there was disappointingly a significant decrease in the belief that telemedicine is a way to improve access to care for all patients, despite literature indicating that telemedicine may be a means to improve access to care. This decrease may reflect the unique technical challenges facing our ambulatory patient population such as limited smartphone and internet access.
The ability to effectively care for patients via video visits has become a critical skill for physicians during the COVID-19 pandemic and will continue to be essential in IM ambulatory practice. Therefore, it is important to consider how to integrate this training into existing clinical and curricular structures. We describe our experience with a four-hour telemedicine curriculum followed by four half-days of video visits, demonstrating significant improvements in internal medicine resident self-reported confidence and skills associated with moderate effect sizes. Importantly, residents reported a high degree of satisfaction with the curriculum; on the post-test, 78.7% reported feeling as though they had had sufficient training in telemedicine during residency. The most significant improvements were in the confidence triaging a patient’s acuity via video visits, indicating that this crucial skill can be developed quickly. Residents also had significant reductions in concerns about their ability to build rapport with patients and address concerns without a face-to-face encounter.
Our results are potentially influenced by maturation bias, as residents’ confidence in their clinical ability would be expected to naturally improve throughout the course of their residency; however, the lack of improvement in related skills not taught in the curriculum (i.e., ability to triage patients’ concerns using telephone calls or electronic messages) suggest that these improvements were in part due to the curricular and clinical intervention. Further limitations include the exclusion of PGY-1 residents and the reliance on resident self-report rather than objectively observed skills.
We believe the structure of our intervention and the results of this study are generalizable to IM training programs across the country. The intervention required very little curricular time and no additional cost aside from teaching time and can inform the design of interventions in programs without existing telemedicine programs or limited patient volume. While further training is undoubtedly needed to achieve mastery in video visits, our brief curriculum assuaged many concerns about the utility of telemedicine and increased the residents’ recognition of their need to use this skill in their post-residency careers.
Acknowledgements: We would like to acknowledge the resilience of our residents during the COVID-19 pandemic, and their willingness to engage in this intervention during this challenging time.