Introduction to virtual care within graduate medical education
Virtual platforms as a means for graduate medical education have existed for many years prior to the forced use during the COVID-19 pandemic. Many programs allowed for live two-way audio-visual software for academic conferences, particularly in those programs were trainees rotate in multiple clinical settings. In fact, a number of primary care and specialty affiliate organizations at a national and international level provided some guidance on use of virtual means for conducting clinical care, albeit brief and sparsely in use. Some specialties that heavily rely on such platforms for clinical care, teaching, and research, such as vascular neurology, dermatology, and pathology were well prepared for a rapid transition to fully virtual environments in the face of the recent pandemic. Although virtual care has its limitations, its utility has been highlighted during one of the most economically burdensome pandemics to allow for continued education at all levels, and particularly in the training of residents, fellows, and medical students.
Trainee perspective on telemedicine
At the start of the COVID-19 pandemic, residency programs had to adapt quickly to ensure safety of both trainees and patients, while maintaining the academic integrity of their programs. Fortunately, many academic institutions already have the infrastructure in place for telestroke programs, making a transition in trainee clinical, academic, and research practice to virtual platforms relatively smooth. Some programs had already begun to incorporate exposure to telemedicine into their training prior to the pandemic, as this is an ever-growing method of delivering timely and effective stroke care. The expansion to other areas of neurology, outside of stroke, has been an exciting, albeit challenging, byproduct of the COVID-19 pandemic, and formal incorporation into neurology residency training appears to be the natural progression in neurology and across all fields of medicine.
Teaching faculty perspective on telemedicine
Many faculty and staff members involved in training medical students, residents, and fellows were likely trained in an era where emphasis was placed on in-person teaching. In fact, this can be highlighted by the reluctance in many providers over the past decade as the transition from paper records was made to the electronic health record (EHR). Most large institutions, where many of the graduate medical programs are primarily based, made the tough and expensive decision to comply with new Centers for Medicare & Medicaid Services (CMS) recommendations for enhancing the ability to exchange health information through the implementation of some form of an EHR platform. Of course, there were many providers who felt that the EHR would truly enhance patient care through ease of electronic exchange and communication among multiple providers, care coordination and patient engagement, and for purposes of billing of patient encounters. EHR allowed for electronic attestations and review of house-staff order entry and vital signs, all from a remote location in the hopes of enhancing patient safety and clinical care.
During the early days of the uptick of coronavirus cases across the continental United States, most program directors and teaching faculty faced the exhaustive challenge of maintaining the standard of education provided to trainees in a novel and innovative way. The major benefit, and likely impetus for doing so, was the early shortage of necessary personal protective equipment for providers, the insufficient testing at the time, and the need to protect trainees from a disease that we knew very little about. Almost overnight, recommendations and guidance were provided by the different academies within specialties regarding the use of virtual care to provide clinical care, conduct research, and continue to provide educational lectures and experiences to students. Cohorts of trainees were reassigned roles, education and resources were provided on conducting visits virtually, and social distancing measures were enforced in all clinical and nonclinical settings. Instead of in-person morning report or noon conference lectures, virtual teleconferencing platforms such as Zoom, WebEx, Microsoft Teams, and many others were implemented and utilized to continue the trainee experience. Program directors and faculty members who were well versed in utilizing technology were given the additional task of training other less experienced faculty and staff on the workings of these platforms for clinical care, academics, research, and administrative tasks. The Accreditation Council for Graduate Medical Education (ACGME) began to prepare and provide further guidance on the recommendations for training programs on continued education. Surveys and other feedback mechanisms were put forth by the ACGME to track the modifications to trainee experience during the months of the COVID-19 pandemic. In fact, in order to continue in some fashion a normal academic year timeline, typically unimaginable in-person events were transitioned to be conducted virtually, including graduation ceremonies and house-staff and faculty social gatherings and retreats.
