Panel 1: Strengthening Your Core: Defining Competencies for Telehealth Education

July 19, 2023

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00:00Welcome everyone.
00:01It's a pleasure to be with
00:04you today at our event,
00:06this first Digital Health symposium
00:09on Crossing the Virtual Chasm,
00:11rethinking curriculum competency
00:13and culture in the virtual care era.
00:15I'm going to go ahead and get started.
00:17Some audience members may still
00:18be filtering in.
00:19If I could have the next slide, please.
00:24So my name is Doctor Lee Schwam.
00:26I'm the Executive Vice Chair of Neurology
00:27and the Director of the Center for
00:29Telehealth here at Mass General Hospital
00:31and the Vice President for Virtual Care
00:33at our health system, Mass General Brigham,
00:35formerly Partners Healthcare.
00:37So today, we're going to really focus
00:40around the issues of competency and
00:43how this massive shift to virtual care
00:46delivery has posed new challenges in
00:48our ability to understand how to train,
00:51educate and assess.
00:53The competencies of our many
00:56trainees in the academic Medical
00:58Center environment, Next slide,
01:01so I like to show this tweet that
01:04appeared early in March that I think
01:07has gotten a lot of play and much as we
01:10were a really aggressively adopting a
01:13digital technology and moving forward
01:15with our efforts to transform healthcare
01:17and move to a virtual environment.
01:19Really COVID-19 was the driving force
01:22that that rapidly expanded our work
01:24and led to this massive adoption.
01:26And so we really had to react to COVID-19
01:29and rethink our model for education.
01:32Next slide.
01:35So the way we think
01:37about virtual care encounters
01:38from a participant perspective,
01:40it's really in four big buckets.
01:43There are providers interacting with
01:44other providers and a patient may
01:46or may not be present when we do an
01:48acute stroke evaluation, for example,
01:50or when we provide a remote consultation
01:54to an inpatient at another hospital.
01:56We have a provider direct to
01:59patient care function where we
02:01have patients using laptops,
02:03smartphones or tablets interacting
02:05with providers either for
02:07established care and follow up,
02:09which was our most common
02:10use case originally.
02:11Or more recently new patient
02:13care or virtual urgent care.
02:15We also had a need for patients
02:17to connect to others.
02:18And so we did a lot of work on creating
02:21portals for patients to be able to
02:23securely communicate with others.
02:25And then lastly,
02:26we really have an automation
02:29function where machines or devices
02:31are communicating with patients
02:33or providers and and creating new
02:36avenues of care delivery and we're
02:38going to focus predominantly.
02:40On the provider to patient,
02:43but in the context of the trainee,
02:45that often means a second provider
02:47is involved in the interaction.
02:49Next slide. So we have 5 panels today.
02:53The first one will be about defining
02:56competencies in virtual care
02:57education and thinking about that in
03:00comparison to in person education.
03:02Or how about to those learners who
03:04have been educated in a purely virtual
03:06environment for some of their encounters?
03:08They may never have had an
03:09in person clinic visit.
03:10They've all been virtual so far.
03:12How do we,
03:13how do we cope
03:13with that next slide?
03:18And so this concept of competence,
03:21I, I really like this the ability
03:23to do something successfully or
03:25efficiently and we have that core
03:27competency concept over there
03:28illustrated with the latters.
03:30But I also like the dated understanding
03:32of an income large enough to live
03:35on typically unearned.
03:36I don't think that applies to our trainees,
03:38but I thought that was kind of funny.
03:40Next slide.
03:44So how do we define
03:46competence in virtual care?
03:47So we clearly have the intrustable
03:50professional activity lens.
03:51We also have this concept of,
03:54you know, core strength. You know,
03:56maybe you're not ready for standing,
03:58maybe it's your start on the floor and
03:59then you work your way up to standing, but.
04:01We have to rethink this in through
04:03the lens of competency and we have
04:04some wonderful speakers who are going
04:06to share a variety of frameworks
04:07with us for that next slide.
04:11How do we rethink assessment?
04:12You know, sometimes virtual care is
04:15the vehicle through which we're going
04:17to assess people and sometimes it's
04:20the environment of practice itself.
04:22So how do we assess the competency
04:24of delivering virtual care,
04:25but also of using virtual environments
04:27to assess in person care?
04:28Because we have constraints
04:29around who can be in the room,
04:31next slide and here we think about other
04:36frameworks that we're familiar with like
04:38the framework for measuring quality,
04:39the the Donabedian structure,
04:41process outcomes.
04:42Our panel is going to give us a
04:45different framework for thinking
04:46about assessment in this new
04:48and complicated world next slide
04:51and we have some established statements
04:53around quality and and outcomes and
04:55how we ought to measure them and.
04:58We we have this in telemedicine
05:00largely focused around stroke because
05:01it's one of the more evolved fields.
05:03But we need to move forward this
05:06framework and be able to define what
05:08quality and outcomes mean in virtual
05:10care so that we can then refine
05:12how we assess whether providers
05:14and and patients have achieved
05:16that in their interactions.
05:17Next slide
05:20the next group is going to talk
05:21to us about how to adapt teaching
05:23and learning in this virtual
05:25care environment and and how.
05:27Can excellence in teaching
05:28and learning succeed in a
05:29new and virtual environment?
05:31And next slide
05:34and so here we're going to think
05:35about what are the what are the
05:37new ways that we have to think
05:38about teaching and learning.
05:39This is an example from a from
05:42a prototype model of making
05:45rounds walk rounds virtualized.
05:47And so if there's only one attending
05:50and 1 trainee in the room and everyone
05:53else is learning from outside the room.
05:55What? What impact does that have?
05:57How do we maintain excellence?
05:59How do we transform teaching
06:01and learning in a way?
06:02And our schools,
06:04right all over the country
06:05are facing this right now.
06:06How do you achieve excellence
06:07in teaching when your pupils
06:08aren't in the classroom?
06:09Next slide,
06:12and this is an example from
06:14a a paper we published in The
06:16Lancet showing an actual virtual
06:18rounds on the neurology service,
06:20where you can see the cursor
06:21is highlighting. A phase reversing spike,
06:23which is an important finding on an EE G that
06:26suggests that there might be a seizure focus.
06:28And along the bottom row there you see the
06:30pictures of learners in various environments,
06:32attending physicians, rounding from
06:34home or other parts of the hospital,
06:36other learners in conference rooms
06:38or in the hallway or at home.
06:42Very powerful tools to enable us to
06:44continue teaching and learning in a
06:46physically constrained environment.
06:48Next slide. And then lastly,
06:51we're going to talk about why it's so
06:53important to keep the patient in the center.
06:55And this is really about the impact of
06:57virtual care on the patient experience.
06:59We have to really think carefully about
07:01structural inequities in healthcare
07:02and healthcare and how to avoid making
07:04them worse when we switch to virtual care.
07:06Next slide.
07:08So my experience with this is
07:09it's sort of like the hydra.
07:11Every time you think you've got this
07:13licked and you cut one of the heads off,
07:152 heads appear.
07:16And so we know about the difference
07:18between equality and equity and.
07:20Every time you think you've
07:22solved this problem,
07:23a new problem arises.
07:24So we really have to make sure that virtual
07:27tools are accessible to those who need them,
07:29that there are barriers that we can
07:31eradicate related to having a device,
07:33having access to Wi-Fi,
07:35having the digital and health
07:37literacy necessary to be successful.
07:39And you have to keep a really
07:41close eye on this or you you miss
07:43the target and you don't end up
07:45providing the care that you need.
07:47Next slide.
07:50So this is our digital gateway, right?
07:51More and more of the work that we're trying
07:54to do relates to patients accessing our
07:56services through these digital tools.
07:58Next slide. If we're not careful though,
08:02we end up excluding people
08:03from access to care.
08:04And when physical limitations
08:06prevent them from coming in person,
08:08if technology limitations prevent them
08:09from coming over the digital highway,
08:11now they have no access to care.
08:13Next slide.
08:15And we know that social determinants
08:17of health have impacted virtual
08:18care access is a nice paper in the
08:21New England Journal Catalyst from
08:22the UCSF group showing that before
08:25and after telemedicine you see big
08:27differences in who is accessing care
08:30by patient characteristics and we
08:32have to be very mindful of that.
08:34Next slide.
08:37So we need to ensure that our
08:40virtual care data dashboards that
08:42we're using to monitor this care
08:43measures variation and adoption that's
08:45related to the social determinants of health.
08:47And it specifically address the needs of
08:49patients with limited English proficiency
08:51or limited digital literacy or access to
08:54technology or who have baseline visual,
08:56cognitive or physical impairments.
08:57And you'll hear some great conversation
09:00from that group including a patient
09:02representative on our panel who
09:03can really help us understand.
09:05This topic in more detail next slide,
09:09so just a few brief logistics.
09:11The sessions from today will be recorded
09:13and they'll be stored after the symposium
09:15at the symposium website we've created,
09:17which is just virtual care
09:19competency.com easy to find.
09:21That's where you can also see the
09:23speaker BIOS and more information
09:24During the sessions.
09:25Please use the Q&amp;A function,
09:27not the chat function.
09:29Use the Q&amp;A function during each
09:30panel to submit any questions.
