Telehealth and the New Normal: Maintaining Bedside Teaching Concepts in a Virtual Environment

Key Learning Points

For clinician-educators, the COVID-19 worldwide pandemic has introduced both challenges and opportunities in maintaining a productive learning environment. As the world moves towards a new normal, educators will need to convert high quality bedside teaching, to equally high-quality webside teaching.
Telehealth is specifically the use of electronic information and telecommunications technologies to support and promote long distance clinical health care, patient and professional health-related education, public health and health administration
Many principles that underlie good bedside teaching can be adapted for telehealth visits.
These principles, which we divide into pre-visit, during, and post-visit, clearly establish the learning possibilities of a telehealth visit.
For medical students, residents and attending physicians, the transition requires a number of adaptations to preparing for visits, communication during visits, and debriefing after visits.
This novel learning environment introduces golden opportunities to teach on topics that are specifically pertinent to a telehealth or virtual patient-facing learning environment.

Introduction

For clinician-educators, the COVID-19 worldwide pandemic has introduced both challenges and opportunities in maintaining a productive learning environment. As the world moves towards a "new normal," educators will need to convert high-quality bedside teaching, to equally high quality “webside teaching.”^1,2

Telehealth—Looking Back and Ahead

Telehealth is specifically “the use of electronic information and telecommunications technologies to support and promote long distance clinical health care, patient and professional health-related education, public health and health administration.”³ It is mainly implemented via video conferencing over the internet.³ Furthermore, telehealth can be provided synchronously or asynchronously (e.g., live video chat or email conversation), and delivered by either a solo physician or multidisciplinary team.⁴ Additional benefits of telehealth include increasing patient and provider satisfaction, cost and time savings, and non-inferiority clinical outcomes for several medical conditions.⁴ However, it has been noted that the lack of training is one of the principal barriers to the adoption of telehealth.⁵ As such, the American Medical Association has repeatedly emphasized the importance of telehealth as a core competency for medical students.⁶

Many principles that underlie good bedside teaching can be adapted for telehealth visits, but the workflow must be clearly modified from a traditional in-person surgical clinic. First, the attending surgeon should be transparent with their residents and medical students about how they offer telehealth visits to their patients and if there are any conditions or issues that the surgeon would prefer to see in-person and not virtually. Next, we recommend that the surgeon clearly divide all patients between the medical student and/or resident well in advance of the actual telehealth clinic and send the information to the appropriate learners. This will give the resident or medical student time to read and prepare for each patient prior to the virtual clinic. To maximize efficiency and minimize technology issues, a patient should probably have either a medical student or resident learner and not both. In terms of the logistics for the individual telehealth visit, we have found that it is ideal if the attending surgeon starts the telehealth visit with the patient and explains that they will first speak with either a medical student or resident and the learner’s role in the encounter. If possible, the attending surgeon should then observe the medical student’s or resident’s interaction. When the learner is done, the surgeon should then clarify any confusing parts of the encounter and summarize next steps with the patient. Feedback or teachable moments should be given to the learners after the patient has ended the encounter. Alternatively, if the surgeon and learner are in the same physical location to each other, they could place the patient on hold and confer privately before the surgeon clarifies and summarizes with the patient. This process would then continue until all the telehealth patients are seen. In the remainder of this article, we outline new roles and actions for medical students, residents, and attending surgeons to maximize the educational value of telehealth visits.

Medical Student

As surgical educators, we aim to help medical students transition from the Reporter level of the Reporter-Interpreter-Manager-Educator (RIME) framework to the Manager level. Table 1 outlines actions and the related rationale that attending surgeons could use to help students transition from Reporter to Manager while employing telehealth visits.^7–9

Table 1. Optimal education when transitioning from bedside to webside: Medical student

