Including learners with “remote” patient encounters

We’ve been focusing on classroom-based teaching tips in recent blog posts, this week, we focus on some practical tips for clinical teaching for clinicians working with learners while using telephone and computers for patient appointments.

By Debra Hamer, MD FRCPC, and Theresa Suart, MEd

Image is an overhead view of a laptop computer, smart phone, coffee cup and stethoscope.

Since March and continuing for some patient populations, physicians have shifted to “remote” technologies to conduct patient encounters, which used to take place face-to-face. This has complicated how to readily include learners – clinical clerks and residents – in those encounters.

First – let’s just put this out there – we don’t like the word “virtual” to describe working with patients using telephone or computer interfaces. This is not simulated care, it’s actual care!

Whether you’re using telephone appointments or a computer-facilitated patient interface, it can be a challenge to incorporate learners. We’re providing some suggestions based on telephone and OTN (in this case); these can be modified for your own tech situations. (As always, feel free to reach out to the UG Education team for help brainstorming solutions.)

The tasks associated with each can be divided into three parts: before, during, and after. These are things you likely do automatically with in-clinic or in-hospital patient visits that include learners because you’ve been doing it for years. Working with “remote” technologies just requires a bit of deliberate thought to what that preparation, appointment, and debrief looks like.

Depending on what social distancing is in effect, you may be in the same room as your learner, or you, the learner, and the patient may be in three different locations. The suggestions below assume you are in three different locations. If you and the learner can be in the same room, this will be simplified.

Telephone Appointments

(You may book your appointments yourself or have an administrative assistant who does so.)

Prior to Encounter:

  • When the patient’s appointment is booked, ask if a learner can be involved with the appointment.
  • If there’s a reminder call, include a reminder that a learner will be involved (if they said yes, of course!)
  • Make sure you’re in a room by yourself with no intrusions or distractions. This might seem self-evident, but work-from-home situations can change day-by-day.
  • Ensure your phone is set up to block your caller ID. On an iPhone, you need to deselect this under settings.
  • Ten minutes before the patient call, call the learner and review the referral and any pertinent information from the chart, since students won’t have access to the chart if they are not physically in the clinic. At that point, you can answer any questions or concerns the learner has

The encounter:

  • If you’re using a phone with “conference” capabilities (adding a participant) you can keep the learner on the phone while you initiate the call with the patient. (On iPhone, this is “add a call, put in the patient’s number, then press merge calls).
  • Once the patient answers, check to ensure both the patient and learner are on the call. All three participants should be able to hear each other.
  • In the greeting, you can remind the patient of the learner’s role on the call.
  • Make sure the patient understands the potential privacy issues with cell phones and consents to continue, then outline what to expect during the appointment.
  • Proceed with the patient interview/discussion/assessment as you would do ordinarily.
  • Depending on the learner’s stage, at this point they may be listening in; if not, let the patient know you will mute yourself and unmute yourself near the end to join back in. (If the learner is going for too long or going off the rails, you don’t need to wait until the end, simply unmute yourself and redirect them, as you would in a face-to-face encounter).
  • At the end of the appointment, if you haven’t already, you can unmute yourself, ask any questions and finish off.

The debrief:

  • After ending the call with the patient, call the learner back and debrief the encounter.
  • If it’s a senior learner, you may take the option to call the patient back – talk to the learner, find out a diagnosis and plan and then call back together with this. This will vary on the learner’s level. (Be sure the patient knows you are going to do this!)

Variation:

  • With a more senior learner, with the patient’s consent, you could use a three-step appointment: the learner initiates the call with patient, then ends that call to confer with you (by phone or other means), then the learner or you calls the patient back with the plan for going forward.

Pro-tip: If you use headphones, then there’s less reverberation and you can use your hands while you’re listening to the phone calls.

Computer-mediated appointment:

(Dr. Hamer uses OTN, you may use another platform. These instructions assume the patient has agreed to an internet-mediated appointment and has received the log-in instructions by email).

Preparation

  • Make sure your computer is set up with a neutral background with nothing to distract the patient.
  • Also, make sure you’re in a room by yourself with no intrusions or distractions.
  • Telephone the learner 10 minutes before the appointment time and review the case with them. End this call

The appointment:

  • Launch the appointment with the patient. (In OTN, this is either “make a video call” or clicking on the link from your schedule). Use your program’s function to add the learner. (On OTN, it’s “add a guest”
  • Ensure the patient still consents to continue with the appointment online, and outline how the appointment will go. Then mute yourself and block your video so it’s just a black box at the bottom of the screen. The learner and patient will just see each other. (This is less distracting)
  • Re-enter as needed (similar to the telephone suggestions above).
  • If there is time available on the appointment, ask the patient to stand by for a few minutes. You and the learner both mute and block your video and have a telephone discussion about the case.
  • Come back to the call to see the patient. (Make sure the gap is no more than five minutes).

Debrief

  • Once the computer-mediated appointment has finished, call the learner back to talk about the case.

Do you have advice or suggestions for facilitating learning with these types of patient encounters? Share your advice in the comments.

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This is Not Normal. Let’s Not Get Used to it.

We are growing accustomed to the sight of people wearing masks in public.

We are growing accustomed to maintaining a distance between ourselves and others.

We are becoming wary, even fearful, of personal contact.

We are no longer expecting that we will be able to celebrate accomplishments or significant events in large gatherings.

We are growing accustomed to not assembling to grieve the loss of friends or loved ones.

We are accepting the need to interact with our patients through remote interfaces.

