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How can we use virtual clinics to maximize education?

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The COVID-19 pandemic has changed the way medical education has been delivered. For those in the clinical phase of their training, restrictions on social distancing and the unpredictability surrounding enforced lockdowns have meant face-to-face clinical time is not guaranteed. Virtual clinics can allow the delivery of an educational experience with several benefits.

Virtual clinics can be used exclusively for education. Setting a template allowing for four to six new patients over three hours allows both the trainee (or student) to observe a variety of expert patients and for senior clinicians to provide effective education.

Parents should be informed that their clinic will be a teaching clinic and may operate slightly differently than usual but with no change to the quality of care. Clinicians may also consider certain patients as future expert patients in the same way they are kept in mind for clinical exams.

Here are some top tips based on our experiences that should ease your foray into using virtual clinics as an educational tool. We’ll lay them out in three stages..

1. The Groundwork (Preparation)
2. Delivery (Of Content)
3. Scaffolding

Doing the groundwork

Preparation is crucial to ensure a smooth, efficacious learning opportunity. This is true whether it is delivered physically or virtually. Setting the aims and objectives of the sessions ensures educators and students (undergraduate, postgraduate and trainee clinicians, but we’ll call them students from now on) are clear on what skills or lessons will be elicited from the session. Here are some things to consider whilst setting up the clinic:-

1. Set the agenda

Inform and consent patients and parents in advance. Let them know that the student will initially lead the consultation (via video or telephone) and that you will be in the same virtual room to observe. The student will then lead the consultation.

After the initial consultation, the call will be paused (or the patient will be placed in the virtual waiting room) to allow the student to discuss their findings and develop differential diagnoses with the senior doctor. Then, let the family know you will call them back after five or ten minutes to continue the consultation.

Studies have shown that patients and consultants are fully receptive to student-led consultations. There is no drop in quality for students seeking to explore the lived experiences of their patients, and patients themselves can provide a wealth of education far beyond any textbook.

2. Decide on the nature of the clinic – first presentation or follow-up?

New patient clinics are wonderful for obtaining structured histories and helping students develop differential diagnoses and management plans. Plenty of time should be allowed for the students to achieve this.

From personal experience, I would allocate at least 40-60 minutes for a new patient. The first half of the consultation should be given to the student to take a robust history. The next ten to fifteen minutes should then be spent discussing the differential diagnosis and plan with appropriate reasoning. Doing this, when the dialogue is only between the clinician and student, can help the formative element of these clinics. Then, the clinician can bring the patient back to the virtual room to discuss the management plan.

Follow-up clinics allow students to learn from the clinician’s initial letters. You can allocate time for students to review them to consolidate their learning.

During these sessions, you can also observe communication skills and provide feedback. Student-run clinics may improve the quality of care and education itself. Having real-time patient interaction via virtual clinics provides the ability to gather confidence in taking detailed histories, develop effective communication skills and develop overall professionalism.

3. Focus on developing clinical skills

While there is no alternative to the physical exam, virtual consultations provide excellent opportunities to develop clinical reasoning skills and understand the importance of a focused history. Clinicians can help develop clinical reasoning as they sift through the information. This allows the student to gain a more holistic learning experience as they follow the patient’s journey from the start to the end.

The Delivery

Here are some ways to maximise the delivery of educational content.

4. Encourage participation in clinic through supervised learning events (SLEs)

Virtual clinics can be a tool to help trainees and students complete supervised learning events (SLEs). These clinics can be ideal for assessments through observed interaction (like the mini-CEX) or case-based discussion. Running SLEs through virtual clinics provides scope to strengthen the event’s aims with a summative focus by having regular virtual clinics over a rotation. This may decrease the burden on trainees during the pandemic or times of high patient load.

5. Provide formative feedback

Evidence suggests that formative assessment and feedback are the most significant development tools for shaping future clinicians. This will narrow the gap between the set standard and the observed performance, aiming to develop skills that improve confidence and provide support when necessary. Doing so via a virtual setting allows for constructive dialogue to take place.

Focused feedback around professionalism, communication skills, and knowledge can be provided, reinforcing a positive learning environment.

6. Solicit patient feedback

Students benefit hugely from receiving feedback from the patient and their carers.

The student must provide consent as well as family.

A recent study in 2019 by Rubliauskas et al. found that most patients thought involving students in their consultations would not influence care outcomes. Baines et al. (2018) observed that patient feedback was more influential in changing practice and habits when it was specific. Incorporating this into the structured breakdown of a virtual clinic can assist in reflection and development.

Scaffold Learning

7. Encourage retrieval practice with the patient

The student can follow the journey of the patient. You can plan for a quick catch-up with the student within the fortnight to review any investigations and discuss what they mean. Retrieval practice has been shown to enhance learning from clinical encounters and lead to superior examination performance, embedding long-term learning.

8. Get students to reflect and action a plan

Students should be encouraged to reflect on what they have seen and experienced. Effective reflection strengthens critical thinking and communication skills and is the basis for formulating an educational plan. This allows the teacher to tailor learning opportunities and collaborate with the students to create the most effective virtual learning environment.

9. Encourage attendance at multi-disciplinary team (MDT) meetings

Students joining MDT clinics gain exposure to the varied aspects of the team. A recent pilot survey undertaken by Trivedi (2019) showed that inclusion at these meetings has overwhelmingly positive educational value.

Beyond all this, the best ideas often come from feedback from students. Understanding the flaws and strengths of virtual learning environments provides sources for improvement. Feedback from the patient and family can also provide novel ideas on how to improve patient-professional interactions best. The clinicians also get ongoing education on how best to talk with patients.

Virtual clinics foster good learning opportunities. While it might seem arduous to set up and occasionally technology might fail, educators need to reinvent the way we teach and train the doctors of the future. Technology-enhanced learning is here to stay and is expected to advance rapidly. It’s time to become an early adopter.

