Preparing Future Doctors for Telemedicine: An Asynchronous Curriculum for Medical Students Implemented During the COVID-19 Pandemic.

PROBLEM: The COVID-19 pandemic led to changes in both the clinical environment and medical education. The abrupt shift to telemedicine in March 2020, coupled with the recommendation that medical students pause in-person clinical rotations, highlighted the need for student training in telemedicine. APPROACH: To maintain students' ability to participate in clinical encounters and continue learning in the new virtual environment, a telemedicine curriculum for clinical students was rapidly developed at Harvard Medical School (HMS) focusing on the knowledge and skills needed to conduct live video encounters. Curriculum leads created an interactive, flexible curriculum to teach students clinical skills, regulatory issues, professionalism, and innovations in telemedicine. This 5-module curriculum was delivered using various primarily asynchronous modalities including webinar-style presentations, prerecorded videos of physical exams from different disciplines, shadowing a synchronous telemedicine visit, peer discussions in small groups, and quizzes with both multiple-choice and open-ended questions. OUTCOMES: During May 2020, 252 clerkship and postclerkship medical students at HMS completed the telemedicine curriculum. All students completed a precourse survey and 216 (85.7%) completed the postcourse survey. Students' self-rated knowledge of telemedicine increased, on average, from 38 (15.1%) reporting being fairly/very knowledgeable over 4 domains before the course to 182 (84.3%) afterward (P < .001). The course was highly rated, with 176/205 (85.9%) students reporting that it met their learning needs and 167/205 (81.5%) finding the delivery methods to be effective. Of 101 (45.3%) students who answered an open-ended postcourse survey question, 91 (90.1%) reported asynchronous learning to be a positive experience. NEXT STEPS: As telemedicine becomes increasingly and likely permanently integrated into the health care system, providing medical students with robust training in conducting care virtually will be essential. This curriculum provides a promising and feasible framework upon which other schools can apply these emerging competencies to design their own telemedicine curricula.

Problem

The COVID-19 pandemic prompted many clinicians to begin conducting synchronous telephone or video visits. Including medical students in synchronous ambulatory telemedicine visits has become an essential modality for their clinical learning. Given the high degree of patient satisfaction and convenience associated with virtual visits, [1] this model of care is likely to become increasingly integrated into the health care delivery system, necessitating teaching telemedicine skills at all levels of medical training.

Despite the 2016 American Medical Association recommendation for telemedicine instruction at all levels of physician education, [2] many U.S. medical schools offer neither preclinical or clinical training in telemedicine. [3] Among the subset of medical schools offering telemedicine training, few have publicly accessible information about their curricula or methodological effectiveness. [4] An urgent need exists to expand telemedicine education, supported by significant medical student interest in formal training to obtain skills necessary to conduct these visits. [5]

On March 17, 2020, the Association of American Medical Colleges released its first set of guidelines strongly supporting a pause on all medical student clinical rotations to ensure the safety of both students and patients. Due to these changes in medical education, as well as the rapid adoption of telemedicine use during the COVID-19 pandemic, including students in synchronous ambulatory telemedicine visits has become an essential modality for students’ clinical learning. This gap, combined with a lack of medical education experience in teaching synchronous video visit skills, necessitated the rapid development of a clinically relevant, timely telemedicine curriculum for students.

Approach

Given the urgent need to train all clerkship and clinical elective students in telemedicine visits, on April 13, 2020, we began developing a curriculum focused on knowledge and skills [6] needed to conduct live video encounters for students in clinical clerkships and clinical electives at Harvard Medical School (HMS). It was deployed on May 4, 2020. Students had 4 weeks to complete the course. The HMS online learning management platform, a customization of Canvas (Instructure, Salt Lake City, Utah), was used to rapidly deploy a curriculum that could be implemented asynchronously, thus reaching students at different levels of training who were simultaneously also engaged in coursework and clinical rotations in a wide variety of specialties. The innovative use of embedded reflection questions, quizzes, and novel videos with faculty demonstrating telemedicine skills created active student engagement. Consistent with adult learning theory in medical education, objectives and assignments targeted learning behaviors associated with increasingly higher levels of Bloom’s taxonomy [7] as students progressed through the modules (Table 1).

Table 1

Telemedicine Curriculum Overview, From a COVID-19 Clinical Curricular Innovation at Harvard Medical School, 2020

We consulted with local clinical and academic telemedicine experts as well as HMS curriculum faculty leaders to develop the learning objectives, which were used to create a curricular map (Table 1). In addition, 3 students served as advisors to the faculty course director, providing the student perspective on important learning goals. To our knowledge, before COVID-19, the literature on telemedicine teaching strategies reported few details of curricular efforts in this domain, [3] despite a recent increase of relevant work.

