Tanir Moreno, MS1, John Rafael, BA1, Brianna Marschke, BS1, and Stephanie Bui, BS1
1 Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430, USA
Correspondence concerning this article and requests for reprints should be addressed to Tanir Moreno (Tanir.Moreno@ttuhsc.edu)
Abstract
Nationwide cancellations of clerkships for third- and fourth-year medical students due to COVID-19 spurred the quick implementation of alternative learning methods. Although the preclinical curriculum is less affected, widespread interruptions of student volunteerism involving patient care such as student-run free clinics contribute to the effective halt of clinical experience for medical students in all stages of their education. Due to this disruption, our institution implemented telemedicine as an alternative method of continuing clinical experience both in clerkship settings and at our free clinic. As four medical students of various years, and therefore varying experiences in using telemedicine, we hope to reflect on its effectiveness and implications for the future of medical education.
Background
Clinical experience as a medical student has consisted of practicing skills such as taking a detailed history and performing a thorough physical exam since the advent of modern medical education. However, COVID-19 abruptly altered today’s landscape of medical education due to the widespread cancellations of clerkships and extracurricular activities involving patient care. Medical schools across the nation have scrambled to create curriculum changes quickly to allow students to continue their education in some form, including the unique implementation of telemedicine.
Telemedicine is an established, evidence-based practice that has been in use for decades and involves “two-way, real time interactive communication between the patient and the physician or practitioner at [a] distance site” [1]. The World Health Organization (WHO) recommended the use of telemedicine to “complement, rather than replace the delivery of health services” and recognized it as a viable option for increasing access to health workers in rural areas [3]. At Texas Tech University Health Sciences Center (TTUHSC) School of Medicine in Lubbock, Texas, an institution that serves 108 counties and covers an area of 131,000 square miles [4], telehealth has long been a necessity to increase access to healthcare for the vast West Texas area. Thus, TTUHSC was one of the early pioneers of telehealth leading to its development into a robust department since 1989.
Our institution’s preexisting infrastructure with telehealth enabled a relatively seamless progression to its utilization in student clinical education in response to COVID-19. As four medical students in various stages of our education, we recognize the widespread applications of telemedicine as a response to mitigating the lack of clinical experience and perhaps even as a learning tool that will revolutionize medical education for years to come.
Telemedicine in Third-Year Clerkships
As a third-year medical student, I was in my psychiatry clerkship when COVID-19 hit. Clerkship directors struggled to find appropriate alternatives for me and my classmates to continue our final rotations without the option of in-person activities. I fully expected my level of clinical involvement in my psychiatry rotation to significantly decrease as a result. However, in a matter of weeks our psychiatry department created and implemented a telemedicine curriculum combining inpatient and outpatient experiences.
I was initially concerned that telemedicine as a medium of patient care would be impersonal, a concern shared by many new users of telehealth. In fact, “resistance to change” is the second largest barrier to telemedicine behind the technological challenge [5]. However, I found that the patient visits were not at all compromised during my clerkship. In fact, virtual interactions with patients became even more meaningful, as the limited human interaction both students and patients were experieincing increased the value of each visit beyond its clinical context.
It is also an important consideration as to whether telemedicine is generalizable to other rotations beyond psychiatry; this clerkship generally involves limited “hands-on” interaction compared to other rotations, such as surgery, which are comprised of more technical skills. Telemedicine’s compatibility with these rotations is not proven, but I consider it the best option we currently have during clinical cancellations. At the very least, telemedicine allows for observation of physicians performing physical exam techniques and allows students to practice interviewing patients, which would otherwise be unavailable at this time.
Although I wish that the circumstances were different, I am thankful to have continued my clinical experience through telemedicine in the midst of COVID-19 and hope to see its broader implementation in medical schools around the nation. Telemedicine’s drastic increase out of necessity during a global public health emergency suggests that the future holds increased roles for digital healthcare solutions and more widespread acceptance of their usage. Hence, it will likely also have a lasting role in medical education in the coming years, as clerkships tend to mirror the current trends and techniques utilized in practice.