Clinical duties in residency fall under two broad categories, inpatient and ambulatory, although inpatient time is heavily favored in most training programs, particularly in the early years of training. At the onset of the pandemic, there was a significant amount of uncertainty regarding how to continue clinical practice in both settings while ensuring the safety of trainees and patients. At institutions that rely on the resident workforce, it is of paramount importance to keep residents safe and healthy to maintain adequate staffing. Virtual medicine is just one avenue of many that has been embraced in both settings to allow for safe delivery of patient care.
Residents are often on the frontlines of patient care in the inpatient setting. Neurology residents are frequently called on to evaluate patients emergently in both the emergency room and on the wards, for the assessment of a variety of acute neurologic conditions including stroke, seizure, and encephalopathy. While initially perceived as more challenging than ambulatory care, inpatient virtual care has been rapidly adapted to effectively care for patients at all levels of acuity and in a variety of inpatient clinical settings, although prior to the pandemic, there was only sparse utilization of acute inpatient virtual care means for patient care by trainees. During the COVID-19 surges, those responsible for training programs were forced to map out innovative ways to continue to care for patients, while keeping trainees and faculty safe, but at the same time preventing unnecessary use of a limited resource of personal protective equipment.
In a hub-and-spoke model of stroke care, spoke hospitals have access to neurologists via telemedicine platforms. At a typical comprehensive stroke center, namely in an academic setting staffed by residents, patients are evaluated face-to-face, and in most instances there was no previous need for telemedicine. Neurology residents may be the first point of contact in the evaluation of acute stroke patients, and often complete their assessment and give a verbal report to an attending faculty member by phone in order to make joint treatment decisions. In the midst of a pandemic, this has the potential to expose residents unknowingly to highly infectious patients, even with appropriate screening processes in place. Utilization of telemedicine has the potential to reduce these exposures significantly, while allowing for timely assessment of acute stroke patients. “Code stroke” pathways have been rapidly modified to include the use of telemedicine following emergency guidelines from the American Stroke Association, and have proven to be effective methods in protecting both health care providers and patients. Being the first line in the care of acute stroke patients can be a significant source of anxiety for young residents, who are expected to assess these patients accurately in order to make rapid treatment decisions in an ever-changing field. Adding the risk of infection with COVID-19, this can be a daunting task, particularly for residents who are inexperienced in managing acute patients in any setting. With the introduction of telemedicine platforms into residency training, attending faculty members can supervise the virtual assessment of patients in real-time alongside residents if needed. This provides an additional safety net for residents who may be uncertain of their diagnostic abilities, and allows for rapid feedback, instruction, and guidance on treatment decisions from their supervising attending.
The classic model of academic hospital rounds led by an attending faculty, with a large group of residents and trainees and other disciplines, has also required a paradigm shift. Due to social distancing protocols, minimizing the number of team members during rounds attempts to limit nosocomial and intra-team transmission throughout the hospital. Effective and safe rounds can largely be accomplished virtually, using a variety of platforms to perform virtual “table rounds,” virtual assessments of patients, and communicate plans of care among team members. From the resident perspective, virtual rounds can save a substantial amount of time in some respects, by reducing the amount of time dedicated to in-person rounds throughout the hospital. Virtual table rounds may also offer additional teaching opportunities, including review of pertinent laboratory and imaging findings on personal devices while maintaining social distancing measures. Physical assessment of patients can be accomplished with designated video-capable tablets or other handheld devices with the assistance of a family member or bedside nurse, and with the device adequately disinfected between patients. This limits not only the exposure of the health care provider to patients, but also the exposure of the patients to multiple teams of health care providers. In an intensive care unit (ICU) setting that is equipped with virtual ICU technology, this can be utilized to communicate with the alert patient or for observation of the nonalert patient with the assistance of the bedside nurse for some exam maneuvers. The major benefit of many of these platforms is the ability to allow third-party members, particularly family members, to see loved ones while restricted visitor access policies are in place during the pandemic. It allows for real time monitoring of vital signs, medication administration, intravenous drips, and frequent clinical assessments.
