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.

In participating regions, you'll also hear a local news segment that will help you make sense of what's going on in your community.

Email us at considerthis@npr.org.

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

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AUDIE CORNISH, HOST:

Mock patient visits are a normal part of medical school, a way for doctors-in-training to practice their clinical and conversational skills.

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ASHLYNN TORRES: We are practicing having kind of serious conversations with patients.

CORNISH: What's not exactly normal is your patient disappearing right before your eyes.

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TORRES: And my Wi-Fi kept going out, and then so I just fully dropped out of the call. And then I came back in, and I was like, so sorry about that. Like, I just think that...

CORNISH: For Ashlynn Torres, walking a patient through technical difficulties is actually a routine part of her training. Her med school, Kaiser Permanente's Bernard J. Tyson School of Medicine, opened its doors a year ago. It's just outside LA, and they opened during the pandemic. Students there haven't just been practicing bedside manner. They've been learning about webside (ph) manner.

TORRES: Yeah, so we talked in class about if you're on a telehealth visit and then you can't really see them well or how to kindly ask them to adjust their camera. And then, sometimes, too, there's tech difficulties. Like, the patient's muted, and they don't realize they're muted. And then...

CORNISH: Kaiser is one of many med schools that had to adapt during the worst of the pandemic - teaching labs, lectures and much else online. Now, that shift has been hard, but it's also showed health care educators across the country that there are benefits to using remote technology in health care training.

STEVEN SCHEINMAN: With moving online when COVID hit, it kind of helped us push the envelope as to what you can achieve with simulation.

CORNISH: Dr. Steven Scheinman is president and dean of the Geisinger Commonwealth School of Medicine in Pennsylvania.

SCHEINMAN: I think that will move simulation farther forward as part of medical education.

CORNISH: CONSIDER THIS - remote technology changed the way people work in all kinds of industries during the pandemic. But now the medical field is grappling with which of those changes should be permanent. We'll explain what that could look like for you and your doctor. From NPR, I'm Audie Cornish. It's Monday, July 19.

It's CONSIDER THIS FROM NPR. Virtual lectures, simulated dissections - these aren't brand-new technologies. Med schools have been experimenting with them for many years now. But when the pandemic forced most students home, Dr. Christopher Friese said new fault lines were exposed.

CHRISTOPHER FRIESE: I've had students attending class in their cars, you know, pulled up to a restaurant where they can get good Wi-Fi because they don't have good Wi-Fi at home or they don't have an environment at home where they can be in a quiet space and participate.

CORNISH: Dr. Friese teaches nursing and health management at the University of Michigan. He says inequities like these changed the way he and his colleagues thought about instruction.

FRIESE: It made me think about meeting the student where they are. If they can't turn their camera on, that's OK as long as we can find a way to connect and engage. And so that's on me to create that environment where they can participate, they can be safe and they can learn. It's not as easy as turning Zoom on. It's a lot more complicated.

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CORNISH: And that's just one way medical educators have been rethinking the way they teach. At Kaiser Permanente's new medical school, technology helps students learn anatomy virtually and through simulated means. Their state-of-the-art anatomy lab - it's like a trip to the future. Yes, there are real cadavers stored away in cabinets rolling around on wheels.

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CORNISH: But in this lab, put on a pair of augmented reality goggles, and a hologram of a cadaver appears before your eyes, one that students can collaboratively dissect. And then those students can continue anatomy practice at home with digital representations of specimens from class on their laptops.

TORRES: I think it's nice to be able to visualize multiple times kind of, like, what these structures are, what lies beneath them because...

CORNISH: Again, first-year medical student Ashlynn Torres.

TORRES: Since it is a software, I mean, you can, like, hit the undo button and restore a muscle that you've just dissected. And so you can really get a sense for what's in the body. And I just appreciate being able to, I think, take that at my own pace as a learner.

CORNISH: NPR's Jonaki Mehta visited the school to learn more about how med students learn, even if at times they can't be there in the flesh.

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JOSE BARRAL: What I'm doing is I'm just taking my iPhone, and I direct the camera to this QR code.

JONAKI MEHTA: That is Dr. Jose Barral. He's professor and chair of biomedical science at Kaiser Permanente's new medical school.

BARRAL: What's happening is it's reading the QR code.

MEHTA: It's like going to a restaurant these days.

BARRAL: It's exactly like getting a menu, yeah. But instead of getting a menu, you get a three-dimensional representation of this precise specimen.

MEHTA: We're in the anatomy lab where Barral teaches medical students. And that specimen in his hand is a real preserved human heart. Attached to it is that QR code he mentioned.

BARRAL: The students can now get it on their iPhone, tablet, whatever they have.

MEHTA: And it's not just a heart. Students can dissect 3D renderings of entire human bodies or put on augmented reality goggles and perform dissections on holograms.

BARRAL: I come back to my control panel, and I choose the virtual scalpel.

MEHTA: The entire layer of human skin just disappeared with the click of that virtual scalpel.

BARRAL: And this process would normally take hours, without much learning really.

MEHTA: It might save time, but I ask Barral if students are missing a learning opportunity by not doing the real thing.

BARRAL: I have had many years of doing traditional cadaveric dissections. I love dissecting cadavers, but I am convinced that this technology is equally effective at learning anatomical relationships.

MEHTA: Barral says it's OK if students wait to get their hands on actual bodies because it's more helpful once they're preparing to do real surgeries anyway. Across town is UCLA's David Geffen School of Medicine. Now, they've been around for 70 years, but they're also shifting towards more virtual instruction.

CLARENCE BRADDOCK: Our experience with the pandemic helped us to realize the things that we could actually do remotely but also to realize what was lost or could be lost.

