Medical Education And The Shift Towards Telemedicine : Consider This from NPR Medical education must always keep up with the times. But the pandemic forcing medical students to learn virtually revealed new fault lines and opportunities to rethink the way medical professionals should learn. The medical field is grappling with which of those changes should become permanent and which ones could jeopardize the quality of healthcare.

To get a better understanding of how technology has enabled new ways of approaching medical education, NPR's Jonaki Mehta visits Kaiser Permanente's Bernard J. Tyson School of Medicine, a school that was uniquely positioned to adapt to the conditions imposed by the pandemic since it opened during quarantine.

Elisabeth Rosenthal, editor-in-chief of Kaiser Health News and a non-practicing physician, shares her concerns about the medical field leaning more heavily on telemedicine as a result of the pandemic.

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How The Pandemic Shaped Medical Education And, Ultimately, Your HealthCare

How The Pandemic Shaped Medical Education And, Ultimately, Your HealthCare

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Technology consultant Frank Thai creates a 3-D scan of a preserved cadaver in the medical school's Anatomy Resource Center. Kaiser Permanente Bernard J. Tyson School of Medicine hide caption

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Kaiser Permanente Bernard J. Tyson School of Medicine

Technology consultant Frank Thai creates a 3-D scan of a preserved cadaver in the medical school's Anatomy Resource Center.

Kaiser Permanente Bernard J. Tyson School of Medicine

Ashlynn Torres has always been interested in public health, but it wasn't until she shadowed medical professionals that she wanted to become a doctor herself. She says it was "the power of the patient-physician relationship" that convinced her.

A few weeks ago, Torres finished her first year of medical school. It was a year that presented numerous challenges as schools attempted to adapt instruction to keep both students and patients safe during the pandemic.

Torres says witnessing the pain and suffering the coronavirus has caused solidified her choice to become a physician, but at times, she was also frustrated to be so early in her career.

"Our skill set is so limited right now and there's not a lot of hands-on things that we can actually do to improve the situation," she says.

That urge to do something hands-on only became further out-of-reach for medical students around the country as coronavirus outbreaks forced students to learn virtually.

Trading in cadavers for holograms

Torres began medical school during the pandemic last year at Kaiser Permanente's brand new Bernard J. Tyson School of Medicine, which opened its doors to students in July 2020. Before opening, the faculty and staff had more than three months to observe and learn how other schools were navigating the unprecedented challenges the pandemic posed to teaching students.

Kaiser had already decided to invest in state of the art technology with virtual learning in mind before the pandemic, which made it uniquely positioned to transition to remote learning as needed. The campus' Anatomy Resource Center, for example, features real-life preserved cadavers for students to study in the lab, but the specimens also have an unusual attachment that became ubiquitous throughout the pandemic — QR codes.

Dr. José Barral, who is a professor of biomedical science at the Kaiser school, demonstrated scanning the QR code hanging on a tag attached to a preserved human heart. "Just like going to a restaurant, you click the link, but instead of getting a menu, you get a three-dimensional representation of this precise specimen. This is not just a heart, this is this heart," he says.

Once scanned, the students can then access these representations on their personal devices from home. Ashlynn Torres says this manner of learning anatomy works well for her learning process.

"I think it's nice to be able to visualize multiple times kind of like what these structures are, what lies beneath them, because, since it is a software, you can hit the undo button and restore a muscle that you've just dissected," she says.

Cutting into real-life cadavers has long been considered a rite of passage for first-year medical students, but at the Kaiser school — and increasingly across medical schools in the U.S. — students are performing virtual dissections. The school even made the deliberate choice to exclude hands-on dissections on real cadavers from its curriculum altogether.

At Kaiser's anatomy lab, virtual dissections include augmented reality goggles and a hologram of a human body. Barral demonstrates a digital dissection by clicking on a virtual scalpel and clicking away the entire layer of human skin in an instant. "This process would normally take hours to do, and without much learning, really," he says.

Some might argue that tactile learning is lost through digital dissections, but Barral disagrees. "I love dissecting cadavers. I think it's fun and I think it's useful," he says "But I am convinced that this technology is equally effective at learning the anatomical relationships." There are ongoing studies examining how simulated and virtual learning experience compare with more traditional models, but as Barral says, "the jury is still out."

Barral says the point of first-years performing dissections is for students to learn human anatomy and maintains that the tactile experience of performing a surgery can be gained in later stages of medical training if students choose that specialization.

"I think this is the direction that many, many schools are going in the future," he says.

A digital representation of a cadaver in the Anatomy Resource Lab that students can use to virtually dissect and learn anatomy. Students can also visualize cadavers like these in three dimensions using augmented reality goggles that produce a hologram. Jonaki Mehta hide caption

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Jonaki Mehta

A digital representation of a cadaver in the Anatomy Resource Lab that students can use to virtually dissect and learn anatomy. Students can also visualize cadavers like these in three dimensions using augmented reality goggles that produce a hologram.

