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Introduction
Although telemedicine has been available for years, the COVID-19 pandemic has accelerated its use not only in patient care but also in medical education. Drs. Rajani Katta and Samir Desai discuss telemedicine rotations and how students can make the most of these learning opportunities while working as part of the healthcare team. With a focus on video encounters, you'll learn how to prepare for an effective encounter, connect with patients, take the history while remaining engaged with the patient, and properly close the session.
Podcast Transcription
Dr. Katta: Welcome to the Success in Medicine podcast. I'm Dr. Rajani Katta and I'm here with my partner, Dr. Samir Desai. And on today's episode, we wanted to talk about telemedicine in medical education and, specifically, telemedicine as a component of clinical rotations. So, Samir, I wanted to start by asking you, as we record this it's just the start of 2021, what is the history of telemedicine in medical education?
Dr. Desai: So, Rajani, telemedicine has been around for decades and there's been an effort to incorporate telemedicine into medical education, but what I would tell you is that it's been a slow process getting it adopted. Even though its promise has always been far-reaching and tremendous in its potential, the process to get it adopted was slow. Of course, with the pandemic, everything changed. And while it was gaining some momentum before the pandemic, that has really accelerated and it's now fulfilling the recommendations of a lot of our leading organizations.
For example, in 2016 the American Medical Association had urged medical schools and residency programs to educate their students and residents on using telemedicine to care for patients. And so, when the pandemic hit and the decision was made to stop in-person clinical experiences for students, faculty across the nation were asked to quickly shift the education to online learning. And so, telemedicine in medical education has really taken off since then.
Dr. Katta: Well, I really want to focus on best practices for our students. But before we get to that, what was the role of telemedicine prior to COVID?
Dr. Desai: That's a great question and students will be interested to know that telemedicine education was present in the curriculum of many medical schools. So in a recent survey that was done before the COVID pandemic, over 60 allopathic medical schools in the U.S. reported offering some sort of telemedicine experience during the clinical years. But when you take a closer look at what this experience was, with few exceptions, telemedicine was really not a required part of the curriculum.
So, typically what happened, Rajani, was that a student might be in a rotation, particularly in certain specialties such as psychiatry or dermatology which had lent themselves easier to adopting telemedicine, and perhaps they would see telemedicine as they were rotating through that particular specialty but there may not have been a formal curriculum related to that. That's not to say that there weren't any formal telemedicine electives. There were a few schools who had developed that and I would consider those schools certainly to be leaders in this area. And students could certainly take part in those rotations that they were interested in but I wouldn't say that student interest in telemedicine was terribly high.
But now of course with the COVID pandemic, as I mentioned it's accelerated the use of telemedicine, and it's really spurred educators to create telemedicine-focused electives. And the student interest in these experiences has really taken off.
Dr. Katta: Well, and you and I have spoken to a number of our colleagues and, certainly, a number of the students with whom we work. And one of the reasons that we really wanted to do this episode was because telemedicine is becoming so much more prevalent right now as a component of clinical rotations. And in speaking to our colleagues and our students, what we found is that there are a lot of different variations on how telemedicine may be incorporated into a rotation.
So for example, as you mentioned, it might be a part of the rotation. You know, for example, you might be in clinic three days a week and you might be doing telemedicine two days a week. And even the way that it's set up is kind of interesting. So, some of our students have been in the clinic with their preceptor sort of, you know, in the same room and then they are doing telemedicine encounters with a patient who is at a remote location. And so, the student might be taking a history, but then they might turn to their preceptor to discuss the differential diagnosis in the plan, and then go back to discussing it with the patient.
Alternatively, I know we've heard of cases where the student is in one location, the preceptor is in a second location, and then the patient is at a third location. So there are different ways to incorporate or different ways that institutions have incorporated, telemedicine into their educational experience. And for the remainder of the episode, I really want to focus on best practices for our students. So questions about,
'What are the goals of a telemedicine encounter and a telemedicine rotation?'
'How can a student work to really enhance their own educational experience?'
'How can they impress upon their preceptor how well they're performing?'
and ultimately, the most important aspect of this is,
'How can they provide the best medical care possible to the patient who's on the other side of that video screen?'.
So let me start with that first question, Samir. What are some goals for students who are taking part in telemedicine rotations?
Dr. Desai: Well, Rajani, I would say that your top goal, as is the case with any rotation, is to work with the health care team to give patients high-quality, patient-centered care. Since telemedicine is going to be playing a larger role in our healthcare system, your other goals are to be exposed to telemedicine because for many students it will be something new for them and they will really want to understand how care can be delivered in this manner. And the other goals include being actively involved in the telemedicine rotation. So if you can take an active role in these patient encounters, you can really begin to build your clinical and non-clinical skills, some of which are going to be very different than what you are used to in an in-person visit.
