3.1. Telemedicine Research Level
Interest in video consultations increased for many as a result of the patient interviews (see
Figure 3). The participating students’ interest in video consultations was predominantly high before the seminar began (5-point scale: median: 4, max: 5, min: 2). Most students denied having much prior knowledge on the topic (5-point scale: median: 2.5, max: 4, min: 1). Of the 12 participants, 11 agreed that the distance learning seminar complemented their previous teaching on telemedicine (median: 101, max: 101, min: 98 + one outlier: 3).
The participants described their learning successes in the field of remote treatment in detail and with examples. They named requirements for remote treatment including technical equipment. They stated that they had experienced its limits and possibilities. They compared their experiences within video consultations with their previous experiences from face-to-face consultations. Video consultations were described as a “good complement to face-to-face consultations” (comment of one participant). Two participants stated that they found it easier to focus on the structure of the conversation than they did in face-to-face consultations.
The students elaborated on the communicative specifics within video consultations. For example, it was important for physicians to speak slowly and maintain eye contact. At the beginning of a consultation, the student who conducted the consultation introduced him/herself to the patient and asked about the sound and image quality. The students circumvented communication problems during technical difficulties with the sound transmission by summarizing and repeating the content of the patient’s conversation.
They learned to assess the limits and dangers of video consultations and the associated perceptual deficits, and to involve the patient in a face-to-face consultation or emergency medical care for appropriate medical concerns.
Students had the opportunity to compare the video consultations of the group appointments within the practice (element A) with the video consultations connected to the patient’s home environment (element B). One student noted that different family medical conditions require different care, and the office is not always the best place for this. On the other hand, video consultations within the family medicine office (element A) also offered advantages. In this setting, selected students were able to actively participate in the consultation, take patient histories, and learn about the use of digital diagnostic tools remotely via instructions to the attending family physician. For example, the students asked the doctor to perform a digital 1-lead ECG on a patient. After a few seconds, the entire group was able to view the findings online. Other diagnostic equipment in the practice was also used, e.g., sonography device, tuning fork, blood pressure monitor, and scales, which were presented to the students via the front camera of a tablet during the reporting of findings. In 4 out of 6 consultations, students asked the doctor to hold the camera closer to specific skin sites.
Within the final discussion at the end of the group appointments (element A), students compared their perception of the situation with the perception of the physician on site. For example, students would not have perceived the signs of shortness of breath via video transmission. Other topics at the end of the group appointments included nonverbal means of communication during video consultations, dealing with preventable dangerous courses, and reporting impressions within individual appointments (element B).
As a suggestion for improvement, students mentioned that a demonstration of a video consultation by an experienced physician during the introductory session would be useful.
3.2. Family Medicine Research Level
The interest in family medicine increased in 7 of the 12 participants as a result of the patient interviews (
Figure 4). Before the start of the seminar, the students indicated a high interest in family medicine (5-point scale: median: 4, max: 5, min: 3). Three participants stated that they wanted to become a specialist in family medicine. Most participants could neither agree nor disagree with the statement that they had a lot of prior knowledge about family medicine (5-point scale: median: 3, max: 4, min: 2). For the statement that the distance learning seminar complements the participants’ previous teaching about family medicine, agreement was heterogeneously distributed on the Likert scale (median: 77, range: 94).
When asked about what they learned, students indicated that they deepened their family medical skills, knowledge, and working techniques. They gained patient-oriented insights into various family medical clinical pictures. The patients came to the teaching consultation for routine examinations/interviews, but acute atrial fibrillation was also diagnosed. The students indicated, as a suggestion for improvement of the teaching project, to include more acute treatment occasions in the seminar.
The students deepened their knowledge of conducting a conversation and taking medical history. They also learned how to view patients holistically. Some students reported back after the individual appointments (element B) that the patients were open to them. Some students succeeded in establishing a stable relationship of trust with the patients.
Within the professional debriefing of the group appointments (element A), among other things, further diagnostics of disease patterns of the patient cases were addressed. The pathological background and complications of the corresponding clinical pictures were also integrated into the debriefing. In the subsequent discussion of the group appointments (element A), for example, anamnesis questions for initial interviews were discussed. One student wished for an even more detailed discussion of patient cases.
As another learning outcome, one student stated that he had learned how to handle complex patient records to obtain an overall picture of a person through the seminar.
3.3. Didactic Research Level and S.W.O.T. Analysis
All participating students agreed with the statement that attending the event had been worthwhile for them (median: 100.5, max: 101, min: 78). The distance seminar was an appealing method of digital teaching (median: 95.5, max: 101, min: 76).
