Teaching medical students in general practice when conducting remote consults: a qualitative study

ABSTRACT Background Telehealth involves real-time communication (telephone or video-call) between patients and health providers. The COVID-19 pandemic propelled general practitioners to conduct most consultations remotely, seeing patients face-to-face only when required. Placement opportunities and experience for medical students were reduced. Initially online learning programmes replaced clinical attachments. Subsequently, clinical teachers supervised students to engage in remote consultations, either in clinics or from their homes. This study aimed to explore the experience of New Zealand general practitioners undertaking clinical teaching with medical students when telehealth consulting. Methods Semi-structured interviews with general practitioners who had taught medical students whilst consulting remotely. General inductive thematic analysis of transcribed interviews. Results Six female and four male participants aged 40 to over 65 years. Participants often focused on general practicalities of telehealth consultations and effects on the patient-doctor relationship, and needed direction to consider remote consultations with students, which added to the interactions. Four themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face; challenges and advantages to remote teaching, each with subthemes. Discussion Clinicians needed to determine practical logistics and develop skills for both remote consulting and teaching. New format and structures of consultations needed planning. Differences from face-to-face teaching included scene-setting for the consultation and supervision factors. Telehealth teaching conferred new opportunities for learning but also challenges (e.g. consent, cues, uncertainty). Remote consultations are likely to remain a significant mode for doctor-patient interactions. Preliminary guidelines for teaching and learning using telehealth need to be developed and embedded into medical programmes and then evaluated.


Introduction
Telehealth involves real-time communication between patients and health providers via a telephone or video call.While telehealth was not new, it had a small-scale impact in the mainstream in Aotearoa New Zealand until the advent of the COVID-19 pandemic and 'lockdowns' propelled practices into a digital transformation.Suddenly general practitioners (GPs) were conducting most consultations remotely, and only seeing patients face-toface when circumstances required it.There were many challenges, with both practitioners and patients struggling from issues such as lack of information technology (IT) literacy or inadequate infrastructure (devices and connectivity) [1,2].COVID-19 reduced the placement opportunities and experiences for medical students [3].Lockdown disrupted general practice placement training for medical students.Initially online learning programmes replaced clinical attachments [4], but later in the pandemic Year 5 and Year 6 students returned to placements, supervised by GP teachers either at their clinics or remotely from their homes, with students engaging in remote consultations with patients.
The aim of this study was to explore the experience of New Zealand GPs undertaking clinical teaching with medical students when telehealth consulting, compared with face-to-face teaching.

Design
Qualitative study using semi-structured interviews and a general inductive thematic analysis [5], founded in interpretive phenomenology [6].

Setting and participants
Potential participants were GPs who had first-hand experience of providing clinical teaching to Year 5 and 6 University of Auckland medical students whilst consulting remotely with patients, in contrast to in-person consulting, on at least three occasions.The students must either have been in the same space as the doctor, or a second remote space, and the patient remotely contacted via 'phone or video.Doctors who had provided only didactic teaching remotely to students were excluded.

Recruitment
Sampling was purposive and a variety of methods were used to increase diversity.GPs involved in teaching or supervision of medical students in primary care placements in 2021 to 2022 were recruited by email.Snowball sampling was also used, whereby participants were asked to forward on the email to colleagues who might be interested.Recent students were asked by a department administrator to identify GPs who had taught using remote consultations who might be approached.Students were advised that this had no impact, nor link to academic requirements, and they were not participants.

Procedures
Participants underwent in-depth semi-structured interviews via Zoom™, audio-recorded with autoencryption enabled to secure cloud-based storage.Recordings were de-identified and professionally transcribed under a confidentiality agreement.The first three transcriptions were reviewed by two team members with minor additions made to the interview prompts to reflect emerging themes.Asking participants explicitly about their experiences when teaching with telehealth was added to the prompts along with the following: 'Can you describe what you did to prepare for teaching in this way'; 'What frustrations and annoyances did you have?'; and 'What moments of teaching joy did you experience with telehealth?' See Appendix 1 for the final schedule.Interviews continued until data saturation.Interview files were de-identified with a unique code name e.g.GP1.

Analysis
Transcripts were independently read, re-read and coded in an iterative cycle by FGS and AW.Analysis followed an inductive approach.Initial themes were identified and refined through discussion and comparison, codes determined and descriptors added.The process emphasised commonality in the data to ensure validity.The whole dataset was then independently coded (FGS and AW).Data unrelated to the study question were not further analysed.Many statements pertained to using telehealth solely with patients and were removed.Conflicts were resolved by adjudication.Data were interpreted and presented according to themes and underlying codes, with exemplar quotes from participants.In the final analysis, findings were consolidated into four overarching themes, each with sub-themes.