So for example, you'll learn how to communicate virtually with patients, you'll learn how to perform a telemedicine physical exam and how to troubleshoot technological issues, and a big part of your telemedicine experience is going to be about developing your webside manner. Notice that I said 'webside' and not 'bedside'. And while you might think that these are the same, there are important differences between your webside and your bedside manner, and that's something we'll talk about in this episode. And the bottom line is to remember that your webside manner, just like your bedside manner, can have a tremendous effect on patient outcomes.
Dr. Katta: Well for students who are taking telemedicine focused electives, how can they impress?
Dr. Desai: Well to excel, it's best to break down the telemedicine encounter into three parts. The first part is what you need to do before you connect with the patient. The second part is what you need to do during the encounter. And then the third part is what you need to do after the patient encounter. By understanding the best practices for every part of this process, you'll be on your way to making a great impression on your preceptor or your attending.
Dr. Katta: So let's start with before the rotation. What do students need to be doing before the rotation begins?
Dr. Desai: A big part of your thinking before the rotation begins needs to be about logistics. So as a first step, I recommend becoming knowledgeable about how that telemedicine is going to be delivered in your rotation. In other words, what software is going to be used and to make sure that you have that software on your device. And, of course, you need to have a reliable internet connection and you have to make sure that the speed of your connection is sufficient to support the platform.
And so, the other things are that you have a laptop with a camera and a microphone, and that you test out your audio and video within the platform to make sure everything is compatible and that the sound and video quality are what you need it to be. And remember that your patient must be able to see and hear you. You don't want technological issues to take away from having a satisfying encounter.
And the other thing is, since you might not be in the same physical location as your preceptor or attending, you need to know what to do when there's a problem. So in case there's a technological issue, how will you be in contact with the health care team. And for that reason, many rotations will establish a communication back channel for this reason, and that's usually via texting or private chat.
Dr. Katta: How can students make a good first impression on their patients?
Dr. Desai: That's a great question. That's something that we're striving to do in every one of our encounters whether it's in-person or virtual. But how patients respond to you will certainly be based in part on how you make them feel at the beginning of the encounter. So immediately after the encounter begins, that patient will be forming an impression of you and that impression will be based on several factors.
So first, your workspace is a big part of this. They're going to get a chance to see your space when you log on and they see you. And therefore, you want to pick a place at your location which is private, where there will be no interruptions or background noise and where your environment is clean and uncluttered. And what you have to do is you have to make sure that you take stock of your environment and what they can see. And right before you log on, the other aspect of this that's very important is you need to make sure that you're in the proper place on the screen. That your body is in the center of your frame or your screen, that your lighting is uniform so that your face is not in shadow. And these are all important considerations.
So there's a lot of prep that you need to do before you log on with that patient. And beyond that, just as you would in an in-person visit, you have to get up to speed about the patient. So you have to review the patient's medical history, their symptoms, their concerns, so you can be as informed as possible before you begin that encounter.
Dr. Katta: It's really an interesting experience isn't it? Because you have to think so deeply about the technological issues and the fact that a video encounter is so distinct from an in-person encounter and you need to think about your setting, your background, your lighting, your interruptions. And then you have to combine that with a consideration of, how would you approach walking into an actual physical exam room? You would take out the patient's chart, you would review the patient's medical history and symptoms. So I think that's really interesting.
I'm just going to alert our listeners that you and I did an episode on virtual interviews where we talked more deeply about some of these issues, especially things like ensuring that there are no interruptions, ensuring that there is the correct lighting and the correct background. So we went very deeply into that in our episode on virtual interviews so I'd really recommend that and I'm going to second that about some of these issues.
So for example, in one of my first virtual interviews where it was a recorded interview for social media, I went back and I looked at it and I realized,
"Oh my gosh, the lighting was really poor!"
And you don't quite realize how much that makes a difference but it's really an aspect I consider of non-verbal communication. So if your face is in shadow and you're speaking an important message, sometimes that message is lost because it's distracting to not be able to see that person clearly. So all of these factors do make an impact on how your patient views you and how your patient absorbs that message. So I do recommend going back to that episode and thinking about proper lighting and, you know, whether that's a ring light or something else, as well as all of those other factors that you mentioned, Samir.
So, I want to now transition a little bit to the actual encounter. So here you've prepared, you're ready to go. How do you start that telemedicine encounter?
Dr. Desai: So starting that encounter is so important because there's a tone that you want to establish with that patient. So I recommend starting by introducing yourself clearly and explaining to the patient what the two of you will be doing during the session. And to some extent, this depends on the workflow in your telemedicine rotation. So for example, if your workflow involves you taking the history and then you have been instructed to step out of the session to discuss it with your preceptor, then that's something that you want to get across to the patient. So, you want to let the patient know that this is what will be happening. So when the patient has, you know, the expectations and an understanding of the workflow, that really sets the right tone.