The students particularly praised the opportunity for patient contact. All students found the consultations supportive of their learning process. The participants’ agreement was asked regarding the following two statements: “The connection to the consultation within the practice supported my learning process” (element A, group appointment) and “The conversation within the video consultation with patients in their home environment supported my learning process” (element B, individual appointment). The correlation of the results of these two items is shown in
Figure 5.
The statements from 7 of the 12 participants show a strong positive correlation (see graphics within the red triangle in
Figure 5). Three of four students who agreed significantly more with the second statement had their discussion lead to a patient consultation during a one-on-one appointment (element B, indicated in yellow within the purple circle in
Figure 5).
Five of the six one-on-one planned appointments took place. In each case, one student led a consultation with an adjunct in the patient’s home environment, while another student and the primary care physician observed. Some of the students reported that they had felt comfortable, especially in the small group of four persons.
The workload for the students has been rated by all as “just right”. The compulsory attendance for the students during the total of five seminar dates was approx. 11 h. The preparation time based on the files as well as the time for post-processing of the seminar dates could be chosen individually by the students. The time for preparation and post-processing of the appointments without leading the discussions was given by the students as a maximum of 30 min. The estimation of the working time for the appointment with discussion leadership is shown in
Figure 6.
The students cited the length of the group appointments as a point of criticism and mentioned suggestions for improvement such as expanding the number of seminar hours or halving the number of consultations per appointment.
The working atmosphere was rated as “good” by 10 of the 12 participating students (median: 99, max: 101, min: 77 + 2 outliners: 8, 54). The other two participants mainly criticized a lack of appreciation of the doctor’s treatment methods, the high number of lecturers, and a high noise level.
Some students criticized the technical difficulties. Differences in picture and sound quality between the participants, problems sharing the screen, and time delays were observed. One student expressed the wish for better technical means to establish more contact with the patient while the doctor is performing the examination. The group developed some solutions to the technical difficulties during the seminar (
Table 1). In addition, the team is in contact with the technical support of the software programs and is looking for alternatives for digital-synchronous diagnostics.
Future student participants should be motivated, technically equipped, and have prior experience in family medicine, according to the students (see
Table 2).
In the following section, the key points of the S.W.O.T. analysis from
Table 3 are explained and questions 4 and 5 are answered.
3.3.1. Strengths
The teachers see the strengths of the learning method in the patient contact which complements the classroom teaching. The students learn practically and authentically at the places where family medicine is practiced by means of video transmission: in the practice (element A) and in the home environment (element B). Without travel, this teaching format offers students the opportunity to conduct professional patient interviews and examinations. The new German licensing regulations call for both the strengthening of family medicine and the strengthening of digital medicine [
21]. The teaching format offers an opportunity to familiarize medical students with the family medical communication technology of video consultation hours and thus meets the requirements.
The participants in the pilot project would have captured the concerns of patients who were in a different region of Germany and whom they had previously only known from files. The results of the evaluation showed the satisfaction of the students with the pilot project and the learning success. The pilot project shows that communication and relationship-building with patients is possible digitally, even on intimate topics. From the point of view of the lecturers, students can be introduced to telemedicine with this teaching method. The strengths and limitations of video consultations were demonstrated and expanded. The family physician had also improved her approach within video consultations.
The students especially praised the commitment of participants and lecturers. The lecturers see the staffing and the appreciative interaction with each other as a strength of the pilot project. This included the participation of committed, empathetic, patient patients who were willing to talk to a student in front of many viewers, some of whom had previous experience with student teaching via video communication. The students were willing to communicate, committed, and very well prepared for the patient consultations, even though students who were primarily interested in obtaining a certificate also participated in the pilot project. This suggests a high intrinsic motivation for the field of interest of the voluntary course. They had been willing to invest time beyond the mandatory courses and demand a more time-intensive expansion of the teaching model. The students’ commitment was evident in the number of suggestions for improvement they noted. Through these, the teaching method could be improved together with patients and teachers. For example, the optimal position of the camera, lighting, and patient chair within the consulting room could be worked out. Also, new technical devices (e.g., for digital vital parameter measurement) could be integrated into the seminar. The strength within the supervision of the students was due to the commitment with which the lecturers carried out the pilot project. This included the openness to change the concept as well as the implementation of a feedback culture. The small group size (2–12 students) had also intensified the supervision. Particularly in the individual appointments (element B, two students), questions were addressed individually and discussion techniques were practiced.
