Overview

In March 2020, NYU Grossman School of Medicine launched a virtual, standardized clinical examination for 23 internal medicine residents. 

Organization Name

NYU Grossman School of Medicine

Organization Type

• Academic Medical Center

Tech Involved

• Electronic medical record
• Telemedicine software

Team Members Involved

• Clinical Trainee or Student
• Physicians
• School Staff

Workflow Steps

• The New York University Grossman School of Medicine Primary Care program converted its yearly, day-long Primary Care Comprehensive Objective Structured Clinical Examination (OSCE) to a telemedicine based format.
  • Before COVID-19, residents would have encounters with 11 standardized patients (SPs) and receive feedback from faculty.
  • Five of these cases were adapted to telehealth and one is a simulation to train residents on medical error/misdiagnosis. 
• The same case focused on medical error/misdiagnosis was provided to nine residents to complete in person to serve as a control group. The purpose of this study was to examine whether or not telemedicine-specific training competencies were achieved in the virtual visits.
  •  The competencies included technical proficiency, virtual information gathering (history, physical exam), and interpersonal skills (verbal, nonverbal). 
  • The residents’ task was to recognize the potential medical error, address patient concerns, utilize EHR tools to verify past medical history, and establish trust with the patient. 
  • Once the visit was complete, standardized patients (SPs) filled out a feedback form, and clinical faculty gave both oral and written feedback to the resident. Overall feedback highlighted significant care gaps in communication and telemedicine etiquette. Though residents were excited by the prospect of telemedicine visits, they were also vocal about how underprepared they felt to conduct the visits. 
  • Based on the findings, the authors concluded that residents would significantly benefit from a greater emphasis on telemedicine-specific training, digital professionalism, and non-verbal communication training. 

Outcomes

• Based on the feedback, residents need to improve on platform competency. Specific improvements include: spending more time setting the stage for the patient, discussing the limitations of telemedicine, asking patients for concerns, and becoming more competent on the telemedicine platform and learning how to use tools.
  • 2/23 telemedicine residents explicitly addressed the telemedicine aspect of the encounter or asked if the patient had ever done a virtual visit before.
  • 0/23 telemedicine residents asked the patient to adjust his/her screen even when they could not see him/her.
  • 4/23 telemedicine residents asked if the SP could see and hear well.
  • 0/23 telemedicine residents reported any technology issues.
  • 0/23 telemedicine residents asked the patient to see his/her file in more detail, or read the file themselves. 9/9 in-person residents asked to review the printed documents that the patient brought along, and asked supplemental questions about those documents.
  • Anecdotally, it was reported that the telemedicine visits had more interruptions and that clinicians spoke significantly more than the patients. Only 1 of the 23 telemedicine learners used silence for more than 5 seconds. Other residents reported that they were unaware of where to look on the screen. Patients reported a palpable difference in the in-person versus telehealth visits.

Unique Challenges

• SPs and faculty assessors did not have the same amount of time to review the case, which can be detrimental in establishing efficacy of telemedicine as  learning competency. 
• Because this was a rapid change in response to COVID-19, residents felt universally uncomfortable with the telemedicine appointments. Residents did not have an adequate amount of time to train on the telemedicine platform, learn digital professionalism, and employ technology-mediated core competencies.

Sources

Lawrence, K., Hanley, K., Adams, J., Sartori, D. J., Greene, R., & Zabar, S. (2020). Building Telemedicine Capacity for Trainees During the Novel Coronavirus Outbreak: A Case Study and Lessons Learned. Journal of General Internal Medicine, 35(9), 2675-2679. doi:10.1007/s11606-020-05979-9