09:32We'll try to get to those
09:34questions during the panel.
09:35If for some reason we don't,
09:37we'll either try to answer them
09:39afterwards or we may respond to you
09:41individually and after the session.
09:43We're going to also post additional
09:46resources for individuals.
09:47If you experience any technical
09:49challenges during the symposium,
09:51just quit and use the same link to rejoin.
09:54If you do need further assistance,
09:55you can try contacting our
09:57patient collaborative partners
09:59Collaborative Media Group by phone.
10:02And we'll do our best to to help you or you
10:06can e-mail them at digitalmedia@partners.org.
10:08Encourage you.
10:09Also just speaking to the
10:12speakers and panelists,
10:13when you join,
10:14please mute your microphone and hide your
10:16camera until it's your turn to speak.
10:19And I would encourage all of you to
10:23recognize that you know this is a four
10:25and a half, five hour session, so.
10:27Be sure to take breaks when you need them.
10:31We have one break built into the programming,
10:33but we imagine that people will come and go.
10:35So we're delighted to have you here and
10:38we're really excited to get started.
10:39And with that,
10:41we'll now transition to the next slide.
10:44And so this is the overview of the day.
10:46As I mentioned,
10:47we're going to have these five panels.
10:48We'll have a just a brief 10 minute
10:50break in the middle and we will close
10:52by 5:00 PM sharp and we will keep
10:54very strictly to the time schedule.
10:56So we will not run over,
10:58that's my commitment to you and I
11:00will join the sessions at the end
11:03of each time to let the panelists
11:05know that it's time to move on if
11:07we haven't closed by the by the time
11:09that we're scheduled to next slide.
11:13All right. So it is my great pleasure
11:17to have the opportunity to introduce
11:19the moderator for the first session.
11:23Doctor Emily Hayden is a colleague
11:24of mine and an expert in the field of
11:28telemedicine within emergency medicine.
11:30She is going to introduce the
11:33panelists and moderate the session.
11:35Doctor Hayden has worked in the
11:38intersection of telehealth and
11:40emergency medicine extensively.
11:41And is very active in the academic
11:44emergency medicine community as well
11:46as working closely with the AA MC on
11:49their Telehealth Advisory committee.
11:51So I'm delighted to turn things
11:52over to Emily at this point and
11:55welcome her as the moderator.
11:57Welcome everybody.
11:57Good morning or good afternoon wherever
12:00you're dialing in from right now.
12:01And it's going to be exciting day.
12:03And so I am also delighted to be
12:06presenting this first panel or
12:08moderating this first panel as we
12:10know telehealth has exploded and
12:12as healthcare education systems,
12:14we really need to figure out and
12:17develop the best practices for
12:19instruction and and assessment.
12:21And so this first panel is going
12:23to be speaking broad strokes on
12:26competencies as well as discussing
12:28some competencies that already exist
12:30or are newly existing in telehealth.
12:32So wanted to run through the
12:34objectives of the session.
12:35So first we want to by the end of
12:38this panel describe the need for
12:40telehealth competencies across
12:42the continuum of you and me,
12:44GME and faculty level education and
12:47their impact on quality of care.
12:49We want you to be able to review
12:51various approaches to competency
12:53development and the competencies that
12:55currently exist specific to telehealth,
12:57and then to discuss what is needed
12:59by health systems and medical
13:00schools to implement competencies
13:02into training and curricula.
13:03Before we jump into there,
13:04if we can go to the next slide,
13:06I wanted to introduce the
13:07panelists and you're lucky today.
13:09There are six experts joining me
13:11today and they have so many different
13:14perspectives on competencies and telehealth.
13:17So just to jump in to introduce them
13:19before they start presenting their material,
13:22Lee has already introduced me
13:23as the moderator, Dr. Shoemaker.
13:25She is someone who has just jumped
13:28into the telehealth world more
13:30recently given the COVID pandemic.
13:32But previously to this she was
13:33almost 30 years as a practicing
13:35as a clinical endocrinologist.
13:37And then more recently has jumped
13:40into being a associate.
13:41I'm trying to make sure I keep
13:43the assistant chair of medicine.
13:44Sorry Peggy,
13:45I tried to promote you to associate she.
13:48Like I said,
13:48she jumped into the pool of telehealth
13:50when all of a sudden the clinical
13:52rotations that she was working on were
13:54then required to switch to virtual.
13:55And so I'm assuming many of you on
13:58this webinar may be in the same vote.
14:00She also jumped in and actually
14:02dove into the pool and now is
14:04funded for telehealth and telehealth
14:05education from both,
14:06I believe Hersa and the USDA.
14:08So congratulations on that.
14:10Sarah Hampton is joining us
14:13from the double AMC and she's a
14:15program specialist with clinical
14:17innovations where she leads the
14:19strategic planning and activities
14:20for the WMC telehealth initiatives.
14:23So it's wonderful to see her here
14:25and hopefully she has good news
14:27about the double AMC competencies
14:29being published any second now.
14:31Next on here is Doctor Jim Marson.
14:33He's a Professor and Vice Chair
14:34for Research in the Department
14:36of Pediatrics at UC Davis.
14:37And so he's been involved with
14:39telehealth for quite a long time and
14:41has been a great advocate for telehealth
14:43as well as telehealth research.
14:45So we're excited to see him here.
14:47He also is on the telehealth
14:49WMC Telehealth Advisory Committee with
14:51me and Sarah on the next slide, please.
14:55We have our next speakers going to be
14:58actually just a little bit out of order here.
15:01We're going to start actually
15:02next with Amy Sigmiller Renner.
15:04She is the Associate Director of
15:06Curriculum and Assessment in the
15:08Office of Applied Scholarship
15:09and Education Science at Mayo.
15:11And in this role she lends her expertise
15:13to curriculum management and the whole
15:15basically gamut epic of education.
15:17So I'm really excited to hear her
15:20perspectives on telehealth education
15:21there at Mayo and and the COP
15:23and see development there.
15:25Doctor John Coe is a general pediatrician
15:27who serves as the Director of Graduate
15:30Medical Education for Mass General Brigham.
15:32And then also is the I think
15:33I'm going to get this right,
15:34John designated institutional official
15:36for the Brigham and Mass General.
15:40And so he has been grappling quite
15:42a bit with leading the GMA system
15:45of how to bring in telehealth.
15:47So it would be great to hear what he
15:48finds are barriers and what he thinks
15:50are maybe possibly some solutions.
15:52We'll see.
15:52And then now I'm going to go back to
15:54the left hand side of the screen here,
15:55Elizabeth Krupinski.
15:56We are really lucky to have her here.
15:58She's an experimental psychologist
15:59who jumped into the pool of telehealth
16:02a while back.
16:03I mean I think it's about 30
16:05years plus now back in Arizona,
16:07she now Co directs the SW
16:09Telehealth Resource Center.
16:10She's involved with the Devil,
16:11AMC with me and Sarah and Doctor Marson
16:15on the Telehealth Advisory Group.
16:17She is the American Telemedicine Association
16:19chair of standards and guidelines.
16:22And then with all this she's
16:23been with all this,
16:24she's definitely been involved in many
16:27guidelines also let her know she's
16:29late or let you know she is not only
16:31involved in all of that currently,
16:33she also is at Emory with their
16:35connected health program and and a
16:38vice chair of research and Radiology.
16:40So,
16:40so many different perspectives
16:42in from just one expert and so
16:44really lucky to have her here.
16:46So on that note with knowing that
16:48you have many experts for this like.
16:51Less than an hour now,
16:52I want to hand the mic over to
16:54Doctor Shoemaker and if we can
16:56advance to her first slide, please.
17:00OK, great. Thank you very much, Emily.
17:03I'm delighted to be here and learn
17:05from all of you more about telehealth
17:07and how we can move our students
17:09forward at Geisinger Commonwealth.
17:12So to set the stage for the discussion
17:15of competencies in this first session.
17:17We need to reflect for a moment on
17:20contemporary changes in medical education.
17:22For nearly a century since Flexner's report,
17:25the typical medical school curriculum
17:27consisted of more of a standard period
17:29of preclinical or basic science,
17:31followed by a standard period
17:33of clinical clerkships,
17:34especially engaged observerships.
17:36And although there were minor
17:39variations on this theme,
17:41the essential premise had been to pay your
17:43dues and do your time and move in lockstep.
17:47With your cohort through a standard
17:50curriculum from matriculation to graduation,
17:53but rapidly changing patient
17:55and healthcare system needs,
17:58as well as disturbing data on
18:00preventable medical error,
18:02brought to light the inadequacies
18:04of an educational tract that
18:06emphasized knowledge acquisition
18:08and was defined by time to better
18:11meet needs of patients in society.
18:14Demonstrated outcomes in
18:16areas of communication.
18:18Professionalism, teamwork,
18:20the application of knowledge,
18:23and patient centered care became the
18:27contemporary goals of medical education.
18:30So the concept of competency based
18:33medical education was then endorsed
18:36by the Accreditation Council
18:38for Graduate Medical Education.
