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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 has 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 time for 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 to usual, but with no change to the quality of care. Clinicians may also keep certain patients in mind as future expert patients in the same way that 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 both 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 somethings to consider whilst setting up the clinic:-

1. Set the agenda

Inform and consent patients and parents in advance. Let them know that the consultation (via video or telephone) will be led by the student initially and that you will be in the same virtual room to observe. The consultation will then be led by the student. After the initial consultation, the call will be paused (or the patient will be placed in the virtual waiting room) to give the student an opportunity to discuss their findings and develop differential diagnoses with the senior doctor. Then let the family know that you will be calling them back after five or ten minutes to continue the consultation.

Studies have shown that both 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 in developing 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 over 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 the student to review them to consolidate their learning.

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

3. Focus on developing clinical skills

Whilst there is no alternative to the physical exam, virtual consultations provide excellent opportunities to develop clinical reasoning skills and understanding of the importance of a focused history. Clinicians can help develop clinical reasoning as they sift through all of 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). Whether they occur through observed interaction (like the mini-CEX) or case-based discussion, these clinics can be ideal for assessments. 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 the most significant development tool for shaping clinicians of the future is formative assessment and feedback. This will narrow the gap between the set standard and the observed performance, with the sole aim of developing skills and improving confidence and providing support when necessary. Doing so, via a virtual setting, allows for constructive dialogue to take place. Focused feedback around professionalism, communication skills as well as knowledge can be provided, reinforcing a positive learning environment.

6. Solicit patient feedback

Students stand to benefit hugely from receiving feedback from the patient and their carers. It’s important that the student provides 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 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 performance in examinations, 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 serves as the basis for formulating an educational plan. This provides the teacher with the opportunity to tailor learning opportunities and collaborate with the student 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 is of an 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 best improve patient-professional interactions. The clinicians also get ongoing education on how best to talk with patients.

Virtual clinics foster good learning opportunities. Whilst it might seem arduous to setup 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

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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

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About the 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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