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Telehealth Attitudes, Training, and Preparedness Among First-Year Internal Medicine Residents in the COVID-19 Era

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Introduction

The COVID-19 pandemic increased demand for direct, real-time patient care telehealth services such as video visits and phone visits to reduce patient and health care worker exposures. In response, medical residents began providing remote visits to their patients and the Accreditation Council for Graduate Medical Education (ACGME) promoted acceleration of telehealth during residency training.1 However, it is unknown whether undergraduate medication education (UME) prepared incoming residents in 2020 to provide remote patient care using video and phone visits.

Descriptions of telehealth training during UME and graduate medical education (GME) have been limited before the COVID-19 pandemic. Surveys of medical schools show that the number and percentage of medical schools offering telehealth courses increased from 2013 to 2018, reaching 60% of all medical schools surveyed.2 At the GME level, a survey of family medicine residency program directors in 2015 found that only 17% of respondents reported the use of live interactive video visits.3 Published data on the frequency and depth of telehealth care in internal medicine (IM) residency programs are lacking.

The COVID-19 pandemic’s effect on medical school telehealth training has not been well described. The pandemic has heightened advocacy for the expansion of telehealth services worldwide,4 leading to increased reimbursement policies, reduced regulatory requirements,5 and large-volume increases in video and phone visits.6,7 Although this increased demand may have led to an increase in training, it may also have been offset by the cancellation of clinical clerkships8 to protect medical students and preserve personal protective equipment.

This study’s objective was to describe the current state of IM interns’ attitudes, training, and preparedness in the use of telehealth, focusing on two skills required for ambulatory patient care: real-time videoconferencing and phone visits.

Materials and Methods

SETTINGS AND PARTICIPANTS

We conducted a cross-sectional survey of IM interns at four different IM residency programs in the United States from June to September of 2020. Interns start ambulatory clinics at varying times across sites. Surveys were administered at the beginning of ambulatory continuity clinic experience in order for that experience not to affect self-assessment of preparedness. Survey questions were developed by the authors, adapting previous experience with surveying residents at these sites, as there are no previously validated survey instruments. Question topics included attitudes toward training and delivery of clinical care via video or phone visits; how much training and clinical experience in video or phone visits they had during medical school; whether the COVID-19 pandemic affected their training; and how prepared they rated themselves in delivering primary care using video or phone visits (Appendix A1). Surveys were distributed online via either Survey Monkey (SVMK, Inc.) or Microsoft Forms (Microsoft Corporation). The U.S. regions were assigned by U.S. Census Bureau definitions. There were no financial incentives for completing the survey.

STATISTICAL ANALYSIS

Analysis was performed by using STATA 14 (StataCorp). The Likert scale questions contained five categories, which by some sources can be considered continuous.9 Skewness and kurtosis tests showed that the Likert scale questions did not follow a normal distribution in responses—thus we ran both chi-squared tests for significance of difference between groups and Wilcoxon rank-sum tests or Kruskal Wallis tests to attempt to preserve the ordinal nature of the data. The significance of our results did not change between the chi-squared and ordinal nonparametric tests. For ease of interpretation, the Likert variables were dichotomized into binary variables and significance results are reported as chi-square tests. Nonordinal categorical variables were compared by using chi-square tests of significance (determined at p < 0.05).

Each site obtained Human Subjects Research exemption.

Results

DEMOGRAPHICS

One hundred fifty-six surveys were collected from 190 eligible interns (response rate 82%). The surveyed population represented 86 different medical schools. Of those whose clinical training took place in the United States, regional distribution was as follows: 25% Northeast, 27% Midwest, 29% South, and 19% West.

ATTITUDES

A majority of respondents, 77% (117/152) agreed or strongly agreed that video visits are an effective means to deliver primary care (Table 1). Prior video visit experience during medical school was not associated with agreeing that such visits are effective (13/15, 87% prior experience versus 103/135, 76%, no prior experience, χ2 = 0.83, p = 0.36). In contrast, only 35% (55/156) of all subjects believed that phone visits are effective, with a statistically significant difference between those who had experience conducting phone visits (17/29, 59%) and those who had not (38/125, 30%) (χ2 = 8.2, p = 0.004). Interns valued telehealth training: 75% (117/156) rated training for video or phone visits to be important or very important. Prior telehealth training was not associated with a difference in how frequently training was perceived to be important (χ2 = 3.4, p = 0.34). Similarly, prior clinical experience with video or phone visits was not associated with perceived importance of telehealth training (video χ2 = 0.001, p = 0.97; phone χ2 = 0.01, p = 0.94).

