Impact of telehealth implementation on medical non-consultant hospital doctors training experience

Abstract

Telehealth is defined as the provision of health care services over a distance. Major health systems, including outpatient clinics and check-ups alike, turned to telehealth and teleconsultation amid the COVID19 pandemic. There are many recognized advantages of telehealth and its increasing implementation, however, not much is known about the specific impact of remote consultation on the quality of non-consultant hospital doctors (NCHD) training experiences in medicine. This study aimed to gain rich descriptive insights into the specific impact of remote consultation on the quality of medical NCHD training experiences and their perceptions, through purposeful sampling. Data was collected via semi-structured virtual interviews of fifteen NCHD participants. The interviews were recorded, transcribed and analysed using thematic analysis. The collective transcripts were analysed using NVIVO data software for common themes. The themes identified suggested that there were both advantages and disadvantages to telehealth and its impact on training across a spectrum of entities including; doctor-patient relationships, peer relationships, service provision, work morale, working hours, clinical skills experience and general feedback as a trainee. NCHD perspectives expressed were mixed across all themes. Further research is recommended to advance understanding of the potential impact of telehealth on current and prospective doctors in training. With a greater understanding of general insights, future changes, including telehealth training programmes, could be implemented to build confidence and familiarity with telehealth utilization and potentiate its conceivable benefits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-05824-1.

Introduction

Telehealth can be defined as the provision of health care services over a distance [1]. It comprises both synchronous and asynchronous doctor-patient teleconsultation via phone, video-linkage, instant messaging or web-based services [2]. Telehealth can be subdivided into three main processes; the patient describes data about their health, the healthcare professional electronically receives this data, the healthcare professional then uses their clinical skills to formulate feedback and relay this to the patient electronically [1, 3]. For the purpose of this project telehealth is limited to the provision of health care services as listed above and will not include non-clinical services, such as formal medical education, telelectures or administrative meetings.

Most recently, telehealth measures were more widely adopted internationally to help curb the spread of COVID19. This piqued research into the impact of the COVID19 pandemic on physicians in training - namely into issues such as redeployment, reduced theatre time and teleconsultation.

There are many recognized advantages of telehealth and its increasing implementation, however, not much is known about the specific impact of remote consultation on the quality of non-consultant hospital doctors (NCHD) training experiences and their own perceptions. This gap in knowledge leads to one questioning telehealth’s impact on trainee experience. Are services blindly using technology without a clear idea of how learners engage with that technology or how they learn from it? We aim to study how it might be affecting trainees’ knowledge and skills and explore if experiences have changed overall. Has training been enhanced or hindered and what consequences, if any, exist?

Background

Evolution of teleconsultation

For decades people have been communicating across considerable distances. In 1879, The Lancet published an article about using the telephone to reduce unnecessary healthcare office visits [4, 5]. A well-recognised imaginative cover of a 1929 Radio News magazine depicted a “Radio Doctor” using both radio and live television images to communicate with a patient [5]. It was not until 1950 that the first reference to telemedicine was published in medical literature [6]. The use of telehealth has been expanding rapidly with technological advancements and to date has been well-received. The COVID-19 pandemic placed increasing demands on the international implementation of digital technologies in healthcare, which are relatively unfamiliar to both physicians and patients. This shift to virtual modalities has provided an opportunity to adapt and grow. As the telehealth realm is more widely accepted and the pandemic advances, the lessons learned should continue to augment patient experience. Telehealth utilization has exploded, with reports of rates of use up 80–200% in some instances [7–9]. However, the effect on the trainee non-consultant hospital doctor (NCHD) experience remains unknown.

Current education of telehealth

At large, telemedicine training literature has identified a need for competency training in basic technology proficiency and quality assurance of communication and consultation skills. While current trainees are by and large “digital natives” this does not always translate to telehealth competency [10, 11]. The role of competency training has begun but remains slow. Many specialities that implement teleconsultation do not have dedicated learning opportunities in preparation for this skill, with rates as low as 10% reported [12]. Benefits of telehealth workshops and teaching sessions are well recognised including self-ratings of understanding and confidence as reflected by Rienits et al. [13]. This has not yet been implemented at undergraduate level though it has been introduced in some national medical training programmes including general practice.

