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    From Bedside to Webside: Future Doctors Learn How to Practice Remotely

    As the use of telemedicine grows, more medical schools and teaching hospitals are offering specialized training in virtual care.


    Even without an in-person office visit, patients can provide doctors with their blood pressure readings remotely, be evaluated for a stroke from miles away, or video chat with a psychiatrist. All this and more are part of the growing world of telemedicine—the use of telecommunications technologies to diagnose, monitor, educate, and treat patients.

    Fueled by advances in digital, mobile, and connected technologies, telemedicine enables health professionals to offer care in underserved areas, stay in close contact with patients, and share specialty expertise with frontline providers.

    Because of such benefits, the use of telemedicine is increasing in places like emergency departments, rural health clinics, and even patients’ homes. In a 2017 survey of more than 100 senior-level executives and health care providers at hospitals, specialty clinics, and related organizations, approximately 75% of respondents said their organization offers or plans to offer telemedicine services.

    To prepare future physicians to use telemedicine effectively, a growing number of medical schools and teaching hospitals are including it in classroom and clinical instruction. According to AAMC data, 84 medical schools (about 58%) included telemedicine as a topic in required or elective courses during the 2016–2017 academic year. In 2013–2014, only 57 schools (about 41%) provided telemedicine training.

    “We learned it’s essential to train our providers to deliver telehealth. It’s a different skill set.”

    Rahul Sharma, MD
    NewYork Presbyterian-Weill Cornell Medicine

    Trainees are developing skills such as conducting a clinical examination by videoconference, monitoring the flow of real-time data from a patient’s wearable device, and adapting to the differences between in-person and remote interactions.

    “We learned it’s essential to train our providers to deliver telehealth. It’s a different skill set,” says Rahul Sharma, MD, MBA, associate professor of clinical medicine and emergency physician in chief at NewYork Presbyterian-Weill Cornell Medicine (Weill Cornell Medicine), a leader in creating his school’s telemedicine and digital health care elective. “We have to tell them exactly how to do this—what works, what doesn’t,” he notes.

    Learning “webside manner”

    The scope of telehealth education in medical schools varies from a few hours of exposure to a full course on the subject. For example, students and residents at the George Washington University (GW) School of Medicine and Health Sciences in Washington, DC, can take part in rotations tailored to their individual telemedicine interests, such as mobile patient monitoring. There’s no established elective yet, says Neal Sikka, MD, associate professor of emergency medicine and chief, innovative practice and telemedicine section, GW Medical Faculty Associates, but each telemedicine rotation teaches telehealth terminology, uses, communication skills, and other topics.

    “There’s really an art to providing a good video consultation that needs to be taught, just like we teach bedside manner and patient interviewing skills.”

    Neal Sikka, MD
    GW Medical Faculty Associates

    GW and other medical schools also train learners in “webside manner,” or the abilities needed to deliver care remotely through monitors or other devices. “There’s really an art to providing a good video consultation that needs to be taught, just like we teach bedside manner and patient interviewing skills,” Sikka says. Key elements include how to position a video camera, maintain eye contact, and effectively engage patients.

    At Weill Cornell Medicine, residents can take an elective in telemedicine and fourth-year students can sign up for a two-week elective in telemedicine and digital health. The course includes lectures, shadowing clinicians working in telehealth, and final projects. In simulated video encounters with standardized patients, students interview a patient over a video monitor, take a medical history, and receive feedback from both the patient and faculty. They also learn how to conduct a virtual exam, which includes patients’ taking their own pulse rates or pushing on body areas to gauge tenderness.

    Telemedicine education often involves hands-on experiences with the technology that makes remote care possible. Trainees learn to conduct physical exams aided by devices like electronic stethoscopes, patient exam cameras, and electronic dermatoscopes. These may even enhance the capabilities of traditional tools, says Ronald S. Weinstein, MD, director and cofounder of the Arizona Telemedicine Program at the University of Arizona College of Medicine – Tucson (UA College of Medicine – Tucson).

    “You can actually see or hear more,” says Weinstein, a telepathology pioneer who saw his first telemedicine case in 1968. Weinstein explains that electronic stethoscopes, for example, can be adjusted to make sounds louder. They could also help group decision-making, allowing physicians to listen in on the same channel or asynchronously hear recorded sounds.

    This summer, the UA College of Medicine – Tucson will open a new health sciences innovation building that will provide a large video wall for telemedicine training. Students will learn the uses and challenges of telemedicine, including how health care providers working with a patient get input from other providers in a remote location. “We’re trying to introduce them to innovations in healthcare and the realities of medicine in the 21st century,” says Weinstein, whose program received the AAMC’s Readiness for Reform Innovation Challenge Award in 2011.

    Preparing for the future

    It can be difficult for medical educators to find space in the curriculum or clinic workflow to add telemedicine training, but it needs to happen, says Kamal Jethwani, MD, MPH, assistant professor of dermatology at Harvard Medical School and senior director of connected health innovation at Partners HealthCare. In a 2016 Journal of Medical Internet Research article, he and his coauthors urged making telemedicine training a standard part of medical school curricula and described ways to incorporate it into preclinical and clinical experiences.

    At Harvard, third- and fourth-year students may choose an elective on health systems that includes training in telehealth, and there are telemedicine options for students taking a fifth year for research. Psychiatry and dermatology residents receive telehealth training for three to six months, and fellowships are offered in digital health and informatics at Brigham and Women’s Hospital. These offerings are tremendously popular, says Jethwani. “We always have more students than we can take. People want to learn about it.”

    Jethwani believes telemedicine will soon become a regular part of medical school education. “Residency programs are going to look at whether you were trained in this or not,” he says.

    Learning about telemedicine during early training can also help students imagine possibilities for their careers that did not exist just a few years ago. The AAMC is considering how telehealth may affect the supply, demand, and distribution of the physician workforce, such as the shortage of doctors in rural areas, notes Scott Shipman, MD, MPH, AAMC director of clinical innovations.

    Technological advances offer exciting possibilities for improving patient outcomes, Shipman adds. “It's hard to imagine a future in which telemedicine isn't a growing part of how we deliver care,” he says. “Understanding the new skills clinicians will need—and how best to train them to use those skills—is essential to providing high-quality care and meeting the needs of tomorrow's patients.”

    Editor’s note: The AAMC is interested in learning about how your institution is teaching students about telehealth delivery. Please send your examples to AAMCNews@AAMC.org.