Table 1. Attitudes Pertaining to Telehealth Video and Phone Visits Among Internal Medicine Interns at the Start of Residency
SURVEY ITEM PERCENT (x/n) SIGNIFICANCEa
Video visits are an effective means to delivery primary careb
 Overall 77 (117/152) —
 Prior video visit experience 87 (13/15) p = 0.36
 No prior video visit experience 76 (103/135)
Phone visits are an effective means to delivery primary careb
 Overall 35 (55/156) —
 Prior phone visit experience 59 (17/29) p = 0.004
 No prior phone visit experience 30 (38/125)
View telehealth training in the use of video or phone visits during medical school as importantc
 Overall 75 (117/156) —
 Received >4 h training 100 (2/2) p = 0.34
 Received 3–4 h training 100 (4/4)
 Received 1–2 h training 81 (26/32)
 Received no training 72 (83/116)
 At least one prior video visit 75 (12/16) p = 0.97
 No video visit experience 75 (103/138)
 At least one prior phone visit 76 (22/29) p = 0.94
 No phone visit experience 75 (94/125)

MEDICAL SCHOOL TRAINING AND EXPERIENCE

The majority of interns reported receiving no dedicated training in video or phone visits during medical school (116/156, 74%). Among the interns who did receive training, the vast majority had 2 h or less (32/38, 84%) (Fig. 1). Similarly, their self-reported clinical experience in conducting telehealth clinic visits was low, with 90% (138/154) reporting no experience with video visits and 81% (125/154) reporting no experience with phone visits. Very few interns reported substantial medical school experience with video or phone visits (6 or more video visits, 4.6%; 6 or more phone visits, 5.8%) (Fig. 2). Those who attended their clinical clerkships in the South and the West had higher rates of telehealth video or phone visit training (29% and 30%, respectively) than the Northeast and the Midwest (22% and 21%, respectively).

Fig. 1.

Fig. 1. Prior telehealth training in the use of video and phone visits among IM interns at the start of residency in 2020. Respondents were asked how many hours of training (defined as a dedicated teaching or training session(s)—separate from direct clinical experience) in the use of telehealth video or phone visits they had during medical school. Columns represent the percent of respondents in each category (total n = 156). IM, internal medicine.

Fig. 2.

Fig. 2. Prior telehealth experience in the use of video and phone visits among IM interns at the start of residency in 2020. Respondents were asked the number of video visits and phone visits they conducted, or assisted with conducting, during outpatient medical school clerkships (direct patient care only, not simulated experiences). Columns represent the percent of respondents for each level of experience for video visits (gray, total n = 154) or phone visits (black, total n = 154).

EFFECT OF THE COVID-19 PANDEMIC

The COVID-19 pandemic reduced clinical care during medical school for the majority of interns, with 69% (108/156) reporting having missed at least some clinical time, and 33% (51/156) missing 5 weeks or more. Interns whose majority of clinical experience during medical school was in the South or international were less likely to have missed clinical time due to the pandemic (Northeast 78%, Midwest 74%, South 55%, West 85%, international 25%; χ2 = 13.2, p = 0.01). Interns’ career choices were, by and large, not affected by the pandemic (90% unaffected, 9.0% more likely to pursue specialty training, none more likely to pursue primary care, and <1% more likely to pursue either hospital medicine or nonclinical work). The majority of interns felt that the COVID-19 pandemic did not affect ambulatory care preparation (87/156, 56%), whereas a substantial minority (64/156, 41%) felt that it worsened their preparation, with only 3% (5/156) who felt that their preparation improved.

PREPAREDNESS FOR AMBULATORY CARE DURING RESIDENCY

A majority of interns, 58% (90/156) reported feeling at least moderately prepared overall for ambulatory care (Table 2). However, only 12% felt at least moderately prepared to conduct either video (18/155) or phone visits (19/156). Those with prior experience with video visits were more likely to feel at least moderately prepared to provide video visits but this relationship was not significant (19% vs. 11%, p = 0.4). Phone visit experience, however, was significantly associated with preparedness for phone visits (24% vs. 9%, p = 0.02).

Table 2. Self-Assessed Preparedness in the Use of Video and Phone Visits Among Internal Medicine Interns at the Start of Residency
SURVEY ITEM PERCENT (x/n) SIGNIFICANCEa
Self-assessed overall preparedness for managing patients in primary care clinicb 58 (90/156) —
Self-assessed preparedness for managing patients in primary care using video visitsb
 Total 12 (18/155) —
 Prior video visit experience 19 (3/16) p = 0.4
 No prior video visit experience 11 (15/138)
Self-assessed preparedness for managing patients in primary care using phone visitsb
 Total 12 (19/156) —
 Prior phone visit experience 24 (7/29) p = 0.02
 No prior phone visit experience 9 (11/125)

Discussion

In this cross-sectional study of IM interns, we found that interns value training in the use of real-time video and phone visits for ambulatory care, yet the vast majority received little training or clinical experience in this type of telehealth during medical school. More interns believed that primary care delivered via video visits is effective compared with phone visits. The majority of interns felt prepared for primary care overall, but few felt prepared to deliver primary care using either video or phone visits.