Potential impact on trainee experience

Thus far, the literature on trainee perspectives is lacking. While telehealth is recognised as an advantageous tool for trainee exposure and engagement with patient care, it does not come without limitations. One of the most significant limitations of teleconsultation is the absence of face-to-face physical examination [14]. Subtleties may be missed via remote consultation that may be relevant to a diagnosis, plan and treatment. It is important to consider the educational impact that these limitations impose on the trainee. Does the absence of a thorough physical examination hinder a trainee’s confidence in accurate clinical sign recognition [15]? Does this make for further reliance on radiological imaging and biochemical investigation in the process of clinical diagnosis [16]? At present, these are questions – among others - that do not have answers.

Communication is another challenging aspect within the telehealth environment. It has been noted that the virtual environment poses challenges for the classical patient-doctor communicative approach [17]. In addition, the use of non-verbal cues such as silences, open posturing and empathetic touch are markedly limited. Trainee experiences recorded to date have highlighted a lack of confidence toward its practice and a further need for educational programmes.

There are many recognised advantages of telehealth and the worldwide accelerated adoption of its use. Its positive impact on vulnerable patient groups, rural geographics, specialty department waiting times and health service costs are well investigated. What is not yet clear is the impact of the implementation of telehealth on trainee experience; development of clinical skills, communication skills, knowledge of disease and management, peer and senior reviews and advice. Although there have been studies looking into the attitudes towards telehealth, there is a paucity of data on its specific impact on training schemes. Crossing the Chasm by Geoffrey Moore published in 1991 describes the adoption of disruptive innovations [18]. This last decade has seen telehealth cross that chasm [19]. Given the further 2020 boom of telehealth what better time to assess the impact on the future figures of healthcare?

Methodology

This study was completed using a qualitative approach which views the world to be a socially constructed reality and bases itself on the foundation of naturalistic enquiry [20]. An interpretivist paradigm was chosen for its recognisable advantages; it is a flexible approach with associated research strategies such as qualitative interview, which generates a wealth of rich information and outcomes to gain a deeper understanding [21].

Study aims

1. To assess the impact of telehealth implementation on NCHD training experience.

2. To examine NCHDs perceptions toward the growing use of telehealth in healthcare setting and its effect on their medical training.

Ethics approval and consent to participate

Study performed in accordance with the Declaration of Helsinki. Ethical approval for this study was sought from and approved by the Royal College of Physicians of Ireland Research Ethics Committee (RCPI RECSAF145), prior to commencement of the study. Study took place from June 2021 to August 2021. Informed consent was gained by all subjects to participate in this study. The participants consent to the publication data and materials.

Sampling

Using purposeful sampling a relevant sample size was determined when data saturation was met and no further new information was forthcoming. A total of fifteen hospital medical NCHD participants were interviewed. As relevant gatekeeper, an Education Co-Ordinator within the hospital body was contacted to help facilitate recruitment and appropriate sampling to provide the most credible interviews for the research question [22, 23]. The sample of NCHDs identified were sent an email of invitation with an information leaflet. An invitation to participate poster was also placed on notice boards in lobby areas, the hospital cafeteria and the doctor’s residence. If interested in taking part participants emailed interest to the chief investigator directly. An information leaflet - with details describing the study and confidentiality - and a consent form were provided in advance of Zoom interviews. Informed consent was obtained from all subjects. The focus was to obtain rich descriptions of the phenomena under study [24, 25].

The sample of NCHD participants chosen included a range of individuals completing the Medical Basic Specialist Training (BST) scheme and others completing a variety of Higher Specialist Training (HST) schemes to ensure both junior and senior-level NCHDs were appropriately represented. This study aimed to focus on medical trainees and so surgical specialties were excluded.

