Panel 3: Survival of the Fittest: Adapting Teaching and Learning in a Virtual Care Environment

July 19, 2023

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00:00So we welcomed everyone back from the break,
00:04and this next session will kick off the first
00:08of the of the last three remaining panels.
00:11And this first panel, panel #3,
00:14is really about how to adapt,
00:17teaching and learning to this new
00:19virtual care environment. And we're.
00:21Extremely fortunate to have an
00:23outstanding panel of experts to
00:26talk us through this moderating.
00:27The panel will be Doctor Alissa Hall from the
00:30Mayo Clinic College of Medicine and Science.
00:32I met Doctor Hall through this process.
00:35I had not met her before,
00:37but I was just really impressed
00:39with her approach to thinking about
00:41curriculum design and education.
00:43She's the director of that field and the
00:46Associate Director of Education Science
00:48for the Mayo Clinic College of Medicine.
00:51And she really plays a key role
00:53in the direction of the College
00:56in thinking about development,
00:58implementation and and sustaining a systems
01:01based approach to curriculum design.
01:03So I think she's going to really
01:06help us understand the AA,
01:08MC sort of approach to this concept as
01:12well as the Mayo Clinic approach to how
01:15we think from a framework perspective.
01:19To put these pieces together and
01:20adapt teaching and learning in a
01:22virtual care environment. So, Dr.
01:24Hall, are you on the webinar?
01:27I am. Thank you.
01:28Let me turn it over to you.
01:31Fabulous. Thank you and
01:35welcome to panel three.
01:36As I kick off panel three,
01:38I really want to do a shout out for
01:41those that were here for panel 2.
01:42Again, it really nicely blends in.
01:44Doctor Sharp was talking about us
01:46being in this together and Doctor Scott
01:48started talking a little bit about
01:50the value add and feedback loops.
01:51And as we start to talk about
01:53adapting the teaching and learning
01:55in a virtual care environment,
01:56I think you're going to see that
01:58that nice synergy between our
02:00panels as well as the first panel
02:02that talked about competency.
02:03So the objectives for our session
02:06are to review approaches to teaching
02:08empathetic communication and skills
02:10around telehealth and telemedicine.
02:12We also want to give you a little
02:14bit of an introduction and dive
02:17into a little bit about that
02:18professional education and how we
02:20collect feedback to continuously
02:22improve our learning environments.
02:24And finally,
02:25we're going to be providing some
02:27tangible examples of ways to
02:29improve workflow for a telehealth
02:31visit and embedding the learner
02:33in that particular process.
02:38It's my honor and pleasure to
02:40introduce our panel members. Thank you,
02:43Lee for the very nice introduction.
02:45I'm going to also introduce
02:48Doctor Aditi Joshi,
02:49who is the Medical Director of Jeff Connect.
02:52And the Director of Telehealth
02:55Fellowship and Assistant professor of
02:57the Department of Emergency Medicine
03:00at Thomas Jefferson University, Dr.
03:04Aditi is has scaled the Ondemand
03:06program for utility and outpatient
03:08testing and screening during the
03:10pandemic to decrease exposure
03:12and increase healthcare access.
03:14She's an Assistant Professor,
03:16as noted and also the Associate
03:18Director of the Digital Health
03:20Scholarly Inquiry Program at
03:22Sydney Kemal Medical College.
03:25Also, it's my pleasure to
03:26introduce Doctor Christine Esper,
03:28who is the Physician Lead of Brain
03:30Health Telemedicine Committee,
03:32Director of the Motion Capture Laboratory
03:34and Assistant Professor of Neurology.
03:37Dr.
03:37Esper is trained at Partners Harvard
03:40Neurology Program at Mass General
03:42and at Brigham and Women's Hospital.
03:44She's completed one year Clinical
03:46Movement Disorders Fellowship at Emory,
03:48followed by an additional year of
03:51Clinical Deep Brain Stimulation
03:53Simulation Fellowship at Emory University.
03:56Her leadership roles include
03:58neurology clerkship,
03:59Education Director as well as clinical
04:01director of Deep Brain Simulation Program.
04:04She's also an active member of the
04:07American Academy of Neurology,
04:08Movement Disorder Society and Parkinson's
04:11Functional Neurosurgery Group.
04:14I'd also like to introduce Doctor Embar
04:17Chris Rush who is also known as Doctor Kay.
04:20He is a board certified family physician
04:24and Assistant Professor of the Department
04:26of Family and Preventative Medicine
04:28in the Department of Epidemiology.
04:30He's an established and skilled physician
04:32taking care of patients in the clinic,
04:34hospital and community setting.
04:35Doctor Kay takes a whole person
04:37approach for the treatment and helps
04:39his patients develop a personalized.
04:41Care plan including life goals.
04:43He has faculty at Emory University
04:45and he did his residency,
04:47training and PhD program at Emory as well.
04:50And then finally Doctor Julian Jenkins.
04:53Doctor Jenkins is a third year
04:55internal medicine resident at UCSF
04:57and also a Harvard Macy Healthcare
05:01Professions 2.0 faculty member.
05:03He has a background in software development
05:06in and as well as the EH R's and in Med Ed.
05:10He's planning his career in clinical
05:12informatics and primary care.
05:14So with that,
05:15I'm going to welcome everybody to this panel
05:17and I'm going to turn things over to Dr.
05:20K to get us started.
05:27Hi, everyone. Thank you for the
05:28introduction, Lisa and Lee.
05:30I'm delighted to be here in our
05:33current healthcare environment with
05:34measures to tackle coronavirus.
05:36It has made it more difficult for
05:38physicians to connect with their patients.
05:39And attending faculty to
05:41connect with their learners.
05:42How can we then make more
05:45meaningful connections?
05:45Next slide.
05:50Just want to make sure Yes, thank you.
05:51Our profession rates empathy as one
05:53of the most highly desirable trait
05:55that medical education should promote.
05:58It includes demonstrating compassion,
05:59caring and a willingness to put the concerns
06:03of patient and society above one's own.
06:05Yeah, even before this current pandemic.
06:08Studies had shown that there can be
06:10a significant decrease in empathy
06:12in medical school and residency.
06:14For example, an empathy skill that
06:16was administered at the beginning
06:18of each academic year.
06:19Empathy significantly decreased,
06:21especially after first and 30 years.
