Telemedicine as an enabler of success: revisiting the undergraduate medical curriculum

Neel Mistry,¹ Paul Rooprai,¹ Stefan de Laplante,¹

¹Faculty of Medicine, University of Ottawa, Ontario, Canada

Telemedicine has grown substantially since the advent of the COVID-19 pandemic. As global cases surged in March 2020, hospitals and primary care clinics quickly turned to telemedicine – the provision of medical care using telecommunication technology over a virtual platform – to increase access to safe and effective patient care.1 Among US medical schools, an increase in telemedicine training in clerkship has been reported over the last five years.2,3 In contrast, only one medical school in Canada includes a formal telemedicine program in the undergraduate medical curriculum.4 As COVID-19 cases continue to surge across the country, the need for medical trainees to achieve competence in telemedicine is crucial. In this paper, we provide an overview of the benefits and challenges of formalizing telemedicine training and discuss steps that Canadian medical schools can take to successfully implement this change.

The future of healthcare

Telemedicine is not yet formalized in the undergraduate curriculum at most Canadian medical schools and very few include it in post-graduate training. In stark contrast, over 25% of US medical schools include telemedicine training in pre-clerkship, and nearly half offer mandatory sessions in clerkship.2 Recently, Wayne State University conducted a pilot study in which third-year medical students were introduced to telemedicine during their core internal medicine rotation.2 The results were encouraging, with 95% of clerks acknowledging the importance of virtual care services and more than 80% considering it to significantly affect their future practice.2 Similar findings were reported at Harvard Medical School, which instigated telemedicine training in clerkship at the start of this pandemic.5 Why, then, is Canada lagging behind when there are just as many reasons, if not more, to promote virtual care as there are south of the border?

An early introduction to telemedicine and virtual care provides multiple educational advantages to medical trainees. Aside from contributing to core competencies in patient care, clinical knowledge, and practice-based learning, it also fosters a greater sense of familiarity, preparing students for a practice where telemedicine is used and may be growing. This can be done in multiple ways. First, asynchronous learning can occur by creating videos that demonstrate how to perform physical exams virtually and allowing clerks to shadow their attending physician via video. Second, visiting electives that were originally suspended for the 2020-2021 cycle can still take place in a virtual format. This would allow students to diversify their clinical experience and, at the same time, help them decide which institution they would like to attend for post-graduate training. Finally, telemedicine can be included in core clerkship rotations such as family medicine, internal medicine, and surgery. Doing so would provide students with opportunities for independent practice while experiencing an array of topics including ethical dilemma, telemedicine-based cases, teleassessments, and procedural skills.

A call to action

The COVID-19 pandemic has instigated unprecedented change across healthcare settings. With hospitals and clinics rapidly shifting to virtual care, a few undergraduate medical programs have begun to implement virtual care; however, training must be formalized across all Canadian medical schools. An early introduction to virtual care offers numerous benefits to trainees as the use of telemedicine grows. This can be done in three main ways: (1) incorporating virtual shadowing opportunities, (2) re-instituting visiting electives via a virtual format, and (3) integrating students into virtual patient consults during clinical rotations. With COVID-19 accelerating the adoption of telemedicine, the need to prepare future doctors to deliver care virtually has never been greater.

References

  1. Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health 2020; 20:1193. https://doi.org/10.1186/s12889-020-09301-4
  2. Waseh S, Dicker AP. Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review. JMIR Med Educ. 2019;5(1): e12515. https://doi.org/10.2196/12515
  3. Jumreornvong O, Yang E, Race J, Appel J. Telemedicine and Medical Education in the Age of COVID-19. Europe PMC. 2020; 95(12):1838-1843. https://doi.org/10.1097/acm.0000000000003711
  4. Aires LM, Finley JP. Telemedicine activity at a Canadian university medical school and its teaching hospitals. J Telemed Telecare. 2000;6(1):31-35. https://doi.org/10.1258/1357633001933916
  5. The Harvard Gazette. The mother of invention, 2020 [Internet]. Available from: https://news.harvard.edu/gazette/story/2020/05/harvard-medical-school-uses-telemedicine-as-a-way-forward/ [Accessed December 30, 2020].

La pandémie de COVID-19 affecte-t-elle votre ouverture d’esprit ?

Does the COVID-19 pandemic affect your mindset?