18:40And the American Board of Medical
18:42Specialties back in 1999 with the
18:45introduction of the now familiar 6
18:48core competencies and then additional
18:51definition was given to this
18:53approach by the undergraduate and
18:55trustable professional activities
18:57and the Milestones Project for
19:00the Graduate trainees and thanks
19:03to efforts of groups such as the
19:05International Competency Based
19:07Medical Education Collaborative.
19:09Along with the support of the Association
19:11of American Medical Colleges,
19:13the A/C GME and A/B Ms.
19:16we're now experiencing a sea change
19:19in medical education from the
19:22one-size-fits-all teacher centered
19:23time based model to one that shows
19:27allows a more customized learner
19:30centered and outcomes based approach.
19:32Next slide please
19:38so. In addition to these high level outcomes
19:41represented by the core competencies,
19:44Capital CA successful competency
19:47based medical education requires well
19:50defined a well defined developmental
19:53road map of which the learner and
19:56teacher have a shared understanding.
19:58This educational framework is built
20:01by multiple sets of competencies.
20:03Lower Case C around topics such as
20:07patient safety, quality improvement,
20:10or telehealth.
20:11Each set encompasses the critical
20:14subject content and offers learners
20:17developmental targets that are
20:20attainable with frequent faculty
20:22feedback and formative assessment.
20:25Educational institutions then
20:27have a commitment to learners.
20:30To ensure competency is achieved across
20:33this educational framework while allowing
20:36for variable learner needs and as such,
20:40a competency based medical
20:42education approach then benefits
20:44learners through engagement,
20:46flexibility of time and resources and ensures
20:51achievement of their educational outcomes.
20:55Likewise,
20:56residency program directors benefit.
20:58As recipients of new trainees were
21:01accomplished and expected skill levels for
21:05entering residencies and most importantly,
21:08patients and society benefit when
21:11physicians are better able to meet
21:14their needs and assist navigation
21:16in complex healthcare systems.
21:19Next slide please.
21:24So competencies like the
21:26ones to be discussed shortly.
21:28Are valuable, and they are way
21:30too valuable to sit on a virtual
21:33shelf in an electronic file.
21:35To narrow the gap between publication
21:38acceptance and application into curricula,
21:41we look to the principles
21:44of implementation science.
21:46Several strategies are noted here
21:49as we consider the implementation
21:52of telehealth competencies into
21:55mainstream medical education.
21:57So we might ask ourselves,
22:00is there an educational need for this?
22:04Will the educators be receptive?
22:07What barriers might impede institutional
22:12engagement once stakeholders agree to begin?
22:15How can we provide support and tailor
22:19to institutional and learner needs?
22:22Who will be the early adopters?
22:24Would an advisory group increase
22:27support with additional stakeholders?
22:30What would be the benefits of
22:32bringing a group of institutions
22:35together to share telehealth
22:37competency adoption experiences?
22:39Will specific training for
22:42faculty educators be needed?
22:44What dissemination approach will bring
22:47the highest return on engagement?
22:50What is the role of patient
22:53advocates and engaging stakeholders?
22:55For this type of education,
22:58is there an opportunity for modifying
23:02financial or credentialing drivers
23:04or barriers to this education?
23:07So, lots of questions and lots of approaches.
23:11So I would say that lessons learned from
23:15previous experiences in implementing
23:18similar sets of competencies reveal the
23:22need to apply these tactics broadly.
23:25And most importantly,
23:27apply them iteratively.
23:29We must persevere in other words.
23:32So I thank you for your attention
23:34and I'm going to check if there
23:37might be any questions.
23:39Let
23:41me see. And yes,
23:43I'm I'm just going to be jumping back on.
23:45For those who are in the audience,
23:46please know that you can be asking
23:48questions throughout the panel when people
23:49are speaking using the Q&amp;A function.
23:51And so as the moderators,
23:53we will be watching the Q&amp;A to see
23:55if there's any questions that come up
23:56that maybe the panelists may not be
23:58seen when they're presenting. So Dr.
24:00Shoemaker, I don't see any right now,
24:02but I appreciate what you brought up
24:03and I failed to mention an introduction.
24:05You have had experience in the past
24:08with competency development in the
24:10quality and patient safety world.
24:11So I think that.
24:13If there are other questions
24:15that come up during the panel,
24:16this panel that she might be able to answer,
24:18please put them in the Q&amp;A.
24:19And we have built in a little bit
24:20of time at the end of this panel
24:23for answering questions too.
24:24So thank you Doctor Shoemaker,
24:26appreciate that.
24:26And I think we are now going to
24:29be handing the microphone or
24:30the zoom over to Sarah Hampton.
24:32So Sarah,
24:33if you don't mind coming on your video now.
24:36Can you see? I think I'm there,
24:38Okay. Thanks, Emily,
24:39and thank you all for having me today.
24:41So I'm going to start out by giving
24:43you a brief background as to why
24:45the W AM C decided to focus on
24:48developing telehealth competencies.
24:50And then I'm going to quickly go
24:52over the process at a high level.
24:54So what you see here is data from
24:56a W AM C survey that goes out to
24:58about 225 hospitals each year.
25:00It gets about a 75% response rate.
25:03And keep in mind this goes
25:04out to the hospital CEO.
25:06So the CEO is answering these questions.
25:09So several years ago we decided to
25:11add a group of questions around
25:13telehealth to better understand
25:15what our members were doing.
25:17So this is the data that we have from
25:19the past four years and the question
25:20is what is the current status of your
25:23telehealth program ranging from none
25:25on the left hand side and going all
25:27the way to having a mature program.
25:29Obviously this is all pre COVID.
25:31This year's survey was just
25:33completed in the spring and summer.
25:35So we are getting that data in now and
25:37we are very anxious to see how the
25:40results have changed in light of COVID,
25:42especially for these telehealth questions.
25:46But so this data really show the
25:48W AM C that there are a lot of
25:50opportunities to learn from each
25:51other and share best practices.
25:53As you can see we had a lot of
25:55members grouped in the pilot
25:57implementation and optimization phases.
25:59So again, it really reinforced that we
26:02needed to address telehealth for our members.
26:05And so with this and some of the
26:07feedback that we gotten from telehealth
26:10leaders at academic medical centers,
26:12we decided to focus on three priority
26:14areas related to telehealth.
26:16So next slide,
26:22these are the three areas and I'm just going
26:24to highlight the medical education one.
26:26So in terms of training and
26:28educating physicians on telehealth,
26:29what we were hearing from national
26:31leaders was that medical education
26:33was late to adapt to telehealth.
26:35There was no formal set of skills or
26:37guidelines and this gap in training could
26:40potentially lead to poor quality and care.
26:42So to help guide us in these three areas,
26:45in 2018 the AA MC established A
26:48Telehealth Advisory Committee.
26:50And to date,
26:51this committee and a lot of you are
26:53on here today has worked really hard
26:55to get us a set of telehealth skills
26:58and also telehealth competencies.
27:00Next slide.
27:03So this was our process at a very high
27:05level for developing the competencies.
27:07We did it slightly different.
27:09We had the committee come together
27:12in January of 2019 to 1st focus
27:15on identifying the skill set.
27:17So skills we defined as a distinct ability,
27:19knowledge or value needed to
27:21deliver high quality care.
27:23And these were meant to be
27:25applicable to all clinicians,
27:26not just physicians.
27:28So together in person,
27:30we drafted first a set of domains
27:32and that was based on the literature
27:34that was already out there and the
27:37committee's own expertise and experience.
27:39So once we had that first set of domains,
27:41committee members went off and
27:43drafted skills for each of those.
27:45And then we had a monthly review
27:47process where we work together in
27:49real time to refine each domain and
27:51those skills that were part of that.
27:55So this past December,
27:56we came together to finalize the set
27:59of skills and we also added five
28:01additional committee members who were
28:03experts in medical education but
28:04also have background in telehealth.
28:06And so with this final set of skills,
28:09we used it to then develop and
28:12transition those into competencies.
28:15So the skills are applicable
28:16to all clinicians,
28:17whereas the competencies are
28:20for physicians and tiered.
28:22So what is it that a medical
28:24student needs to know?
28:25What is it that a resident needs to know?
28:27And then what is it that a
28:29practicing physician needs to know?
28:30And as you can see here,
28:32they're aligned with the EPA's
28:33and the six six core competencies
28:35from a CGME and A/B Ms.
28:39So after coming together in person
28:41and then putting together that
28:43first draft of competencies,
28:44we had several rounds of external feedback
28:47with stakeholders and I think Jim's going
28:49to talk a little bit about that next.
28:51But through various reviews and refinement,
28:54we do have a completed final set of
28:57telehealth competencies. And Emily,
29:00I know you asked about this in the beginning,
29:02so they will be published any day now.
29:05They are final.
29:06They will be up on the web.
29:08It's just going through the final approval
29:10steps for actually getting it on the website.
29:14So the competencies will be released with a
29:18final formal report coming out in the fall.
29:21And then this report will also fall
29:24under the new and emerging areas and
29:26medicine series that the AA MC has,
29:29which also includes competencies
29:30in quality and patient safety.
29:33And we will also be releasing
29:34competencies in diversity,
29:35equity and inclusion.
29:38And so with that,
29:39I think I'll pass it on to Jim who's
29:41going to talk a little bit about
29:43the specifics of these competencies
29:45that we developed.
