Bedside to 'Webside': Telehealth training for rheumatology fellows could bridge care gaps
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When it comes to rheumatology and telemedicine, the general consensus is that COVID-19 has dragged the field, kicking and screaming, into the 21st century.
But at least one expert was planning for the eventuality of telemedicine in rheumatology even before the pandemic struck.
A proposal to integrate telehealth as a component of rheumatology fellowship training earned Marcy B. Bolster, MD, a rheumatologist at Massachusetts General Hospital, the Clinician Scholar Educator Award from the Rheumatology Research Foundation. Prior to the pandemic, Bolster believed that telemedicine could help to address the rheumatology workforce shortage and the uneven distribution of practitioners around the U.S., particularly in underserved regions such as the Rosebud Indian Reservation in South Dakota, where she is piloting the curriculum.
The goal of her project is to train rheumatology fellows in all aspects of telemedicine, from synchronous and asynchronous care, to “webside manner,” to the use of various interactive technologies. COVID-19 has accelerated the necessity and urgency of such training among all rheumatology providers.
With this in mind, a program like Dr. Bolster’s is positioned to be an essential tool for any rheumatology provider moving forward. Healio Rheumatology sat down with her to discuss the past, present and future of her plan.
Q: Could you provide some background on your proposal?
Bolster: I decided to apply for the Clinician Scholar Educator Award because I believe that this grant is an impactful way to provide professional development in the area of medical education. Some colleagues who have received this grant have created incredible resources to provide for people who have an interest in medical education. I wondered where I similarly could have an impact. This was before COVID.
I helped lead the Graduate Medical Education component for the 2015 ACR Workforce Study, which revealed that there is a huge gap between supply and demand for rheumatology providers. I thought about how to prepare ourselves for this growing gap. One way is to focus on trying to train more fellows — as a program director, I am definitely in favor of that.
But even if we double the number of trainee slots, we still will not overcome the increasing gap. This made me think about how we can address access to care as well as, more specifically, provide care to underserved areas. It occurred to me that developing a telehealth curriculum would be a good way to bridge that gap. Training rheumatology fellows in telehealth, before they become the new entrants into our workforce, would allow us to expand our abilities and access to care for patients.
Q: Where did you start with this program?
Bolster: The Rosebud Indian Reservation in South Dakota has a relationship with my institution. This seemed like a natural place to pilot this in terms of providing care to an underserved area, so we contacted the medical director at Rosebud, within the Indian Health Service.
Q: What are the parameters of the proposed curriculum?
Bolster: One of the best ways for fellows to learn is through direct observation by a faculty preceptor. In our proposed curriculum, a faculty member (me) observes the trainee delivering synchronous virtual care from start to finish of a visit.
In this way, as the preceptor participating in direct observation, I can provide feedback on all aspects of the virtual encounter, such as, the trainee’s interactions with the patient — aka, their “webside manner” — the virtual physical exam, as well as everything that occurs before, during and after the visit. The curriculum also features simulated telehealth patient encounters, with direct observation in a precepted environment for synchronous patient care visits.
I am developing checklists for clinical performance to be used in observed virtual encounters. These checklists will also be applicable to simulated encounters as may occur in a rheumatology observed structured clinical examination, or ROSCE. The curriculum and assessment tools are designed to optimize the trainee’s ability to achieve competency.
Q: Does the program extend beyond individual doctor-patient visits?
Bolster: Yes. The third part of the project is to participate in a didactic series to provide rheumatology education to the primary care providers at Rosebud and surrounding health centers. A rheumatology fellow from my institution has created a schedule of monthly didactic sessions in collaboration with the Rosebud primary care providers and myself. The fellow plans and creates case-based didactic sessions with my feedback and leads these discussions with the providers.
This is another opportunity for direct observation, as I attend each conference and provide feedback through a formal evaluation form as well as via one-to-one discussion with the fellow after the session. We also request formal feedback from the primary care provider attendees. These fellow-led sessions have been exceptional and very well-received.
Q: Given that many established rheumatologists did not grow up with virtual technology, while many fellows did, were the fellows able to provide some insight on the curriculum?
Bolster: It definitely functions best as a two-way street, so, importantly, there should be ample time and space for fellows to provide feedback to the faculty member in the same way the faculty member is providing feedback for the fellow. We can all learn from each other. There is not anyone out there that knows it all.
Q: Why do rheumatologists, in particular, need this training in their curriculum?
Bolster: It all relates to the workforce shortage. There are so many underserved communities and regions in this country. Telehealth improves access to care in those places, but even beyond access, patients are highly satisfied with telehealth. Many patients have to spend hours in the car for a 30-minute visit. With telehealth, they log on 5 minutes early for that same visit, and it only takes 35 minutes of their day. They do not have to deal with the frustrations of traffic or be nervous about the difficulties or expense of parking in the city. It is cost-saving, time-saving and angst-saving.
Q: Are there drawbacks to the curriculum or areas that still need work?
Bolster: Not everyone has access to Zoom or the other video platforms that are used for virtual care. An audio-only visit does not provide the same depth of care for most patients. Some patients are unfamiliar with any of the technologies that we use.
We are currently working on establishing the synchronous visits for virtual care delivery at the Rosebud Health Center. There have been delays due to COVID-19 to be able to create the precepted synchronous virtual care visits. We are also working on establishing an e-consult system between MGH Rheumatology and Rosebud.
Q: Have you received patient feedback on the curriculum?
Bolster: No, but that is an important point. Because of COVID, I have not been able to be in touch with patients in the same was as I had planned with my grant proposal that was written before the pandemic. We are still working out both synchronous and asynchronous delivery of health care. As we work through that, we will have the opportunity to obtain feedback from patients, which will be essential for the advancement of this curriculum.
Q: Could you discuss the future of the program?
Bolster: This is a 3-year project. We started in July 2020 and have until June 2023. COVID has obviously helped it along in some ways and been a barrier in others. Probably the most important way it helped is that COVID forced everyone to engage in telehealth. It is difficult to predict how things will change as the pandemic evolves. I will say that I am excited to advance this work and accomplish even more in the next year and a half plus.
For more information:
Marcy Bolster, MD, can be reached at 55 Fruit Street, Bulfinch 165, Boston, MA 02114; email: tim@markstein.com.
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