Results
There were 10 GP participants: six female and four male aged from 40 to over 65 years.Participants often focused on the general practicalities, the urgency created by the pandemic requiring telehealth consultations, and the effect on the patient-doctor relationship.Through the interview guide, they were directed to consider the changes from a teaching perspective, where a student was included in the remote doctor/patient interaction.Four over-arching themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face teaching; challenges and advantages to remote teaching, with between two and four subthemes for each (a total of 11 sub-themes) -see Table 1.

Changes needed in teaching delivery format
Within this theme, participants discussed the additional actions needed to incorporate students in telehealth delivery.This fell into two subthemes: preparatory activities, and planning the format and structure of the consultations.

Preparatory activities
Practices already had orientation processes which were adapted to include telehealth.In general, the approach was to orientate to the electronic medical record (EMR) and using the 'phone, for students to observe for a period, and then start doing consultations under supervision.Watching or listening-in came first, and some described giving students a template or approach: 'it's been quite templated . . .and then making a plan with the patient' (GP10).Some taught specific skills such as 'how to participate in phone triage' (GP1).Sometimes, circumstances meant that the student training was conducted remotely as well as the consulting.

Format and structure of the consultations
All participants considered the flow of consultations with students, but for a few it was more pragmatic than planned: Trying to get in and do it and listen and getting them to do it.I didn't really think about what should we do and how should we do it.(GP7) Doctors often screened requests for telehealth and chose suitable patients for students, specially at the start of an attachment.New patients and presentations were sometimes triaged specifically for students, 'Giving the students the new patients was great . . .you would get a really decent story that's clear and concise' (GP5).
The flow of interaction altered with time and was not dissimilar to what happens face-to-face.Typically students would first observe a few consultations, undertake some with the doctor in the room, and then consult independently and present to the doctor, with patient present or absent.However, there were subtle differences, because most consultations were by 'phone.
We touch base first thing in the morning, [the student] would ring me . . .at home.We'd look at my screen and work out who would be appropriate for her to ring . . .she would text me . . .then call me with the history and present . . .I would ring the patient back to follow everything else up.(GP3) Patients needed to know when a supervisor or student was present, and whether to stay online or be called back.Students needed to be reminded to be present and professional and this including dressing appropriately.One participant had students initially working in pairs, and another used a group method.
They presented all ten of their cases.I was driving with the computer and we'd have a discussion, and then they would spend the afternoon calling back their patients with the management plan agreed by everybody.(GP5) Providing continuity for students was important for several participants.Where a patient needed to be seen in-person following a telehealth assessment, the doctor often tried to ensure that the student was involved.

Direct comparison with face to face teaching
Differences between teaching students in face-to-face and telehealth consulting were scene-setting for the consultation, process issues and supervision factors.

Scene-setting
Compared to face-to-face, with remote consultations the doctor and student were more likely to speculate on the reason for a consult ahead of the interaction, and talk about it together: 'Get a better understanding of who the patient is from their clinical record . . .what they might be here for and then . . .focus on what it might be' (GP7).In some cases, doctors shared their own anxieties of telehealth: 'I found it really difficult to adjust, but once I had, I talked to the students about how this was part of practice and we just had to work it out' (GP4).A new introductory 'patter' was created, and students were reminded of the unchanging basics such as models of history-taking, and gaining consent from patients for student involvement.
Process issues.EMR was used more creatively to communicate within the team: 'my staff tell me with either a smiley face or not whether the patient wants to see a student' (GP6).While the format was much the same, the telehealth process was felt to be different.One GP explained that because they could not see the patient: 'it's a very different dynamic . . .I had to get the patient to repeat more even though the student had presented' (GP1).Many different models were described, with everyone virtual, patient virtual, doctor and student in the same or different rooms with patient virtual, 'Threeway Zoom™, so the student is watching the patient's face, the GP's face and watching that interaction . . .that's really valuable learning for the students' (GP3); 'They [student and patient] would be at the clinic, so I would be on Zoom with them and I'd be talking to the patient on the phone' (GP9).One GP used a digital virtual assistant, 'I've set up Alexa in both my rooms so the student can just say, "Alexa, announce I'm ready"' (GP1).

Supervision factors
Ground rules needed to be set for everyone at the start, such as informing the patient that the student will present the history first.Several doctors identified a new focus that came with telehealth: 'I think when you're face-to-face you can get a bit distracted' (GP2).Many supervisors felt less pressured with telehealth, creating space for supervision.'We actually found that sometimes that shortened the consult because the patients prefer the face-to-face which allows them to keep going, but on the 'phone call they've got out everything' (GP8).However, some found it less satisfying: 'I'm comfortable teaching with them face-to-face but doing it over the phone, I found that a bit difficult' (GP7), or that their role was not the same: 'It's very different than face-toface . . .from I'm the hovering supervising person, to being one of three equal voices around the phone' (GP1).

