Are you prepared to take care of patients via telemedicine? How's your "webside" manner? How do you take a history in a telemedicine encounter?
With the ever-increasing use of telemedicine, these questions and more are important. While this is an area that's still developing, there are definitely best practices that you, as a student, need to be aware of.
In this post, we'll go over telemedicine in medical education, and specifically telemedicine as a component of clinical rotations. We'll review:
The history of telemedicine in medical education
What your goals should be in a telemedicine rotation
How to impress in your telemedicine rotation
Final thoughts and conclusions
What is the History of Telemedicine in Medical Education?
Telemedicine has been around for decades, and there's been an effort to incorporate telemedicine into medical education-- but it's been a slow process. Getting it adopted was slow, even though its promise has always been far reaching and tremendous in its potential.
Of course, with the pandemic, everything changed. While telemedicine 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. Then, once 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. Telemedicine in medical education has really taken off since then.
How is telemedicine used in clinical medical education?
In speaking to our colleagues and students, I've found that there are a lot of different variations on how telemedicine may be incorporated into a rotation.
Telemedicine may be a part of the rotation already. For example, you might be in the clinic three days a week and doing telemedicine two days a week.
The form of that telemedicine may vary. Some of our students have been in the clinic with their preceptor in the same room, and then conducting telemedicine encounters with a patient who is at a remote location. In this case, the student might be taking a history, but then they might turn to their preceptor to discuss the differential diagnosis and the plan and then go back to discussing it with the patient.
Alternatively, 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. In other words, there are different ways that institutions have incorporated telemedicine into their educational experience.
Now of course, with the COVID pandemic the use of telemedicine has accelerated, and educators have been spurred to create telemedicine-focused electives. The student interest in these experiences has really taken off as well.
What are the Goals in a Telemedicine Rotation?
Your primary goal, as is the case with any rotation, is to work with the healthcare team to provide patients high quality, patient-centered care. Since telemedicine is going to be playing a larger role in our health care system in the future, your other goals include:
Exposure to telemedicine: For many students, this will be something new, and they will really want to understand how care can be delivered in this manner.
Active Involvement in a Telemedicine Rotation: 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 during an in-person visit. For example, you'll learn how to communicate virtually with patients, how to perform a telemedicine physical exam, and how to troubleshoot technological issues.
Developing “Webside” Manner: Notice that I said "webside" and not "bedside." While you might think that these are the same, there are important differences between your webside and your bedside manner. The bottom line is, your webside manner, just like your bedside manner, can have a tremendous effect on patient outcomes.
How Can You Impress in a Telemedicine Rotation?
To excel, it's best to break down the telemedicine encounter into three parts:
What you need to do before you connect with the patient
What you need to do during the encounter
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.
Before the Encounter: Logistics
A big part of your thinking before the rotation begins needs to be about logistics. As a first step, I recommend becoming knowledgeable about how telemedicine is going to be delivered in your rotation. In other words, what software will you be using?
Make sure that you have that software on your device. Of course, you also 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.
You also must have a laptop with a camera and a microphone. I recommend that you test out your audio and video within the platform beforehand to make sure that everything is compatible and that the sound and video quality are what you need it to be. 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.
Another thing: 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. In the case that there's a technological issue, how will you be in contact with the healthcare team? For that reason, many rotations will establish a communication back-channel, and that's usually via texting or private chat.
During the Encounter: First Impressions
It's really important to make a good first impression with your patient, and this is something that we're striving to do in every one of our encounters, whether it's in-person or virtual. How patients respond to you will certainly be based, in part, on how you make them feel at the beginning of the encounter.
Immediately after the encounter begins, that patient will already be forming an impression of you, and that impression will be based on several factors:
Your Workspace: The patient is going to get a chance to see your space when you log on, so you want to pick a place that is private, where there will be no interruptions or background noise, and where your environment is clean and uncluttered.
Your Position on Screen: You want to ensure that you're in the proper place on the screen. Your body should be in the center of the screen. Your lighting should be uniform so that your face is not in a shadow.
Prep for the Patient: Just as you would in an in-person visit, you have to get up to speed about the patient by reviewing the patient's medical history, their symptoms, and their concerns so that you can be as informed as possible before you begin that encounter.
It's really an interesting experience 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. You need to make sure you put in the time and think about your setting, your background, your lighting, and your interruptions. Then you have to combine that with a consideration of how you would approach walking into an actual physical exam room. You would take out the patient's chart, and you would review the patient's medical history and symptoms.
As an illustrative example, in one of my first virtual interviews recorded for social media, I went back and looked at it and realized that the lighting was really poor. You don't quite realize how much that makes a difference, but I really consider this to be an aspect of nonverbal communication. If your face is in shadow, your message can be lost because it's distracting to not be able to see a person clearly.
During the Encounter: Introductions and Getting Started
Starting the encounter is so important, because you want to establish the right tone and connection with the patient.
I recommend starting by introducing yourself clearly and explaining to the patient what the two of you will be doing during the session.
To some extent, this depends on the workflow in your telemedicine rotation. For example, if your workflow involves you taking the history and then stepping out of the session to discuss it with your preceptor, then that's something that you want to get across to the patient. If the patient has the right expectations and understanding of the workflow, that really sets the right tone.
In addition, we sometimes make small talk with our patients. Again, that helps us establish a bit of a connection with them. Small talk can also take place in a virtual interview, and it can help your patient relax, especially if they have not done this before.
