The philosophy of getting a medical student trained and prepared to care for patients independently is often simplified into the adage of, “see one, do one, teach one.”
The idea is both simple and effective. There is an observation period for the student, while they watch an experienced physician mentor deliver care. Then the observed skill is applied by the student, again under the close observation and support of an experienced physician. The cycle then ends as the student matures through their training cycle, mastering the needed skills and then teaching future generations of medical students, interns, residents and fellows. All along the way, refinements and enhancements, ideally based on best practices, are woven into this age-old tradition. The end result is a new generation of physicians ready to tackle the challenges of a complex medical practice. However, what happens when an entirely new practice model is introduced, such as telemedicine?
Although the term telemedicine was first introduced in the medical literature in 1974, its rate of adoption is still extraordinarily low. Estimates suggest that there were 800,000 online consults in the United States in 2015. In that same time period, there were over a billion visits to a physician. With over 950,000 actively practicing physicians in 2015, the United States did not even average one telemedicine visit per physician. How can this be, considering video-conferencing technology is far more advanced than it has ever been before, high-tech computers, phones and tablets are more affordable, patients are being exposed to video technologies in numerous other industries and broadband, satellite and cellular services cover almost the entire continental United States?
There are numerous shortfalls that have been cited for the delay in the broader adoption of telemedicine. The usual suspects include; slow payer adoption causing limitations in reimbursement, costs of technology, practice integration issues, cumbersome interstate licensing rules, restrictions in malpractice coverage and many more. These are legitimate issues and despite significant progress being made to address all of these concerns, the adoption rates for telemedicine are still low. Perhaps a more powerful reason for this lack of adoption, is a deficiency in physician training within the field of telemedicine.
In a 2014 American Academy of Family Physicians survey of 1,557 actively practicing respondents, only 15% of those surveyed had provided a telehealth service in the previous 12 months. This was in contrast to 78% of respondents from the same survey saying telemedicine improved access to care and 68% noted telemedicine improved continuity of care. The number one barrier to telemedicine listed was a lack of training in the field. This really shouldn’t be a surprise considering there is only one medical school in the United States that teaches 1 st and 2 nd year medical students the academic and clinical components of an integrated telemedicine practice.
The New York Institute of Technology College of Osteopathic Medicine at Arkansas State University (NYITCOM-ASU) in Jonesboro Arkansas, is the only medical school in America that has integrated telemedicine into their students’ core curriculum. The goal is as the freshman medical students advance through their classroom lectures, take care of mock patients, complete their externship, and then graduate, they are just as prepared to deliver care through telemedicine-based technologies as they are with a traditional visit. NYITCOM-ASU has also taken it one step further by working with their partner training sites to offer telemedicine services to communities in need. The hope is that this exposure leads to their graduates becoming telemedicine champions for the communities they serve.
However, one medical school cannot do it alone. It is time for other medical schools to consider not just the role telemedicine plays in the delivery of today’s healthcare services, but the role it will have in the future. This concept can be officially reinforced by getting medical school and post-graduate accreditation entities such as the Association of American Medical Colleges (AAMC) and Accreditation of Graduate Medical Education (ACGME), on board with mandating some level of telemedicine education into their members core curriculum. These influential organizations set the standards for the quality of our future physicians, and without their mandate, it will be left up to the individual educating bodies to sort out how best telemedicine education should be delivered.
Despite a lack of formalized telemedicine training guidelines, forward thinking residency programs are providing physicians exposure to telemedicine encounters. This may be the first time these young physicians have ever seen a telemedicine visit. A resident participating in a neurology rotation may have the opportunity to observe their attending neurologist do a stroke evaluation for a remote patient. Or a dermatology resident may have the chance to review a medical image taken from a rural patient’s skin examination during their annual well visit. Both examples provide much needed telemedicine exposure, but limitations in practice rules and clinical knowledge often prevent the resident from interacting directly with patient.
This early exposure to successful telemedicine models are also helping to reduce the bias that a telemedicine visit does not meet the same quality standards of a traditional visit. When healthcare executives were asked what issue was most significant regarding physician acceptance of telemedicine in their health system, 48% cited physicians’ concerns over quality assurance. 8 Quality concerns, and rightfully so, are common amongst physicians who have never conducted or participated in a telemedicine encounter. However, these worries are typically mitigated by working closely with existing medical staff on the specific role telemedicine will play in their care delivery models. This is also why early education and adoption for physicians in training as to how telemedicine services can be integrated into traditional care models is important.
The American Medical Association (AMA) is also working towards this goal as an advocate for more formalized training in telemedicine for medical students and residents. In a June 2016, press release, Past President Robert M. Wah, M.D. stated, “As innovation in care delivery and technology continue to transform healthcare, we must ensure that our current and future physicians have the tools and resources they need to provide the best possible care for their patients.” To that end, the AMA is working with 32 medical schools to create the, “medical school of the future.” The goal is to better leverage new and developing technologies to expand access to care. The AMA is even providing grant money for the most innovative care delivery concepts.
Even the Department of Veterans Affairs (VA) sees the potential for integration between their graduate medical educational needs and the role telemedicine can play in its outreach. In a February 2017 Request for Proposal (RFP), the VA was looking for ways to expand traditional graduate medical education into new areas by using technologies such as telemedicine to expand access to care for their rural veterans, while finding new training models for their young physicians. Specifically, the RFP supported the creation or expansion of telehealth capacities to rural areas for mental health or primary care. As the largest utilizer of telemedicine technologies in the world today, the VA is leading the way in expanding the medical education role for telemedicine.
The integration of telemedicine into the curriculum of more medical schools, followed by the continuum of post-graduate medical education, is critically important for the long-term adoption and success of telemedicine. As the telemedicine industry grows and becomes more influential, it will need to continue to work with various governing bodies to not only improve reimbursement and licensing issues, but also to ensure future physicians see telemedicine as an indispensable part of their future practice. This can only be accomplished by eliminating traditional practice biases and preparing our next generation of physicians to deliver care across traditional and non-traditional platforms.
By Darren Sommer, DO, MBA ON
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