How to Train Surgical Trainees in Digital and Telemedicine During Social Distancing

Since its discovery in December 2019, COVID-19 has changed the way we live and work. In the UK we are living with social distancing of 2 metres, with a slow release of lockdown measures. When social distancing is not possible we should be wearing masks to protect each other. Elective surgery is going to be slow to move to pre-COVID capacity, and clinics are increasingly being performed by telephone or video consultation. Okland et al (2020) have an article in press in J.Surg Education about teaching surgical residents in the COVID-19 era. This concerns technical learning, simulation of procedures with the use of “surgical kits”.

Interactive, small and large group teaching is still ongoing with the help of conference or meeting platforms. In the North West of England this has been led by strong example by the orthopaedic group on a custom-built live platform.

In the UK, pre-COVID-19, secondary/tertiary level care has generally continued to provide face-to-face clinics in preference to other modes of patient contact. In the Lancet perspectives, Dorsey and Topol (2020) discuss the adoption of telemedicine more broadly, and comment that ‘the UK’s National Health Service Long Term Plan says, “digitally enabled care will go mainstream”’. COVID-19 has fast tracked this. However, how have we trained ourselves and our trainees to perform this style of consultation to gain the most from it? Eppich et al (2018, 2019), comment on using simulation to train doctors in how to prepare for professional interactions by telephone. Cooper and Alexander (2019) have performed a scoping review to examine the characteristics necessary for the initial telephone consultation with a patient, what skills are required, and what training should be given to those undertaking these phone consultations. They comment that communication and listening skills are key, along with the ability to convey empathy on the phone. They recommend specific communication and listening training, standards, observation periods, training packages and assessment of competency.

Currently, we are in a situation of full speed ahead and certainly where I work, we are now completing the vast majority of clinics by telephone or video with few face-to-face appointments. Personally (as an artist as well as a surgeon) I feel that it is critical to enable the patient to paint a picture for you in your mind. The skill of asking questions to bring out the story and the examination without seeing the patient and their parent is very different to normal. Listening is key and asking open questions as there are no clues from body language, nor from the examination. Silence is golden, and often allows the patient the room to say what they need to say. These are all skills we are likely to have learnt and utilised on a regular basis, however they need to be used together, and skilfully to gain an accurate picture. I have started to dial in with my trainees to allow us to build these skills whilst maintaining patient safety. Feedback from the trainees has been positive and they have enjoyed the opportunity of being observed performing this different type of consultation. We speak about the interactions and fill in appropriate CBD and CEX’s. Below are the tips enabling me to achieve this:

1. Make sure clinic load is manageable and identify patients you wish to observe/be observed in talking to. Often 2 cases which are similar are useful as you can see growth and change throughout the 2 consultations.
2. Initial discussion through the case, possible eventualities and likely management strategy, which allows you as the consultant to remain as quiet as possible once the consultation begins.
3. Phone the patient, explain you will be performing a conference call and then use the add call (on most smart phones) and merge the 2 conversations.
4. Explain that the trainee will be leading the consultation. As the consultant, I will only interrupt if I feel more questions need asking or if I am requested to intervene or asked a direct question. If this is the case, you need a way of handing the consultation back to the registrar – get them to explain something, but signposting this is important so the patient knows who they are talking to.
5. After the call, stay on the line for a debrief, and planning of the next consultation.
6. The more silent you can remain the easier it is for the trainee to lead. So hold your tongue (hard for me), they may have a different style to you, ask questions in a different way, but as long as the info is gained accurately there is no need to interrupt.

Problems encountered have been failure to merge calls. As long as the trainee is happy with the consultation and plans, this isn’t a disaster. If they are very junior/very concerned about this potential, the consultant should make the call and merge call so if it fails you are not leaving the trainee or patient in a vulnerable position.

Attend Anywhere and software allowing MDTs as phone or video can also be used as long as technology is available. As I have pointed out to my management the only problem with this type of consultation is you may disadvantage those families who do not have ready access to a computer, or have limited data allowance. The telephone is widely available and less likely to discriminate.

So let’s carry on training, find novel ways to teach and feedback and keep our patients safe. Good luck.

References

Cooper K., Alexander L. Conducting initial telephone consultations in primary care: a scoping review. Int J Evid Based Healthc 2019; 17: S38-S40

Dorsey ER., Topol EJ. Digital medicine. Telemedicine 2020 and the next decade. Lancet 2020; 395: 485

Eppich WJ et al “Learning the Lingo”: A grounded theory study of telephone talk in clinical education. Acad Med. 2019; 94: 1033-1039

Eppich WJ et al. Learning how to learn using simulation: Unpacking disguised feedback using a qualitative analysis of doctors’ telephone talk. Medical teacher 2018; DOI:10.1080/0142159X.2018.1465183

Okland TS., Pepper JP., Valdez TA. How do we teach surgical residents in the Covid-19 era? J Surg Ed 2020; DOI:10.1016/j.surg.2020.05.030

About the author:

Sarah Wood MBChB.BSc (Pathological Sciences) .MA (Healthcare Education). FRCS Paed Surg

Paediatric Surgical Consultant, Alder Hey, Liverpool.