(English translation below)

Dr Alexandre Lafleur,1 Mme Claudie Michaud-Couture,2 et Dre Miriam Lacasse3

  1. Professeur agrégé de clinique. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD
  2. Assistante de recherche. Département de médecine, Faculté de Médecine, Université Laval, Québec, Canada
  3. Professeur agrégée. Département de médecine familiale et de médecine d’urgence. Faculté de Médecine, Université Laval, Québec, Canada. Co-titulaire de la Chaire de leadership en enseignement en pédagogie des sciences de la santé AMC-MD

Ressentez-vous de l’anxiété ou de la frustration lorsque vous sortez de votre zone de confort? Êtes-vous démotivé lorsqu’un collègue ou un supérieur vous donne une rétroaction? Ruminez-vous pendant des heures lorsque vous n’avez pu atteindre le résultat escompté?

Si vous avez répondu « oui », vous êtes davantage sujet à adopter une position de fermeture face aux apprentissages (fixed mindset en anglais)1. Ne craignez rien, en prendre connaissance est déjà une partie de la solution ! En tant qu’étudiant, résident et médecin, vous avez fort probablement vécu des expériences qui vous ont confronté à vos limites physiques, émotionnelles ou intellectuelles. En pareilles situations, vous avez avantage à adopter un état d’esprit d’ouverture face aux défis à relever (growth mindset)1. Vous apprendrez plus, tout en ayant un plus grand sentiment d’accomplissement et de contrôle.

Miser notre réussite uniquement sur notre performance apporte un grand sentiment de réalisation lorsque les résultats convoités sont obtenus. Toutefois, face à l’échec nous vivons des frustrations.  L’estime de soi, la motivation et le plaisir d’apprendre diminuent2. D’autant qu’en médecine, les résultats échappent souvent à notre contrôle. Bien que cela soit appelé à changer, les études médicales nous outillaient peu sur la résilience face à l’erreur ou l’échec3. L’erreur n’indique pas que nous ne sommes pas intelligents. C’est signe qu’il faut continuer de se perfectionner.

Un esprit fixe croira que l’intelligence et les talents ont tout à voir avec la chance; ces dés qui ont été lancés à la naissance. Que si vous n’arriviez pas à jouer des accords à la guitare, réussir votre intubation ou encore rassurer adéquatement un patient endeuillé : « Ce n’est pas fait pour moi, je n’ai pas ce talent ». Vraiment? Le défi est-il une menace à notre intelligence? Une personne qui vise à accroitre ses savoirs dans un état d’ouverture d’esprit vous répondra : « Je ne sais effectivement pas faire cela, pas encore »1.  L’échec et les remises en question les atteignent, mais sans toutefois les définir. Ils demeurent pragmatiques. Ils ne croient pas devenir exceptionnels dans tout, mais certainement meilleurs, avec le temps et les efforts.

Traduit et adapté de Dweck CS1 par les auteurs

Bien qu’elle ne soit pas à balayer du revers de la main, une méthode pédagogique qui met uniquement l’accent sur l’évaluation de la performance mène les apprenants à se juger et à se comparer, amenant son lot de stress. D’ailleurs, nous sommes exposés à un environnement compétitif parfois depuis nos premiers pas : « Tu marches trois mois plus tôt que ta sœur! » La performance de l’un est récompensée au détriment des efforts de l’autre. Or, Carole Dweck, professeure à l’Université Stanford, a démontré que les enfants qui apprenaient à valoriser uniquement la performance plutôt que l’effort, délaissaient les buts d’apprentissage à long terme.2 Le risque est de vouloir sembler performant aux yeux d’autrui plutôt que de devenir réellement compétent.4

Au cœur de cette pandémie, où chacun doit sortir de sa zone de confort, c’est l’occasion idéale de réagir positivement aux nouveaux défis et de les aborder comme des opportunités d’apprentissage. Ce n’est pas le temps de conserver des pensées fixes qui nous incitent à croire que nous allons échouer, que nous ne sommes pas assez qualifiés ou encore que notre intelligence sera minée.

Certaines notions vous manquent? Vous doutez de vos compétences? Changez votre mentalité et considérez cette occasion unique d’apprendre et d’aider. Essayez, lorsqu’un défi se présente, de considérer l’opportunité de devenir meilleur, plutôt que de croire que vous n’êtes pas en mesure de le relever. Profitez des critiques et des commentaires pour vous améliorer. Félicitez les efforts de vos collègues et redoublez d’ardeur pour atteindre encore plus de qualifications.