The curriculum was presented in 5 separate modules to allow students flexibility to proceed through materials at their own pace while engaged in other remote coursework. The overarching curricular goal was to provide all medical students engaged in clinical learning with the foundational knowledge required to successfully engage with their faculty and patients, to continue developing their clinical skills using remote encounters. The first 2 modules introduced telemedicine and its role during the pandemic, as well as best practices for setting up a telemedicine visit with a patient. Module 3 focused on history-taking and physical exam skills through interactive recordings of standardized patient telemedicine visits across different specialties that addressed several key clinical questions (Table 2). Given the wide range of learners from early clerkship to advanced elective levels, links for supplemental clinical resources were provided and questions were presented to challenge the students’ clinical reasoning and documentation skills. Each vignette also included personal reflections from the faculty.

Table 2

Module 3 Curricular Content, From a COVID-19 Clinical Curricular Innovation at Harvard Medical School, 2020

For students to apply concepts covered in the first 3 modules, Module 4 required observation and reflection on at least 1 synchronous telemedicine visit, using a framework for recording student observations and a set of reflection questions to consider (see Supplemental Digital Appendix 1, at http://links.lww.com/ACADMED/B149). Most clerkship students observed their longitudinal primary care clerkship preceptor. To expose students to the breadth of clinical skills needed in different virtual patient encounters, additional faculty from various specialties were recruited to participate as preceptors. For Module 5, students were placed in small groups to share their observation experiences with peers who observed different specialties. Each group collectively authored a 3-page paper addressing potential solutions to 1 of 5 current challenges in providing care through synchronous telemedicine visits (Table 1).

At the start of the course, each student was required to complete a precourse survey, administered online via the course platform immediately before the course. Eight questions in the presurvey gathered demographic information and evaluated self-assessed baseline knowledge and self-efficacy in telemedicine. The 12 anonymized postcourse survey questions were administered immediately at course completion and also accessed through the online course platform. These questions were designed to align closely with the learning objectives (Table 1) and enable assessment of any change in students’ self-efficacy and knowledge in conducting telemedicine visits as well as engagement in each module (Table 3).

Table 3

Telemedicine Course Evaluation: Pre- and Postcourse Surveys, From a COVID-19 Clinical Curricular Innovation at Harvard Medical School, 2020

The pre- and postcourse surveys were approved by the HMS Program in Medical Education Educational Scholarship Review Team as a quality improvement study and thus exempt from full institutional review board review. Statistical analysis was conducted using SPSS statistical software, version 27 (IBM Corp., Armonk, New York). Z-tests for proportion were run on the aggregate data. In addition, we conducted a qualitative analysis of anonymized free-text responses. One author (S.F.) coded themes in free-text response answers regarding the course’s asynchronous format. Two authors reviewed the final assignment topics (S.F. and A.W.S.).

Outcomes

Participants in the new HMS curriculum were 252 students: all 167 students in the clerkship year (66.3% of participants) and 85/178 eligible postclerkship students (HMS years ≥ 3) (33.7% of participants) who participated electively. All students completed a precourse survey; the postcourse survey was completed by 216 (85.7%). Pre- and postcourse survey results are reported in Table 3. The learning objectives of Modules 1–3 were assessed by querying student self-rated agreement with several statements (see Table 3). On average, students’ self-assessed knowledge over 4 domains increased: 38 (15.1%) reported being fairly/very knowledgeable before the course and 182 (84.3%) afterward (P < .001). The postcourse survey recorded students’ assessment of delivery method effectiveness, whether their learning needs were met, and if the material was engaging (Table 3).

Nearly half of students (101/216, 46.8%) responded to an optional open-ended question about the course’s strengths and weaknesses, and 91 (90.1%) made positive comments; for instance, “The videos of the simulated visits were fantastic. It was great to have faculty in different areas of medicine run visits for their particular specialty.” Support for the course’s efficacy was further demonstrated in comments such as, “I will definitely be using some of the lessons from these videos moving forward.” Students also indicated enjoying other innovative aspects of the course such as the asynchronous format, which allowed self-paced and self-directed work plus flexible scheduling. Another student wrote, “I think that the most useful things were the observation of a telemedicine visit and then being able to discuss those as we all had different experiences and could learn from each other.” When asked for suggestions about course improvement, one student noted, “It would be helpful to have discussion/examples that show work with interpreters and/or patients who have challenges with technology/access.” Students also mentioned they would have welcomed an opportunity to practice telemedicine visits with peers, faculty, or patients beyond the single observation session.

