Psychiatrists at the University of Virginia counsel adults and children throughout the state using videoconferencing. Nurses at FirstHealth Home Care in North Carolina use wireless blood pressure cuffs to remotely monitor patients recently discharged from the hospital. And emergency medicine physicians at Avera Health, a regional health system based in South Dakota, provide real-time emergency consultations to more than 100 distant community hospitals.
The use of telemedicine is on the rise. Nevertheless, widespread adoption is lagging despite advances in technology and demonstrated benefits, according to the Center for Connected Health Policy, a research organization. For example, fewer than a quarter of rural family physicians responding to a recent survey said they use digital technology to connect to specialists or to communicate with far-flung patients.
Inconsistent insurance reimbursement, limited broadband access and varying cross-state licensing laws are some well known barriers to implementing telemedicine, and states and the federal government have begun to address those issues. Less discussed is the lack of formal education in telemedicine for physicians-in-training.
The Association of American Medical Colleges (AAMC) found in an annual survey that 84 out of 145 medical schools said they included telemedicine as a topic in either a required or an elective course in the 2016-2017 academic year.
But that could mean almost anything, from a brief mention of telemedicine in a lecture to full-fledged simulations of remote patient care. The survey does not ask for details.
“The types of experiences that schools offer students range as widely as the penetration of telemedicine clinical services themselves,” says Dr. Scott Shipman, AAMC’s director of clinical innovations.
Robust telemedicine training at medical schools and in residency programs is far too rare, says Dr. Susan Skochelak, group vice president for medical education at the American Medical Association. Yet such programs are necessary if the majority of physicians are to become comfortable practicing telemedicine, she says. “You can’t assume that [medical students and residents] are going to learn it once they get out in practice. It’s too important,” says Skochelak.
In 2016, the AMA adopted a new policy encouraging accrediting bodies for both medical school and residency programs to include core competencies for telemedicine. “But the main thing that we have done at the AMA is, within our consortium of medical schools, to showcase this as a topic to other medical schools,” says Skochelak.
Since 2013, the AMA has been working with leading medical schools – the consortium now totals 32 members – to bring medical school education into the 21st century, awarding them a total of $12.5 million in grants to create innovative programs. The University of North Dakota School of Medicine and Health Sciences joined the consortium in 2016 with a project to develop comprehensive telemedicine training.
“We told the AMA that we were not doing this as a proof-of-concept. We were going to integrate this into the school’s curriculum,” says Richard Van Eck, PhD, the associate dean for teaching and learning. In other words, it would be mandatory for every medical student.
“We don’t think you can prepare medical students, certainly not for North Dakota, which is primarily rural, without focusing on telemedicine,” says Van Eck, who adds that an important component of the program is to train students across healthcare professions to work together as a team.
Second-year medical students, along with nursing, occupational therapy, physical therapy and social work students—274 students in all—went through the first training, which took place in November and December. In the school’s simulation center, the students moved through three scenarios involving “Sandra,” a patient played by a high-tech manikin or a scripted volunteer.
In the first scenario, Sandra arrives in the emergency room with chest pains and shortness of breath. The medical and nursing students use a computer tablet mounted on a motorized pedestal to videoconference with a cardiologist, who is using a computer in another room. Heart monitors and other devices are wirelessly connected to the tablet. Sandra is diagnosed with myocardial infarction, drugs are ordered and she eventually has a stent placed.
In the second scenario, Sandra does not have cardiac rehabilitation in her small town and insists on going home. Nursing, occupational therapy, physical therapy and social work students join Sandra and a family member, played by a volunteer, to videoconference with her physician—a medical student—over laptops. They determine she needs to be moved to long-term care.
In the third scenario, social work and nursing students, along with family members, use a laptop to teleconference with a medical student about end-of-life planning.
Throughout the process, the students are learning skills that are unique to telemedicine, such as establishing rapport over the internet with both patients and specialists, and they found it a lot more difficult than they had anticipated, says Van Eck.
When consulting with the cardiologist, the students did not always position the camera so that the cardiologist could see all the members of the team and understand who was talking. They forgot to adjust the volume. They had distracting sidebar discussions, ignoring the cardiologist, “which you tend to do when somebody is at a distance,” says Van Eck.
When speaking remotely to family members and the patient in the last two scenarios, the students had to remember to fill the screen with their face, to maintain eye contact and to not constantly look down at their notes. “When you are trying to explain things to people who are frightened by the possibilities, it’s hard to do in the best of circumstances, and telemedicine makes it even harder,” says Van Eck.
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Other comprehensive telemedicine training can be found at academic health systems that have a long history of using telemedicine with their patients, such as the University of California, Davis, says Shipman. However, they appear to be mostly electives.
At the UC Davis School of Medicine, about 20 percent of students are enrolled in three community health scholars programs—one focused on rural health, one on the majority-rural San Joaquin Valley and one on the urban underserved population—and they receive telemedicine training in their first and second years.
At the school’s telehealth center, the students move through mock cases with a volunteer “patient” operating from a script and a remote specialist, with whom they communicate through a computer equipped with a camera and attachments, such as a stethoscope to hear the heartbeat, a microscope to look at skin lesions and an otoscope to see the inner ear.
In addition to learning so-called webside rapport with patients and families and how the technology works, these students learn how to clearly and concisely ask questions of specialists, says Dr. Blanca Solis, the director of the school’s pre-clinical curriculum.
“Telehealth is a challenging medium, and when you are reaching out to someone who may be in the middle of a busy day, it’s best to be prepared to present information concisely,” says Solis. “We’ve heard from specialists that, over time, providers using telehealth learn to anticipate what the specialist may want to know or what labs they need to have prepared.” It would be better if they could learn that skill while in school, she says.
And for the rural health scholars, Solis says the training has another goal: to keep them interested in rural health as they move through medical school. “By exposing them early to telehealth, they get to see that they won’t be alone in a rural practice, that they have these means to reach out.”
The school has considered expanding the training to other medical students, but it is logistically challenging to coordinate the schedules of specialists, faculty, standardized patients and students, says Solis. “I think reaching 20 percent is pretty good,” she says.
Coordinating schedules is just one barrier to implementing telemedicine training in medical, nursing and other health professional schools. Finding specialists experienced in telemedicine to help develop the curriculum and teach it and finding money in the budget for equipment are two others.
Perhaps the biggest barrier is finding time inside an already packed curriculum. But it can be done, says Van Eck. The University of North Dakota plans to expand its training into simulations of other chronic diseases, such as diabetes management and mental health. “My guess is that three-quarters of our simulations will eventually have telemedicine in them,” Van Eck says. Adding it to the simulation on heart disease “was a lot easier than we thought it would be, although it took a lot of time and work to figure that out.”
He and his colleagues would like to save other medical schools that time and work. They have proposed to the AMA that they write a toolkit about how to integrate telemedicine into medical curriculum scenarios.
“Learning telemedicine on the fly, as doctors, is not the responsible thing,” says Van Eck. “We need to start that earlier.”