29:47Thanks so much,
29:48Sarah. And questions, Questions
29:55are we, I think we're waiting until the end.
29:58Okay, very good. All right.
29:59So very quickly, thanks a lot, Sarah,
30:01and again, thank you to Sarah,
30:03Doctor Scott Shipman and AA MC
30:05for their leadership and in
30:07coordinating the development of
30:09these competencies in these domains.
30:11It was a lot of work hurting
30:13lots of cats here.
30:14So to begin competency with the definition,
30:17it's an observable ability of health
30:19professional related to a specific
30:22activity that integrates knowledge,
30:24skills, values and attitudes.
30:26So the purpose of this is what does
30:31a physician progressing towards
30:33attainment of expertise do know and
30:35value in relationship to telehealth.
30:38So these were developed, you know,
30:40for use of course by educators as
30:42a starting point for connecting
30:44collaborative discussions on telehealth.
30:46They can be used to develop strategies
30:48to teach and address local needs as
30:49well and they can also be shared.
30:51The point of these is to be shared
30:54across clinical settings and
30:55clerkships for consistencies as a core.
30:58We maintained as Sarah had mentioned
31:00kind of an approach and scope that
31:02we tried to adhere to.
31:03Again, she alluded to this,
31:04but a tier based system for the learner,
31:07a student resident and attending and
31:09something that would be applicable
31:10to all physicians regardless of
31:12their special team.
31:14We wanted to be able to integrate
31:16and build from existing milestones
31:18and again as previously mentioned
31:20by both Margaret and Sarah that
31:22it'll it's aligned with the six core
31:24competencies of the A/C, G and ME and A/B Ms.
31:27So the next line.
31:30So these are TADA,
31:32the six domains right here and I'll
31:34just go ahead and read them patient
31:36safety and appropriate use of of care,
31:39data collection and assessment
31:41via telehealth.
31:42Communication via telehealth ethical
31:45requirements and legal requirements for
31:48telehealth technology for telehealth
31:50access and equity in telehealth.
31:53The development of these domains
31:55was a very long process.
31:57As Sarah mentioned,
31:57it's coming up on two years now and
31:59involved many, many stakeholders.
32:01And again,
32:02hats off to the AA MC for doing
32:05a tremendous job of listening to
32:06lots of different stakeholders and
32:08opinions when these were developed.
32:10Just FYI,
32:11these were originally we had come
32:13up with 9 domains,
32:15but through this whole process we
32:17we came down to these six here.
32:20The next slide actually shows an
32:23example of one of the the first
32:26domain there and again that's a
32:27patient safety and appropriate
32:29use of telehealth begin.
32:30The point is understanding when
32:32and why to use telehealth as well
32:34as assessing patient readiness,
32:36patient safety.
32:38Practice readiness and end user readiness.
32:42And you can see there for the
32:44entering residency,
32:45entering practice and experience,
32:47faculty position for the student
32:50resident and attending physician.
32:52And again,
32:53I won't go through the details of this.
32:55It was a long process.
32:57And then when we thought we were done,
32:59the AA NC sent it out to I think about 350.
33:03Or so folks to gather opinion,
33:06which was came back to us in a book format
33:09and we went through and they helped us
33:12thoughtfully address as many of these
33:14as as humanly possible and that resulted
33:16in a lot more modifications of these.
33:18So again, we're looking forward to the
33:21final publication of these coming up.
33:23And again thanks so much to Sarah Hampton
33:25and the group at the AA MC and then I
33:27will hand it off to the next speaker.
33:32Right. Thank you very much.
33:35Elizabeth Kupinski here.
33:36It it it'd be great if we could
33:38say that we were the first ones
33:40to do this and that we created
33:42all of these sort of de Novo.
33:44But we really did go through the
33:47literature and look and see what's
33:49out there in order to develop the
33:51competencies and there actually is
33:53a growing literature on this topic.
33:55A lot of it is recommendations
33:57and and possible frameworks
33:59that people are proposing.
34:00The majority of them are
34:03directed towards MD's and DO's,
34:04but there are some out there in the
34:07allied health specialties which
34:08are interesting to look at as well.
34:11There's a few reports on implementation.
34:13There's really not a whole lot
34:15out there on this side of things,
34:17which I I think is very interesting
34:19and that's pretty much, you know,
34:20what we're after here is how do we,
34:22how do we implement all of this,
34:24most of what's out there in
34:26terms of implementation that's
34:27been published at least.
34:29These are usually elective courses or very
34:32short term courses like 1 semester or less.
34:35And again most of these are
34:37directed at medical students,
34:38although there is some out there
34:40on nursing and like I said some
34:41of the other allied health.
34:43Most of them in terms of metrics and
34:46reporting on sort of the effectiveness
34:48of the the competencies and so on.
34:51Most of them are just
34:53class report evaluations,
34:54evaluating the lectures,
34:55the content and so on.
34:57There's some test performance
34:58that's out there in the literature,
35:00but not a lot actually.
35:03There's very little in terms of what
35:06I'm going to call real life carry
35:08on or or follow up longitudinally
35:11looking at longer term assessment
35:13of whether these competencies that
35:16that are are are taught or being
35:19exposed to students are actually
35:22being effectively implemented
35:24in daytoday clinical practice.
35:26What's much more common out there
35:29are are not literally competencies,
35:32but online courses and training for
35:36practitioners that hint at competencies.
35:37And a lot of the objective state
35:39that they're after developing
35:41competent providers and so on,
35:43but they really aren't in the framework
35:46of or created as competencies.
35:49There's a lot of courses that are
35:52offered for continuing education,
35:53continuing medical education,
35:55professional development and so on.
35:57Again,
35:57a lot of these are probably one
36:00hour webinar type courses.
36:02Many of them offer a certificate,
36:04but this is more in line of
36:06a certificate of attendance.
36:07Some claim certification,
36:09but be aware that certification
36:12gets into a whole different.
36:14A ball game and has a lot of implications.
36:17So whether they're actually offering
36:19true certification is a whole other story.
36:22And there's actually a lot of
36:24people getting into this game
36:25currently with the COVID Crisis,
36:27putting courses and webinars
36:29online and so on,
36:31and saying that you've got some sort
36:33of certification and now you are
36:36competent to perform telemedicine Also
36:38somehow with an implication that it
36:40it makes you if you don't do this,
36:43you're not eligible to.
36:44Conduct telehealth, which is simply
36:47wrong or that you know some organization
36:50is requiring this certification in
36:53order to practice or to to bill.
36:56Most of what's out there is really best
36:59practices or how to type pieces of
37:02information and some of these charge,
37:04some of them are for free to some extent.
37:07It's you know caveat M turbier
37:09beware on all of this. Next slide.
37:15These are just some of the things that
37:16are out there in the literature that
37:18I found very useful and that I think
37:21are a good way to approach the topic.
37:24Don Hilty has actually done quite a lot
37:27in this area in telebehavioral health
37:30and I like to look at his publications.
37:33This is just one of them.
37:35It's the need to implement and evaluate
37:38telehealth competency frameworks.
37:40And went through and again in the in
37:42the area of behavioral health and did a
37:44kind of a compare and contrast of what's
37:47out there from different specialties
37:50as well as different countries.
37:52And I think that this type of compare
37:55and contrast across specialties,
37:57across countries,
37:58across specialties is going to be
38:01incredibly useful as we kind of narrow
38:04down on perhaps a universal set of core
38:06competencies that we can all agree on.
38:09Next slide,
38:13this one is also from Hilti.
38:15This is a another article looking at a
38:18competencies for mobile technologies
38:20again in psychiatry and medicine.
38:22And I think it's useful just to look at
38:26these in terms of you know the breadth
38:29of the competencies that really must
38:32be expected and the different groups.
38:35That competencies is going to impact the one
38:38on the the right really talks about apps.
38:40But if you look at all the
38:42different spokes from there,
38:46it really does touch upon a whole
38:49variety of institutions or types of
38:55environments that telehealth is going
38:57to interact with and that you've
38:59got to take into consideration when
39:01you're developing these competencies.
39:03The one on the right there again
39:05is specific to mobile health,
39:07but I I think it kind of crosses
39:09all all the things we're talking
39:11about and really outlines all the
39:13different areas that really must
39:15be considered very much like what
39:18we do with the AA MC next slide.
39:23So when we are going through and looking
39:25at the literature on on what's out there,
39:28you know we developed sort of a good
39:31understanding of what the common themes
39:33are of what's what people are presenting
39:35and then what some of the gaps are.
39:37And some of the the themes that that
39:40are in the literature that that we found
39:42is a good deal of what's out there in
39:45terms of competencies has to do with
39:47being able to use the technology.
39:49And for the most part,
39:51it's a virtual teleconferencing
39:53real time telemedicine.
39:55There's not a lot out there
39:56on store and forward.
39:57There's not a lot out there on mobile health,
40:00dealing with apps and so on.
40:02A lot of the competencies kind of address
40:05it tangentially or or kind of incorporated,
40:08but it's not really a major focus and
40:10and a good deal of what's discussed
40:12and talked about is privacy and
40:14security in terms of technology.