Previous studies of postgraduate trainees’ attitudes toward telehealth in family medicine and psychiatry residency programs found similarly favorable views.10–12 Dermatology residents report high levels of satisfaction with teledermatology, although such care typically involves the use of store-and-forward of clinical images, rather than the live, real-time videoconferencing that is more relevant to primary care.13 In addition to describing the attitudes of IM interns, which have not been previously well characterized, we additionally identify a potential concern regarding the perceived lower effectiveness of phone visits compared with video visits. Although the reasons for this finding were not explored in this study, video may facilitate a stronger human connection and allow for the use of physical exam elements that audio-only visits cannot replicate. Rural health leaders have advocated that video visits are preferred over phone visits, citing evidence for equal efficacy of video visits compared with in-person visits for mental health care.14,15 If video visits are, in fact, superior to phone visits, then disparities in care may be exacerbated by variations in broadband access16 and access to videoconferencing technology. Notably, the IM interns who had previously participated in phone visits were more likely to find them effective than those who had not, suggesting that experience may enhance the perceived role of phone visits. A single-site study of IM residents in August of 2020 showed a strong preference for in-person visits over phone visits; however, video visits were not conducted at that program.17

Despite widespread advocacy for telehealth training, there are surprisingly few studies of telehealth training that occurs during medical school. The most recent data available from the Association of American Medical Colleges (AAMC) show that 44 out of 147 schools offered pre-clerkship courses and 68 offered clerkship courses.18 A review of medical school telehealth training found that it was more common in specialty care (e.g., psychiatry, neurology, dermatology, radiology) and in the Midwest region.19 These studies, however, included both required and elective courses, and they did not define what skills were taught. Our study’s findings that three quarters of IM residents reported receiving no formal telehealth video or phone visit training during medical school suggest that UME telehealth trainings were either not elected or, if chosen, represented telehealth curricula that did not include the vital skills in video and phone visits needed to conduct real-time remote patient care. These findings echo a survey of medical students in the United States conducted before the COVID-19 pandemic in which only 20% reported having telemedicine training offered at their medical school, and 43% were unsure whether such training was available.20 Unfortunately, the majority of IM interns in this study missed clinical time due to the COVID-19 pandemic, a potentially lost opportunity to conduct telehealth training.

The limited nature of medical school training and direct patient care experience using video or phone visits translated into low levels of self-reported preparedness in these telehealth methods at the start of residency. Low confidence levels in using phone visits to manage chronic diseases have been reported among IM residents.17 Low levels of confidence have been found in prior studies to be a potential barrier to telehealth use.21 This lack of preparedness identifies an important “catch-up” need during residency. Data pertaining to residency programs’ training are limited. Surveys of other GME programs indicate that exposure increases comfort. For example, dermatology residents exposed to teledermatology during residency were more likely to feel comfortable practicing teledermatology after residency.22 However, exposure to live virtual visits was low in primary care settings in the pre-COVID era, with a survey of family medicine program directors reporting that less than one fifth of programs used live-video visits, and only 3% reporting that their residents conducted such visits on at least a monthly basis; rather, most telehealth was practiced via asynchronous services such as e-consults.3 In addition, previously published telemedicine education initiatives in IM residency programs emphasized adjunctive chronic disease management and nonvisit-based telephone medicine, rather than virtual visits.23–25 More research is needed to clarify whether IM residency programs are able to close this preparedness gap in the use of video and phone visits.

This study has limitations that are common to survey-based cross-sectional studies. Respondents’ recollection of medical school training is subject to recall bias, and it is possible that a single, distant training session may be forgotten. However, as the survey was conducted during the first 3 months of residency, and within 6 months of the start of the COVID-19 pandemic in the United States, it is likely that the recollection of medical school clerkship experience is accurate, especially as to whether the intern conducted video visits during medical school and the amount of time missed due to the pandemic. Other limitations include that survey questions query self-assessed preparedness and do not assess clinical competency. Finally, we did not survey all IM interns in the United States; however, our sample represented a large number of different states and regions.