06:24Although this process of becoming
06:26somewhat immune may aid physicians cope
06:28with heavy workload on a daily basis,
06:30this runs counted to the patient's need
06:32for being an empathetic caregiver.
06:34A physician may possess competent
06:37diagnostic skills.
06:37Yet be considered by patients as
06:40ineffective because the physician misses
06:42the link between patient satisfaction,
06:44adherence to medical instructions
06:46and physician empathy.
06:48Next slide,
06:51Lack of empathy is also one of
06:53the key factors for high rates
06:55of burnout among physicians.
06:56Recent studies have shown that physician
06:59burnout continues to remain high even
07:01between 35 to 50% depending on the
07:03type of speciality urology, neurology.
07:05ER and family medicine have a higher rates.
07:09What is empathy and more specifically
07:12what is physician empathy as a trait.
07:15So the general accepted definition
07:16is it's an understand is to
07:19understand the patient's situation,
07:20perspective and feelings,
07:22be able to communicate that understanding
07:24and also then act on that understanding
07:26with the patient in a helpful way.
07:28We all know that empathy is
07:30important to patient care.
07:31It enhances patients
07:34participation satisfaction.
07:35Self efficacy and trust,
07:37which in turn may facilitate
07:39better diagnosis,
07:40shared decision making and compliance.
07:42It changes patients.
07:44Responses from my doctor seemed
07:46rushed to my doctor really cares.
07:49Empathetic doctors experience
07:51greater job satisfaction,
07:52psychological well-being,
07:53and have lower burnout scores as
07:56has been shown by many studies.
07:58Next slide.
08:01In fact, physician empathy as perceived
08:03by patients here in the study
08:05with the Common Core significantly
08:07predicted subsequent duration and
08:09severity of illness and is also
08:11associated with immune system changes.
08:13The perfect score group in empathy
08:15levels was associated here with a
08:17more robust aisle eight response than
08:20those who gave a non perfect score,
08:22as you can see on the graph on the right.
08:25Data presented here suggests that
08:27a consultation which is rated high
08:29in empathy a positive emotion.
08:31Is associated with an enhanced immune
08:33response and a shorter illness.
08:35Similar research has changed
08:37empathy from a soft skill to a
08:40neurobiologically based competency.
08:42Thus emphasizing empathy in the
08:44curriculum and clinical encounters
08:46Has positive influences that extend
08:48beyond the medical consultation.
08:50As physician and learners general
08:52with telehealth and in person visit
08:55skills and interventions aimed at
08:57improving empathetic engagement
08:58and resilience can help to reduce.
09:01Burnout improves satisfaction and
09:03ultimately enhance clinical outcomes.
09:06My colleague Christine doctor
09:07Christine Esper,
09:08will elaborate and discuss some
09:10tips and helpful tools in this area.
09:12Over to you, Christine.
09:18Thank you, Amber.
09:19So Amber gave us a great overview
09:22on the importance of empathy
09:24in medical school training,
09:26although telemedicine certainly
09:28has a number of advantages.
09:30As we envision it here on the left side
09:33of the slide demonstrating a successful
09:35interaction between the patient,
09:37her nurse and the physician remotely. Next
09:43on the right side,
09:45you can see such examples of the
09:47realities that telemedicine may pose,
09:50such as technical difficulties
09:51with the camera not turning on.
09:54Patients may be distracted or
09:55cooking as you can see in the top
09:58left of the side for lighting.
10:00And poor eye contact,
10:02making it even more difficult
10:04to connect to a patient.
10:06New patients can be additionally challenging
10:08as you're meeting them for the first time.
10:11Virtually engaging in a virtual visit
10:13with three or more people on video,
10:15such as with a caregiver,
10:17can seem even more impersonal.
10:20How can you exhibit trust and
10:22empathy towards a patient that
10:23you are meeting for the first
10:25time through a screen Next slide.
10:29Clinical empathy has been defined as a
10:33psychological hug in some literature.
10:35In this article,
10:36Doctor Halpern defines empathy as a way
10:39of grasping another's emotional states.
10:42It argues that empathy enhances patient
10:45physician communication and trust,
10:47and therefore treatment effectiveness.
10:49Doctor Helen Reese, a psychiatrist at MGH,
10:53conducted A randomized control trial,
10:55empathy, and created her own acronym.
10:59E for eye contact,
11:01M for muscles of facial expression,
11:04P for posture, A for affect,
11:07T for tone of voice,
11:09He for H for hearing the whole patient
11:12and why Your response next slide,
11:19lack of empathy can be compounded
11:21further in a virtual visit simply
11:23due to the nature of the encounter.
11:26Remember, this was not taught
11:27to us in medical school,
11:29and now many of us have been thrust
11:31into a new world of telemedicine.
11:34The pillar of emotional competence
11:36is selfawareness and reflection.
11:38As you can see at the bottom of the pyramid,
11:41we as providers must be aware of our
11:43body language and be deliberate in
11:45our communication with the patient.
11:46It's important to build a positive
11:49relationship with the patient.
11:51Next slide.
11:55This is a reference entitled
11:57Empathetic Intelligence.
11:58It embraces the four main
12:00pillars of teaching empathy.
12:02In the first pillar being present,
12:04clear your mind of distractions
12:06and listen to the patient's story.
12:09Be sure to make eye contact and
12:11be aware of the camera's position.
12:14Be silent. Allow the patient to
12:16speak regarding body language even
12:18though you are not in the same room,
12:21the patient is watching you.
12:23Do not appear distracted or
12:26disinterested in some encounters.
12:28Charging, charting may be required.
12:31Be sure to explain this
12:32to the patient in advance.
12:33They feel as though they're
12:35still active participants in
12:37the visit in the second pillar,
12:40taking a patient's perspective,
12:41Be curious.
12:42Reflect on the patient's life experiences,
12:45and let them tell their story.
12:47A virtual visit is also an
12:49opportunity to observe the patient
12:51in their own surroundings.
12:52Engage more with a patient as you may see
12:55a family member or perhaps even a pet.
12:57In addition,
12:58certain aspects of a patient's home
13:00may impact clinical management,
13:02such as a cluttered home in a patient
13:05that is a fall risk in the third pillar,
13:09empathetic listening.
13:10Acknowledge the patient's needs,
13:12paraphrase your story and follow up
13:15with questions to confirm you are
13:18indeed addressing their concerns lastly.
