A new elective in telehealth at the UND School of Medicine & Health Sciences has faculty reimagining how they teach medicine to students at a distance.
“I really think this is the direction medicine is going, and I think all of us are going to have to have some experience with it,” mused Dr. Suzanne Human. “I kind of enjoy it—but I’m also a bit of a weirdo.”
Laughing at this admission, Human, speaking via video conference from a Veterans Affairs (VA) clinic in northwest Minnesota, was describing her teaching of a UND School of Medicine & Health Sciences (SMHS) elective for fourth-year medical students – FMED 9322 – on telehealth in family medicine.
“This morning I did telehealth for someone who lives in very rural Minnesota,” Human continued. “And I got to see this little grandchild run past in the background, and [the patient] chuckled and said, ‘Yeah, I’ve got two dogs, a cat, and 15 chickens downstairs because they’re too cold outside, the little baby chicks.’ It’s a lot of fun.”
Here to stay
The spring 2022 elective was the first of its kind to be offered by the SMHS, said Dr. Bryan Delage, co-director of the SMHS Department of Family & Community Medicine clerkship for third-year students. And it certainly won’t be the last. (Editor’s note: the SMHS Department of Internal Medicine now houses a similar course, IMED 9503, for interested students.)
“Telehealth has become a critical part of patient access since the pandemic and was able to fill a gap for some patients who needed contact with their provider more consistently,” Delage wrote in an email. “The risks and fear of [COVID] exposure when coming to the clinic had forced some patients to forego treatment, so part of the driving force for the elective was its timeliness in light of the increased demand for skills in telehealth nationally.”
No doubt about it, added Dr. Eric Johnson—telehealth is here to stay.
“If it wasn’t apparent that the telehealth boom during the pandemic was relevant, it very likely is understood now, just due to the sheer volume of telehealth delivered by hospitals and clinics,” said Johnson, who is director of interprofessional education at the SMHS.
A former radio personality who has been training students on virtual body language and communication skills for years, Johnson noted that while the School’s Department of Psychiatry & Behavioral Science was training psychiatry residents in telehealth some time ago, there wasn’t an official course for medical students on the subject until recently.
“[Students] need to learn these skills now, as most practices will have a least some telehealth encounters of various types, including residencies and fellowships,” Johnson continued, noting that he has helped incorporate telehealth into an interprofessional Simulation Center experience since 2017, after he, Dr. Richard Van Eck, and Dr. Jon Allen secured grant funding for a Simulation Center-based program. “Students today need to learn good camera skills and microphone presence. In addition, they need to manage the camera, patient screen, and a screen with the patient’s electronic health record simultaneously. It’s not easy.”
Housed within the School’s Department of Family & Community Medicine, the elective helps train students on practicing medicine at a distance, experience with which the pandemic made almost a requirement for many health providers.
Part of the reason this new healthcare delivery model is complicated, added Dr. Andrew McLean, the chair of the SMHS Department of Psychiatry & Behavioral Science, is that it raises a series of thorny questions related not only to patient safety and care, but privacy, reimbursement, and licensure.
“While medical students have had the ability to take part in this depending on their rotations or attendings, it’s important that trainees understand the importance of these factors,” he said, imagining a patient encounter where the patient on vacation calls up their doctor for a telehealth session from a state in which the provider is not licensed. “What does one do when there is a crisis on the ‘other end,’ and what are the legal or licensure issues that might be different from in-person experiences?”
Along the way, added Van Eck, students learn how they need to approach diagnosis and treatment differently.
“The debate quickly becomes: is it as good as face to face?” asked Van Eck, the School’s associate dean for Teaching and Learning. “But as Dr. Human points out, you can’t just ask ‘Is it as good [as in-person]?’ It’s just different. And if you align what you’re trying to do with what the technology is good at, it can be better in some ways.”
For example, said Van Eck, a gait test on a patient walking back and forth in an exam room in-person can’t show providers how a patient moves around their own home.
Newly minted physician Dr. Ryan Norris agreed.
“Overall, I think the elective was great, and I highly recommend it,” said Norris, who is in the first year of an anesthesiology residency at Wake Forest University. “I started clinicals in the height of the pandemic, and there were several times that the doctor would do a telehealth visit. And sometimes they had me sit in, and it was really interesting to see how much we could do virtually—physical exam maneuvers for shoulder pain, knee pain, hip pain, looking at rashes, and getting some idea of the problem.”
All the educators agreed that it is students like Norris whom they have in mind as they seek to improve the School’s curriculum.
And because Human and Johnson are likely ahead of many of their colleagues in not only providing telehealth to patients but serving as a telehealth preceptor to medical students, Van Eck, Johnson, and others helped develop the AMA educator-focused Telehealth Clinical Education Playbook in 2021.
“Initially, the cognitive burden of telehealth and the physical and emotional pressure associated with the pandemic required physicians and other health care professionals to (rightly) prioritize patient care over medical education,” wrote Van Eck and his co-editor Vimal Mishra in the first chapter of a book designed to help teachers train medical students in providing telehealth services. “Now, with our growing familiarity and comfort with the telehealth process comes an increased capacity to expand our focus to include education again.”
Part of this increased capacity involves helping providers-educators reimagine what a patient encounter looks like, how it’s reimbursed, and what it means to be on-call—or make a house call.
In that sense, telehealth is not such a new idea.
“The VA started some of this 50 years ago,” continued Human. “In rural medicine, we’ve done ‘telehealth’ forever. My first job 25 years ago was in Wadena, Minnesota, and we would do teleconferences with the University of Minnesota once a month. The VA has been doing this kind of thing in very rural areas with nurse practitioners and physician assistants for a long time. We’re coming full circle here in some ways.”