Stage	Action	Rationale
Pre-Visit	Students should review the patient’s EHR and discuss any relevant data they find prior to the telehealth visit.	Telehealth visits are often even briefer and goal-oriented than a regular visit, which minimizes the opportunity for learners to ask questions during the visit. Reviewing the EHR before the visit allows the learner to clarify any initial questions and allows for a smooth telehealth visit.
Pre-Visit	Students should develop a “script” for the telehealth visit.	By having a student develop a “script” for the telehealth visit allows for the attending surgeon to review with the student what specific questions may be necessary in a virtual setting when the patient is not physically present for basic observations or examination (e.g., have you taken your BP recently?).
During Visit	Students should take notes during the telehealth visit and asking relevant questions.	By taking notes, the student can easily formulate questions to ask the patient during or the attending surgeon after the telehealth visit to achieve active learning.
Post-Visit	Students should develop a summary of the telehealth visit, along with a differential diagnosis.	This is a best practice for any patient-centered encounter and is especially important as the active didactics tend to more appropriately situate themselves either prior to, or after, the actual encounter.
Golden Opportunity	Students should develop an awareness for the medical, legal, and ethical considerations pertaining to telehealth visits.	Telehealth and the virtualization of healthcare brings many technology-related opportunities and challenges to the surface. These include concepts such as confidentiality in a virtual environment, legal responsibility and liability in the virtual setting, and effective communication in a virtual setting. Educating a student in a virtual setting makes a discussion around these topics especially relevant.

Resident

Surgery residents should be able to accomplish all of the medical student actions described in Table 1, but also demonstrate the actions required to manage a busy surgical clinic as outlined in Table 2.

Table 2. Optimal education when transitioning from bedside to webside: Resident

Stage	Action	Rationale
Pre-Visit	Residents should be able to clearly articulate a differential diagnosis based on their review of the patient’s medical records as well as needed H&P elements or diagnostic testing to determine the next steps for surgical management /treatment.	By reviewing the patient’s EHR, the resident can determine what standard components of the clinical examination are necessary and those that are not. The resident can then develop a plan on how to conduct an examination virtually. For example, if seeing a wound or surgical site is critical, the resident can determine if it should be photographed and sent by the patient or if it should only be seen via webcam during the telehealth visit. The resident may also recognize that certain diagnostic tests should be done prior to the telehealth visit to maximize efficiency and minimize surgical delays.
During Visit	Residents should adapt the non-verbal cues and body language to put a patient at ease during a telehealth visit and to focus the visit while identifying and prioritizing all problems brought up by the patient for follow-up.	During a telehealth visit, non-verbal cues and body language may be challenging to convey but are as important in the virtual setting as during an in-person visit. Therefore, residents are provided with an excellent learning opportunity to adapt their body language in a new setting and, at the same time, learn how to maintain a focused and fluent consult in the virtual environment. During a telephone virtual visit (e.g., no video), the lack of non-verbal cues may prove particularly challenging; however, try regular check-ins with the patient during the visit (e.g., Do you have any questions so far?). Additionally, maintaining a smooth telephone visit with good patient rapport can be challenging, which necessitates that feedback be requested on the telephone fluency domain.
Post-Visit	Residents should both teach medical students and learn from attending surgeons following the telehealth visit.	A resident’s dual educational role as a teacher and learner continues during telehealth visits. For example, a telehealth visit might be entirely unfamiliar for many medical students, so a resident will need to help the students properly prepare. Additionally, residents should reflect and obtain feedback from attending physicians to identify areas for improvement.
Golden Opportunity	Residents should also be able to develop an awareness for the medical, legal, and ethical considerations pertaining to telehealth visits.	Telehealth and the virtualization of healthcare brings many technology-related opportunities and challenges to the surface. These include concepts such as confidentiality in a virtual environment, legal responsibility and liability in the virtual setting, and effective communication in a virtual setting. In their dual educational role, residents are involved in both practicing these concepts, as well as teaching them to students.

Attending Surgeon

Attending surgeons should be able to effectively teach both medical students and residents, who face some common, and different, opportunities and challenges during a telehealth clinic. While educational principles can hold true in both the virtual and non-virtual environments, some adjustments are needed to facilitate effective clinical care and beneficial education, which are outlined in Table 3.

Table 3. Optimal education when transitioning from bedside to webside: Attending surgeon