13:20Summarize the intent of the
13:23visits and in the fourth pillar,
13:25acknowledging feelings.
13:26Not all patient interactions are happy.
13:29We all have good days and bad days.
13:32How do you handle a patient
13:34that is depressed, anxious,
13:35or perhaps even crying during
13:38a telemedicine visit?
13:39Body language and human touch
13:41often help in these situations,
13:43but it is not available for a virtual visit.
13:46Statements such as.
13:48Your feelings make sense and it's hard,
13:51but we can get through this help
13:54validate the patient's feelings.
13:56Next slide
14:00here is another resource that Stanford
14:02has provided regarding similar
14:04themes for what we have discussed.
14:06In conclusion, communication and empathy
14:09result in empathetic communication or a
14:13trusting partnership with your patient.
14:15Next you will hear from Julian and Elisa,
14:18who will cover engaging learners in
14:21a telemedicine visit. Thank you.
14:25Forgive me. I am in an unfamiliar
14:27clinical environment and trying to use
14:28the technology that I have on hand.
14:30So we're working with it.
14:32So Christine and Amber, thank you
14:34so much for that part about empathy.
14:37I think I just wanted to express my
14:40gratitude for being here as a trainee.
14:42I know I acknowledge that my
14:43expertise may not be at the level
14:44of some of the other panelists here.
14:46But as I hope to convince you,
14:48it's important to have trainees at the
14:50table when you're discussing things
14:52like education and and particularly
14:54as the end users of the the education
14:57systems that we're building,
14:58I also want to just express that I'm.
15:00I'm eager to answer any questions
15:02that any of the panelists or attendees
15:05may have with regards to the trainee
15:09experience in telemedicine.
15:11Over the next few minutes,
15:12Alisa and I are hopeful to take the
15:15the concept of empathy that Ambar
15:17and Christine have mentioned and
15:19and begin to build it more into a
15:21framework for curriculum development
15:23as well as evaluation for those
15:26curriculum particularly in the virtual
15:28clinical education environment.
15:30Just briefly on on my experience
15:32and my background UCSF transition
15:35to virtual clinics.
15:36Really about a month into the pandemic.
15:39And so we've had an opportunity or
15:40I've had an opportunity to internal
15:42medicine resident to be doing
15:44virtual clinical training for the
15:46past closing in on six months now.
15:48And so I'm hopeful to share some
15:50of my experience and there's more
15:52information available on how UCS
15:54have chose to implement their
15:55curriculum through the a double AM
15:58CI collaborative platform that I can
16:00share with anybody who's interested.
16:02And then what I'm going to dive
16:03into is kind of starting with this
16:05prompt with regards to your learners
16:07are back in virtual clinic and it's
16:09your job to make it better.
16:11What do you do this,
16:13this is a concept that we
16:14introduced as part of the AM,
16:15a telemedicine and medical education
16:19webinar series as as a group that
16:22Elissa and I worked on actually
16:23broadly and nationally with AM,
16:25a telehealth working group hoping to
16:28revise the their telehealth playbook.
16:31To include virtual education
16:32and and educating owners in the
16:34virtual clinical environment.
16:36So please the next slide.
16:39So I'm going to introduce these
16:41four quadrants which are framework
16:42that we put together as a group
16:43as well as in conjunction with a
16:45colleague of mine Benjamin Lee who's
16:47another resident here at UCSF.
16:48And the idea is that these are
16:50four quadrants that you can you,
16:52you can use to optimize or
16:54improve the telemedicine clinical
16:55experience for your trainees.
16:57My focus and my perspective
16:58is again as a trainee,
16:59not necessarily as as a faculty member.
17:02And the four quadrants,
17:03just to be explicit,
17:04are optimized logistics, building skills,
17:06facilitating learning and innovating.
17:09Next slide please.
17:11So with regards to optimizing logistics,
17:13the idea here is to think about
17:16how you minimize some of those
17:18logistical or infrastructural
17:20challenges that may lead to extraneous
17:23cognitive load that's not going
17:24to help your learners actually.
17:26Engage in the learning process or
17:28develop the skills that they may be
17:30you may be wanting to develop as
17:32part of the germane cognitive load
17:34of the tasks that they're working in.
17:36And just to give some examples of this,
17:38this is things like as simple as
17:39thinking about setting up the workspace,
17:41so the the physical environment at home.
17:45And I think to to touch on what
17:47Lee may have mentioned earlier
17:48with regards to equity,
17:49I want to encourage the the
17:51attendees here to think about
17:53the equity for the learner.
17:54And how perhaps the environment
17:56at home is not the same and is not
17:59terribly conducive to delivering care
18:01and is maybe not terribly conducive
18:03to engaging in in learning as well.
18:06And so thinking about how you can
18:08deliver that that environment with
18:09equity as as the as the administrators
18:11is also thinking about tool specific
18:13logistics like learning how to use
18:16Zoom or other platforms, clinical,
18:17virtual clinical platforms.
18:19And then finally,
18:20thinking about clear expectations for
18:23preceptor and trainee communication.
18:25And I know we've already expressed
18:27different models that may represent
18:29different ways that trainees
18:30and preceptors can interact,
18:31but I think it's important to
18:33have clear expectations.
18:34Things like a preclinic huddle we
18:35found very useful at UCSF to make
18:38sure that there's a modality of
18:40communication that's set up and
18:43framework for understanding how you'll
18:44be communicating with your preceptor
18:46throughout the clinic visit or clinic shift.
18:50The next quadrant,
18:51next slide please is Building Skills
18:53and this is,
18:53I'm not going to belabor this one
18:55because we've heard a lot about it
18:56already and this is really the idea
18:57of building clinical skills and
18:58intentionally working into your,
19:01your curriculum,
19:03learning how to use telemedicine.
19:05It is not something that's intuitive
19:07necessarily or perhaps not something
19:08that we can assume will be learned
19:10through experience, experience alone.
19:12The AM, CA, AA, MC,
19:14Commons,
19:14these are of course the I think the
19:16gold standard that we have right now
19:17and I don't want to believe that.
19:18And I think ADT also will share more
19:21about some specific experiences that
19:23she has had and and implementation
19:25of this
19:25later in our panel.
19:27And I want to also mention something
19:29kind of to lead into Alyssa which
19:31is thinking about curating and using
19:32programs that have already been set up
19:34for faculty or at other institutions and
19:36the value of collaboration to to help
19:38develop these skill building curriculum.