References

Alrasheedi AA. Deficits in history taking skills among final year medical students in a family medicine course: A study from KSA. J Taibah Univ Med Sci. 2018;13(5):415-421. doi:10.1016/j.jtumed.2018.07.001

Athanasopoulos L V., Athanasiou T. Are virtual clinics an applicable model for service improvement in cardiac surgery? Eur J Cardio-thoracic Surg. 2017;51(2):201-202. doi:10.1093/ejcts/ezw411

Baines R, Regan De Bere S, Stevens S, et al. The impact of patient feedback on the medical performance of qualified doctors: A systematic review. BMC Med Educ. 2018;18(1). doi:10.1186/s12909-018-1277-0

Bansal A, Singh D, Thompson J, et.al. Developing Medical Students’ Broad Clinical Diagnostic Reasoning Through GP-Facilitated Teaching in Hospital Placements. Adv Med Educ Pract. 2020;Volume 11:379-388. doi:10.2147/amep.s243538

Burgess A, Mellis C. Feedback and assessment for clinical placements: achieving the right balance. Adv Med Educ Pract. 2015;6:373. doi:10.2147/amep.s77890

Darragh L, Baker R, Kirk S. Teaching medical students, what do consultants think? Ulster Med J. 2015;84(1):37-41. www.ums.ac.uk. Accessed November 8, 2020.

Deng F, Gluckstein JA, Larsen DP. Student-directed retrieval practice is a predictor of medical licensing examination performance. Perspect Med Educ. 2015;4(6):308-313. doi:10.1007/s40037-015-0220-x

Gogia SB, Maeder A, Mars M, et.al. Unintended Consequences of Tele Health and their Possible Solutions. Contribution of the IMIA Working Group on Telehealth. Yearb Med Inform. 2016;(1):41-46. doi:10.15265/iy-2016-012

Kassab SE, Bidmos M, Nomikos M, et al. Construct Validity of an Instrument for Assessment of Reflective Writing-Based Portfolios of Medical Students. Adv Med Educ Pract. 2020;Volume 11:397-404. doi:10.2147/amep.s256338

Keifenheim KE, Teufel M, Ip J, et al. Teaching history taking to medical students: A systematic review. BMC Med Educ. 2015;15(1). doi:10.1186/s12909-015-0443-x

Khan ML uz Z, Jawaid M, Hafeez K. Patients’ receptiveness for medical students during consultation in outpatient department of a teaching hospital. Pakistan J Med Sci. 2013;29(2):454. doi:10.12669/pjms.292.3186

Marwan Y, Al-Saddique M, Hassan A, et.al. Are medical students accepted by patients in teaching hospitals? Med Educ Online. 2012;17(1). doi:10.3402/meo.v17i0.17172

Monrouxe L V, Grundy L, Mann M, et al. How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014. BMJ Open. 2017;7(1). doi:10.1136/bmjopen-2016-013656

Murphy RP, Dennehy KA, Costello MM, et al. Virtual geriatric clinics and the COVID-19 catalyst: A rapid review. Age Ageing. 2020;49(6):907-914. doi:10.1093/ageing/afaa191

Patel M, Agius S, Wilkinson J, et.al. value of supervised learning events in predicting doctors in difficulty. Med Educ. 2016;50(7):746-756. doi:10.1111/medu.12996

Pflugeisen BM, Mou J. Patient Satisfaction with Virtual Obstetric Care. Matern Child Health J. 2017;21(7):1544-1551. doi:10.1007/s10995-017-2284-1

Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791. doi:10.3109/0142159X.2012.684916

Rees CE, Cleland JA, Dennis A, et.al. Supervised learning events in the Foundation Programme: A UK-wide narrative interview study. BMJ Open. 2014;4(10). doi:10.1136/bmjopen-2014-005980

Rubliauskas K, Šalkauskaitė A, Macas A. Patient feedback on medical students in tertiary health care: are medical students accepted in clinical practice? Acta medica Litu. 2019;26(1):107. doi:10.6001/actamedica.v26i1.3963

Schuelper N, Ludwig S, Anders S, et.al. The impact of medical students’ individual teaching format choice on the learning outcome related to clinical reasoning. J Med Internet Res. 2019;21(7). doi:10.2196/13386

Thampy H, Willert E, Ramani S. Assessing Clinical Reasoning: Targeting the Higher Levels of the Pyramid. J Gen Intern Med. 2019;34(8):1631-1636. doi:10.1007/s11606-019-04953-4

Trivedi DB. Educational Value of Surgical Multidisciplinary Team Meetings for Learning Non-Technical Skills – A Pilot Survey of Trainees From Two UK Deaneries. J Surg Educ. 2019;76(4):1034-1047. doi:10.1016/j.jsurg.2019.02.001

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Authors

  • Pramodh Vallabhaneni is a clinician-educator currently working as a Consultant Paediatrician in Swansea(2014-present). He has undertaken various roles in postgraduate and undergraduate medical education. Current academic roles include Lead for child health speciality attachment, pathways to medicine clinical lead at Swansea University Medical school. His past academic roles include Lead for Education: HEIW School of Paediatrics(2019-21), Foundation programme director at Morriston Hospital (2018-22), Local programme director(Paediatrics-2018-19). He was awarded Best paediatric educational Supervisor in 2016 and won the Rising star award in 2017 from Swansea University Medical School. He has recently been awarded Excellence in Learning and Teaching Award (2021) by Swansea University. His research interests include formative assessments in medical education and medication error prevention. He/Him.

  • Tharshan Sivakanthan is currently a third-year medical student in the graduate entry medical (GEM) course at Swansea University. He/Him.

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