40:16There's increasingly information out
40:18there on history, taking clinical skills,
40:21patient assessment and exam.
40:24It's interesting there.
40:25Right now,
40:26Emory is doing a a webinar
40:29simultaneously with this one on how
40:31to conduct a patient exam virtually,
40:33which I thought was a little ironic.
40:35But a lot of this is getting
40:36out there now again,
40:37especially because of COVID and
40:39people are trying to figure out
40:40how to do a virtual patient exam.
40:43We actually just got a question
40:45yesterday in our in our Southwest TRC.
40:48Is there a minimum number of
40:50things you must do in a physical
40:52exam in order to get reimbursed?
40:54Not exactly competency,
40:55but I mean you know it it
40:58it's very much related.
40:59Communication is a huge topic in
41:01a lot of the competency frameworks
41:04and propositions that are out there,
41:07oral communication,
41:08but people don't think about written
41:10communication and that's out there too.
41:11And this is not just on the part of the
41:14the the patient and talking and so on.
41:16This also has to do with the the,
41:18the care team and communicating with
41:20each other professionalism report,
41:22cultural aspects,
41:23incredibly important and that is a very
41:26much an aspect of all things legal ethics,
41:29consent, consent,
41:31financial documentation.
41:33These are sort of the nuts and bolts
41:35that that are out there and that kind
41:38of goes I think with the technical side.
41:40But they're also talking about learning and
41:43understanding benefits and limitations.
41:44The environment within which telemedicine
41:47is practiced, telehealth is practiced,
41:50the the structure, the workflow and so on.
41:52Management operations,
41:53What do you do in an emergency situation?
41:56And specialties?
41:58Specific recommendations like,
42:00like I said, with the telepsychiatry ones.
42:03There are some gaps however.
42:04As I already noted, non video conferencing,
42:08storm forward, M health,
42:09E health,
42:09remote patient monitoring that the
42:13competencies around this are far less well,
42:15well described and addressed right now.
42:17Metrics is not really described
42:20at all in a lot of the proposals
42:22that are out there and this is
42:24going to be very important if we're
42:26going to implement.
42:27There's got to be some way of
42:28of finding out if we're we're
42:30creating or or creating a process
42:32by which learners do actually learn
42:35or develop the competencies that
42:37we're trying to get out there.
42:40Not a lot on interprofessional either
42:43communication or working together
42:45in the telemedicine environment.
42:47There's also not a lot of uniformity
42:49or consistency in terminology.
42:51Or in terms of level of ranking,
42:54the importance of the various competencies,
42:56a lot of times they're put out there,
42:59but no ranking in terms of what we
43:01should really be concentrating on.
43:03And there's not a lot out there on
43:06differences across training continuum
43:08medical students or other allied health
43:10students versus those who are in
43:12their their residency or in in their,
43:14you know,
43:15kind of post didactic training periods.
43:17Versus those who are out there in
43:19practice or those who have been out in
43:21practice for 20 years and are trying
43:23to learn some of these skills now.
43:24So there there's still a lot
43:26of work that's been done,
43:27but I think there's a lot of
43:28work that we still have to do.
43:30And this, you know,
43:31this whole meeting is going to be
43:34addressing some of these issues and
43:36these gaps, I think. And I hope so.
43:38Next slide.
43:42And with that, I hand it over
43:43to the next speaker. Thank you.
43:50Thank you and hello to all of our attendees.
43:55We wanted to provide examples of
43:57initiating competencies and so one
43:58example we have is at Mayo Clinic.
44:01Within the Mayo Clinic College
44:03of Medicine and Science,
44:04we utilized a college wide approach
44:06to reviewing and implementing
44:08the WMC competencies.
44:10We pulled together an enterprise
44:12wide team of subject matter experts.
44:15The image on the right details are
44:17interdisciplinary team.
44:18We had individuals from the education shield,
44:20so each of our schools within the college,
44:23our simulation center,
44:25our Mayo Clinic education platform,
44:27we had PhD educators.
44:30We also paired that with our practice side
44:33with representation from our physicians,
44:35nurses, nurse practitioners,
44:37our physician assistants,
44:38various Ln health staff and the
44:41Center for Connected Care.
44:44As a collective group,
44:45we reviewed the draft competencies
44:47and provided feedback.
44:51We were able to maximize our curriculum
44:53work by starting with the end in mind
44:56for curriculum design and development,
44:57keeping in mind the knowledge,
44:59skills and attributes we want our
45:00learners to be competent in at the
45:03end of their program and working
45:04with the WMC Draft competencies
45:06really allowed us to be able to
45:08structure this in a manner that would
45:11assist with curriculum development.
45:13Next slide please.
45:20Through our collaborative work,
45:21we were able to curate,
45:23create and vet assessments and
45:26created a curriculum repository.
45:28We designed the repository to lead
45:30with the AA MC competencies as
45:32pictured in the image on the right.
45:34This provided curriculum resources
45:37for our all of our schools.
45:41And really helped our faculty to
45:43review and utilize assets in specific
45:46competency competency domains.
45:48For example,
45:48our nurse practitioner program
45:50provided assets to the repository
45:52and we're also able to utilize
45:55assets from the repository to
45:57fulfill certain competencies.
45:58We had similar experiences with our
46:00clerkships and our medical school as
46:02they were able to share and utilize
46:04assets within the repository really
46:07providing a nice standardized way for.
46:10Our faculty to have foundational
46:14curriculum at the ready already aligned
46:17with the double AMC competencies.
46:20Thank you.
46:33Thanks. Dr. C Miller. I know that Dr.
46:35Koh, I believe you're next here. Yep. Can
46:39you hear me? Yeah, perfect. OK, great.
46:44Thanks everybody for joining
46:46us today and want to thank the.
46:49Conference organizers for inviting me,
46:51I'm coming at this not from
46:53being a telehealth expert,
46:56but really more from a leadership
46:58position in medical education
47:00and GME in our health system.
47:02And obviously, you know,
47:04telehealth was sort of thrust upon us.
47:07I think some of our subspecialists
47:10and even general practitioners have
47:12been using it to a certain extent.
47:14But then COVID hit and in essence everyone.
47:18You know, got on board very quickly.
47:21I think in some ways that
47:23actually was a good thing.
47:25And actually in some ways it also
47:27present presented a challenge.
47:29And what I mean by that is in speaking to our
47:33trained directors and some of our faculty,
47:36some of them felt like, you know,
47:38when we talked about like
47:40learning how to do virtual care,
47:42they sort of felt like, well,
47:43we're kind of doing it, you know, like.
47:45What do you what,
47:46what is it that you're going to teach us?
47:47Because we're actually doing it now
47:49and we've been doing it for some time.
47:51So I do think there is a real importance to,
47:57you know,
47:58even providing rationale for why
48:01formal instruction and where the
48:04gaps are is to is to your train
48:07director and your faculty because
48:08some of them actually feel like.
48:10You know, we sort of know what this is.
48:13And and in fact in some cases where
48:16I've spoken to the train directors about
48:18creating a core curriculum in virtual care,
48:21their interpretation of that was
48:23taking didactics that they were
48:26doing on specially specific topics
48:28and simply making that virtual.
48:31And they weren't even thinking about
48:33sort of like the core competencies that
48:36many of which were presented earlier today.
48:38So I think.
48:40Clear communication to your
48:42program leadership and to the
48:44faculty about what this really is,
48:46is important.
48:47And and related to that,
48:50I think some of the people
48:52that we approached,
48:52you know in terms of saying
48:54like do you want a curriculum,
48:56we actually were surprised when they
48:58felt when we heard that they they
49:00actually felt they didn't need one.
49:01And I think partly is because they
49:03didn't really know what they didn't
49:05know getting back to my first
49:07point about sort of just doing it.
49:09And maybe assuming that they're
49:10doing it well,
49:11but actually not knowing that
49:13that's the case.
49:14The 2nd is that I would try to be very,
49:19you know,
49:20clear and realistic about creating
49:22a road map to implementing this.
49:25There's obviously a lot going on in
49:27our training programs across the continuum.
49:30Lots of changes.
49:32I mean,
49:33even just changing lectures that were
49:36in person into virtual creates work.
49:40And so I think all our training programs
49:43are actually undergoing huge changes.
49:45And this is just one of the things that
49:49they're encountering very specifically
49:51around virtual care competencies.
49:54With that,
49:55I think you have to prioritize
49:56what you want them to focus on
49:59for teaching these competencies.
50:01I think Sarah and others
50:03presented a very nice framework.
50:05That's being developed or really
50:07is nearly developed by the AA MC
50:09and you really have to say OK,
50:10for all of that that we've
50:12seen in these frameworks,
50:14is there something that we want
50:15to focus on in our specialty and
50:17in our program and sometimes even
50:20making cases very specially specific
50:23actually makes the the engagement
50:25at the at the outset much higher.
50:29I'm also struck by just generally whenever
50:32we introduce new competencies into training.
50:35Often there's this sort of sense Okay.
50:39Well, now we, you know,
50:40let's just teach it to the
50:42residents and the fellows.
50:43But a very important part of
50:45this is figuring out like do the
50:48faculty actually understand what
50:49it is they're trying to teach.