In the ambulatory care setting, many virtual platforms allow multiple users to participate in video calls, and thus both trainee and attending faculty can simultaneously participate in the evaluation of patients. The resident can take on the primary role of obtaining pertinent history and performing a virtual exam, under the direct supervision of an attending. This provides additional educational guidance and opportunities for one-on-one instruction, which is especially useful in mastering the teleneurology physical exam. It also allows for additional guidance and molding of the trainee’s history taking ability, which is often not directly supervised by teaching faculty. The use of telemedicine in the ambulatory care setting has also extended the possibility of residents working from home. Those residents on ambulatory rotations can participate in virtual clinics, and thus create a pool of residents who are reserved for backup of essential rotations in the event that staffing becomes compromised by illness. Attending faculty members also reevaluated staffing models to allow for less frequent rotation and extended blocks of time on and off service in order to allow for an alternative backup pool in the event that one may become infected and require quarantine.
Prior to the COVID-19 pandemic, many residents and attending faculty had only a cursory exposure to virtual care visits, if any exposure at all, as virtual visits have not been a significant part of typical ambulatory care. This has become an increasingly valuable part of clinical practice education and teaching, with a rapid and steep learning curve for both trainees and faculty. It has become fairly clear that teleneurology and telemedicine will be a consistent part of clinical practice now and in the future. From the viewpoint of faculty members, if residents are exposed to virtual ambulatory care at regular intervals and as an integrated part of their training, the next generation of practicing physicians will be well equipped to implement telemedicine in their routine clinical practice. Additional competencies are likely to be added to the current clinical milestone criteria for demonstrating clearance for independent practice without supervision.
A substantial amount of time during residency is dedicated to didactic teaching on the part of the faculty, and learning on the side of the trainee, outside of clinical practice. This takes a variety of different forms including lecture presentations from faculty, case conferences with residents and supervising faculty, preparation of and delivering talks on areas of progress within neurology by residents, attending meetings on special areas of interest, preparation for the board exam, and even participating in medical student education. Frequently this involves residents, faculty members and other trainees gathering in close quarters.
Limitations on the number of individuals allowed to meet in person has resulted in the expanded use of teleconferencing platforms in medical education. While there are occasional technical drawbacks like poor internet connectivity, by and large the transition to primarily web-based didactic sessions was a smooth process. Benefits to web-based conferences include accessibility—residents can participate in conferences via tablet, smartphone, or computer from any location, which can allow residents to work from home when they are on nonessential or elective rotations. Many programs have trainees and faculty that rotate at multiple facilities and who may not be on site to attend in-person educational conferences, for which a virtual conference medium has led to increased participation. Likewise, speakers from outside institutions may be more easily accessible without need for travel, opening avenues for exposure to areas of expertise that may not be well represented at the home institution. In 2020, the American Academy of Neurology (AAN) also made accessible the materials and lectures for the annual meeting, and provided all members, including trainees, with free access. This allowed some residents and faculty members who have never had the opportunity to attend this meeting with access to valuable educational materials that may not have been readily available during previous years.
Despite the ease of use and possible benefit of increased accessibility, there are a number of limitations to be considered when implementing web-based learning as a substitution for face-to-face conferences. In the in-person learning environment, resident participation and engagement are frequently better than via teleconference. In fact, faculty participation and engagement also has the potential to be more passive. Active participation with the speaker and immediate feedback from residents can be a struggle when conducting meetings via web-based services, as it is easier for residents to continue with multitasking when hidden behind a screen. Residents may also experience “screen fatigue,” as a large part of the workday is spent in front of a screen for review of patient information, video visits, and didactic learning. In the future, a combination of in-person and virtual learning may be able to strike a balance between the benefits and limitations of web-based conferences. Furthermore, while the AAN has the ability as a large organization to provide conference materials at low cost, smaller organizations and meetings may not be capable of such broad access, and thus residents with interest in subspecialty conferences may be at a disadvantage if the restrictions of 2020 continue.
