"You're on mute"-lessons learned with virtual academic detailing.

Academic detailing is a medical education outreach service that typically features in-person individualized discussion of therapeutic decisions. The onset of the coronavirus disease 2019 (COVID-19) pandemic compelled many existing academic detailing services to switch to providing their services virtually. This format switch brought opportunities and challenges to detailing programs across North America. Technology enabled programs to continue, but adaptations were necessary, including communication style changes enabling automated booking and optimizing support materials for a virtual environment. Specifically, communication decisions, including when to screen share and strategies to encourage 2-way communication must be addressed to maintain the advantage of a discussion format. As pandemic limitations resolve and academic detailing services move forward, it is important to consider advantages and challenges of virtual academic detailing and how pandemic work will inform future approaches to academic detailing that may blend in-person and virtual outreach.

Background

Conventional academic detailing has primarily relied on in-person conversations to effectively build relationships and communicate therapeutic information.

The COVID-19 pandemic disruptions compelled academic detailing services to a sudden adoption of new virtual meeting technology.

Findings

The switch to virtual visits during the pandemic resulted in intentional adjustments in how sessions were booked, the modification of traditional educational material formats, and shifts in communication technique.

Virtual academic detailing presents both advantages and disadvantages.

In early 2020, the academic detailing community, along with the rest of the health care world, became immersed in adapting practice to function during the coronavirus disease 2019 (COVID-19) pandemic. To maintain relationships while reducing physical presence, many academic detailing services across North America were compelled to adopt Internet-hosted virtual meetings, also called electronic detailing or e-detailing, a previously explored but historically underutilized platform for academic detailing sessions. , The need for rapid transition has resulted in lessons that may inform how academic detailing services choose to utilize this mode of communication going forward (Table 1 ).

Table 1

Pearls to pursue

Pearls for successful e-detailing visits	Comments
Before visits
Market e-detailing as a legitimate and desirable participation option.	Use a self-scheduling tool (e.g., Calendly, SignUpGenius) to organize visit date and time options. Include the sign-up link in e-mail signatures, websites, and promotional materials. Verbally mention this option at all visits. E-mail the link as part of a personal invitation, especially with clinicians who have previously participated in academic detailing.
Design topic summary materials in simple, digitally shareable, and useable formats.	Slide presentation format may be more shareable than paper brochures.
Pursue a professional environment for e-detailing.	Plan for a high-quality video stream. Stage the environment to include a pleasant background. Optimize the webcam, camera positioning, lighting, and sound quality.
Rehearse with your technology platform as extensively as possible before hosting sessions and have a simple backup plan if your preferred Web conference software doesn’t work smoothly, even if it is just a basic phone call.	Have a plan for delivering hardcopies of visual materials, which can minimize or eliminate the need for screen sharing at the visit. Send a day before reminder with meeting link. Consider sharing a vision of what to expect and/or aim for.
During visits
Establish conversation as a norm at the start of a session. This will help to build relationships and avoid a one-sided presentation.	Plan to start visits with face-to-face video. Once the detailer has greeted the clinician and tended to any logistics, the detailer can begin sharing visual materials on screen.
After visits
Follow up promptly with resources to be shared, either by post for paper or e-mail for digital.	Obtaining permission to use e-mail also ensures a reliable contact method for future bookings.