Challenges to remote teaching
Participants identified a number of challenges to teaching medical students during remote consultations, relating to changes in the format, patient and student factors, and issues around consent.

Changes in the format
The unseen, serendipitous or missing information in 'phone telehealth normally observable in face-to-face consultations was frequently cited as a particular challenge for students: 'because you don't have any of those cues that you see when the patient walks, in and I talked to the students about that' (GP4).The loss of the physical examination meant that teaching the normal clinical reasoning process was harder, and without the examination there may be more uncertainty.Students were missing out on the normal flow and interaction of a face-to-face consult: 'there is a certain value in . . .learning how to engage with the patient with a physical exam, getting them undressed, getting them behind a curtain, that would be missed' (GP9).

Patient factors
Managing telehealth consultations where the patient became upset was a challenge, and having a student present added complexity, 'I was telling the student: "This is a lady who's had several back surgeries, she's riddled with pain" . . .and the patient started to weep on the phone which was very difficult' (GP2).

Student factors
Supervisors noticed that students were commonly anxious, but telehealth gave them opportunities to grow their skills: 'It takes them out of their comfort zone, and they might be apprehensive to start with, but overall it makes them a lot rounder in their approach to patient health' (GP3).In a situation where students were taught in a group, a GP describes one student: She was really, really shy at the start . . .you could see on her face, she'd be like woah, I want to do this alone . . .But you know within two weeks when she was more confident, she was happy to start doing it in front of the rest of the team, and she actually noticed that she found more value in doing it [this way].(GP5) Students gained confidence over time, and their supervisors remarked that these new telehealth skills would serve them well going forward: I think their growth was equally substantial.For one student it was a complete transformation.They were completely gaga at the beginning and okay, your turn, and they had to just do it, and then by the end they were saying I can do this (GP4).
However, in-person was generally preferred for learning: 'This week it's been a little bit of phone consults but a lot more face-to-face, which they're enjoying' (GP2).

Consent
The medical programme has a clear policy on consent for student involvement, and staff are familiar with this in practice.Final confirmation of consent, after noting at booking and/or reception check-in is done without the student.However, telehealth added a new dimension.Patients needed to know to whom they were speaking: 'I tell the patient, I have a student with me, we're all in the room together.Some patients say "no, kick them out", and I kick them out' (GP6).Some supervisors found it easier to set up the telehealth consult with the student present, and then seek confirmation of consent, but were aware that the student was then an invisible presence.Others rang the patient first to gain consent, but most started with the student in the room.
'It just seems like I'm imposing on people when I do a telehealth thing and then I'm saying, "And would you like to have a student?"Whereas in the office it's . . ."Hi, come on in, would you mind seeing somebody?"I can broker it a little easier.A bit hard to broker "Oh by the way, we're not doing this face-to-face and we've got a student"'.(GP9)

Advantages to remote teaching
Some advantages to teaching using telehealth were identified, with benefits for students and new opportunities for learning.

Student benefits
It was frequently observed that telephone consults (the most common telehealth interaction in our sample) were more focused: 'The good thing about tele-consult is nobody faffed.Patients didn't go wandering off the topics.There were two issues and we caught them' (GP2).This had benefits for teaching, both in terms of simplifying encounters, but also in providing more supervision time.
The remote nature of telehealth was sometimes a benefit for students, reducing some of the anxiety of face-to-face, 'The students might have felt a little bit more protected because they were on the end of a 'phone, not face-to-face and alone with the patient, so potentially less intimidated' (GP4).Sometimes phone telehealth worked in the favour of the student, with patients being more accepting of their involvement and value: 'I think it eliminated that obvious hierarchy, and I think it improved the patient's trust of the level of knowledge that the student they were talking to had' (GP1).
In some telehealth consultation models, supervisors and students could use non-verbal communication unseen by the patient which could positively influence the flow: 'So she was weeping, "Oh I don't know why I'm being so stupid".I kept putting my finger on my lips to say "Don't interrupt, let her keep going"' (GP2).Supervisors were able to add their existing experience to interpreting the 'unsaid' in a phone consultation, and then unpack that process for students 'There is a patient . . .where we did the phone consult and [the student] listened in, and we had a good discussion about this person who's very stoic, plays down their symptoms.I was no, they need to come in'.(GP8).