In some ways, research in residency may be the simplest activity to convert to a solely virtual practice, particularly retrospective studies with chart review. Most case scenarios, in fact, are already conducted electronically with review of imaging and the EHR, and in some cases remotely. Unless participating in basic science bench research or clinical trials that require active treatment and evaluation of patients, most research activities that residents participate in require individual efforts of composing a clinical question, chart review, literature review, and write-up. Collaboration with colleagues and advising faculty can be achieved via teleconference or videoconference. The COVID-19 pandemic has also offered a unique opportunity for research across many disciplines, with the possibility of rapid acquisition of data due to the influx of cases and expedited processes for publication. Research and pursuit of publication is a valuable process for residents to be actively involved in to hone critical thinking and communication skills.
The ability to communicate and interpret research and scientific data effectively is an invaluable skill, particularly with respect to public speaking. Presentation of research at conferences, whether local, national, or international, is one of the primary methods by which residents gain experience in this skill. The most accessible mode of presentation is through poster sessions, in which residents can practice their communication skills in a smaller group setting and often one-on-one. Unfortunately, this method of presentation is not readily adaptable to teleconferencing platforms. Speaking engagements, including grand rounds presentations, are more easily transitioned to virtual platforms, and are perhaps a slightly less daunting task when performed virtually versus in-person. Whether through their home programs or in conference settings, residents should be encouraged to participate in such speaking engagements, and they may be more willing in the setting of a virtual platform as some of the pressure of speaking to a large audience is relieved when that audience is primarily out of sight.
Research in the sense of large randomized clinical trials poses yet another challenge during the pandemic. Many studies halted enrollment during peak surges to prevent exposure of faculty and staff, and due to limitation in resources, and study materials. In the broad sense, however, the COVID-19 era has brought forward decades of advancement in clinical, translational, and basic science research with the means of expanding enrollment and inclusion with virtual platforms. Use of electronic signature for electronic consenting, performing physical exams virtually for the purpose of assessing inclusion and exclusion criteria, and involvement of family members through multiparty conferences for consenting by proxy in certain situations have all been made possible due to rapid adaption to technology. As a result, many of the clinical trials that were halted at the beginning of the pandemic were able to continue their enrollment with the rollout of a virtual consenting and enrollment process.
The transition and rapid expansion of telemedicine and virtual education requires coordination of efforts among faculty members, residents, and ancillary staff. Prior to the COVID-19 pandemic, many individuals had little or no exposure to the now commonly used and widely embraced virtual platforms. Transition to virtual care is a steep learning curve for some, and adequate technical support is necessary to make the transition as smooth as possible. As there was quick realization, many departments recognized “champions,” or leaders who could assist in the training, education, and rollout of virtual platforms. Faculty and trainees equally required guidance, and a robust infrastructure in information technology was created to help meet the demand required to assess and use case scenarios specific to individual practices and practitioners, address bandwidth, and remain available for troubleshooting.
During a time of rapid change, there is also a need to disseminate the most up-to-date information quickly to a wide range of clinical staff. This has required a transition to web-based platforms to hold large meetings, both system-wide and departmental. Frequent administrative faculty meetings, which are typically conducted in-person, were quickly transitioned to virtual platforms to abide by social distancing measures. Additionally, town halls and resident rotation feedback sessions can and were conducted virtually to allow for ongoing program director and trainee feedback. A unique challenge that will take place in the first interview season after the outbreak of COVID-19 is the need to conduct recruitment and a match virtually. This requires use of a virtual platform and extensive scheduling to ensure that a “room-to-room” workflow, albeit virtual, remains on an interview day. Marketing of a program becomes difficult due to the inability for trainees out of state or city to visualize themselves in the environment that they may spend the next few years training. Institutional GME programs have offered to make video walk-throughs of the hospital and clinic settings, and to assist in creating a proper interview day experience as good as possible. It remains to be seen how the first cycle of matching training programs will adjust to the new normal, for now.
Final thoughts from trainee and mentee
In some ways, the COVID-19 pandemic brought us into the future of medicine by accelerating and expanding the use of virtual care throughout all aspects of medicine. From expanded clinical use in both the inpatient and ambulatory care settings, to teaching and instruction of residents and medical students, virtual platforms have proven to be effective methods of delivering care and education. We propose that, moving forward, some form of a hybrid of in-person and virtual means will exist in the continued education of future trainees.