Data collection

The survey strategy involved semi-structured Zoom platform interviews using the topic guide. The interviews were recorded, transcribed and analysed using thematic analysis. In an attempt to maximize the validity and data analysis, interviews were transcribed to text. Notes taken by the interviewer during interview were also summarized and transcribed to text format. All participants were given the opportunity to review their interview transcript and to change, omit or rectify responses or errors prior to inclusion for analysis. The interview process took place over a period of eight weeks.

Data analysis

Data analysis was conducted using Braun and Clarkes six-phase framework of thematic analysis [26]. The collective transcripts were analysed using NVIVO data software by two coders.

Results

The setting for this study was a large, tertiary hospital in Ireland. The purposive sample of fifteen participants consisted of seven males and eight females. There were nine junior (basic specialist training scheme) and six senior (higher specialist training scheme) NCHDs interviewed. Four main themes emerged from the data as outlined in Fig. 1.

Fig. 1.

Four main themes of the impact of telehealth implementation on Non-Consultant Hospital Doctors Training Experience (subthemes represented in italics)

Theme 1: the novelty factor

This main theme looks at telehealth as a novel tool for participants with subthemes including; increasing use of remote consultation, unfamiliarity, low self-confidence levels and a need for education in the area.

Every participant had exposure to telehealth services; all fifteen participants had experience with telephone consultation, and five participants with video consultation. No participants used sole instant messaging as a tool for remote consultation. Participants unanimously reported a surge in uptake of teleconsultation utilization over the last 12-month period with some participants using these methods “every day, sometimes multiple times in one day”, as exclaimed by participant 2.

Reflections made by the participants indicated that there were uncertainties in their skillsets and confidence levels in practicing teleconsultation and especially noted the lack of training for this form of consultation. Participant 5 remarked that “it’s like practicing a new skill set you have never been taught before”.

Participants also discussed uncertainty in what was expected from the consultation, with participant 3 reflecting that “I was unsure if I could solve a patient problem over the phone without seeing them and examining them”, “a lot of [my] consultations would be rescheduled to face-to-face appointments, which felt like a failure of the system”.

Some participants in senior training schemes alluded to the fact that junior NCHDs could have found teleconsultation more difficult than their senior counterparts. A notable point from participant 1 highlighted the importance of clinical acumen and examination in preparation for membership examinations, with “virtual consultation making that difficult”.

There was marked convergence of opinion in that participants felt an introduction and formal teaching of a telehealth module would be beneficial. Participant 12 believed that “at undergraduate level would probably be best” while participant 9 enthusiastically reported, “I would really love some teaching in the area, it is a training scheme and it is a skill in itself”. Of note, one solitary opinion (participant 15) felt teaching sessions and practices would be of little benefit, “it’s all practice…it would be too difficult to teach”.

Theme 2: impact on applied professional knowledge and clinical skills

This theme reflects on the impact telehealth has had on clinical skills and professional development, including subthemes of both the relevant advantages and disadvantages recognised by participants. The majority of interviewees’ opinions converged in that they enjoyed the ability to consult from afar. The previously documented advantages of teleconsults were echoed in some descriptions:

• Participant 10; “They [teleconsults] keep patients safe, away from infection and out of the potentially dangerous hospital environment”.

• Participant 15; “With the right resources I think all clinics could be made virtual with a face-to-face [option] kept for safety netting those who need to be seen in the flesh…decision making for which is needed is a skillset in itself”.

Many participants indicated they strongly preferred phone clinics to video platforms and this was the most utilized type of teleconsultation. A minority of NCHDs who were noted to prefer video linkage were speciality NCHD trainees in specialities of Dermatology and Rehabilitation Medicine.