Beyond that, you want to think about the things that we do in in-person visits and that is, you know, we sometimes make some small talk with our patients because it, again, helps us establish a bit of a connection. And that small talk can also take place in a virtual interview and it can help your patient relax, especially if they are somebody who's not done this before.
Now, patients have varying degrees of comfort with telemedicine, and so it's a good idea to ask the patient if he or she has any questions or concerns about conducting the visit remotely. And as I mentioned, you know, some people have done this before, some people haven't. So if it's something that's new for them, you'll quickly get a sense if they have any concerns or hesitations. And if you find that they are uncertain about this experience, that's the time when you can offer some reassurance. And don't forget to ask the patients if they can see and hear you properly. This is something that's easy to forget and you don't want to get too far into the encounter to find out that they can't hear you properly.
Now, one more very important point, and that is if you're going to be doing things during the encounter that's going to take your attention away from the patient, it's very important to let the patient know that up front so it doesn't come as a surprise. For example, if you're going to be typing during the patient visit, let the patient know. And, you know, it's just important to say that, you know, very politely. You know, as an example,
"Before we get started, Mrs. Smith, I wanted to let you know that you may see or hear me type from time to time and that's because I want to make sure that I get your story just right".
And so, that's a big take-home point. If there's going to be anything that you do, whether it's typing or looking away from the patient to search something up in the medical record, it's important to let the patient know about that.
Dr. Katta: Now, after you've sort of set the tone and you've established the introductions and how the encounter will go, you're going to then take the history. And what would you say to our listeners is important to remember while you're taking a history?
Dr. Desai: Yeah, great question Rajani. So this gets back to a bit about what you had said before about communicating with patients and how we do that. We basically communicate with patients in two ways. We have our verbal communication and we have our non-verbal communication or our body language. Now, in a virtual patient encounter, the patient won't be able to see all of you so your non-verbal communication will largely take place through your facial expressions, your eye contact, and the tone of your voice and your body language must support and be consistent with what you're saying. And you really have to make the patient feel that you are engaged and you are attentive, so that means sitting up straight.
If you're with a patient for 20 or 30 minutes, it's very easy for your posture to change, right? You know, you could find yourself starting to lean back and maybe you start to do something, you know, with your arms, like cross your arms. And that can communicate things to patients so you really have to make sure your body language is consistent with what you're saying.
And finally, I want to just say, you know, your voice should make them feel like you are, you know, friendly and confident. That's the the feeling you want to get over to them.
Dr. Katta: And apart from that, which is very important, your tone of voice, your body language, can we talk about eye contact? Because you and I have discussed how that's actually different in a virtual setting than it is in an in-person encounter.
Dr. Desai: It is and this is something that's really easy to lose sight of. And eye contact is huge, right? We talk about it all the time in in-person visits. But in a virtual interview, it's so important because again we're limited in the way that we can communicate. And so there's a natural tendency in virtual patient encounters to want to spend the entire time looking at the patient's face on the screen, but when we do that we have to understand how that feels to the patient.
So to the patient, when we look at their face on the screen, it appears as if we're looking down and not making eye contact. So what we have to do is learn how to look into the camera. It's not something that I would say is natural. And even when it's something that's on your mind, we can easily slip into our old habits of looking on the screen. But if you do that again, it can take away from the connection and the relationship that you are building with the patient.
Dr. Katta: And, apart from eye contact, how else can you make the patient really sense that you are listening to them?
Dr. Desai: So, to make the patient feel like you are listening, in addition to eye contact, you want to verbally acknowledge what they're saying. You want to nod your head and you want to paraphrase periodically to confirm what you've heard. So you can take a moment every so often to just, you know, paraphrase or summarize. You know you can say,
"Mrs. Smith, you know, if I understood you correctly...",
And then you can paraphrase what you had heard. And in this way, Mrs. Smith will be able to really get that feeling that you have been paying attention and you've been engaged.
Dr. Katta: And we wanted to talk about how when a student is taking the history, and certainly you're going to focus on the, you know, what we've learned in medical school, how you take a patient history. But I know you also talk about how important it is to ascertain the patient's goals for the visit at this time. Can you talk more about that?
Dr. Desai: So ascertaining goals in a patient encounter has always been important and it's something that we spent a lot of time doing in in-person visits, and it's no different in a virtual encounter. So when you receive your patient for a virtual patient encounter, you'll have some information on what that patient has scheduled that appointment for. And let's say, for example, that it's a follow-up for hypertension, and that may be the case but that patient may have one or two other things that he or she wants to discuss or ask questions about. Maybe that patient wants to also ask about the COVID vaccine. So specifically asking upfront what the goals of the visit are will really allow you to meet their needs. And if they express any concerns or have questions, you can make a note of these so that you can address them with your preceptor.
