Fellows Front and Center: Tele-Training and Telehealth

Problem

The Developmental-Behavioral Pediatrics (DBP) Division at Stanford, in response to COVID-19 “shelter-in-place” directives, abruptly shifted from face-to-face outpatient clinic visits to exclusively remote telehealth (TH) visits on March 18, 2020. DBP faculty determined that continued DBP fellow training was a priority. The hospital system provided no guidance about maintaining teaching in the TH environment where faculty and fellow were not co-located. Extant literature offered limited information about evaluated supervision of medical trainees during TH visits, focusing on medical students¹ or intensive care environments.^{2 , 3}

Approach

Our innovative fellow training model began with a challenge: faculty had to engage simultaneously, in learning and teaching TH. We utilized an educational framework rooted in experiential learning, quickly identifying 3 predominant strategies: 1) faculty and fellow paired for entire TH visit; fellow led the visit, faculty observed; 2) for each TH visit, we added time for focused “pre-brief” and “de-brief” discussions; and 3) during visits, we capitalized on observation of patients at home. An additional challenge was that the existing TH platform did not support multiparty functionality. Therefore, we experimented with other video communication strategies to ensure that multiple individuals (eg, fellow, faculty, interpreters) could simultaneously participate in TH visits.

Outcome measures. To assess maintenance of fellow clinical experience, we calculated number of remote TH visits conducted by faculty and the proportion of those visits led by fellows. We gathered fellow and faculty perspectives regarding advantages and disadvantages of “tele-training.” End of April, 2 focus groups were conducted (Group 1 faculty n = 7; Group 2 fellows n = 4). The semistructured discussions were audio recorded, transcribed, and analyzed using inductive content analysis.

Outcomes to Date

After 1 month, 324 remote TH physician visits were completed, with 101 visits led by fellows and supervised by faculty (31%). Visit number was comparable to the same period in 2019.

Results of qualitative analyses. Three themes represented shared beliefs of fellows and faculty:

• (1)The nature of supervision changed. Faculty observed fellows intensively, without interrupting. The new format spotlighted fellow skills in communication, organization, and transitions.
• (2)Feedback was enriched. New opportunities emerged for confidential feedback during the visit (using chat features) and after the visit (using planned de-brief time). Feedback content was informed by faculty's ability to take notes unobtrusively.
• (3)Unexpected opportunities for fellows to observe and practice skills have emerged: leadership, flexibility, timeliness prompted by technological demands, and problem-solving.

Two themes highlighted differing perceptions of fellows and faculty:

• (1)Faculty expressed concerns, not endorsed by fellows, about possible disadvantages of tele-training, including fellow perceptions of lost autonomy, heightened scrutiny, decreased collegiality.
• (2)Fellows had increased awareness of clinical advantages of TH visits (eg, seeing patient's home environment, concentrating attention to clinical priorities), not mentioned by faculty.

Next Steps/Planned Curricular Adaptations

We will re-assess faculty and fellows after extended experience with remote TH and tele-training, to determine the degree to which important themes continue or change. Based on this experience, we will include ongoing TH in clinical care and a robust training in TH for future fellows, even as in-clinic visits resume.