19:40Next slide please.
19:43The next squadron is facilitating learning
19:44and this may seem similar to building skills,
19:46but I think it is a is a fundamental
19:50difference because what I want
19:51to focus on here is methodology.
19:53So you're thinking about how are you
19:55educating over the virtual clinical
19:57environment and this means thinking about
20:00what about this virtual learning experience,
20:03be it live in a clinical
20:06learning setting or actually.
20:07Their virtual classroom,
20:08what makes it different,
20:10what makes it harder And there's
20:11an abundance of challenges that I
20:13think we've all experienced things
20:15like increasing distractions.
20:16I mentioned inequities,
20:17different visual and physical cues,
20:19not being physically present.
20:20And I think there's a new there's
20:23a need to to help the learners
20:25relearn how to learn and educators
20:26to to revisit how to educate.
20:28And so there's the robust literature
20:31that exists from things like K through
20:3312 education and beyond regards to.
20:35How to actually educate in
20:37a virtual environment.
20:37I think implementing technology with
20:40the with an attention to pedagogy
20:43is very important and helping to
20:45to do this intentionally and and
20:47with competencies but also with
20:49pedagogical frameworks in mind.
20:51Next slide please.
20:55In the final quadrant here is innovation
20:57and I think this is intuitive and and
20:59is in many ways why we're all here.
21:02Is thinking about how COVID-19,
21:04the pandemic has thrown us into this what
21:06I would call emergency remote teaching
21:09experience And that that idea that we
21:11need to now iterate and innovate and
21:13change and and we've a lot of language
21:16has already been shared but the idea of
21:18a framework called the Stammer framework,
21:19which I'm not going to go into thinking
21:22about using technology to redefine rather
21:24than just substitute the existing experience.
21:28And and I want to end this
21:29innovation section with I think
21:30reiterating what I've already said,
21:32which is engaging the end user,
21:33engaging the learner in how to innovate
21:35and how to collaboratively iteratively
21:38redesign the clinical learning environment.
21:41So next slide please.
21:43So these are four quadrants that back on,
21:46thank you,
21:464 quadrants that I think you,
21:48you as or individuals, as educators,
21:50as administrators,
21:51as curriculum designers can think about both.
21:53To design A curriculum around identify
21:55weaknesses perhaps that exist in your
21:58current setup and your current configuration,
22:00as well as to get feedback from learners.
22:02And I know that part of our section
22:04is focusing on feedback,
22:05so I think that this might help as
22:06a way to imagine needs assessments.
22:08So you may have a strong foundation
22:10or backbone of skill building
22:12and clinical skills training,
22:13but perhaps the logistics haven't
22:15really been optimized and.
22:16You can target your learners and
22:18get feedback and understand what
22:19are they missing at home and how
22:21can we help to augment that home
22:23clinical virtual learning environment.
22:24With that,
22:25I'm going to hand over to Alyssa
22:27who's going to talk more about
22:29kind of the collaborative nature
22:31and social constructivism,
22:31the learning process as well as some
22:34specific examples from the Mayo Clinic
22:35with regards to this four quarters.
22:38Thank you, Julian, for providing
22:40us with such a tangible telehealth.
22:43Training framework that we can all adapt
22:44to our teaching and learning environments.
22:46And as Julian shared,
22:47my name is really to describe one approach
22:50of how to operationalize the four quadrants.
22:53So as I'm describing the process
22:55I really want you to think about,
22:58we were taking into consideration
23:00the different quadrants in regards
23:02to logistics skills and that
23:05facilitation of learning and really
23:07trying to be that emphasis on that.
23:09Social construction,
23:10that innovation quadrant in our
23:13organizational approach and as
23:15I start to share this approach,
23:17I want to ground it in that
23:19Mayo Clinic has three Shields.
23:21We've got the practice shield,
23:22the education shield and the research
23:25shield and our Department of Connected Care,
23:27who you will be hearing about hearing from,
23:30excuse me,
23:30in panel 4 is housed in the practice
23:33shield and they have been actively engaged
23:35in developing professional education assets.
23:38For practitioners in the
23:40topic areas of ethics,
23:42legal best practices and compliance,
23:46in the fall of 2019,
23:48the education team that I am a part of,
23:50our Office of Applied Scholarship
23:52and Education Science,
23:53joined efforts with the Connected Care
23:56team and our focus was very simple
23:58at the time and I think also allowed
24:02us to pivot quickly when we needed
24:04to for during the onset of COVID-19.
24:07But what we did is we started with
24:09implementing the professional
24:10telehealth education assets that
24:12were designed for the practitioners
24:14by our department of connected care
24:16into curriculum of our four school,
24:18four of our five schools.
24:20And so our approach was why not
24:21right we can do this.
24:23So to scale our efforts very quickly,
24:25we first collaborated with stakeholders.
24:28So our two teams coming together
24:32coordinated enterprisewide
24:33interprofessional working group.
24:35Representative of our School of Medicine,
24:37our School of Health Sciences,
24:39our Graduate Medical education programs,
24:41our continuous professional
24:43development programs,
24:44as well as Simulation Humanities,
24:46our education technology teams,
24:48media support and multiple departments
24:50in the practice.
24:51You can imagine it was quite a a large
24:54group on the zoo meetings and our
24:57stakeholders were quite expansive.
24:58Dr.
24:59Sigmiller Renner and panel one did
25:01have an image up, but just to.
25:03Shout out to our stakeholders.
25:05We had allied health staff,
25:06administrators, directors, MD's,
25:10PHD's, career educators,
25:11nurses, nurse practitioners,
25:13physician assistants and many,
25:15many more individuals.
25:17We then moved to crowdsourcing and curating.
25:20So with the various stakeholders
25:21and subject matter experts,
25:22we've been able to curate and bet
25:24internal and external assets in those
25:26quadrants that Julian talked about.
25:28We focus first on the Evergreen
25:30telehealth 101 content,
25:31which has allowed us to maximize
25:33our collective bandwidth to really
25:35focus on filling gaps and then
25:38also reduce this creation of
25:40duplicate duplicative content.
25:42And then finally,
25:43we constructed.
25:44So through this collaborative cocreation of
25:46education assets with our working group,
25:49we've been able to adapt the teaching
25:52and learning environment fairly quickly
25:54in this first phase of our work.