In Module 4, 92.9% of students (234/252) who completed the telemedicine observation submitted information about their observed preceptor’s specialty. These were 119/234 (50.9%) from adult primary care, 26/234 (11.1%) from internal medicine specialties, 23/234 (9.8%) from pediatrics, 23/234 (9.8%) from neurology, 16/234 (6.8%) from surgery, and the remaining 27/234 (11.5%) from other specialties. A total of 209 individual faculty precepted telemedicine visit observations. These data demonstrate that faculty from a wide variety of disciplines volunteered to teach in this online telemedicine curriculum. The high level of student self-reported learning and satisfaction reported above indicates student satisfaction with multidisciplinary faculty participation. These observations support the conclusion that faculty across specialties may serve as effective telemedicine preceptors and that the medium and the content are applicable to the major clinical disciplines.

Students were divided into 64 groups of 3 or 4 for Module 5. Each group worked collaboratively to write the final reflection paper on a topic chosen from 5 potential prompts (Table 1). All 64 groups (100%) completed this assignment. Although all topics were chosen, the most popular topic was “health disparities in telemedicine,” selected by 21/64 (32.8%) of the groups. These students applied concepts of geographic and socioeconomic disparities to telemedicine, exploring the potential to address problems or to worsen gaps in care delivery. Groups presented innovative solutions to address the potential impacts of telemedicine in each of the topic domains (see student responses in Supplemental Digital Appendix 2, at http://links.lww.com/ACADMED/B149).

Next Steps

This innovative course demonstrates that an asynchronous telemedicine curriculum offers a promising and scalable approach to rapidly teach medical students key aspects of telemedicine, a skill now critical for all physicians. Although designed and implemented at a single medical school, it offers a generalizable mechanism for disseminating telemedicine knowledge and skills to medical students learning remotely or for learners pursuing an elective independently.

Key lessons include the ability to cover a wide breadth of skills-based material with practical video recordings, as well as the flexibility of an online asynchronous modality conducive for students with competing academic demands. Providing a sequenced and logical approach to telemedicine added to students’ self-reported learning, allowing immediate application of new concepts to an authentic clinical learning environment.

Next steps for this curriculum include potential improvements for future iterations of the course and anticipated applications for future students and faculty. For instance, students could conduct the virtual visit with faculty supervision and feedback and solicit reflections from others involved in the encounter, including patients, caregivers, or other members of the care team. In addition, the creation of virtual telemedicine objective structured clinical examinations (OSCEs) may serve as a formal assessment tool to objectively evaluate curricular effectiveness and as a means to ensure students are evaluated systematically in developing telemedicine competencies. A pilot of such a virtual OSCE shows promising results [8] in which students could successfully demonstrate telemedicine skills within a simulated setting.

Where telemedicine instruction is best positioned across a 4-year medical school curriculum in relation to a pandemic is a key question. Ideally, students will learn telemedicine skills in step with foundational clinical skills, building proficiency and facility with virtual care delivery as they move through their education. At HMS, our curriculum committee plans to integrate telemedicine instruction across the 4-year course of study. Future courses should build on telemedicine’s advantages for student learning: fostering longitudinal relationships with patients, building skills in motivational interviewing and patient counseling, and close follow-up and in-home care for chronic disease management.

As the popularity and novelty of this course reached the larger HMS education community, faculty requested information on how best to integrate students into their telemedicine visits. We have developed virtual faculty development sessions (e.g., “Making the Most of Telemedicine Visits with Students”) and widely disseminated a teaching tips sheet and checklist. [9] Pairing these faculty development efforts with student education fills critical gaps and provides best practices to enable meaningful student engagement in telemedicine visits and optimize clinical instruction in virtual settings. Ultimately, acquisition of novel telemedicine clinical skills needed to ensure readiness of future physicians to care for patients in evolving clinical environments requires innovative approaches to curriculum, assessment, and faculty development.

Acknowledgments:

The authors wish to thank Drs. Catherine Dawson, William Kettyle, Todd Griswold, Swathi Damodaran, Alexandra Hovaguimian, Arun Ramappa, Elizabeth Pingree, Beth Harper and her daughter Ingrid, and Alexandra Chabrerie for writing and recording the video vignettes to demonstrate specific specialty skills via telemedicine examples; Agnieszka Jackson for expert administrative assistance in bringing together so many moving parts; New England Clinical Skills Consulting for providing the standardized patients in the video vignettes; and the talented individuals of the HMS Media Services, Michael Mascheri and Nestoras Nestoros, for all their support in bringing this course to life.