The most common negative attitude expressed towards telehealth was that the participants were unable to perform a physical examination on patients, with a number of trainees putting this down to inexperience. Participant 6 reflected “I find it hard to communicate well with a patient if I cannot physically see or examine them, I cannot make an informed decision without this step”. Despite the enjoyment and recognition of advantages made by interviewees, participant 3 mentioned the inability of “hearing breath or heart sounds” or “palpating an abdomen”, this was a sentiment that featured throughout a number of interviews.

With the most common negative attitude expressed is that of inability to perform a physical examination on patients a resultant swing of focus to the importance of history taking was unanimously mentioned by interviewees. Participant 1 felt “history via teleconsultation is heavily relied on and weighted and is a great opportunity to improve this skill”. A positive impact of telehealth on history taking was reported by a notable number of interviewees.

Participants unanimously indicated they strongly preferred a “natural” face-to-face consultation for learning and “consequential career progression”, as described by participant 14. The following exchange reflects how this preference was noted by the participant 13.

Interviewer: “In your own words, do you think there is a future for telehealth”.

Subject: “It will never take over, it will always act as an adjunct…I think everyone can relate to its advantages but for me, my learning, my future, and my ability to teach a student – you need to see the pathology to recognise the pathology. Descriptions and histories via phone aren’t always enough. I might say the sea is green you might say its blue!”

Another striking perspective was that of participant 2; “the more virtual consultations, the less face-to-face communication…there isn’t enough experience or evidence out there to tell us what makes a better doctor or a better patient experience”.

Despite noting consultations to be “smoother, quicker and efficient”, as proclaimed by participant 1, most participants felt its use had an overall negative impact on their clinical skills exposure, most marked within the junior cohort of NCHDs, with participant 5 reflecting “I don’t yet know what’s all normal and what’s all not so trying to decipher through a voice or a screen image is difficult”.

Theme 3: impact on communication and doctor-doctor and patient-doctor relationships

This main theme looks at the impact of telehealth on the communication skills of trainees and their relationships with peers and senior colleagues – including subthemes of both collegiality and feedback structures within training schemes.

Interestingly, the impact on senior advice and guidance was echoed by many participants – which was reported as negatively impacted and difficult, mostly by the junior cohort. If senior advice - on a patient case or management - was sought this was often “inaccessible”, some clinics involved virtual consultations in remote rooms/centres in different areas of the hospital leading to “delays” in affirming a plan or indeed change one as told by participant 6.

Participant 11 remarked: “patient consultation is where we learn, look and listen, examine and report back. You are often told when you are right or wrong, what was good or bad. Virtual consultation does not lend itself to that structure”. Participant 14 suggested “it’s like repeatedly taking an exam…but never getting your results”, with the convergence of participant opinions that feedback was lacking. A solitary participant discussed a supportive environment and recall of patients and plans. However, the majority reported support were difficult to attain, with participant 1 feeling “lost” in this respect.

Given its recent acceleration of uptake and relatively novel implementation, the NCHDs felt there was a strong “collegiality”, “teamwork”, “we are all in it together and all learned together”, (as said by participant 7), approach to unfamiliar landscape of virtual consultation.

Patient-doctor relationships were mentioned universally by all participants. Participants unanimously felt these were positively maintained, with participant 6 expressing they were both “thankful” and “surprised” to report these continued to a high level. No participant reflected a negative impact on doctor-patient relationship specifically. Participant 7, among others, believed that care remained “patient-centred” and “trust was maintained” by both doctor and patient.

Theme 4: impact on service and work satisfaction

The final theme encapsulates the impact of telehealth on service provision (including work morale, work hours, logistics) and its effect on relationships between doctor and patient. Of interest in this study is the impact of virtual consultations on NCHD time commitments. Overall, participants repeatedly alluded to the fact that virtual clinics have the added benefit of being quicker and faster – however, given the implementation at large during the COVID19 pandemic and resultant delays and waiting lists patient numbers “tended to be larger per clinic” resulting in “greater workload, paperwork and longer days”, as discussed by participant 5 and 3 respectively. Several participants took an objective outlook on virtual clinics as “a tool to battle backlogs”. A sole opinion expressed by participant 8 reflected that telehealth meant “slower service”.