25:57And given assets have been developed,
25:59have that have been developed or
26:01designed for diverse stakeholders,
26:03we've been able to focus on coaching
26:06educators and our learners and how
26:08to take that asset and integrate it
26:11into a situational context aligned
26:13for the appropriate levels of
26:16supervision and entrustment that
26:17we heard about from panel two.
26:20Through this iterative approach,
26:21we are learning together with the
26:23educators and learners. So again.
26:25That that continuous feedback loop,
26:26how are we integrating the learner voice
26:29in this particular process as well as
26:31our faculty and program director voices
26:33and looking ahead with our future phases,
26:36we are focusing on three key things.
26:38One, continuing to adapt and evolve our
26:40repository of resources aligned with the
26:43stakeholder voice always at the forefront,
26:45looking at remaining focused on
26:47the collaborative innovation
26:48instead of this duplication.
26:49So again, how can we continue
26:52to move forward fast together?
26:54And finally,
26:55capturing the stories of our learners to
26:57innovate the faculty development initiative.
26:59So that facilitation of learning
27:01really working closely with our faculty
27:04development pillar and integrating the
27:06learner voice in that portion as well.
27:09Thank you.
27:10And I'm going to now turn things
27:12over to Aditi Dr.
27:13Josie.
27:16Hi everyone. Thank you for having me.
27:18Like for my video back on,
27:20I know we're running a little bit behind.
27:21When they asked me to speak on this,
27:23I told everyone I can speak
27:24for 5 minutes for one hour.
27:26We're going to try and do the
27:27shorter time of that anyway.
27:29So I'm coming from Thomas
27:30Jefferson University.
27:31And so briefly in 2015, Jefferson
27:34started a very comprehensive program.
27:36We had provider provider consults
27:39direct to consumer program.
27:41And so for that,
27:42we were doing it in every department.
27:44And so for that reason,
27:45we had to create trainings
27:47for a variety of learners.
27:48And so we've had some version for
27:50all of the groups that I'm going
27:51to go through since about 2016.
27:53One thing that I did not actually mention
27:55is our telehealth facilitator course
27:56that was created by Doctor Shruti Chandra,
27:58who's also speaking here.
28:00But what was important to know
28:01about that particular course,
28:02as I know she probably
28:03is going to mention it,
28:04is that they created a lot
28:06of modules and videos on the
28:08background and on telehealth.
28:09Prior for a very broad based
28:12group and so we use some of those
28:15for some of our other groups and
28:17we go to the next slide please.
28:20So we're going to go through
28:22medical education first UME&amp;GME
28:23and the reason I put this together
28:26because in our first iteration our
28:28UME&amp;GME was essentially the same.
28:30We you started out with a visiting
28:32resident or resident elective
28:34and a medical student elective.
28:36And so for that students or residents
28:38would come in for a month and they
28:40would do clinical telehealth,
28:41have some exposure.
28:42But the real goal is really try
28:44to get them to understand the
28:46administrative aspects of also running
28:48a program so they would see how the.
28:50Business ran how we had to think about
28:52marketing because they're still new,
28:54this is pre COVID and so we will be
28:56able to engage them in that aspect as well.
28:58And then all of them would have to
29:00do a short research and literature
29:02review on telehealth and use
29:04cases for our emergency medicine
29:06residents since we were emergency
29:07medicine run essentially in the
29:09telehealth department to emergency
29:11medicine doctors are running in it.
29:13So we had them do some callbacks coming
29:15out of the emergency department.
29:17That didn't run as long because
29:20it turns out that ER doctors
29:22are pretty good at discharging.
29:24And so we realized that most patients
29:26didn't actually want to keep their
29:28visits because they didn't need them.
29:30So we actually did a lot of different
29:32iterations of this and in the
29:34end we decided to forego most of
29:36that for specific ones and we now
29:37continue to have an elective.
29:40Some of the things that changed during
29:42the pandemic as just like anywhere,
29:44we had to increase the amount
29:46of availability for training.
29:47So for residents who are working
29:50alongside the attendings
29:51who are doing telemedicine,
29:53we put every module and space,
29:56which I'm going to go through a little bit
29:58more on the faculty training into our portal.
30:00And so they had access to all the same
30:02videos, modules and physical exam checklists,
30:06information on tech troubleshooting,
30:08everything that all the faculty had.
30:10Access to the residents also had access to.
30:13In general, however,
30:14they were being trained by and working in
30:17telehealth alongside their own attendings,
30:19and so they were learning alongside them.
30:22So in that way we only gave
30:23them tools on how to do it.
30:25But of course each practice
30:26understands their own practice best,
30:28and so they could actually
30:29teach their residents that way.
30:30Now for you and me, just like everybody else,
30:32our, our medical students were
30:34pulled away for a few months.
30:36And so when they came back,
30:37they came back to a world where telehealth
30:39was now part of their clinical environment.
30:41And so for that a few of us had to put
30:44together a module for the medical school.
30:47And So what we did was exactly the
30:49same type of modules that we had.
30:50We put,
30:51we did a physical exam one because at that
30:53point both third and fourth years have
30:55a background in the end physical exam,
30:57all of the background of telehealth
30:59and just different types of
31:00introductions on why this is going to
31:02be important for their clinical career.
31:04And so we use that as an introduction.
31:06It was a 2A1 and 1/2 hour module.
31:09And then again they would go into
31:11their various clinical environments and
31:12learn telehealth alongside of that.
31:14And so that continues.
31:15Now today we're going to improve
31:17it and expand it,
31:18especially because we have a little
31:19bit more time to do that for them.
31:22Next slide please.
31:25The next thing I wanted to
31:26talk about was our fellowship.
31:28So the idea we started this in 2016,
31:30it's a one year or two year
31:32fellowship and it's S AM approved.
31:34The idea being that we for the future
31:36leaders of telehealth departments,
31:38how do we train them?
31:38What do they need to know?
31:40So just like we talked about how we
31:42have an administrative department,
31:45we have our fellows do 4 pillars right?
31:48They work clinically.
31:49All of them currently work out
31:50of the Emirates department.
31:51We are considering having them work out
31:53of other departments if they can handle
31:55using them in the clinical environment.
31:57Everyone has to do a research project,
31:59but the most important things,
32:00what they're learning are the administrative
32:02and the entrepreneurship aspects of it.