Vous pouvez aider vos étudiants et collègues à accroitre leur ouverture d’esprit.5 Ciblez vos rétroactions sur le processus plutôt qu’exclusivement sur le résultat. Formulées sous forme de questions, vos rétroactions laisseront place à la discussion : « connais-tu une autre manière de faire? ».  Donnez-leur l’opportunité d’initier eux-mêmes les moyens à mettre en œuvre et appuyez leurs efforts.4 Créez un climat de travail positif dans lequel votre entourage se sentira à l’aise de demander conseils, sans peur d’être jugé.

Nous espérons qu’en terminant la lecture de ce texte, vous penserez : «  Je ne suis pas toujours ouvert d’esprit … pas encore, mais j’ai hâte d’y travailler ! »


Do you feel anxious or frustrated when you go outside of your comfort zone? Are you feeling down when a colleague or superior gives you feedback? Do you grumble for hours when you have not been able to achieve the desired result?

If you answered “yes”, you are more likely to adopt a fixed mindset1 towards learning. Don’t panic, learning about it is already part of the solution! As a student, intern and doctor, you most likely have had experiences that challenged your physical, emotional or intellectual limitations. In such situations, it is to your advantage to adopt a growth mindset1 position to face the challenges that lie ahead. You will learn more, while having a greater sense of accomplishment and control.

Betting our success solely on our performance brings a great sense of accomplishment when the desired results are achieved. However, when confronted with failure, we experience frustration. Self-esteem, motivation and the pleasure of learning diminish.2 Especially since in medicine, results are often beyond our control. Although this is bound to change, medical studies have given us little insight into resilience when dealing with error or failure.3 Error does not mean that we are not smart. It is a sign telling us that we need to keep improving.

A fixed mindset will believe that intelligence and talent have everything to do with luck; those dice that were thrown at birth. That, if you can’t play chords on the guitar, succeed an intubation or adequately reassure a bereaved patient: “This is not for me, I don’t have that talent.” Really? Is the challenge a threat to our intelligence? Someone who aims to increase his or her knowledge in a growth mindset attitude will answer: “I don’t really know how to do this, not yet.1 Failure and questioning affects them, but without defining them. They remain pragmatic. They do not believe they will become exceptional in everything, but certainly better with time and effort.

Adapted from CS Dweck1 by the authors

Although it does not have to be brushed aside, a teaching method that focuses solely on performance assessment leads learners to judge and compare themselves, bringing its share of stress. In fact, we have been exposed to a competitive environment sometimes from the very start: “You’re walking three months ahead of your sister!” One person’s performance is rewarded at the expense of the other’s efforts. But Carol Dweck, a professor at Stanford University, has shown that children who learn to value performance rather than effort only, neglect long-term learning goals.2 The risk is to want to appear to perform well in the eyes of others rather than to become truly competent.4

In the midst of this pandemic, where everyone has to get out of their comfort zone, this is an ideal opportunity to react positively to new challenges and approach them as learning opportunities. This is not the time to hold fixed thoughts that lead us to believe that we will fail, that we are not sufficiently qualified or that intelligence will be undermined.

Are you missing any notions? Do you have doubts about your abilities? Change your mentality and consider this unique opportunity for you to learn and help. Try, when faced with a challenge, to consider the opportunity to become better, rather than believing that you are not up to it. Take advantage of criticism and feedback to improve yourself. Praise the efforts of your colleagues and work harder to achieve even more qualifications.

You can help your students and colleagues to increase their growth mindset.5 Focus your feedback on the process rather than exclusively on the outcome. Your feedback should be in the forms of questions, and should include a discussion: “Do you know another way to do this?” Give them the opportunity to initiate the means to implement themselves and support their efforts.4 Create a positive work environment in which those around you feel comfortable asking for advice, without fear of being judged.

We hope that when you finish reading this post, you will think: “I’m not always open-minded… not yet, but I look forward to working on it!”