Academic e-detailing

Academic detailing is a form of educational outreach featuring an individualized discussion between a clinician and an “academic detailer,” , who is most typically a pharmacist. It incorporates social marketing concepts to support adoption of medical evidence into clinical practice. Therefore, in addition to thoroughly reviewing the medical literature, detailers are well-trained in communication techniques that facilitate relationship building and generate behavior change. , These techniques include closely observing responses of the clinicians whom they are interacting with and individualizing each discussion to the identified needs of the learner. This balanced approach helps academic detailers become a trusted independent resource for clinicians desiring to implement evidence-informed practice. Because of the personal conversational format, most academic detailing services were conceived to be performed as in-person office visits. Over the past 20 years, there has been increasing interest in utilizing virtual meetings, or e-detailing, as Internet interface technology has improved, especially as a way to reduce travel in rural or large geographic areas. For example, in 2012, Hartung et al. compared both in-person academic detailing and Web conference e-detailing sessions with the same participants and demonstrated that both formats can be effective for information exchange but also that the majority of participants maintained a preference for in-person discussion. Indeed, before the pandemic, when both in-person and e-detailing options have historically been offered, our services have found low clinician interest in e-detailing, with less than 5% of completed sessions being e-details. The pandemic provided external motivation for our services to focus on developing the e-detailing format and has resulted in some pleasant surprises along with identifying new challenges for detailers to overcome.

Booking virtual visits

The first challenge that immediately arose was how to best contact prescribers to book an e-detailing visit. Our detailing services have historically used many different models and techniques for arranging in-person visits, several of which were necessarily abandoned during the pandemic. Previously, an initial step has been to drop by the clinician’s office, either hoping for immediate clinician time or meet with office staff in hopes of booking future appointments. Another historically useful model has been to arrange access to clinic shared space over the lunch hour and detail prescribers as they eat. Quickly, we recognized that neither of these convenient options were compatible with social distancing restrictions; extra people were simply not welcome into a clinic’s physical space. Detailers who relied on cold calling to book visits were especially challenged by the lack of contact information needed to arrange a first or subsequent session. A standard technique that remains useful is to phone the office and book session times directly with the prescriber or their staff. Even here, additional challenges have arisen, as many medical offices have restructured their internal operations in response to pandemic guidance, and some detailers found that their established key contacts had left the clinics or had changed roles.

Our detailing services have found that using automated online booking services can be effective in efficiently booking visits. This involves software such as Calendly (Calendly LLC) and SignUpGenius (Signupgenius Inc) that creates a shareable calendar with available times and enables clinicians to sign up directly for an academic detailing appointment at their convenience. Finally, whereas our services have gradually managed to re-establish much of our prepandemic visit volume, some contacts have not been willing to visit this way. We are uncertain at this time whether this is due to discomfort with the virtual format or with increased pandemic-related demands on their time and attention. Overall, although the most reliable contact methods may differ locally and regionally, we generally have found that detailers who have obtained consent to directly access their local prescribers via e-mail, phone, or text message seem to have had more successful transitions. Going forward, it seems wise to determine a clinic or prescriber’s preferred method of direct communication that is less likely to change in trying circumstances and to consider automating the booking process with the evolving technology.

Changing the setting from the office to the cloud

Communication is a primary component of an academic detailing discussion, and detailers quickly recognized that e-detailing introduced an array of subtle but important communication challenges. Historically, one key element in establishing honest communication has been arranging meetings at a familiar location of the participants’ choosing, typically at their place of work. In addition to convenience, the office setting sets an expectation that a consultation or conversation is the preferred mode of communication. Over the course of the pandemic, instead of sharing of office space, e-detailing has utilized Web conference solutions such as Zoom (Zoom Video Communications, Inc.), Microsoft Teams (Microsoft Corporation), and Webex (Cisco Systems, Inc), which can be used for conversations as well as the more typical large group presentations. As many organizations embraced these platforms, social norms have developed that are often more suitable for large group gatherings. For example, passive listening is encouraged in group meetings as attendees are compelled to mute microphones and deactivate their cameras. Academic detailers trying to use the same virtual meeting programs to conduct conversation-based learning frequently found the need to invite participants to engage in a more active learning process, specifically, to give participants permission and encouragement to activate their cameras and microphones. While this conscious re-setting of social norms for the academic detailing context can sometimes take up valuable minutes of an initial online visit, we have found it time well spent to differentiate academic detailing from didactic lectures.