Jonaki Mehta

Across town at UCLA's David Geffen School of Medicine, which was established over 70 years ago, vice dean of education Dr. Clarence Braddock says that his school, too, was forced to experiment with virtual means of learning during the pandemic. Unlike Barral, he remains skeptical about what the right balance of virtual versus in-person medical education should look like.

"One area where [augmented reality/virtual reality] has not yet met the live dissection or prosection approaches to teaching anatomy [is] variation," he says. "And so the advantage of anatomy is being able to explore in three dimensions — with both visual and tactile senses — the ability to better appreciate the...look and feel of live, human tissue."

Braddock agrees that students can wait until their third or fourth year of medical school to learn those skills, but he still feels something less tangible may be lost for first-years no longer getting that experience.

"In some ways, [a human cadaver] is their first patient," he says. "And it's not a patient with whom, of course, they have a live interaction, but they come to develop a sense of respect for the person that that was." The UCLA medical school even hosts a ceremony in remembrance of the people who donated their bodies to the anatomy lab that the families of the deceased partake in. Braddock says that kind of intimate connection helps young medical students form their identities as future doctors — a connection that cannot be made with a hologram.

Dr. Barral from Kaiser says that no matter how an instructor or school feels about this new way of doing things, medical education must become more efficient in one way or another. As medical science evolves every year, he says there is less time to teach more things. Some schools already find the standard four year format to be too long. "So we really need to find efficient means [for students] to teach themselves," he says, which virtual learning encourages.

A pandemic-fueled shift to telemedicine

Virtual learning may also prepare medical students to work in a new healthcare system that includes an increased number of telemedicine visits. Over the past year and a half, the American healthcare system tested its limits with soaring coronavirus patients, leaving many patients with other conditions untreated. Telehealth, which was already being utilized across most leading healthcare systems in the country, became a ubiquitous way to fill a part of that gap.

In Pennsylvania, the Geisinger healthcare system saw telemedicine visits jump from under 100 per week before the pandemic to about 20,000 per week during the height of the pandemic. Now, that number averages around 6,000 telemedicine visits per week, which is substantially higher than pre-pandemic numbers. Dr. Steven Scheinman of Geisinger Commonwealth School of Medicine is enthusiastic about what telemedicine can accomplish.

"The no-show rate in a telemedicine visit is much lower than for actual visits with patients who have to travel distances to get there ... It's going to be an important part of care delivery in the future, particularly in large, rural areas," he says.

At Geisinger, this shift towards telemedicine was reflected in the school's medical training as students spent more time learning "webside" manner — how to assess patients virtually — rather than traditional in-person practices.

Although virtual medicine has been an important stop gap during the pandemic, some medical professionals worry that efficiency through telemedicine, both in medical training and medical delivery, could be a trade-off for quality healthcare.

Dr. Elisabeth Rosenthal, who is a non-practicing physician and editor-in-chief of Kaiser Health News (unaffiliated with Kaiser Permanente), thinks telemedicine should be used primarily as a screening tool.

"I think we overestimate the value of convenience in telemedicine and underestimate the value of being in an office," she says. Rosenthal says that for her, and for most physicians, the joy of practicing medicine is in interacting with patients. Beyond the gratification, she says if medical students don't get enough hands-on experience with patients, they may not develop a "crucial on/off switch" to determine when telemedicine is actually appropriate and predicts that misdiagnoses will become a more common issue if healthcare continues to tip its scales towards virtual medicine.

Telemedicine also provides incentives for the business of healthcare that Rosenthal worries could hurt the patient. "Telemedicine can be very lucrative, right? You don't have to have exam rooms...If you take it to the extreme, you don't even have to have a hospital or an office. You can just have a phone bank somewhere."

In that scenario, she imagines a patient calling in to a hotline of physicians for virtual help, only to be told to go to an emergency room or see a doctor in-person. "Meanwhile they'll be charging you for that useless advice" she says.

Rosenthal predicts many battles over the interests of hospitals, insurers and patients in the coming years — battles over who is responsible for care, what kind of care is appropriate, and how much that care should cost. "I especially worry that, say, for people who are poorly insured or on Medicaid, that the answer will be you do everything by telemedicine."

Stakeholders in the medical field are in the midst of determining the care and cost models that will shape the industry in years to come. Ultimately, Rosenthal hopes that the future of medical training and care delivery are determined not by business interests, but by what is medically sound.

This episode was produced by Brent Baughman and Jonaki Mehta. It was edited by Sami Yenigun and Lee Hale. Our executive producer is Cara Tallo.