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Why some students easily tend to cheat during online examinations? A perspective based on theory of planned behaviour

Drs. Rajasekhar and Kumar. Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

Yet another topic of concern related to COVID-19 academic is the students’ etiquette during online sessions and examinations. Students, who had been taking examinations in physically restricted atmosphere under rigorous invigilation, are now free from the clutches of supervision and this is the time when academic integrity gets tested. Since bioethics became a topic of interest, we overwhelmed students with barrages of non-canonical teaching on ethics and professionalism. So, it is the time to test whether we have been successful and if they have internalized something.

Indeed, we were interested to check this phenomenon out before commencing online examinations and our question was, “Would the students self-regulate when seemingly ‘invisible’ opportunities are available for cheating or fall prey to the impulse of cheating?” Upon examination, we felt that there is no prescribed definition of cheating or academic dishonesty during online examinations. Like, carrying unauthorized material into examination halls or peeping into a peer’s examination paper shall constitute a culpable evidence of cheating in conventional examinations. We don’t have any such time-tested invigilation tricks while going online. Both examiners and examinees are novices with respect to that and students are way more tech-savvy compared to middle-aged examiners who learned to share screens in Zoom® just few a months ago. So, we surfed the net to map out the possible techniques by which a student could cheat when he / she is allowed to take examinations from home. Interestingly, Google® provided us more ways than what we could have thought of and now we were puzzled about what could happen if students were similarly searching (not at all improbable).

In our experience with online examinations, we have pre-empted certain methods that can be used by the students to cheat in the examination and we have prepared certain rules to prevent cheating. We have communicated those rules to the students before they take the examination. In this way we have tried to reduce certain methods employed while cheating in an online examination. In spite of our effort to thwart cheating during online examinations the students have come up with a range of methods to cheat. While conducting the model examinations in an online mode, we have observed that the students had used cheating methods which were not so clever such as reading from the schematics pasted on the wall behind the computer screen, and certain very clever ways such as employing the voice recognising personal assistant software to search for answers to the questions, that are read aloud. Therefore, the ways and means with which the students would be able to cheat are manyfold. The purpose of the examination conducted in online format will lose its relevance unless the student decides to be truthful while taking the examination. If the student decides to cheat in the online examination, then it is very difficult for the examiners to administer a fool proof examination, which will stand the test of all online cheating methods. Factors such as ethical behaviour and self-control on the part of the students will alone prevent cheating in online examinations.

Taking cues from Icek Ajzen’s theory of planned behaviour 1, student’s behavioural control is a summative influence of attitude, subjective norms and perceived behavioural control. A) Attitude: the students’ behaviour to cheat or not to cheat depends on how the student feels about the act of cheating. The students’ feelings are manifested based on his past experience, moral certitude and personal ethical standards. B) Subjective norms: The decision to cheat or not to cheat may also be influenced by the behaviour of students’ peer group and often the student conforms to the group behaviour. C) Perceived behavioural control: The student might consider that the cheating brings enormous amount of pressure and may result in a negative outcome, and hence does not subscribe to the idea of cheating and compel themselves to stay away from cheating. On the other hand, morally compromised students may perceive the cheating as an opportunity that is readily available to compensate for their lack of preparation for the examination. Certain students often lose self-control and are tempted to cheat in the examination just because it is easy to do so.

All the above factors, such as attitude, subjective norms and perceived behavioural control may form the foundation of the thinking and may influence the intension of the student as to cheat or not to cheat. Ultimately, the intension manifests as the behaviour of cheating or abstaining from cheating in the online examination. Sometimes the perceived behavioural control can independently control the behaviour and manifest the action.

What can be done to prevent students from cheating in the online exams? Firstly, there is a need to delink the process of learning with the quest to attain good grades in the examination. Secondly, we have to inculcate in the minds of the students that any breach in the ethical behaviour, major or minor, may once for all take away the value system in ones behaviour, and no amount of justification will ever legitimise the unethical behaviour among the students. There is need to impress up on the students that examination is a process of feedback of learning process in order to augment the very process of learning. Only a honest and legitimate examination will truly assess the quantum of learning. Generating an active orientation and a constant awareness about the philosophy of maintaining personal ethics and bioethics to the students throughout their learning career may be the way forward.

Reference:
1. Ajzen I. The theory of planned behavior. In: Lange PAM, Kruglanski AW, Higgins ET (eds.) Handbook of theories of social psychology. London, United Kingdom: Sage. 2012, p. 438-59.

You may reach Drs. Rajasekhar and Kumar:
sekhar5883@gmail.com
dinesh.88560@gmail.com