32:04They were long run operations.
32:06Our fellow last year did all of the
32:08QA for us, which is a big help for me.
32:11And most interestingly,
32:12I thought, you know, we've had,
32:13like I said, since 2016.
32:14But last year, my fellow,
32:16when the pandemic happened,
32:18he was incredibly helpful to me for all
32:20the work that I needed to get done to
32:23expand the way that we used it in COVID.
32:25And he had had a job lined up
32:27or like a preliminary interview.
32:29But as soon as that happened and
32:31telehealth became much bigger,
32:32he got three more job offers just like that,
32:34and he found the job that he actually wanted.
32:36So that was great.
32:37Now this, of course,
32:38we're taking current applications for
32:39anybody who might be. Interested.
32:40All right. Now last slide, please.
32:44All right.
32:45So the provider thing is obviously
32:46the biggest part of what we're
32:48doing for all of our training.
32:49So I would say this is the
32:51hardest and easiest, right,
32:53because I always tell everyone that we are,
32:54as clinicians who've been
32:56in practice for years,
32:57we have our own way of doing things.
32:59We've been trained.
32:59We're not really sitting there learning
33:01a lot of new skills all of a sudden.
33:03So we're a little bit more
33:04resistant to change,
33:05not everybody, but you know,
33:06a little bit more resistant
33:08than everybody else.
33:09But on the,
33:10on the other hand,
33:10it's the easiest to train because
33:12they're we're much more comfortable
33:14with our clinical practice.
33:16And so because of that we only
33:18really need to learn the technology.
33:19We may need a few tips on what to do
33:21and then we can actually figure out
33:23how to the clinical portion easier.
33:25We don't need to teach them
33:26the clinical aspects.
33:27When I first came to Jefferson was
33:29in 2016 and really at that time
33:31there wasn't a lot of background,
33:33there wasn't education,
33:34there were no training modules.
33:35So I came in, I did a lot of,
33:37created a lot of that.
33:39But for example,
33:39one of the favorite things I talked
33:41about was just how we just did things.
33:43So our clinical path is you
33:45made 52 of them
33:46based on. Common acute care complaints
33:48and they use a modified Delphi method.
33:50Each faculty member would take it
33:52and they would round it out with five
33:53people and they came with consensus
33:55with 52 different complaints.
33:56It would go through just
33:57what what the complaint was,
33:59what you look for red flag triggers
34:00and how you can apply it to telehealth.
34:02And we still use those today.
34:03We made you know epic charts and
34:06as we continue to expand it,
34:08what I actually we create a lot more things,
34:10right.
34:10So I made various checklists for
34:13on demand training for Tele triage
34:15when we started that in 2017.
34:17We made physical exam modules.
34:19We actually made those three years
34:21ago and it was basically how do you
34:23do physical exam for telehealth
34:25and it's 7 modules.
34:26We did it,
34:27made it for CME and it became
34:28much more popular this year as
34:30opposed to the last few years,
34:32even though we've had it for a couple
34:34when the again pandemic happened,
34:36it wasn't just a few first movers
34:38that we had around the institution.
34:40Despite the fact that Jefferson
34:42had a wide-ranging program,
34:43it doesn't mean that every department
34:45had a ton of people doing telehealth.
34:47Now, of course,
34:48during March,
34:49when we had to create and expand
34:51how much telehealth we were doing,
34:52we had to put a lot of things
34:55quickly into that section.
34:56The portal that I created that
34:58we were talking about and created
35:00for all of that training was again
35:02available to all of the faculty.
35:03So we put almost anything and everything
35:05that we had created in there.
35:07I can't stress enough how much it was,
35:09how easy it was to do this and
35:11train people because everything
35:12was done for our acute care,
35:14which is our first line for
35:15COVID screening and evaluation.
35:17We made a bunch of other videos.
35:19And again,
35:19checklists and availability for
35:21everyone to get it anytime everything
35:23on their COVID resources,
35:25our COVID checklist so that everybody
35:27could find it all the time and then
35:29we would just do QA after the fact.
35:31But I'll tell you it saved me
35:32a lot of time just having those
35:34videos available and for people to
35:36adding to do it and post Pandemic,
35:38we've actually created a whole lot of other.
35:41Well, one collaboration,
35:42right,
35:42because now we have a lot of other
35:44departments working with us,
35:45figuring out how are we going to
35:46improve our physical exam videos,
35:47how are we going to improve our training
35:49videos now that we have an entire bigger
35:51group of people who are doing this.
35:52And we started to expand those.
35:54And we're hoping that in the next
35:56few months we're going to have
35:58some of those videos created.
35:59Also,
35:59Doctor Chandra and I also created
36:01an advanced connective care course,
36:03which is going to be an update for all
36:05of those things to include a lot more
36:07of what we learned about telehealth.
36:09Now most of this, what I'm talking
36:10about is not the actual practical
36:12aspects because that's going to be
36:13spoken about in a different panel,
36:15but this is more to talk about how when
36:17you're doing and creating a program,
36:19the reality is you're just going to
36:20tailor it to each different learner.
36:22It wasn't like we made a whole
36:24lot of different things.
36:25We just used it and it determined
36:26okay at this level of learner,
36:28this is what you need at this is
36:30what level this is what you need and
36:31figured it out how we were going to.
36:34Just put it and put it out there for
36:36each different group and then figure
36:38out how we are going to evaluate them.
36:40Our next group for for example for our
36:42GME is to use a SIM checklist that a
36:45few multicenters are going to validate
36:47and hopefully use in education in the future.
36:49So thank you all.
36:50I am looking forward to any questions
36:53and I think I kept in time.
36:54Thank you.
36:57You did fabulous Doctor Joshi.
37:00I'm going to invite the panel
37:02members to please turn on their
37:04video and also their audio.
37:06And as we invite the participants
37:09and the panelists to please
37:12post some questions in the Q&amp;A,
37:14I'm going to just do a quick round
37:16Robin with each of our panel members.
37:19I'm asking Doctor K and Doctor Esper
37:22a little bit about empathy. Dr.
37:24Jenkins, I'm going to have a question
37:26on workflow for you and then Dr.
37:28Joshi, I'm just going to.
37:29Loop back around with the
37:31learning environment.
37:32So Doctor Esper,
37:33some of the specialties often
37:34include a family member or caregiver
37:36as part of their clinical visit.