Stage	Action	Rationale
Pre-Visit	Attending surgeons should develop an educational structure for the telehealth clinic, which may consist of alternating visits with medical students and residents or having both participate in the same visit.	Ensuring a patient-focused encounter is critical in the virtual environment, however, it can be challenging to achieve this when learners of various levels are involved. For a telehealth visit, it is important for attending surgeons to have developed a plan with educational goals and objectives for the visit, along with ground rules and clear expectations for the learner’s involvement during and after the visit. Additionally, this plan must be appropriately crafted based on the learner’s current knowledge and skills. A huddle prior to the start of the telehealth clinic with all learners included may help ensure expectations and roles.
During Visit	Attending surgeons must ensure that the telehealth visit remains a safe space for both the patient and learners.	The lack of familiarity may cause increased tension for all parties involved in a telehealth visit. First and foremost, the attending surgeon must ensure that the patient feels safe during a virtual visit and is comfortable with learners present. Additionally, the attending surgeon must review information collected by the medical student or resident physician to ensure that the information is accurate and that all questions have been answered.
Post-Visit	Attending surgeons should review teachable moments and questions after the telehealth clinic as opposed to after each telehealth visit.	While a telehealth visit is often more fast-paced and focused than the in-person or bedside encounter, we recommend reviewing teachable moments after a clinic is completed, rather than after each visit. Doing this allows the clinic’s flow to continue, and as the learners have been taking notes, higher level teaching points can be discussed after all visits have been completed. If teachable moments are to be reviewed in between visits (e.g., when the feedback might positively impact the immediate next visit), these should be kept to a maximum of 1-2 salient points. We also encourage a frank discussion of the limitations of telehealth technologies and what further information is required to ensure excellent patient care and outcomes.
Golden Opportunity	Attending surgeons should focus attention on particular issues pertaining to telehealth visits, such as specific HIPAA concerns.	Attending surgeons must make sure that all ethical and legal principles and regulations are followed during any patient-encounter. Specifically, in the telehealth environment, the importance of discussing and properly educating all learners around these principles and regulations is critical.

Conclusion

The COVID-19 pandemic has greatly emphasized the need to maximize the educational value of surgical telehealth visits. While changes in medicine are ubiquitous, we believe the principles outlined above may provide some guidance to combine sound educational principles with the limitations of telehealth visits to ensure they best address the learning needs for the patient, medical student, resident, and attending surgeon. As a final point, while the role of telehealth visits increases, we encourage attending surgeons, residents, and medical students to continuously reflect on the appropriateness of telehealth visits versus in-person visits. Patient selection for a telehealth visit will likely vary between surgeons and clinical practices, but we encourage instructors to be transparent with learners about what factors they consider before offering patients a telehealth appointment. While the benefits of telehealth visits are many, especially amid a pandemic, the loss of the in-person, hands-on experience is likely to have some clinical and educational implications.

References

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Dorsey, ER, Topol, EJ. State of telehealth. New England Journal of Medicine 375: 154-161; 2016.
United States Health Resources & Services Administration. Telehealth programs. Retrieved from https://www.hrsa.gov/rural-health/telehealth/index.html.
Jonas, CE, Durning, J, Zebrowski, C, Cimino, F. An interdisciplinary, multi-institution telehealth course for third-year medical student. Academic Medicine 94(6): 833-837; 2019.
Moore MA, Coffman M, Jetty A, Klink K, Petterson S, Bazemore A. Family physicians report considerable interest in, but limited use of, telehealth services. J Am Board Fam Med. 2017;30:320-330.
American Medical Association. Statement of the American] Medical Association to the House Committee on Energy and Commerce Subcommittee on Health, RE: Telemedicine. Retrieved from: https://searchlf-ama-assn-org.treadwell.idm.oclc.org/letter/documentDownload?uri=/unstructured/bi%20nary/letter/LETTERS/statement-sfr-telemedicine-congressional-review.pdf. Accessed on April 23, 2020.
Pangaro L. A new vocabulary and other innovations for improving descriptive in-training evaluations. Academic Medicine 1999, 74(11):1203-7.
Pangaro L. Investing in descriptive evaluation: a vision for the future of assessment. Med Teach 2000; 22:478 -81.
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About the Authors

Carl Gustaf S. Axelsson, MD, MPhil, MMSc, is a post-doctoral medical education researcher at Massachusetts General Hospital, Harvard Medical School in Boston, MA.

Michael G. Healy, EdD, is a research fellow at Massachusetts General Hospital, Harvard Medical School in Boston, MA.

Roy Phitayakorn, MD, MHPE, is a general and endocrine surgeon and director of medical student education and surgery education research at Massachusetts General Hospital, Boston MA and associate professor of surgery at Harvard Medical School in Boston, MA.

Telehealth and the New Normal: Maintaining Bedside Teaching Concepts in a Virtual Environment

Key Learning Points

Introduction

Telehealth—Looking Back and Ahead

Medical Student

Stage

Action

Rationale

Stage

Action

Rationale

Resident

Stage

Action

Rationale

Stage

Action

Rationale

Attending Surgeon

Stage

Action

Rationale

Stage

Action

Rationale

Conclusion

References

About the Authors