50:50So faculty development and really
50:54assessment of faculty competency in
50:57these areas is extremely important
50:59before you put them forward as sort of a.
51:03You know a wonderful instructor
51:05in any of this and then I think
51:09just developing an assessment
51:12strategy for faculty,
51:13residents and fellows
51:14overall is really important.
51:15I think some of the talks later
51:17today will go through that I think
51:21centralized resources like Amy
51:23mentioned are extremely valuable
51:25and I would say there's sort of
51:28just cases and we're we're as well.
51:30Building a digital case library which
51:33we hopefully will build up quickly
51:35and share with our health system.
51:37So we don't have every program
51:39trying to to do this.
51:41And I think we can create and are
51:43are aiming to create some core
51:45cases that can be really shared
51:48across specialties and the other
51:50is just centralized resources
51:51for faculty development.
51:53So we have program director.
51:55Workshop series.
51:56I know people have faculty
51:58development series within
51:59departments and with institutions,
52:01and as much as we can work together
52:03on this within the institution,
52:05I think we'll gain a lot of
52:07efficiencies and just learn how
52:09to do things better more quickly.
52:11So thank you,
52:12Emily.
52:17Great. Thank you, Doctor Koh,
52:19and thank you for the panelists.
52:22Thank you everybody for being
52:23on time with your present team.
52:24So now we have time for
52:26for discussion and for Q&amp;A.
52:27So for our panelists here,
52:30I am going to pull up the one
52:32question that came from Q&amp;A and
52:33I think I'm going to direct it
52:35first over to Doctor Kerpinski and
52:36because it came up during your time,
52:38so that's why you got the
52:39hot potato on this one.
52:40But I think it's a great question and
52:42I think if I can distill it down.
52:43This is from Kurt Kennell.
52:45The question about, you know,
52:46is there a way for some of this
52:49telehealth to actually help?
52:51Competencies that are required for
52:53healthcare training just in general.
52:56Maybe not specific to telehealth competency,
52:58but could these be actually used
53:00for other competencies that we've
53:02struggled as a health system or as
53:04an assessment system to capture?
53:06Maybe like the obstruct having
53:08to do a simulated patient exam
53:10for the clinical skills,
53:11Is there a way to do telehealth
53:13and do an actual live stream,
53:14virtual or live stream exam for assessment?
53:18I think
53:19absolutely, absolutely. I mean,
53:20you know, the The thing is, you know,
53:24you struggle between wanting to create a
53:27set of competencies you need to telehealth.
53:30Yet we're saying that the future
53:32is telehealth and it's going
53:33to be just part of practice.
53:35So absolutely, I think that almost
53:38everything that we're creating is
53:40going to be applicable to, you know,
53:42quote, UN quote regular practice.
53:45And and telehealth,
53:46because at some point it's going
53:48to be seamless and you're really
53:49not going to have that much of A
53:52differentiation between which is which
53:54you know in the past it was I'm going
53:55to go to my telehealth clinic now I
53:57think that's going to be changing
53:59enough that these competencies,
54:01I agree 100% that it's going
54:03to be across both.
54:06And can I sort of take that the
54:08what you said a little bit on a
54:10different tangent with another
54:11question that I think is one that's
54:13been debated a lot before COVID and
54:15then I think maybe a little bit less.
54:16But you know should there, I mean we're
54:20developing competencies for telehealth.
54:22Should there be a subset of clinicians
54:24that are doing telehealth or should this
54:27be required for everybody and hearing
54:28what you're saying because it's almost
54:30going to be ubiquitous that really.
54:31Everybody should probably having training
54:35on and meet competencies on telehealth.
54:38So I'm wondering your thoughts
54:39on that too in in the long
54:41run. Yes. I mean, right now, you know,
54:43I can, I can see someone who's,
54:45you know, you know,
54:46I'm going to retire in three to five years.
54:49I don't want to get involved
54:50in this telehealth stuff.
54:51I don't want to, you know.
54:52So I think at some point there
54:54there's going to be a crossover,
54:55but I think everybody should, yes.
54:57You know, at some point it's hard to imagine.
55:00That you're going to have somebody no
55:02matter what the clinical specialty
55:03that they're not going to be doing
55:05some sort of telehealth in the future.
55:07You know people,
55:08people refer to you know like Tele,
55:10Tele, radiology,
55:10radiology is my home department.
55:12They're going to say come on,
55:13what are you going to be doing?
55:14You're sending images,
55:15you never see the patient.
55:16But during COVID and increasingly
55:18we are communicating with patients,
55:21we've got you know,
55:22patients coming in for a biopsy.
55:24So before that our radiologists are
55:27communicating with the patients virtually.
55:29They're doing followup visits with
55:31the patients interventional radiology.
55:33So even those specialties
55:34where you would say come on,
55:36they're never going to be you
55:38know doing what we call telehealth
55:40communicating with patients they are.
55:42And so even those I I think
55:43everybody at some point will be,
55:46yeah, Emily, it's Lee.
55:47And I also want to encourage
55:49any of the other panelists,
55:50you know just unmute and you don't
55:52have to be called on by Emily
55:53to to contribute. I think that.
55:56I would take your question
55:57just in a slightly different
55:57direction, which is, well, look,
55:59we have people who specialize
56:00in hospital medicine, right?
56:01They still can see patients in a clinic,
56:03but they they focus their
56:04efforts on inpatient.
56:05We have other doctors who almost
56:07exclusively focus on outpatient.
56:09And I think the question
56:10to me the way you've asked it is,
56:12will we have a group of providers who
56:14focus most of their efforts on telehealth?
56:17Everyone needs to be competent in it,
56:18but not everyone's doing it every day.
56:20Will there be, should there be?
56:23A cadre of people who do a lot of telehealth.
56:25And if that's the case,
56:26should the level of competency for
56:30them be expected to be different or the
56:32same as the more casual telehealth,
56:34you know, participant.
56:35And I don't know what the panelists
56:38think about that, that challenge.
56:44I think in some places there
56:46already are people who who are,
56:47you know, we've heard we have a
56:49colleagues at the Barrows Neurological
56:52Institute in Arizona and you know,
56:54the initial plan was okay,
56:56everybody's going to do telehealth
56:57and you're going to be assigned,
56:58you know, Monday afternoon this is this.
57:00And they found that some people
57:01like I don't want to do this,
57:03I'm no good at it and it
57:05doesn't matter about competency.
57:06Some people just simply are not
57:08going to be good at doing this.
57:10And so they eventually developed a
57:12model where those who were interested,
57:14who wanted to do it felt comfortable.
57:16They became the go to people for the
57:19telehealth, where those who were like,
57:20this isn't my bag,
57:22they were the in person people.
57:24And then you had some who would do both.
57:26So I think it's it, you know,
57:28you can't force, you know,
57:30one way of practicing on somebody
57:32if they're if they're not going
57:33to be good at it, if,
57:34if virtual is just too hard for someone.
57:37And it can be some people just freeze like
57:39a deer in the headlights and it's like,
57:41you know,
57:42they don't know what to do
57:43while others can get on.
57:45I'd love to hear others thoughts.
57:46I'm going to push back a little bit.
57:48And you know, in my role here
57:49in the neurology department,
57:51I'm not sure I'm comfortable with the faculty
57:53member saying I don't like telehealth.
57:54I'm patients can come see me in
57:56person or I'm not interested in
57:58following them like followups.
57:59If they don't want to come in person,
58:01I'm not going to see them.
58:02They can see a colleague of mine.
58:04I think it's sort of like saying I
58:06don't really like the cardiac exam
58:08so I'll do the rest of the exam but
58:09someone else can listen to the heart for me.
58:11I think we I'm being a little bit
58:14provocative but but I do think that
58:15we need to be able to ensure that
58:17patients can access the care they
58:19need and have the continuity that
58:22they expect in times of duress.
58:24It doesn't mean that you know in the
58:27post pandemic era when things get get
58:29more back to an assumption around
58:31the ability to appear in person but.
58:33I would say if you're an established
58:35patient of Doctor Schwam and you
58:37can't travel to Massachusetts right
58:39now because of COVID,
58:40you should be able to see Doctor
58:42Schwam over the video.
58:44I'd like every one of our providers
58:46to be capable.
58:47Whether they are,
58:48whether they demonstrate excellence
58:50at virtual care, I don't know.
58:52So it's an interesting question, right?
58:53Is competency the same as excellence?
58:56And are you look everyone,
58:57not everyone's good at CPR,
58:59but they all should know how to do it.
59:01Some of us do it every day, some of us do it.
59:03Only you know at the supermarket because
59:05our regular job doesn't demand it
59:07but we expect a minimum level of competency.
59:09I wonder what what others think
59:12this is Jim Marks.
59:13I just there's already variability
59:15between health systems on whether or
59:17not it's you somebody is privileged
59:19to be able to do telehealth.
59:21Some centers, we don't have any of
59:23standards but other health systems
59:25requires A privileging as if you're
59:27going to do a lumbar puncture or a
59:28central line so that you're privileged
59:30to be able to do telehealth.
59:31And it's a good question.
59:32I mean, there's pros and cons to both of it.
59:34And there's been discussions about
59:35even starting a board of telemedicine.