Despite alleged added time pressures trainees did not perceive this as a negative impact on their training, “with basic or higher specialist training I expect to stay a bit later to dictate letters, fax scripts or follow results for patients – whether they were face-to-face or via a virtual medium”, as explained by participant 14.

Service provision entities including organisational and legal dimensions were touched upon by a minority of participants – when discussed, positive reflection was given on technology equipment, record keeping, confidentiality and practice management. A “team effort” was noted by participant 3 “charts pulled, work stations ready, notes recorded and safely put away.good teamwork”.

Participants 1 and 5 both reported a “good work satisfaction” associated with virtual consultation, with positive comments reflective of good work morale such as; “rewarding”, “feel good”, “gratifying” and “worthwhile”, as described by participant 10.

Discussion

This study identifies four cornerstone themes underpinning the impact of telehealth implementation on trainee experience and provides valuable descriptions and insight into these impacts. The themes identified suggested that there were both advantages and disadvantages to telehealth and its impact on training across a spectrum of subsections including; work morale, work pressures and hours, clinical skills experience and general feedback as a trainee. NCHD perspectives expressed were mixed across all themes. To our knowledge, this is the first paper to look at the impact of telehealth directly on medical trainee experience.

An overwhelming feature of research to date, also mirrored throughout this study, is trainees lack of own self-confidence in telehealth as a consultation medium. A 2020 UK-based nationwide survey of 26 dermatology registrars was completed looking at their confidence in teleconsultation. Dermatology has revealed itself as one of the most advanced specialities in terms of telehealth utilization [27]. Taking this popular speciality as an example, training curriculums for trainees within the UK does not yet include education on remote consulting. The national based survey showed that only 15% of respondents were “slightly confident” in their abilities with teleconsulting while an impressive 96% felt more education was necessary within this area [27].

A further case study performed by Lawrence et al. based in New York selected 32 Primary Care medical residents to complete a comparative face-to-face Objective Structured Clinical Examination (OSCE) and a teleconsultation version aimed to evaluate experiences with a simulated case across the principle domains of telehealth [10]. The domains identified were; technical proficiency, interpersonal skills (verbal and non-verbal) and virtual history taking, collateral information and physical examination [28]. Once again residents reported concerns about preparedness for teleconsultation and expressed wishes for further education and learning for a great competency going forward. Similar findings were seen among this study’s participants. It can be suggested that the introduction of telehealth modules at both undergraduate or postgraduate levels could help combat low confidence levels for doctors in training. By increasing confidence levels and experience with telehealth, the overall patient-doctor experience should hypothetically be optimized.

Another unique finding of this study was the propensity for junior NCHDs on junior training schemes to be less confident in their skillset needed to perform teleconsultation. This may translate to a lack of general experience and clinical acumen and may not just be limited to the virtual world. Lack of feedback and supervision was once again most markedly noted by the junior participants.

Training schemes must continue to acknowledge importance of maintaining clinical skills through the clinical shift with advancing technologies. This is an important concept to keep in mind with further implementation and advances in telehealth, without full understanding of its impact on doctors in training.

Noted lack of person-person interaction maybe delay confidence development, personal practice style and overall strength of independent clinical acumen as we have previously eluded to. We must acknowledge in the context of physical examination a quick exam will often yield expectant clinical findings but it is the more thorough examination that will yield the unexpectant [16]. Hence, the benefits of telehealth should be tempered with processes to overcome negative impact on trainee experience. This was echoed by the perceptions of NCHDs within this study cohort. The emphasis on core values on training programmes is imperative including technology, leadership and mental well-being [29].

The Accreditation Council for Graduate Medical Education (ACGME) is one example of an independent led organization that provides updated guidelines to help combat disruption of fellowship educational or training programmes, including the implantation and impact of telehealth [30]. Provisions of the ACGME have designed for direct supervision and feedback, either by simultaneous use of an electronic platform or distant monitoring of the teleconsultation. This allows for supervision and feedback provided by attending to fellow on clinical performance and overall training [31].