Technology does not always work as intended

One unsurprising issue was that new technology rarely works exactly as everyone expects, and many initial sessions were marred by unanticipated disruptions as new software capabilities and limitations were explored. Given the urgent need in 2020 to move online, early virtual meetings were often performed by detailers with minimal platform training, and detailers quickly discovered that good intentions could be sabotaged by unexpected computer limitations. From basic hardware issues such as poor quality microphones and speakers, to software glitches or Internet bandwidth limitations, early sessions required quick thinking and practical workarounds. Many detailers quickly identified the importance of preparing a simple backup plan; switching to an alternate software option or a basic phone call to enable the booked session to proceed as scheduled. In the initial transition, our participants were very patient with this steep learning curve, but as the technology has become more entrenched, part of providing a professional experience involves being prepared and adept at solving technology issues as they arise or pre-emptively avoiding them altogether. Going forward, appropriate training of detailers will need to include a thorough exploration of the preferred virtual conference solution, and academic detailers should ensure that they have quality compatible hardware components before going live with e-detailing sessions.

Interpreting nonverbal communication virtually requires new skills

Academic detailers rely on effective communication skills in order to tailor the discussion to the clinician’s needs and perspective. Body language cues are one aspect of communication that provides valuable insights to the skilled detailer. These cues, or leaning in or out to express increasing or decreasing interest, are much harder to notice and interpret when the participants can only observe each other in a small windows on computer monitors. Although detailers can utilize simple hardware upgrades such as larger monitors and high-quality cameras, they cannot control clinician device limitations. Participants will access the virtual meeting using whatever device they possess, which is sometimes just a small-screen smartphone or tablet, with a very small picture and handheld camera. These sessions can still be useful and rewarding but may require a commitment to verbally sharing and identifying what was previously communicated wordlessly. We expect the pandemic-fueled societal transition to online meetings to trigger social science and communication research that may inform future steps to improve effective e-detailing communication.

Support materials may get in the way of the conversation

A key component of an academic detailing encounter is the prepared educational material that can guide the discussion and be given to the prescriber for future reference. Educational material is typically designed by the academic detailing program leaders to complement a discussion and act as postsession reference material. It was quickly noted that using documents in virtual meetings required different visual considerations than in person; presenting landscape format slides is much more natural than scrolling through portrait displays. By utilizing simple appealing images designed for viewing on computer monitors, the virtual meeting seems more natural.

Generally, when meeting in person, detailers aim to maximize eye contact and occasionally point to a print brochure for emphasis, quickly transitioning back to personal conversation. In a virtual meeting, the standard way to share visual materials is by screen sharing, a program feature enabling both parties to observe the same document. Moving to a screen-sharing mode typically results in the shrinking of the participant’s webcam video into a much smaller secondary box. Because the virtual brochure appears much larger than the participant’s image, the personal interactive nature of the conversation may suddenly change. To establish a conversation, detailers can delay screen sharing for the initial part of the visit, focusing instead on beginning a conversation about the prescriber’s experience with the topic, discussing memorized evidence or messages, and only transitioning to screen sharing when supplementary visuals become necessary. Alternatively, a detailer could frequently activate and deactivate screen sharing, although that too can break up conversational flow. A third option is to deliver the material to participants ahead of time, either electronically or as a paper brochure, and not utilize screen sharing at all. Each of these options comes with advantages and drawbacks that are importantly different to sharing a paper brochure in person; detailers and service leaders need to be cognizant and intentional with these choices, whichever strategy they decide to pursue.

Summary

As the pandemic evolves and society moves toward in-person meetings, we look forward to integrating what we have learned about e-detailing with our past experiences with in-person academic detailing. Detailing services that have successfully transitioned to a strong virtual presence may need to decide which form of detailing to rely on, going forward. Early indications are that many services will use a hybrid of in-person and virtual sessions. Where in-person visits are efficient and preferred, they will be offered. Where logistics or preferences suggest that in-person visits are not suitable, the availability of a virtual alternative will help to expand the reach of many services. One unique aspect of academic detailing is the ability to customize the discussion to the needs and setting of the participant. We encourage academic detailing programs to enable their academic detailers to assess and offer the format that will best meet the individual needs and wishes of their prescriber clients.