MEHTA: Dr. Clarence Braddock is a vice dean for education at UCLA's medical school. He says things like admission interviews and lectures may well stay online for the long run. And he agrees with Kaiser's Dr. Barral that simulated dissections can help first-years learn the fundamentals of human anatomy. But he does have reservations about losing the hands-on experience. He says it helps students...

BRADDOCK: To better appreciate the look and feel of live human tissue.

MEHTA: The outcomes of simulated medical training are still being researched. It's too early to tell how effective it is. And there's another thing Braddock says students could miss out on - a kind of relationship.

BRADDOCK: The medical student who's in an anatomy lab - in some ways, that's their first patient. They come to develop a sense of respect for the person. And in fact, every year, we hold a celebration and remembrance for all the patients who became the cadavers in the anatomy lab.

MEHTA: Braddock says these experiences are pivotal in helping students form their identities as physicians. But Dr. Jose Barral from Kaiser says no matter how an instructor or school feels about this new way of doing things, medical education has to become more efficient.

BARRAL: As we learn more and more about basic science, there is less and less time to teach it, right? So medical school is four years. Some schools are moving to shorter. So we really need to find efficient means to teach themselves.

MEHTA: Which could look like students practicing surgery on a digital heart in their bedrooms.

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CORNISH: That's NPR's Jonaki Mehta.

While younger doctors may come up in a field where remote technology is the new normal, for a lot of practicing physicians, it still feels all really new and a lot to manage. Steven Scheinman with the Geisinger Commonwealth School of Medicine, again, in Pennsylvania - he says before the pandemic, his hospital system handled less than a hundred virtual patients a week.

SCHEINMAN: With COVID, within a few months, Geisinger went up to 20,000 telemedicine visits a week, half of which were video visits.

CORNISH: Now, that's leveled off to about 6,000 but still a huge jump from the before times. And there are benefits.

SCHEINMAN: The no-show rate in a telemedicine visit is much lower than for actual visits when patients have to travel distances. There are certain things that you cannot do directly. But telemedicine, particularly in large rural areas, we know is going to be an important part of care delivery in the future.

CORNISH: And some doctors think that's an upside that's worth potential trade-offs, but not Elisabeth Rosenthal.

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ELISABETH ROSENTHAL: I think we overestimate the value of convenience in medicine some times and underestimate the value of being in an office.

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CORNISH: Rosenthal is a non-practicing physician and editor-in-chief of Kaiser Health News. That's not connected to Kaiser Medical School. Rosenthal wrote that COVID let telemedicine out of the bottle. And when the pandemic is over, she's worried it won't go back in. We spoke about why.

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ROSENTHAL: I think it should be used as a screening tool in the sense of if your doctor schedules a telemedicine visit and can solve your problem with that, great. That's wonderful, and a lot of things can be solved that way. But if the doctor says, ah, you know, I can't tell if that's strep or COVID over the phone, I need you to come in, then maybe the cost of that first visit should be folded into the eventual in-person visit. So I think to me, the ideal is a kind of hybrid model where providers can use telemedicine and in-person medicine interchangeably as appropriate. And I just worry so much that for many people, it's going to be one or the other.

CORNISH: What questions would you have for something like the Geisinger, you know, Commonwealth School of Medicine - right? - something that's trying to be a medical school with a big virtual kind of experience or that is also trying to bring that kind of training to the field as well?

ROSENTHAL: I mean, I think you need to teach medical students that crucial, like, on-off switch. So they have to see enough patients in person so that they know when they are in practice, is this something that benefits from a physical exam or is this something that I could do just as well over the screen? So what we get in the end I hope will be determined by what's medically right, but it also will be heavily influenced by the competing financial interests at play in our health care system.

CORNISH: It's funny. We've been focused on the medicine part of it, but you're also pointing out that this is doing something to the business model of medical care in the U.S.

ROSENTHAL: Sure. I mean, telemedicine can be very lucrative, right? You don't have to have exam rooms. You don't even have to have - 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. And that's what really worries me, that, you know, instead of being able to see an actual physician, if needed, you'll be talking to, you know, a bunch of physicians in a room somewhere 3,000 miles away who have no capacity, if they see something that looks funky, to say anything other than, oh, go to the ER. You know, that's - and meanwhile, they'll be charging you for that useless advice of go to an ER. So I do worry about how it's going to be monetized, particularly in this era of high deductible health plans and big co-pays, out-of-network care. Patients could be on the hook for a lot of money for care that isn't very effective.

CORNISH: We started this with your quote about COVID-19 letting telemedicine out of the bottle. It's hard to get things back in the bottle, as we know. So how do you think about this going forward? What do you think that balance should be between traditional and in-person?

ROSENTHAL: Well, there are going to be a lot of big battles over this. And we already see insurers saying, you know, we're not going to reimburse that as if it was in person. So I expect a lot more negotiating battles between insurers and providers about what this new kind of service is worth.

Now, you know, that being said, in some cases it is - I'll give you an example of where it could be amazing. For example, home monitoring of cardiac rhythms, right? That could be a godsend for patients. Rather than lying in a hospital bed for two days, you can wear a home telemetry unit for two days and just transmit the rhythm strip into a cardiologist to read. Now, a hospital might want to say, oh, that's - that should be worth the same as two days in a hospital, meaning, in the U.S., you know, $8,000. An insurer might want to say the patient's doing all the work here. So yeah, there's a big gulf there. And I do not know how that decision is going to be made.

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CORNISH: Elisabeth Rosenthal, editor-in-chief of Kaiser Health News. It's CONSIDER THIS from NPR. I'm Audie Cornish.

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