Opportunities for future research include repeated surveys over time to identify temporal trends. Although this study shows that the rapid deployment of telehealth, by and large, did not reach the current cohort of IM interns in 2020 before completing medical school, published responses to the pandemic in UME and GME are likely to grow: One medical school conducted a pilot study in the COVID-19 era in which third-year medical students use video medicine visits during their IM clerkship.26 If similar curricula become widespread, then training for the residency class starting in 2021 would be expected to improve. In addition, further identifying learners’ needs through either quantitative assessment or qualitative studies, as has been done in the psychiatry literature,27 may help to establish the scope and depth of telehealth training necessary during residency.

Conclusions

Our data constitute both a snapshot of what is needed moving forward in IM residency telehealth training and a glimpse backward at what was taught and experienced during medical school. This study suggests that there is opportunity during medical school to better prepare future IM residents for outpatient video and phone visits, as IM interns surveyed had positive attitudes toward such care delivery, but little prior training or experience. Compounding this training deficit may be a lack of opportunity, as a substantial proportion of current interns missed at least some portion of their clinical training due to the COVID-19 pandemic. Until medical school telehealth training is expanded, there is an ongoing need to conduct such training during residency.

Authors’ Contributions

All authors meet criteria for authorship.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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Appendix A1. Survey

Thank you for participating in this survey.

FOR THE FOLLOWING QUESTIONS
 “Video Visit” = A clinic appointment using real-time videoconference (both video and audio) to deliver clinical care.
 “Phone Visit” = A clinic appointment conducted via telephone only (no video) to deliver clinical care.
 “Telehealth” = All types of remote health care delivery.

1. I believe that the following Telehealth visits are an effective means to deliver primary care:

  STRONGLY DISAGREE DISAGREE NEUTRAL AGREE STRONGLY AGREE
Video visits ○ ○ ○ ○ ○
Phone visits ○ ○ ○ ○ ○

2. How important is it to receive training in conducting Telehealth Video Visits or Telehealth Phone Visits during medical school?

NOT IMPORTANT MINIMALLY IMPORTANT SOMEWHAT IMPORTANT IMPORTANT VERY IMPORTANT
○ ○ ○ ○ ○

3. How many hours of training (defined as a dedicated teaching or training session(s)—separate from direct clinical experience) in the use of Telehealth Video Visits or Telehealth Phone Visits have you had during medical school?

0 (NONE) 1–2 H 3–4 H GREATER THAN 4 H UNSURE
○ ○ ○ ○ ○

4. How many of the following Telehealth visit types did you conduct, or assist with conducting, during outpatient medical school clerkships? (Direct patient care only, not simulated experiences)

  NONE 1–5 6–10 11–20 >20
Video visits ○ ○ ○ ○ ○
Phone visits ○ ○ ○ ○ ○

5. How much clinical medicine (defined as clerkships in which you took care of patients) during your medical school experience was cancelled because of the COVID-19 pandemic?

0 (NONE) 1 DAY–4 WEEKS 5–8 WEEKS 9–12 WEEKS MORE THAN 12 WEEKS
○ ○ ○ ○ ○

6. Are you interested in a career in primary care?

7. How has the COVID-19 pandemic affected your thoughts on potential career choice?

MORE LIKELY TO PURSUE PRIMARY CARE MORE LIKELY TO PURSUE HOSPITAL MEDICINE MORE LIKELY TO PURSUE SUBSPECIALTY MEDICINE MORE LIKELY TO PURSUE NONCLINICAL CAREER OPTIONS HAS NOT AFFECTED MY POTENTIAL CAREER CHOICE
○ ○ ○ ○ ○

8. How has the COVID-19 pandemic affected your overall preparation to provide ambulatory internal medicine care?

STRONGLY WORSENED SOMEWHAT WORSENED NEUTRAL SOMEWHAT IMPROVED STRONGLY IMPROVED
○ ○ ○ ○ ○

9. How many total days of adult primary care clinic rotations have you had during your fourth year of medical school (including family medicine, internal medicine, med/peds clinic, urgent care)?

___________ (write-in)

10. What is the last month/year of your most recent adult primary care rotation (Including family medicine, general internal medicine, med/peds clinic) during medical school?

___________ (write-in)

11. Please rate how prepared you are based on your experience with primary care:

  NOT AT ALL PREPARED SLIGHTLY PREPARED MODERATELY PREPARED QUITE PREPARED EXTREMELY PREPARED
How prepared are you to manage patients independently in a primary care clinic based on your medical school training? ○ ○ ○ ○ ○
How prepared are you to manage patients in primary care video visits based on your medical school training? ○ ○ ○ ○ ○
How prepared are you to manage patients in primary care phone visits based on your medical school training? ○ ○ ○ ○ ○

12. In what state (if United States) or country (if outside the United States) did you have the majority of your clinical clerkships during medical school?

___________ (write-in)





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