Additionally, patients have varying degrees of comfort with telemedicine, so it's a good idea to ask the patient if he or she has any questions or concerns about conducting the visit remotely. If it's something that's new for them, you'll quickly get a sense if they have any concerns or hesitations, and that's the time when you can offer some reassurance.
Again, 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 and then find out that they can't hear you properly.
One more very important point: if you're going to be doing things during the encounter that will take your attention away from the patient, it's very important to let the patient know that upfront so it doesn't come as a surprise.
For example, if you're going to be typing during the patient visit, politely let the patient know. You may say, “Before we get started, Mrs. Smith, I wanted to let you know that you may see or hear me typing from time to time, and that's because I want to make sure that I get your story just right.”
Here is the 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.
During the Encounter: Taking a History
What is important to consider when taking a patient history? This question gets back to the previous point about effectively communicating with patients.
As with any encounter, we have two methods of communication: verbal and nonverbal (or body language).
In a virtual patient encounter, the patient won't be able to see all of you, so your nonverbal communication will largely take place through your facial expressions, eye contact, and tone of voice.
Your body language should support and be consistent with what you're saying. You really have to make the patient feel that you are engaged and attentive, which means sitting up straight and leaning forward.
It can be very easy to lose your posture through the course of a virtual interview if you're with a patient for 20 or 30 minutes, so you want to make sure you are paying attention to that and maintaining the proper body language.
In addition, your voice should make them feel you are friendly and confident.
Now let’s discuss eye contact in a virtual format because it is very different from eye contact in-person. There is 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. 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. What you want to do instead is look into the camera. This may not be something that feels natural to you, so you may need to consciously focus on this. This can be tricky, of course, because when the patient is speaking you also need to focus on their facial expressions and non-verbal communication. When possible, I try to move the patient's image on the screen as close to the camera as possible to try to cover both of these priorities.
In addition to eye contact, you want to make sure the patient knows that you are listening attentively to them. To do that, you will want to verbally acknowledge what they're saying. This includes things like nodding your head and paraphrasing the patient’s words periodically to confirm what you've heard. In this way, the patient will be able to really get that feeling that you have been paying attention and you've been engaged.
Lastly, ascertaining goals in a patient encounter has always been important. It's something that we spend a lot of time doing in in-person visits, and it's no different in a virtual encounter.
When you receive your patient for a virtual patient encounter, you'll have some information on what that patient has scheduled that appointment for. For example, let’s say that it's a follow-up for hypertension. That patient may also 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. Specifically asking upfront what the goals of the visit are will really allow you to meet their needs.
If they express any concerns or have questions, you can also make a note of these so that you can address them with your preceptor.
During the Encounter: Ending on the Right Note
In ending the encounter, it's all about making a final impression. When you’ve worked hard to make a great first impression, you want to make sure you leave your patient 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.
One thing you need to do plan ahead so that it doesn't end up being an abrupt ending.
You also want to make sure that you take the time to answer any questions from your patient, go over the treatment plan to make sure that they've understood it, and 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 is, which is something that we do in in-person visits.
After the Encounter: Notes and Reflections
After the encounter, it's your job to follow through on all tasks related to that patient encounter. That might include completing your patient note in the chart, sending the patient a follow-up note summarizing the visit and the plan, and/or arranging for prescriptions or lab work. That is 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.
It is also important after an encounter to reflect on what went well, and what you would like to change. You want to get better after every experience. Start with the opening of the encounter and ask yourself:
How did I open this encounter?
Did I establish a good rapport?
Was I able to make the patient feel comfortable?
Then move into the rest of the encounter. Ask yourself:
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?
For example, if you didn't realize the importance of asking certain questions in a patient presenting with back pain, you want to make a note of that so that with the next patient that presents with back pain, you'll be sure to ask those questions.
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? If it did, what can you do about it in the future?
Seek Feedback After Your Virtual Patient Encounter
Now let’s talk about getting feedback from your preceptor or attending. Feedback is so important in a rotation, and in a virtual rotation where you have had less experience,, I think it's vital for your growth.
It's important to ask your preceptor for feedback, and if they observed you during the encounter, you can get very specific feedback about any aspect of that encounter.
If your preceptor didn't observe you and you're wondering about how you can improve in some area, don't be afraid to ask. This may prompt them to give you some specific advice and even observe you doing that aspect of the encounter next time, which will then provide you with some actionable information.
Remember that the goal here is to make the most of your learning opportunities. Your preceptor can certainly help you hone your webside manner as well, and that will help you create and strengthen your patient relationships.
Final Thoughts and Conclusions
It is important to remember that these rotations are not just new experiences for you. They're new for many attendings and preceptors, and you'll find that they, in many cases, are learning alongside you.
They've had to get their telemedicine up and running quickly. They are figuring out how to engage students in a virtual visit so that students can learn from the experience, and they are very interested in maximizing your educational experience.
I would encourage you to keep your preceptors informed about your progress so that they can help you reach your goals. If you do that, you'll be well on your way to making a great overall impression on your attendings.
For more information on how to succeed in rotations, please check out our other posts in this series:
Dr. Samir Desai is the author of 20 books that together have sold over 250,000 copies, including The Successful Match and The Clinician's Guide to Laboratory Medicine. He has been a faculty member in the Department of Internal Medicine at the Baylor College of Medicine for over 20 years and has won numerous teaching awards.