Telemedicine in Student-Run Free Clinics
As first-year medical students at TTUHSC serving on The Free Clinic leadership team, we struggled to facilitate patient care for the uninsured and indigent population of Lubbock when COVID-19 restrictions began. In-person patient visits and student participation were curtailed, meaning that patients were losing their only source of healthcare and students were losing a valuable clinical learning opportunity. Student-run free clinics across the nation faced the same problem and models of telemedicine were created and shared with promising results. Understanding that effective care was still possible even in the face of the pandemic, our leadership team worked quickly to finalize the protocol and smooth out logistics for the implementation of telemedicine at our clinic. Within a couple of weeks, telemedicine at the TTUHSC Free Clinic came to fruition.
The benefits of this new telemedicine protocol are far-reaching. Not only are we able to allow students of all years to continue gaining experience seeing patients independently, but we are also able to provide direct care to patients in need. Furthermore, the future applications of this method of healthcare are particularly exciting. We have discussed its continued usage when clinic operations return to normal as an additional tool to allow medical students and patients unable to physically appear in clinic to still participate in the provision and receipt of care, respectively. Additionally, telemedicine can expand our services, particularly in mental health, to patients in the region and serve as an educational tool for students interested in using telemedicine in their respective careers.
Although we feel that the benefits of offering telemedicine far outweigh any costs, some challenges continue to need further attention. Not all established patients at our free clinic have access to or knowledge of how to seek care through telehealth. Some patients also report hesitancy in adopting telemedicine, instead insisting on waiting for physical visits or more established models of communication such as phone calls. Even with our clinic’s emphasis on bridging the technological gap (e.g. providing tablets for telehealth visits, sending clear instructions to access telehealth visits, etc.), it is difficult to control for variables such as a stable internet connection or a private space in which to conduct the appointment. Given the correlation of low health literacy with a lower likelihood of using newer forms of health technology [6], increasing both health and technological literacy of patients drives our refinement of telemedicine use for the benefit of our patients.
The COVID-19 pandemic may have altered our respective clinical educations, but it has also reaffirmed our desire to find innovative ways to serve the community. Both our students who make up the backbone of our operations and the patients we serve constantly remind us that, even in the face of adversity, a collective of mission-driven stakeholders can still work together to serve others.
Final Thoughts
Virtual options such as telemedicine are already rising in popularity as modalities to continue medical education. The United States Medical Licensing Examination (USMLE) has released a statement that accelerated plans are being made for a “testing solution that employs a telehealth model, where examinees and standardized patients would interact online, via a web browser” for the Step 2 Clinical Skills (CS) exam [7]. Additionally, “virtual sub-internships” are being created in multiple specialties for fourth-year students unable to participate in typical away rotations. Overall, it seems that telemedicine drastically increased its presence within the medical school curriculum in the span of a few short months.
The WHO outlined potential limitations to telemedicine’s widespread implementation, including infrastructure requirements, costs, and training requirements of health workers to use these technologies [3]. From our experience, these limitations are not significant barriers to telemedicine in medical education evidenced by our institution’s successful implementation in our student-run free clinic and psychiatry clerkship within one to two months. Despite minor issues with internet connectivity, both medical students and patients were able to utilize telemedicine effectively with limited training.
Ultimately, we believe that telemedicine has the same applications for medical school curricula as for patient care described by the WHO; it is not a substitute for clinical experience, but a reasonable and effective alternative when options are limited. Caution should be exercised in implementing telemedicine where it is not regularly used, such as an assessment tool for student clinical skills for Step 2 CS or individual schools’ Objective Structured Clinical Exams. Further research and data are needed to understand the full scope of telemedicine’s curricular applications, but it is undoubtedly a promising new practice for the future of medical education.
References
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Texas Tech University Health Sciences Center Factbook: 26th Edition. History. Texas Tech University Health Science Center. December 2019. (Accessed May 18th, 2020, at https://www.ttuhsc.edu/about/factbook.aspx).
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Announcements. United States Medical Licensing Examination website. Updated April 3, 2020. (Accessed May 18, 2020, at https://www.usmle.org/announcements/default.aspx?ContentId=266).