Learning opportunities
Teaching by telehealth afforded some learning opportunities with respect to content, training of tutors, and additional material for the curriculum.Students were given more autonomy with the Information Technology systems and learnt to do things that they may not have otherwise, such as triage.Many doctors embraced the opportunities afforded by the pandemic to learn to teach in a different way, explicitly including the patient in teaching.'I get joy from teaching in any way . . .everyone's open to learning, . . .so it's not been a negative experience at all . . .You've got to adapt and get your students enthusiastic as well' (GP3).
Participants frequently identified telehealth consults as a way of sharpening communication skills, historytaking and clinical reasoning, but also in developing important professional skills: 'Really hone in on their interviewing skills and going back to the good old medicine, if you take proper history you can actually reach a diagnosis' (GP5).
There was new learning about other e-medicine modalities in association with telehealth, some of which had not previously existed.
If it was a rash, for example, be great to get a photo of this rash . . .then having to do that extra teaching around this is the system to get the photo and upload it into the records.I have never taught a student that before.(GP10) Telehealth brought safety to the forefront: knowing how to probe with questions, having the right threshold for seeing the patient in-person, putting in place a safe plan and being proactive.'Reaching out to vulnerable patients and families and that's a theme that our students will hopefully take away, you don't just sit here and wait for your patient to call for an appointment' (GP3).Several of the participants raised the necessity for training.Telehealth was new to many, and teaching with telehealth was novel to almost all.They understood the need to adapt and were keen for guidance.'I need to be more cognisant of how I work with the student.Whereas you think this is temporary . . .I think the time has come to do something a bit more . . .' (GP9).There was a unanimous view that teaching skills for telehealth should be part of the curriculum.Participants viewed telehealth as another modality of interaction that is now embedded in practice.Telehealth requires well-developed communication skills and clinical reasoning.
Because telehealth is not going to go away.If you're truly being patient-centric you've got to give them the options of what is best for them . . .Is it part of the curriculum to talk about virtual telehealth consults?I do think it's going to be a bigger scope than just primary care.(GP8)

Discussion
Our study found that teachers needed to make changes to their processes to incorporate students in telehealth delivery, particularly to consultation scene setting and supervision compared with face-to-face teaching.Challenges to remote consultation teaching included issues around consent, but student benefits included new opportunities for learning.
Other commentators have identified the need to reconfigure processes for remote consultation teaching.One English study documents the workflow required to deliver primary care remote teaching consultations during the COVID-19 pandemic [7], and another made recommendations where the students and patients were in their own homes and the supervising doctor was either based at a practice or also at home.These included techniques to signpost the line of communication in three-way consultations, and training students in interpersonal skills for handling remote consulting 'awkward moments' [8].Both issues were confirmed in our setting.Selection of appropriate patients prior to the consultation was considered important in a study [8], as it was for ours.Our participants saw preparation as important, and this is reinforced by a Scottish study where medical students received three-hour training sessions prior to attending general practice placements during COVID-19 [9].Several United States studies have similarly recommended changes to teaching practices for virtual consultations [10][11][12][13].
Our participants identified the challenges and limitations associated with teaching using remote consultations, also noted in other studies.For example, students using a virtual curriculum using telemedicine in the United States generally rated the experience positively, although indicated it lacked good opportunities for performing minor procedures, patient counselling and interprofessional experiences for a small number of final year students [10].An Australian study of remote consultation teaching precipitated by COVID-19 found GP teachers identified new learning opportunities for medical students [14].As found in other research [8,15], a particular advantage conveyed by our participants was the opportunity that telehealth consulting provided to sharpen history-taking skills.
Most of the virtual placements described in the literature were test or pilot cases, involving very few students.In our case however, following the initial online learning programmes developed during lockdown [4], our entire cohorts of Year 5 and Year 6 students returned to general practice placements and conducted remote consultations.GP teachers had to rapidly develop new processes on-the-fly, with many different innovations.

Strengths and limitations
Our study generated a rich dataset from a range of GP teachers, and we used robust methods including independent coding to develop our themes.This is the first study to explore the experience of GPs teaching while consulting with patients remotely, and hence adds to existing knowledge.However, this was in a single context and our findings may not always be generalisable to other contexts.Further, student experience data would have added a triangulation element to the study.

Implications
Clinicians needed to determine the practical logistics and develop the new skill of teaching alongside consulting remotely.Our participants identified a strong need for training in remote teaching, and for telehealth to be incorporated into the undergraduate medical curriculum.Other commentators also recommend this [16], both teachers and learners.Australian medical students who experienced telehealth in rural placements during COVID-19 expressed a wish for this to be embedded throughout their curriculum, and for clinical supervisors to be trained in its use [17].
COVID-19 has propelled the use of telehealth in general practice into usual business and this is likely to stay [18,19].It is important that students are included in telehealth interactions as they provide a context for learning that is both similar and different to in-person indications.Preliminary guidelines for teaching and learning in the setting of telehealth need to be developed and embedded into medical programmes, and then evaluated to test these in practice.