Dr. Katta: Let's talk about the last phase of the telemedicine encounter: the concluding phase. Why is it so important to end the encounter properly?
Dr. Desai: So ending the encounter, it's all about making a final impression, right? You've worked hard to make a great first impression. You want to leave them with a great lasting impression. On top of that, there are some very important things that need to be accomplished at the end of the telemedicine encounter. And one thing you need to do is give some thought to that so that it doesn't end up being an abrupt ending.
You want to make sure that you take the time to answer any questions that they have, to go over the treatment plan, to make sure that they've understood it, and to outline what the next steps will be. I think a very effective way of closing is to have them tell you what their understanding is of the treatment plan. And that is something that, you know, we do in in-person visits and certainly that will also serve you and the patient well in a virtual encounter.
Dr. Katta: What about after the encounter?
Dr. Desai: So after the encounter, it's your job to follow through on all tasks related to that patient encounter. So that might include completing your patient note in the chart. It may involve sending the patient a follow-up note, summarizing the visit and the plan. It could be arranging for prescriptions or lab work. So that's something that you will decide with your attending or preceptor. And then, it's important that you work with the team to have that proper follow-through so that nothing falls through the cracks.
Dr. Katta: Apart from those patient care considerations, what else is it important to do after the encounter?
Dr. Desai: Well, after the encounter, it's important to reflect on what went well and what you would like to change. So we're all trying to get better with every experience, so start with the opening of the encounter and ask yourself,
'How did I open this encounter? Did I establish good rapport? Was I able to make the patient feel comfortable?'
And then move into the rest of the encounter and ask yourself, you know,
'Was I able to provide comfort and empathy wherever and whenever it was needed? ' 'How did I do with the history? What was the quality of my history? Did I get all the information that I needed to get?'
So for example, if you didn't realize the importance of asking certain questions in a patient presenting with back pain, you want to make note of that so that with the next patient that presents with back pain you'll be sure to include that. And, of course, you'll be getting that information not only through your own reflection, but through talking with your preceptor. You also want to think about the technological aspects of the patient encounter. Was there a technological issue that came up? And if it did, what can you do about it in the future?
Dr. Katta: What about speaking to your preceptor for feedback? Do you have any suggestions about that?
Dr. Desai: I do. I think feedback is so important in a rotation and in a virtual rotation where you have had less experience doing the things that you're doing. I think it's vital for your growth. If your preceptor has observed you during the encounter, you can get very specific feedback about any aspect of that encounter. You'll learn about how you did when you opened the interview. You learn about what you did during the history taking. If the physical exam was part of the telemedicine encounter, you'll learn about that.
And so, you can take that feedback and really grow from it. And if your preceptor didn't observe you and you're wondering about how you can improve in some area, don't be afraid to bring it up. Bringing it to your preceptor's attention may prompt them to give you some specific advice and even observe you doing that aspect of the encounter which will then give you some more actionable information. And remember, what you're trying to do here, in terms of goals, is to make the most of your learning opportunities. And your preceptor can certainly help you hone your webside manner and that will help you strengthen your patient relationships.
Dr. Katta: As we're concluding this episode, I just wanted to ask. Do you have any final thoughts that you want to share?
Dr. Desai: What I would tell students is that these rotations are not just new experiences for you, they're new for many attendings and many preceptors. And you'll find that your preceptors, in many cases, are learning alongside you. They've had to get their telemedicine up and running quickly and they are figuring out how to engage students in a virtual visit so that students can learn from the experience. But they are very interested in maximizing your educational experience so I would encourage students to keep their preceptors informed about their progress so that the preceptors can help them reach their goals. And if you do that, you'll be well on your way to making a great overall impression on your attendings.
Dr. Katta: Well, thank you for sharing all that information, Samir. And for our listeners, I want to direct you for more information, and the show notes for this episode, to our website which is www.thesuccessfulmatch.com. And again, we thank you for listening. I'm Dr. Rajani Katta here with my partner, Dr. Samir Desai, on the Success in Medicine podcast.
Dr. Rajani Katta is the author of the best-selling residency match book, The Successful Match. To receive a free 100-page book excerpt, sign up here.
Dr. Samir Desai is the author of The Successful Match, faculty member at the Baylor College of Medicine, and founder of MD2B Connect, the nation's most highly rated and personalized provider of hands-on U.S. clinical experience for IMGs.
Follow us on YouTube at: https://www.youtube.com/c/MD2BConnect
Original Podcast Published from: https://www.thesuccessfulmatch.com
Published on February 25th, 2021 by Drs. Samir Desai & Rajani Katta