In my previous post, I gave an overview of telehealth visit training basics, why it’s important and how we framed it. While, the need for increasing and standardizing training for residents also applies to current providers, the needs are different.

Our education has gone through several changes as we try to figure out what is most relevant to the next generation of emergency physicians. It’s also a challenge to figure out how to implement a successful education program due to the following challenges inherent in our clinical practice:

• Supervision: Usually as residents progress, they become more independent with less and less need of direct supervision. Since there are few options to do this efficiently over Telehealth, it leads us back to directly supervising learners. The advantage, of course, is getting real time feedback both on clinical judgment as well as camera presence. It does, however, likely lead to a different behavior than may be present when not being supervised.

• Necessity: Telehealth is a care modality, not a new branch of medicine so does it really need specific education? Is it based on having a safe encounter, lack of tech issues, patient disposition, or whether there was a readmission within 72 hours? Most of these are standard QA clinical criteria and (mostly) irrelevant to telehealth.

While that’s true, telehealth is becoming more ubiquitous and necessary to expose our trainees. Currently since only used as care modality, the comfort has more to do with the provider’s level and in person clinical experience. However, just as other parts of medicine have drastically changed, making telehealth visits an everyday part of graduate medical education may change that in the upcoming years.

• Judging competency: If the adage of 10k hours or patients is enough to be branded an expert, how do we extend that to telehealth. If you consider it only a care modality, it likely means the components of webside manner including professional environment, patient interaction, eye contact and ability to resolve minor complaints without in person evaluation.  Most of these are still not standardized.

• Unintended consequences: Most telehealth programs don’t make use of students or residents as the primary provider due to the above-mentioned need for efficiency. Because of this, education can be affected if attendings at teaching institutions are doing things that may be a necessary skill for residents. For example, any program that uses their faculty to triage patients, whether in person or over telehealth, leaves the initial evaluation, decision making and order placing to someone already experienced (we do it over telehealth). There is less time to learn that skill in training. This is one reason it’s important to note how changes to practice affect those you are training and try to predict the unintended consequences. Well, if not predict, at least account for them, be nimble and change the program.

Although not all of us are at teaching institutions, how we get trained in and use telehealth will affect everyone. It’s not surprising that we need ways to determine competency, how to do a quality visit and figure out what is important in EM. The future efforts at standardization will be essential so all future providers have access and feel comfortable with its use.