59:38And that's
59:41I would draw caution to that now,
59:42but ultimately, I don't know
59:43where it's going to end up,
59:44but there's a lot of variability
59:45and I think that the AA,
59:47MC efforts at least set up
59:49competencies and standards.
59:50Is it a good place to start,
59:54Lee? And this is John.
59:54I I think part of your question
59:57depends on how the specialties
59:59evolve and is it clear?
01:00:02That in certain specialties like it's
01:00:05mostly in the hospital and you know,
01:00:08virtual care is is you know a
01:00:11vast minority of of the episodes
01:00:14of care or the interactions.
01:00:17I would say even in that case
01:00:20there is some level of familiarity
01:00:22a person has to have with it,
01:00:24like sort of the role I could imagine
01:00:27care models being built where.
01:00:29Certain providers don't have to
01:00:32do as much telehealth or virtual
01:00:34care but as we as we know that's
01:00:37even just from some of the comments
01:00:39just now that some of that's
01:00:41health system dependent but but
01:00:43everyone needs to know the role of
01:00:45it and the proper uses of it too.
01:00:47So
01:00:50interest yeah, I I agree it's a thorny topic.
01:00:53I would share James's concern about a board.
01:00:57You know, in in telemedicine,
01:00:59I feel like there are regulatory and
01:01:01compliance reasons why we want to make
01:01:04sure providers are properly licensed,
01:01:05properly privileged property credentialed.
01:01:07And I would argue there are valid reasons
01:01:10for telemedicine only privileging,
01:01:12like if I'm practicing
01:01:14telemedicine only in Montana,
01:01:16it should not be subject to the need
01:01:18to have my TB test and my flu shot.
01:01:20And you know, all those things
01:01:22because I'm never physically present,
01:01:23I don't have to know how to use the,
01:01:25you know, the fire.
01:01:27Extinguisher that happens to be you know
01:01:29present at the University of Montana.
01:01:31But but I think we have to be very
01:01:33cautious about this idea that we should
01:01:36carve out some kind of specialty
01:01:38around telemedicine because we,
01:01:40we practice by medical specialty
01:01:42or problem based specialty.
01:01:43I I don't want someone who's a
01:01:46virtualist to do virtual orthopedics,
01:01:48virtual neurosurgery and virtual psychiatry,
01:01:50right.
01:01:50I mean how would someone be proficient
01:01:52in that that's that's a good GPI guess,
01:01:54but we don't.
01:01:55Meet a board for telemedicine
01:01:57enabled general practice.
01:01:58So I think that it this is really more
01:02:01about procedure specific competency,
01:02:03right?
01:02:03Telemedicine in some ways is a
01:02:05procedure and it's also just
01:02:07a delivery mode for your care.
01:02:09The technical elements of the
01:02:10procedure are how do I turn it on,
01:02:12how do I make sure I'm using a system
01:02:13of appropriate quality, you know,
01:02:15what do I do if things go wrong?
01:02:17That's sort of like how do I
01:02:18operate an endoscope.
01:02:19It doesn't mean that I'm
01:02:20privileged to do endoscopy,
01:02:21but I need to know.
01:02:22The technical proficiencies of how
01:02:24to plug it in, how to turn it on.
01:02:26So I I feel like there's a there's an
01:02:29interesting spin on the word even competency,
01:02:31right?
01:02:31Is this a competency as it relates
01:02:34to medical practice or is this a a a
01:02:37procedural or technical competency?
01:02:38We assume, for example,
01:02:40that people are competent to
01:02:41navigate to the hospital, right?
01:02:43Like your fellowship or
01:02:44your residency program.
01:02:45Never.
01:02:45Emphasize the core competency of
01:02:47getting on the bus or getting in
01:02:49the car and going to the parking
01:02:50lot and walking into the hospital.
01:02:52We just assumed you could get there
01:02:53and then the learning begins.
01:02:55When you arrive telemedicine you
01:02:57have to figure out how to get there.
01:02:58You have to get to the encounter
01:03:00with these tools.
01:03:01And so there is some layer
01:03:03of competency there.
01:03:04There's no really good analogy
01:03:05I think for in person care
01:03:07to to to that component
01:03:10Lee. I would say you know This
01:03:12is why it's important to sort
01:03:14of take the competencies being.
01:03:16Developed and really, you know,
01:03:20do the next level of work to to see
01:03:22how they apply very specifically to
01:03:25specific specialties because I think
01:03:26that's where it'll become very clear
01:03:28what we need to teach and assess.
01:03:30The other is that I agree like having
01:03:33this become a separate, you know, yeah.
01:03:39Discipline, you know that I think there's.
01:03:42That would be challenging on many levels,
01:03:45I think. It doesn't mean, though,
01:03:46that we don't need more people
01:03:48to do scholarly activity and have
01:03:50research fellowships.
01:03:51People develop academic interests in this,
01:03:54but to develop sort of a separate,
01:03:56make it a separate subspecialty.
01:03:58I agree.
01:03:59I think there's some,
01:04:02I'd have some concerns about that.
01:04:05And I'm going to jump in here too,
01:04:06because I think Kirk Kendall had
01:04:08another comment come up in the
01:04:10Q&amp;A box on this same thread.
01:04:12And I think it's, I think it behooves
01:04:15us as educators to figure out.
01:04:18What are these companies going to be back to,
01:04:19Lee, what you were saying of,
01:04:21you know what, What are they?
01:04:22Is it a procedure of the skill?
01:04:23Should everybody be doing this or not?
01:04:26Because depending on how we
01:04:28present this to our trainees,
01:04:29they may decide themselves that as
01:04:31Kurt was saying in there, you know,
01:04:32I'm going to be a hospitalist.
01:04:33I'm not going to be using
01:04:34this and what I'm doing.
01:04:35And then they come down 1015 years later,
01:04:37change careers and then are they now deemed
01:04:40competent because they actually did it.
01:04:42Did their training in 2021.
01:04:46And so I think it does depend on how
01:04:49we as educators decide on what these
01:04:52competencies are and how what the
01:04:55breadth of the trainees that need
01:04:57to accomplish these competencies.
01:04:59And I agree with Doctor Kinsky
01:05:02and with others that.
01:05:04It's going to be ubiquitous.
01:05:05It's just as I see John Hollander is
01:05:07one of the participants on this too.
01:05:08As he said before, you know,
01:05:11telehealth is just a tool,
01:05:12just like a stethoscope.
01:05:13And so we we should know how to use it.
01:05:15And yes,
01:05:16there might be other gradations
01:05:18of people that are doing some very
01:05:21specialized pieces with telehealth,
01:05:23but I do believe everybody should.
01:05:25And I think that the education
01:05:27community should come together
01:05:28on deciding how we're going to
01:05:31approach these conferences.
01:05:32Like,
01:05:32yeah, I mean, you know,
01:05:33if you think about it, the.
01:05:34Maybe the better metaphor is the
01:05:36electronic health record, right?
01:05:37We went from paper records
01:05:38to electronic health records,
01:05:40and some physicians did retire rather
01:05:41than adopt an electronic health record.
01:05:43They were generally,
01:05:44you know it toward the end of their careers.
01:05:46You can't say, well, I'm a hospitalist,
01:05:48I don't have to interact with the EHR.
01:05:50You have to learn how to interact.
01:05:52And I think, you know,
01:05:53crystal ball, I don't know.
01:05:55But my sense is that the work that we did
01:05:58on the inpatient side during the pandemic.
01:06:01Showed us the value of having
01:06:03interactive video capability in
01:06:05hospital rooms in a way that is likely
01:06:08going to find value going forward,
01:06:11particularly as we think about
01:06:12ways to be more efficient,
01:06:13to have specialists, staff,
01:06:15multiple campuses where there may
01:06:17be expertise in short supply.
01:06:19And so I think even if you're a hospitalist,
01:06:22right, maybe today,
01:06:23maybe three months ago or eight months ago,
01:06:26being a hospitalist meant you were
01:06:27never going to touch this stuff.
01:06:29I think the hospital room of the
01:06:31future is evolving very fast and I
01:06:32don't think hospitalists are going
01:06:34to be immune from from this either
01:06:35in the same way that hospitalists
01:06:37are using their smartphones, right.
01:06:38They're texting, they're looking things up,
01:06:40they're accessing the EHR.
01:06:41So I think that we have to,
01:06:44I like a comment that Susan Edwin
01:06:47Levitan made in the in the Inside
01:06:50the Panelists box,
01:06:51which is we need to think about it
01:06:53differently. Why are people uncomfortable?
01:06:55What is it about the practice
01:06:57that's making them uncomfortable?
01:06:59And how can we coach or train
01:07:01them to overcome that limitation?
01:07:04So if you have trouble communicating in
01:07:06person and communicating over videos,
01:07:08even harder.
01:07:08But what can we do to help support
01:07:10your communication skills?
01:07:11Or if it's a digital literacy
01:07:13issue you just don't understand
01:07:15and you have cognitive overload,
01:07:16how can we make the technology better?
01:07:18Or how can we provide you with
01:07:20bedside support so that you can
01:07:22then overcome those barriers?
01:07:23But I think that we.
