I have a confession to make—I have never been particularly interested in virtual visits. To me, the electronic medical record (EMR) was a lurking presence during clinical encounters that demanded my attention and derailed me during important moments of communication. The idea of adding even more technology to the clinician-patient relationship seemed daunting. Also, I was reluctant to embrace any technology that seemed to implicitly undermine the relevance of the physical exam, suggesting that healing by the “laying on of hands,” is merely a formality.
Enter the COVID-19 pandemic. Suddenly, the entirety of my outpatient clinical schedule consisted of virtual medicine patients—I had to learn how to do it well. Now. To add insult to injury, I also had to be teacher and role model to the learners in my residency program on the skills of virtual medicine. And I had to do that virtually, too.
With some urgency, my colleagues and I inventoried our curriculum, and found very few sessions which taught learners the skills necessary for successful virtual medicine encounters, such as building rapport, tolerating clinical ambiguity, and making clinical decisions in the absence of physical exam findings. Utilizing the principles of adult learning theory, concepts of active and passive learning, and strategies for fostering learner independence,1,2,3 we developed a new case-based curriculum that leverages digital learning platforms and small-group work to teach learners essential skills in virtual medicine. In this article, we describe our new case-based virtual medicine curriculum.
Virtual Medicine Curriculum
The Center of Outpatient Education (COE) was developed in order to train future healthcare professionals to work successfully in interprofessional teams. Trainees within the COE include residents and students from the following fields: Medicine, Nurse Practitioner, Nursing, Pharmacy, Psychology, and Social Work.
Beginning in April 2020, the initial parts of the curriculum (Part 1 and Part 2) were taught in individual one-hour sessions using a VA-based telephone (audio only) conference system—subsequent sessions (Part 3) were conducted using Zoom. Trainees were asked to activate their webcams and microphones to facilitate robust interaction.
Part 1: The Fundamentals (One Hour)
In the first session, learners and faculty consider the differences between office-based and virtual outpatient medicine. Discussion focuses on appropriate selection of patients, virtual engagement with care providers, and managing technical difficulties. Learners are led through a discussion of faculty providers’ anecdotal “Top Ten” strategies for developing virtual rapport with patients. Additionally, faculty emphasizes the importance of creating a professional virtual environment through attention to clinical attire, lighting, and background.
Part 2: Advanced Skills in Virtual Medicine (One Hour)
During the second session, learners meet in small groups to discuss a series of case-based scenarios. These scenarios, which are adapted from Reisman and Brown’s article.4 highlight challenging aspects of virtual clinical practice, such as interviewing patients with dysarthria, navigating requests for opioid medications, and obtaining clinical information from caregivers. Learners discuss strategies for taking detailed medical histories, attending to non-verbal cues, and assessing for understanding in a virtual setting. They also develop strategies for avoiding diagnostic error and managing clinical uncertainty. Faculty facilitators help learners identify virtual best practices.
Part 3: Chronic Disease Management and Virtual Medicine (2-3 hours)
Subsequent meetings focus on chronic medical conditions (diabetes, hyperlipidemia, hypertension, depression) and explicitly highlight the similarities and differences in managing them in the virtual setting as opposed to the clinic. In contrast to Parts 1 and 2 of the curriculum, which are conducted over the VA telephone conferencing system, all of these sessions are held over Zoom. The faculty facilitator uses the first 10 minutes to introduce the case, outline the session format, and discuss group expectations. Learners are instructed to work together on an “unfolding” case, in which a clinician and patient navigate an outpatient visit, a follow-up telephone visit, and a video visit occurring during the COVID-19 pandemic. The cases are written to encourage robust discussion regarding management strategies (i.e., there are no right answers). However, the learners must work as a team to review appropriate guidelines and weigh the risks and benefits of various therapeutic options. The role of the faculty, in these sessions, is to highlight take-home points in virtual management, rather than to provide direction. Learners independently come to consensus regarding their recommendations and present them when the facilitator reenters the virtual meeting.
The “unfolding” cases encourage the learners to consider clinical decision-making in data-limited scenarios. For example, clinicians who engage in virtual medicine must consider the impact that physical exam findings (which are unavailable) might have on their diagnoses. Similarly, social or environmental circumstances (such as the COVID-19 pandemic) might limit a patient’s ability to complete laboratory testing necessary for treatment monitoring. These scenarios challenge learners to consider how evidence-based guidelines can be best tailored to the individual patient and their current situation.
To successfully practice virtual medicine, outpatient clinicians need to develop an evolved set of skills. This includes clinical skills unique to the virtual environment (gained through an evolving case-based approach with explicit attention to differences in the virtual environment and how to navigate them) and an emphasis on leadership/teamwork/communication (gained through independent small group work/accountability). We have found that our virtual curriculum helps to foster those skills through the utilization of a developmental model where there is more independent small-group work and less faculty involvement as learners progress through the program. A focus of learning is for trainees to navigate the virtual learning environment, developing rapport with their colleagues, clearly communicating their opinions, and coming to consensus with their team. The virtual platform allows faculty to enter and exit the learning environment easily, fostering group cohesiveness, leadership, and autonomy among learners.
To date, this curriculum has been well-received by learners, who report satisfaction with the content as well as the small group activities. In the future, we plan to investigate how patient outcomes may be influenced by participation in this course.
Teaching virtual medicine through virtual platforms requires clear goals, creativity, and dedicated faculty. While practicing virtually is not always easy or preferred, utilizing a developmental case-based curriculum can help learners recognize the most beneficial components of virtual practice. Ideally, by providing not only content/clinical skills, but fostering and reinforcing skills in teamwork, leadership, and effective communication, virtual learning empowers trainees to optimize their experiences with this modality of practice.