37:38How do you incorporate empathy with
37:41multiple people in a telemedicine visit,
37:44including the learner?
37:46That's
37:46a great question.
37:48In my specialty, the majority of my
37:51patient population is geriatric,
37:52so I actually run into this quite frequently.
37:56And I find that it's important to
37:58maintain eye contact and engage
37:59all parties, so family member,
38:02caregiver as well as the patient during
38:05the visit in order to communicate
38:08effectively and establish A meaningful
38:10relationship with the patient.
38:11Now I will say this can become even
38:14more challenging when the third party
38:17actually participates as another remote
38:19participant and I had this happen a few
38:22times in visits took threw me off of it.
38:25It does depend on your platform.
38:28Make sure you know the patient is fine with
38:31the third party being admitted to that visit.
38:35And similar to what I described,
38:37again, engaging all the parties,
38:41allowing everyone to speak,
38:43maintaining eye contact,
38:45just to emphasize the
38:47empathetic communication.
38:50Thank you. Thank you.
38:54Doctor Kay, you talked about some
38:56skills and interventions or built
38:58that into your presentation.
39:00So thinking about that,
39:01how can empathy be further incorporated
39:05into medical and residency curriculum
39:07around telehealth telemedicine?
39:11Thank you, Alisa.
39:12I think that's a really important
39:14question because, you know,
39:15some studies have actually suggested
39:17that there is a bit of a confusion
39:20about what empathy means in among
39:22residents and medical students.
39:24And they often frequently think that if we
39:27did them emphasize about empathy too much,
39:29does it compromise the objectivity
39:31and also impair reasoning.
39:33So I think one of the things we as
39:35faculty and I'm part of the residency
39:37programs and I've also try to figure
39:39out what solutions would work best.
39:41But I think as much as we emphasize
39:43about the diagnostic skill building,
39:45we should also promote the
39:47humanistic medical model, right?
39:49And some of the tried and tested start
39:52strategies that have shown to be useful in
39:55promoting empathy include like you know,
39:57recording a video with a patient encounter,
40:01role-playing is is important and
40:03having a having basically continuity
40:06of patients once once residents and
40:08medical students see the same patient
40:10go through you know their life journey.
40:13I think that promotes empathy in general.
40:15But I think the key point is it
40:17it should not be a very forced or
40:19superficial kind of curriculum.
40:20It has to really be done in a way that,
40:23you know,
40:24students and residents all appreciate it.
40:26And I think with the point about burnout,
40:29I would really like to mention that I
40:31think burnout happened in physician,
40:32but I think the seeds of it are
40:34laid much earlier.
40:35So recognizing fatigue and earlier
40:38is really important among medical
40:41students and residents as well.
40:43So you know I think those are some
40:45of the ways we can do and as our
40:48journey evolves in incorporating
40:49more telehealth visits,
40:51I think it also becomes a question
40:53that came up when Lee was mentioning
40:54earlier that we have to also decide
40:57which patients are ready for telehealth
40:58which may be still better seen in person.
41:01So when we are after this pandemic,
41:04when we have a choice,
41:05I think one of the skill building
41:07would require us to is this patient
41:10more suited for any health visit or.
41:12Should it be better seen in person
41:13and a lot of factors will go
41:15into informing us about that.
41:18Thank you. I'm going to ask a question
41:23of Julie in regards to workflow and I
41:25appreciate we're starting to see some
41:27questions come in through the Q&amp;A.
41:29So please keep those coming in and I'm
41:32going to make sure the panelists as we're
41:34wrapping up this round Robin of questions,
41:36I encourage my panelists
41:37to also look at the Q&amp;A.
41:39Julian, I'm going to focus this question
41:41on workflow for you and think about your
41:44experience as a trainee so far in the
41:46telemedicine virtual care environment.
41:48But it would have been some of the
41:50best ways to organize that the virtual
41:52clinical environment to optimize
41:54the logistics you talked about in
41:56Quadrant 1 and thereby maximize
41:57that facilitation of learning.
42:00Thank you, Melissa.
42:01And I'm hoping you can hear me now.
42:02I think I've fixed my technical
42:04difficulties. Wonderful so.
42:08Yeah, it's it's been challenging
42:09I think both from a GME and A
42:12and a UME perspective to to try
42:14to make this easier on folks.
42:16I've done a lot of work also with
42:18just virtual learning for the UME
42:21students at UCSF and I think there's
42:24shared challenges with regards to
42:27distractions and the home environment.
42:32I I think that to to optimize.
42:36The the clinical workflow is one
42:38thing perhaps to pick one item.
42:40We've made a transition in our clinics
42:43from the residence and sometimes
42:45attendings being responsible for
42:48debugging those clinical workflows.
42:50You know the patient that that is
42:52having trouble connecting or the the
42:55patient that just doesn't have video
42:57visits set up or or trying to figure
42:58out how to get them on the call.
43:00I was often taking 10/15/20
43:01minutes actually do that.
43:03And we've now actually developed a
43:04workflow with a preclinic cuddle that
43:06includes a virtual MA or virtual nurse
43:08that's able to help us contact our
43:10patients and get them on the calls.
43:12And well,
43:13that's more of a telemedicine
43:15workflow piece I think for our,
43:17our virtual learning environment.
43:18What it's enabled me to do is to really
43:20focus my time with the preceptor.
43:22So we're spending time with kind of a
43:24preparatory questions or anticipating
43:26needs of the patient and what I may need
43:28to learn or what I want to focus on.
43:30And then also it allows me to have
43:32more time with the patients, honestly.
43:34And that's where the real learning
43:35is happening.
43:35So maybe a small Pearl there.
43:38Thank you. And Dr.
43:41Joshi, thinking about learning environment,
43:44I really appreciate how you've described
43:47your approach as well as furthering the
43:50development of a fellowship curriculum.
43:53And as many of us here are on
43:55this panel as participants,
43:57we're in this constant.
43:58Battle of quality versus quantity
44:00when it comes to curriculum and
44:02although this education, telehealth,
44:05telemedicine education is necessary,
44:07we also have to think about
44:10overloading curriculum.
44:11And I think Doctor Sharp actually or
44:15Doctor Scott earlier talked about
44:16the value add versus that add on.
44:19And how do you recommend that we make
44:21this transition for our learners?
44:23What are some of the tips and tricks
44:25and strategies you recommend for us?
