Here are the questions supervisors need to be asking.
Last time, I talked about education and the overview of why it’s important and some of how we framed it. While the need for increasing and standardizing training for future providers also applies to current providers, the needs are different.
Our education has gone through several changes as we try to figure out what is most relevant to the next generation of physicians. As we are training emergency medicine physicians, most of it is remote triage as that is most similar to what they will do in their careers. Some of the continued questions are related to the following:
- Supervision: Usually as residents progress, they become more independent with less and less need of direct supervision. As there is no current way to do this efficiently over Telehealth, this leads back to direct supervision. The advantage of course, is getting real time feedback both on clinical judgment as well as camera presence. It does also likely lead to a different behavior than when not being supervised; while better patient interaction is a positive, being nervous can negatively impact what the resident gets out of it and their feedback.
- Needs: Telehealth is a care modality, not a new branch of medicine. How does one gauge whether someone is competent in telehealth? Is it based on having a safe encounter, lack of tech issues, patient disposition or whether there was a need for follow-up within a certain amount of time? Most of these criteria are actually clinical practice in general and (mostly) irrelevant to telehealth. In that case, what is the type of need for telehealth training? There are always changes to education; procedures that were often done when I was training are becoming less common as improved methods and devices exist. Telehealth is necessary to expose our trainees to, but it’s not clear as to what level.
- Time: This goes back to how to gauge competency. If the adage of 10k hours is enough to be branded an expert, what is considered competent and what facets are considered to be considered competency? We can take a look at patient interaction, eye contact and ability to make patient feel comfortable as specifically related to telehealth. However they are difficult to grade as they are intangible.
- Education progression: Most telehealth programs don’t make use of students or residents as the primary provider due to the above mentioned need for efficiency. It may also affect their education if attendings at teaching institutions are doing things that may be necessary skills for residents. For example, any program that uses their faculty to triage patients leaves the initial evaluation, decision making and order placing to someone already experienced. Then there is less ability to learn that skill of evaluation during training. This is one reason it’s important to note how changes to practice affect those you are training and try to predict the unintended consequences.
These barriers are a group effort to overcome. As we continue to use telehealth and more physicians and patients use it, it becomes clearer, not less, which parts are important.
It’s not surprising that we need ways to determine competency and to do a quality visit. The future efforts at standardization will be essential to determine what is needed and to disseminate so all future providers have access and feel comfortable with its use.