By recognising the impacts telehealth has had on trainees through this studies reflective interviews, it can be summarize that the degree of reported negative impact is often linked to two main elements; unfamiliarity and lack of feedback and confidence.

It is well recognised that feedback is an essential to the process of learning in medical training. “Effective and regular feedback reinforces good practice, promotes self-reflection, and motivates the learner to work towards their desired outcome” [32]. The style of feedback delivery can influence the development on the student. Through implementation of adequate telehealth training and feedback platforms NCHD satisfaction and overall engagement with telehealth may help benefit their training experience. Though comparable, face-to-face consultation will continue to yield different clinical skills, particularly clinical hands on experience.

Using the aphorism, ‘a careful history will lead to the diagnosis 80% of the time’ appears to originate from a 1975 paper by Hampton, which examined a consecutive sample of new patients seen in a weekly medical clinic [33]. Remote consultation, in the absence of notable clinical signs or physical exams via photographs, videos or live screening focuses on patient history, a hugely important part of NCHD training as recognised by some participants.

Participants naturally compared experience of face-to-face consultation to remote counterparts. As expected there was a healthy comparison of advantages and disadvantages of each. Personal preference character types and personal traits may also influence a physicians preference.

Participants report strong work and patient-doctor relationships throughout the use of teleconsultation. A conceptual piece by Glick et al. felt that the distance created via remote consultation between patient and trainee undermines the patient-doctor relationship. This disconnect may further impede a trainee longitudinal learning of medical illness [34]. This was not the case throughout our study, but it is important to note that this is not a longitudinal study and would require large studies with longevity to further assess this prospect.

Critical appraisal and methodological considerations

Limitations of the data collection style, in person face-to-face interview may, in theory, be more informative than via technology platform. By hosting on a technology platform this may influence individuals willingness to participate. Recruitment may have been effected by the dedicated time commitment needed by participants for interview. Keeping focus during semi-structured interviews can also be challenging with participants going off topic or focusing on one area/answer of the interview.

Sample sizes were small and reflected feedback from a large tertiary centre in Ireland. Telehealth needs and usage can be highly dependent on geographical locations and so should be interpreted with caution.

In terms of quality and rigour, giving participants the opportunity to reflect and review the interview transcripts aimed to minimise errors and inconsistency. This so called “member checking” improved interpretive validity, verified accuracy and therefore optimized credibility and overall trustworthiness [20]. Careful consideration was taken when analysing the data not to over use or over quote the more talkative or eloquent participants – each participant and reflection was weighted equally, with attention given to outlier opinions and minority views to ensure all perceptions are represented.

Descriptions, raw data, relevant literature and quotations enabled the chief investigator to make informed decisions on the transferability of the data and the relevant findings. The utilization of NVIVO software, helped facilitate an audit trail from reading to final themes and interpretation. These tools helped maximize clarity of the transcript to theme journey [20, 36].

Personal biases, values and beliefs may affect data analysis. The chief investigator, primary collector and two coders of data were also an NCHD on a training scheme with large exposures to teleconsultation. This was best dealt with through the advice of Houghton et all by maintaining a reflective journal identifying and addressing possible research bias throughout [35].

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

L.P and S.P. wrote the main manuscript. All authors reviewed the manuscript.

Funding

No relevant funding to declare.

Data availability

Data and materials can be requested by contacting the corresponding authors.

Declarations

Ethics approval and consent to participate

The study was performed in accordance with the Declaration of Helsinki. Ethical approval for this study was sought from and approved by the Royal College of Physicians, Ireland prior to the commencement of the study. Informed consent was gained by all subjects to participate in this study. The participants consent to the publication data and materials.

Consent for publication

Informed consent was gained by all subjects to participate in this study. The participants consent to the publication data and materials.

Competing interests

The authors declare no competing interests.