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MAY 08, 2020 -- The garbage trucks outside my window are so loud that I can't hear what the "patient" is saying. I try to obtain a medical history but soon give up. I switch to the physical examination. I know how to do this in person, but how do I do this over a computer? Before I know it, my allotted time runs out.
A proctor directs me to a virtual portal that contains a note template I've never seen before. I waste precious minutes trying to decipher it. Time runs out for this portion too. I've produced an incomplete note. This was a "less than optimal" patient visit. Actually, it was a total disaster. The virtual Objective Structured Clinical Examination (OSCE), my first real telemedicine experience, was a complete train wreck.
Virtual exams are becoming the new norm during the COVID-19 pandemic. The struggles I had with the virtual OSCE showed me that telemedicine is not as simple as having a Zoom chat with a patient. Just like any specialty requires specific training, telemedicine requires appropriate preparation. Until now, that is training and preparation that many of us medical students haven't had.
The COVID-19 pandemic is almost certainly going to lead to medical schools introducing telemedicine earlier in training. Here's what taking the virtual OSCE taught me that we need.
What I Wish I Had Been Taught
Teaching telemedicine and related skills to students doesn't need to be radically different from training courses already available to practicing clinicians, such as the one offered by Thomas Jefferson University. The difference is that by introducing that material earlier in medical training, students could learn traditional and virtual approaches simultaneously. This would obviously allow for a better, deeper understanding of both. Presenting content in multiple formats often helps us truly learn something. For example, I didn't fully comprehend the concept of pulmonary hypertension from just hearing about it in lectures. I only "got it" when I actually saw it in a patient.
In fact, learning a new approach like virtual examinations may help solidify older, traditional clinical skills. We medical students currently learn to take a patient history through in-person classes that incorporate a physical examination, note writing, and other basics. Conducting virtual visits would be an excellent way to solidify our history-taking skills and reiterate their importance. Being challenged to arrive at a diagnosis solely through a patient history obtained during a virtual visit would be a strong test of clinical acumen.
In terms of virtual assessments, I struggled with how to adapt the typical methods of examination—listening to the heart and lungs, palpating the abdomen—in a nonphysical environment. In a virtual OSCE exam, medical students are expected to verbally describe examination maneuvers. Just as how the best quarterback in the NFL may not be able to describe exactly how he throws a football, a great medical student may not be able to describe how to listen for a carotid bruit or tracheal breath sounds.
If virtual exams are expected to be accurate assessments of our clinical abilities, students require training on how to verbalize physical examination maneuvers. For example, during my exam, I wanted to assess for signs of end organ damage (like retinopathy) in a patient with diabetes. Without a funduscope, and looking through a computer screen, I wasn't able to assess his eyes for hypertensive damage. I wasted precious time thinking about ways I could check for any retinal irregularities.
Another challenge for me was the patient note portion of the virtual OSCE. During my exam, the portal where we recorded our patient notes was not available during the "history and physical" portion. I was forced to write my notes in a Word document. This made it very difficult to input the information into the portal later on and wasted precious time. Videos and other training about how and where to document patient data during a virtual visit would have helped immensely. Administrators should also take this into account and ensure that note templates are available to students before a virtual exam or visit, so that they have time to become acquainted with it. Just as senior clinicians are routinely retrained to use new electronic health record systems, medical students should be taught to use virtual technology platforms to ensure technological fluency during visits.
Perhaps the biggest issue for me during my OSCE was simply a lack of time spent with virtual patients. In our preclinical years, we were trained in classes centered on physical diagnoses and in-person communication skills with standardized patients, who offered us useful feedback. I learned how to ask for a patient's consent before ever beginning a physical exam and how to modestly drape a patient. We need to learn best practices for virtual visits as well. For instance, more communication tactics should be incorporated into our talk-centered visit training to ensure that we help the patient understand us and feel satisfied.
Although it may be too late to help me with my exam, there is no reason why schools shouldn't be offering virtual patient interaction training for students right now. No doubt COVID-19 is going to cause institutions to rethink key aspects of the curriculum, and adding hands-on education with hands-off (virtual) patients should be included.
After my virtual OSCE, my standardized patient told me the exact phrases I had used that had put them at ease and advised me on a certain phrasing I used that made them feel judged. This feedback was invaluable, and it would be greatly beneficial to be offered more of these sessions, where we could learn how our mannerisms and words come across in a digital setting.
Advice for Those Taking Virtual OSCEs
I admit that I was totally thrown off-guard by this exam. For those who haven't taken it but may in the future, a few steps can help ensure success. First, it's important to practice those "verbal physical examinations" I've mentioned. Decide on a few maneuvers that you are likely to conduct during every visit and practice saying them aloud. Time yourself doing this so that you have a sense of how many "virtual physical exam" findings you can reasonably complete in 5 minutes, which was the amount of time I had allotted. For each "chief complaint," you can add in one to two extra maneuvers, preferably from a short list from which you have already practiced verbalizing.
Second, ask your school ahead of time for the note template and portal that you will be using. Then do a practice run in it. Get familiar with how you will input the data, and time yourself while writing up a patient note in the portal. During my OSCE, I was not able to see the patient's information or vital signs in the portal. I struggled to determine how to conduct a visit without that key information. Find out in advance what information will be available to you. Clarify with your school whether the note template will be available to you during the "history and physical" portion of the exam. That way, you can know ahead of time where you will be able to take notes.
The first time you use any electronic health record (EHR) is challenging. Before we began using EPIC at my school, we were offered an entire clinical training course on it. We had to pass multiple tests on the subject. Even then, I struggled during my first month on the wards, trying to figure out what to click in order to write a note, pull in a smart phrase, or send out a request. Although it is much simpler than an EHR, a virtual medicine portal does require practice to understand the layout and to be able to quickly navigate it.
Also, and it may sound simple, be sure to let your spouse, roommate, or family know that you cannot be disturbed during this time. I decided on my kitchen table as my testing spot, as it has a neutral background and good lighting, and I could cordon off this spot from the rest of the house. I alerted my boyfriend ahead of time that, for that hour, he could not go into the kitchen. He took all of his calls in a different room in the house that morning so that I wouldn't be interrupted.
Finally, and maybe most important, do a test run where you will be taking the virtual OSCE to ensure that you have a suitable environment. Find a spot with the best Wi-Fi and the least amount of noise. I had picked a spot with reasonable Wi-Fi but hadn't anticipated that garbage trucks come at 10:00 every morning outside my building. If your OSCE is at 3:00 PM, make sure you have practiced the exam at that time and know what your building's Wi-Fi, street noise, and outdoor light are like during that period.
Despite my less-than-ideal experience with my first virtual OSCE, I am still enthusiastic about telemedicine. As it continues to increase in popularity and necessity, it is equally important that medical schools begin to train their students on how to excel in a virtual environment and how to use virtual tests to accurately reflect medical trainee preparedness. Online clinical examinations and patient experiences can serve as an excellent training ground for students to begin preparing for the increasingly digital future.
COVID-19 has forced us to change what medical education looks like and move our courses, exams, and clinical experiences online. I am hopeful that medical schools will seize upon this opportunity and offer extended telemedicine training to prepare their students for success—not just on exams but in caring for real patients.
Monique Sager is a second-year medical student at the Perelman School of Medicine at the University of Pennsylvania. Before medical school, she worked in consulting and healthcare technology and has since served on Penn's HealthX board. She is interested in the intersection of telemedicine and clinical care.