01:07:25We have to recognize that we can't
01:07:28rely on people walking through the door
01:07:30as the default mode for seeking care
01:07:32in the future because increasingly,
01:07:35look,
01:07:35if you live in Northern California,
01:07:37you're not getting to the hospital
01:07:38very easily right now either because of
01:07:40the fires and all the stuff that's going on.
01:07:42So this is almost like the, you know,
01:07:45the the Army National Guard,
01:07:46right.
01:07:47This capability of delivering care
01:07:50over telemedicine is our backup.
01:07:53For when the ordinary expectations
01:07:55of show up in person are
01:07:57barricaded or impeded in some way.
01:08:00So I think it really is a
01:08:03national competency issue.
01:08:04We need enough of the physician,
01:08:06nurse and provider workforce
01:08:09digitally enabled so that we can
01:08:11meet the needs in in situations of,
01:08:13you know,
01:08:14natural disasters or mass casualty
01:08:16events or you name it,
01:08:18we now understand we can move
01:08:20expertise around efficiently.
01:08:21I think it's a kind of a in some
01:08:23ways it's a national priority
01:08:25that we need to be able to to
01:08:27rapidly upscale this competency.
01:08:30But I think the whole discussion kind of
01:08:32and and some of the comments in the in
01:08:35the Q&amp;A especially the one on a I it,
01:08:38it kind of reiterates or solidifies
01:08:39what I was saying about that.
01:08:41It's got to be addressed across the
01:08:43continuum that we've got to have metrics.
01:08:46And that we've got to figure out how
01:08:47do we periodically assess this because
01:08:49new technologies are coming out.
01:08:51AI comes out if I do,
01:08:53if I did my competency in 2020 and all
01:08:55of a sudden two years down the road
01:08:58there's this AI enabled tool for clinical
01:09:01decision support that's integrated in,
01:09:03I have to know about that now.
01:09:05So it's got
01:09:06the dreaded specter of
01:09:08maintenance of confidence. Yeah.
01:09:10Yeah, that thing. Yeah.
01:09:14Excellent. Yeah, that's right.
01:09:16You know it's not.
01:09:17But the same is true of,
01:09:19you know when what you learned
01:09:20about antibiotics, right.
01:09:22You can't just do amgent and flagyl
01:09:23and you know shock, shock, shock,
01:09:25epilito shock anymore, right?
01:09:26You got to you got to stay
01:09:28current with what the practice is,
01:09:31is you know giving you I,
01:09:33I see John smiling.
01:09:34I'm not sure that ampicillin
01:09:36existed that you know.
01:09:37When John was born.
01:09:39But it it is a challenge right?
01:09:41And that's why we often end up
01:09:43with sub sub specialization,
01:09:44because the amount of knowledge
01:09:46necessary to master across such
01:09:48a wide array of medicine is
01:09:50becoming increasingly unsustainable
01:09:52for for the for the sort of
01:09:55General practitioner Emily,
01:09:56we have about 5 minutes left.
01:09:58I don't know if you have any
01:09:59other questions you wanted to
01:10:00pose to the panelists or or
01:10:02maybe summarize the session.
01:10:03Oh, I was going to, if that's OK,
01:10:05if I had another minute or two for a
01:10:07couple questions that I know we sort of
01:10:09went on to this tangent about sort of
01:10:10the competencies and where we should go.
01:10:12But if we do have some competencies,
01:10:14can we need to start somewhere and
01:10:15we have some that are out there
01:10:17from the double AMC and that.
01:10:18I'm just wondering from from Sarah,
01:10:20your perspective,
01:10:21what would be sort of the next
01:10:22steps that like people have worked
01:10:24on competencies like how do,
01:10:25how are you planning to get these out there?
01:10:30The WMC is planning to do a robust
01:10:33dissemination plan, but I do think
01:10:34the next step is to understand how
01:10:37health systems are implementing these.
01:10:39So I know colleagues of mine and medical
01:10:42education are planning to start collecting
01:10:45some examples that are already out there.
01:10:47And we want to host some of the
01:10:49material for people to have access to
01:10:52so that we can support implementation,
01:10:54especially in terms of assessing these.
01:10:56In developing curricula based
01:10:58on the WMC competencies,
01:11:02I also and some of
01:11:03that will be included in the dissemination.
01:11:05Yeah, I was just going to say,
01:11:06Emily, I think a topic we're going
01:11:08to hit on very heavily in Session
01:11:105 and it's going to come up I think
01:11:12repeatedly throughout the subsequent
01:11:14panels before we get there is the
01:11:17patient experience and particularly
01:11:19for patients who suffer from social
01:11:22determinants of health or health inequity.
01:11:25We have to really understand how
01:11:28these tools differentially impact
01:11:30those individuals and either create
01:11:32or eradicate barriers to access.
01:11:34But that has to always that equity
01:11:36lens has to always be there or
01:11:38we can think we're knocking it
01:11:39out of the park with 80% of the
01:11:41patients while 20% are drowning.
01:11:43So I think that that issue of
01:11:46competencies is also vitally connected
01:11:48to who are the patients you serve.
01:11:51And are you serving the same
01:11:53patients when you turn on the camera
01:11:56and the digital experience as you
01:11:58are in the inperson experience?
01:12:00And some patients don't have
01:12:02health inequities,
01:12:03but they have conditions that do
01:12:05not lend themselves to a safe
01:12:07practice of telehealth,
01:12:08like a person who's a victim
01:12:11of domestic abuse and is being
01:12:12expected to have a visit from
01:12:14their home where the abuser lives
01:12:16or somebody who doesn't have the.
01:12:20You know,
01:12:20Wi-Fi at home and is being forced
01:12:23to make a very private encounter in
01:12:25a more public or unfriendly space.
01:12:28So I I just think we have to think
01:12:31about there's another layer of
01:12:33competency here which doesn't usually
01:12:34come into play and in person care
01:12:36because that person's in your office,
01:12:38they've already made it to the encounter
01:12:40and you have control of the environment.
01:12:42We have to think about how an an extra,
01:12:46a seventh sense that the
01:12:48provider has to develop.
01:12:49Of whether this is the right
01:12:50environment of care,
01:12:54Lee, I'd just make one comment
01:12:56about the competencies too.
01:12:57And I I know in some frameworks and
01:12:59good frameworks, we're thinking
01:13:01about what students would learn,
01:13:03what residents and fellows should learn,
01:13:05what faculty should learn.
01:13:07And in some ways, at this moment,
01:13:09when a lot of people are just
01:13:11getting on board, you know,
01:13:13simultaneously, that distinction
01:13:14may not actually be that important.
01:13:17I'm not saying it isn't.
01:13:19You know, at all.
01:13:20But I'm saying that where people are
01:13:23starting out may be actually very similar.
01:13:26And to think about how to, you know,
01:13:29efficiencies around teaching the stuff.
01:13:32Because I know when we've
01:13:33had these discussions,
01:13:34we're talking about doing,
01:13:36you know, sessions for trainees,
01:13:38but also realizing that the
01:13:40faculty need it just as much too.
01:13:42So
01:13:42yeah, you know, it says an interesting
01:13:45sort of reverse diffusion of knowledge.
01:13:47Elizabeth alluded to this.
01:13:49You know, we introduced a new procedure,
01:13:51ultrasound, in the emergency room or the ICU.
01:13:54The trainees get proficient almost
01:13:56immediately because one instructor in the
01:13:59emergency room teaches all the trainees.
01:14:02Trainees far outstrip the faculty
01:14:04and competence in that domain.
01:14:06How do you get the faculty
01:14:07then to then become competent?
01:14:09And sometimes, quite frankly,
01:14:10it's by watching the trainee do it
01:14:13a few times and then they're ready
01:14:14to tell other people how to do it.
01:14:16But. We need, we need a fast on
01:14:18ramp to the highway to make sure
01:14:21our faculty are competent,
01:14:22not just to do it, but to teach it.
01:14:25Right. That's the second,
01:14:25which is a different level, right?
01:14:27Yeah, definitely teaching and assessment.
01:14:31Emily, you get to close this out.
01:14:34You're muted. You're muted.
01:14:35Your best comments were lost.
01:14:38That was so profound.
01:14:39You didn't catch that. Oh, man.
01:14:41So, so no, I thought you were
01:14:43going to close out Lee, but no,
01:14:44I I really appreciate it.
01:14:46I'm watching the time.
01:14:47There's not much time left here.
01:14:48But I think this is definitely
01:14:50in the discussion too.
01:14:51Sparked a lot of discussion and I think
01:14:53there's so many questions that hopefully,
01:14:56I think I'm going to put the hot
01:14:57potato on all the other panels today.
01:14:59But there are a lot of questions and
01:15:01hopefully some of the other panels
01:15:03can start attacking some of these.
01:15:04And I I do feel there's gonna be
01:15:06some questions at the end of this
01:15:07that we as a health training system,
01:15:09health education training system needs
01:15:11to need to decide on and probably needed
01:15:13to decide on maybe two years ago,
01:15:15but here we are now.
01:15:15So thank you for the panelists
01:15:17for all of your perspectives.
01:15:19Thank you Lee for organizing this.
01:15:20It was great to have this and
01:15:22I'm really looking forward to
01:15:23the rest of panels today.