44:31God, you would think I'd be better at
44:32this by now on Zoom all these months.
44:34All right, I'm unmuted now,
44:35but that's a great question.
44:37So, you know, when I was mentioning
44:39just the first iteration of our GME
44:42for our emergency medicine residents,
44:44you know, it ended up at that point just
44:46being something they were forced to do.
44:48It didn't really show any value added to
44:50them, right. So looking back at that time,
44:53that's exactly what happened.
44:55So. You know what,
44:57we because that for that reason we made
44:59an elective to some degree, right,
45:00Because then everybody could decide
45:01do they want to do it and we would,
45:03we would have regular people coming
45:05to visit and do these relectives.
45:07So obviously nothing changed.
45:08Everything changed dramatically during
45:10COVID because prior to that it was
45:12mostly attendings running all telehealth
45:14visits or doing the telehealth visits
45:15with residents thrown in here and there.
45:17Now there's an actual value to this,
45:20right, because now there's a recognition
45:21that this is going to be part of your
45:23clinical practice in some form, whether it's.
45:26Various cases.
45:26Obviously,
45:27I'm not going to go through those details,
45:28but for that reason I think that has
45:31dramatically shifted how we think about it.
45:33And that's probably and that is not
45:34something that I did.
45:35Obviously, it's just something that we had.
45:37But again,
45:38I can't stress enough how it
45:39was much easier already thinking
45:40through these problems and figuring
45:41out what we may be able to do,
45:43what we could do that gave our
45:45students and residents and even our
45:46faculty and ability to get a leg up
45:48a little bit and do things faster
45:49because we had that recognition.
45:51We already thought through it.
45:53And then of course,
45:54you know,
45:54we could just learn from each other
45:56because everyone had to do it.
45:57The amount of you know,
45:57emails and like and I'm sure all
45:59the other people who have their
46:01education programs out there had
46:03the same experience for people
46:04just want to know what do you do,
46:05how do we do this?
46:06How do we make this a value for everybody?
46:07And the reason is it's part of
46:09your future clinical practice.
46:10There is a value to this.
46:13Fabulous and I, I think everyone on
46:16the panel has done a a wonderful job
46:18of being us intangible takeaways
46:19and we all are learning together and
46:21we'll continue to learn together,
46:23especially with individuals
46:24that have moved things forward.
46:26I want to go back just to
46:29our audience question,
46:30Julian, are there any tips,
46:33practical tips about what you've
46:35described in this limited burst of time?
46:39Yeah, I I love that question.
46:41Thank you Sophia for that.
46:42I hope I'm saying your name right.
46:45So two quick thoughts because I
46:46know we're running out of time and
46:48I see Lee turning his camera on.
46:49So thing one is I've done a a few stuff
46:54specially rotations myself and we've
46:55begun to reimplement subspecialty
46:57telemedicine training at UCSF.
46:59And I think things that have
47:01really worked are a sometimes it's
47:03felt a little bit out of control.
47:06But what makes it feel in control is
47:07knowing one or two of the patients
47:09I'm going to see beforehand have
47:11a lower expectation for the load
47:12that the the trainee may be seeing,
47:14but actually provide them with as much
47:16anticipation of who they're going to
47:17be seeing so they can prepare for it.
47:19That's thing one.
47:20Thing two is also to think
47:21about asynchronous content.
47:23So it to some degree we're doing everything
47:25synchronous in terms of clinical visits,
47:27but now that we're not in person in clinic,
47:29there's not that same opportunity
47:31for those chance encounters where
47:32the attending and you are there
47:34together and you're like.
47:35Hey, I had a question about,
47:36you know thyrotoxicosis.
47:37I was in an endocrinology clinic recently.
47:39And so can you provide that asynchronous
47:43online bedrock of learning that can
47:45then you can point learners to or
47:48can provide that curriculum even
47:50in absence of those same robust
47:52in person clinical encounters or
47:54chance encounters with fellows
47:56and and faculty and clinic.
47:58So two ideas,
48:00asynchronous and knowing patients before.
48:03Thank you, Julian.
48:04As I turn things back over to Lee,
48:06I'm going to invite our
48:07panel members to if you,
48:09if you have a Pearl or a take away
48:11to just post that in the chat
48:12and it keeps us right on time.
48:14So thank you.
48:16Great, thank you.
48:17Panel 3, that was just a fantastic.
48:20You know, I think one other point
48:22I would just add as my little
48:25Pearl to Julian is that you know
48:27sometimes like many things teaching
48:29is in the eye of the beholder.
48:32And we do a lot of teaching that that
48:34our trainees don't see as teaching
48:36unless we name it as teaching.
48:38And so I would just emphasize again,
48:41it's the same thing with empathy, right?
48:43You need to be have it drawn out
48:45for you from as the foreground
48:47against the background.
48:48So entering a room, having a very
48:51empathic encounter with a patient,
48:52and then walking out of the room,
48:54if you just assume that the
48:57trainees will have understood.
48:58But you were consciously exerting skills
49:00to create an empathic connection.
49:03They may not appreciate it.
49:04But if you just take that moment to say,
49:06let's talk for a minute about that encounter,
49:08do you see how I asked about the family?
49:10Or I looked at the picture on the board
49:11and I said, tell me, who's that? Whose?
49:13Whose picture do you have up there?
49:15You know,
49:15I did that to engage the patient in
49:17a therapeutic relationship so that I
49:18could then ask them more challenging
49:20questions, whatever the dynamic was.
49:23So labeling sometimes is very important
49:26when we do the neurologic exam.
49:28When we demonstrated finding the
49:29Babinski or something, we say it.
49:31We said, look, that's the Babinski,
49:32the toe went up, it didn't go down.
49:35You make it happen like this.
49:37So we're very explicit about
49:38some forms of teaching,
49:39but we tend not to be as explicit
49:41about some of these other forms.
49:42So I would just encourage the the,
49:44you know, the audience and the panelists.
49:46When you're teaching these skills,
49:47make sure that the learner understands
49:49that there's teaching going on because
49:51it puts them in the right frame
49:52of mind to receive the learning.
49:54But it also helps them recall that
49:56in fact they had explicit learning.
49:58When that happens, wonderful.
50:00Well,
50:00we're going to switch gears again
50:02now in this progression.
50:03I hope the panelists and the audience
50:05are feeling this natural progression
50:07as we've built this sequence.