All this is necessary given our current circumstances. These measures deserve and require our support. We may even be coming to regard many of these changes as beneficial, efficient, a “new normal” in how we engage our professional and casual relationships.

But they are not desirable. They are not virtuous. They come with a price.

Nelson Mandela, who learned a thing or two about isolation during his 27 years of imprisonment on Robben Island, is quoted as saying “Nothing is more dehumanizing than isolation from human companionship”. Although our restrictions may seem like trifling inconveniences in comparison to his experience, the parallel is valid.

Personal relationships require personal contact. An image on a screen can never convey the same meaning or depth of understanding. The concept of caring or concern for another person cannot fully be expressed or understood remotely. Learning how to encounter, assess and care for a person in need can only be accomplished through individual, personal contact.

Beyond these individual considerations, our social structure is built on the concept of “community”. Communities can be defined in purely geographic terms as a group of people inhabiting the same location. The deeper and more significant meaning relates to the commonality of values, attitudes and goals. Communities, in short, are made up of people who share certain understandings of how they wish to live and what they hope to accomplish collectively. Community requires its members to be accepting and concerned about each, which can only come through personal interaction.  

The education of its young people is, by any measure, a defining characteristic of a community.

The very word “education” has etymological roots that are both interesting and revealing.  It evidently derives from the Latin “educo”, roughly translated “I lead forth” or “I raise up”.  “Educatio” is “a breeding; a bringing up; a rearing”.  The definition that I prefer is simpler and more consistent with the origin and intent of the process; “an enlightening experience”

Facts and information can be learned in isolation. True education requires contact with teachers, mentors and, in the case of medical education, patients.

A community without social interaction and personal exchanges is not a community. A society without healthy and vibrant communities is not a society.

Getting back to Mandela, the remarkable thing is not that he survived 27 years of social isolation, but that he emerged from it all not embittered but with an even greater sense of purpose and understanding. The quote cited above continues as follows…“there I had time to just sit for hours and think.”

Let’s hope we emerge from our own prisons soon, a little more appreciative of what we are sacrificing, and a little more enlightened.

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Five non-pedagogical things to do to get ready to teach using Zoom

The UGME Education Team has prepared “how to” documents that outline the technical aspects (with such things as downloading the Zoom app, and things like checking that your microphone works). And we’ve previous written with tips about how to engage students in a virtual classroom which might seem rather unfriendly. This post is about other practical things – things we don’t need to think about, or just do automatically – when going to teach in a physical classroom with students there face-to-face.

Here’s our top-five non-pedagogical things to keep in mind before teaching live on Zoom:

1. Look behind you! Give a bit of thought to what’s behind you when your camera is on. Most things are fine, but consider if there’s a lamp that’s coming out of your head like an antennae or something equally distracting. Think about any privacy concerns, if you’re teaching from your home. My work-from-home space is in my basement all-purpose room. If I’m situated in one direction, you’ll see my husband’s degrees on the wall; another you’ll see a collection of elephant figurines (yes, there’s a story to that), and a third shows my Nancy Drew, Cherry Ames, and LM Montgomery books from my childhood. Most stuff is innocuous, but think about if you want to share those things with everyone.

Zoom virtual backgrounds are, of course, an option for an instant non-personal look. Keep in mind, however, that the green-screen technology isn’t perfect. If you move around or (like me) talk with your hands, you may have visual blips of hands or your head momentarily disappearing.

2. Turn off all things that beep, buzz, or whirr Just like in a movie theatre (remember those?!), it’s helpful if you can turn off sounds that are within your control – like your cellphone or email notifications. Also, any environmental noises you can control. My home workspace is adjacent to the laundry room. At the exact moment I was typing this sentence, the dryer buzzer went off (loudly!). It’s also helpful to remind housemates that you’ll be teaching so they can make good noise-related choices.

3. Refreshments, anyone? If you’re settling in for a two-hour session, that could be a lot of talking. It’s good to have a glass of water handy, or throat lozenges nearby. Or, if you’re teaching an 8:30 class: COFFEE. Also, tissues or paper towels perhaps – you likely don’t want to dig into a pocket while sitting down for a sneeze or spill of aforementioned coffee.

4. Office supplies, what office supplies? If you typically take notes of questions students have or keep track of which groups you’ve already called on, make sure you have pen and paper on your desk. Also, do you have any small props you want to show? Figure out where in your teaching space you can put these to keep them nearby, but out of the way of things like your refreshments (above) to avoid needing the tissues or paper towels.

5. Time, please. It’s easy to get caught up in teaching material and lose track of the time. Keep your eye on the clock on your computer, or set a timer (this sound we’ll allow) so you finish on time. There will likely be another instructor waiting to begin their session right after yours and you won’t have the usual visual cue of your colleague appearing at the back of 032 or 132.


Keep in mind, this is real life, real time teaching, not a Hollywood film. Things will happen and it will be fine – paging, for example, is unavoidable if you’re teaching in your hospital office. Also, you won’t be the first of our instructors (or students) who’ve had a child or pet wander into camera range. (I routinely warn of random “teen boy” appearances when I’m on Zoom calls. He wandered in while I was drafting this, too).

Are there things you would add to this list? Use the comments box below to share your tips.


For a different (more humorous, maybe more accurate?) take on preparing your environment for online teaching, check out this video by Dr. Andrew Ishak at Santa Clara University. https://vimeo.com/447645552?fbclid=IwAR3lKAaNY0zCPgVJWdPUjog-AD0g7FjsSNBtUL5HAEdcFlUgWaUHi–7JqU

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