The family physician’s conviction that the care of patients can be sustainably improved by means of video consultations had shaped the course of the seminar. The knowledge resources of the lecturers include several years of experience in family medical practice, the implementation of video consultation hours, and the implementation of university teaching. Another empowering resource was the amount of time the faculty invested in organizing and the amount of time the students and patients invested in implementing the pilot project. The digital format of the course allowed for focused work, especially due to the reduction of language and the limited image section of the participants, as well as the reduced sensory impressions from their own home environment.
From the external perspective of the students, the patient contact from the position in charge of the interview as well as the observer role was praised above all. In particular, the responsibility and freedom granted to the students with regard to the design of their patient interview and the preparation and follow-up were positive.
The students state that they have learned the difference between face-to-face contact with patients and contact via video consultation. Working remotely made it easier to focus on the relevant content of the course more than in a face-to-face setting.
The students see the small group size as an added strength. Especially in the individual consultations (element B), the atmosphere between the doctor, two students, and the patient was very pleasant and relaxed.
The results of the evaluation show that the students are satisfied with the event overall and that the teaching method can increase the interest of participating students for video consultations. The learning process in the team was seen as particularly positive by the students, as was the incorporation of suggestions for improvement. The combination of practice and theory is appealing. The preparation for the seminar including the provision of the files in advance was helpful.
When asked about the strengths of the project, the commitment and motivation of the teachers and students was stated within the evaluation.
The increasing relevance of video consultation was mentioned as a reason for participating in the seminar. The students see the trend that the digitalization of medicine is increasing and see the teaching format as an opportunity to deal with this and, in particular, to recognize its limits and opportunities.
3.3.2. Weaknesses
Due to the lack of experience on the implementation of this teaching method, there were uncertainties among the teachers. In particular, the dimensions of the topics that would be of importance to students in this seminar could not have been estimated despite prior inquiry.
The instructors invested time in meetings about schedule coordination, testing of technology, and discussions of students’ comments. Additional organizational effort was required for the acquisition and education of patients and students. From the university side, time and costs are incurred for the activation of student access to the data-protected video platform. Additional costs are incurred for equipping the family physician’s practice with cameras, a tablet, a computer, a smartphone, a digital stethoscope, and access to a video platform certified by the health insurance fund. There would be an additional time commitment due to the individual setup of the platforms, e.g., uploading patient records and sending access links for students.
The teaching model is dependent on functioning technology. The technical problems that disrupted the course of the seminar were mentioned by the teachers as a weakness. These were partly compensated by improvements. Nevertheless, it could not be guaranteed that, for example, all participants in the seminar would be able to speak to the patients without delay, that examination findings would be transmitted, and that, for example, findings of the skin could be viewed in realistic image resolution. More intensive preparation and tests before the start of the teaching project could have prevented some of the problems that occurred. Depending on the demands, an acceptance of the current transmission possibilities is conceivable.
The teachers see the teaching model as a supplement to face-to-face teaching. Especially due to the greater perception by means of touching and smelling, the face-to-face contact with patients is indispensable for the students.
One lecturer criticized the lack of an emergency checklist for video consultations with the students. In addition, the time frame did not allow for a detailed discussion of treatment needs besides the exploration of the peculiarities of video consultations. In addition, some seminar appointments exceeded their agreed-upon duration. Nevertheless, a larger number of patient-side discussions would be desirable.
When patients are cared for by two specialists, there is a variance in the style of treatment and the course of treatment. This requires acceptance, clear communication about the areas of responsibility, and possible debriefing of professional differences.
Communicating remotely with participants could lead to a loss of information, according to faculty. A lack of accessibility by phone or unread emails makes remote communication difficult.
According to the teachers, there was no guideline for high-quality communication within teleconsultations, which could be used as an orientation for the lessons.
The students see the weaknesses of the pilot project primarily in the scope of learning, in the absence of time, and in the technical difficulties. They criticized the scope of learning within the group appointments for being too large and the family medical focus for being unclear when the appointments were too long. More frequent and shorter (<2.5 h) appointments could be a solution approach. However, the amount of time given by the lecturers cannot be reconciled with the number of patient interviews the students would like to conduct.
The students suggested including patients with acute treatment needs in the teaching project. Inviting patients on a long-term basis reduces the likelihood of acute treatment occasions.
The students wished to expand the telemedical learning environment with a view to the future and in comparison with other countries. The scope of learning on the topic of data protection was too small for the students. They also called for the improvement of technical equipment.
3.3.3. Opportunities
The teaching method enables medical students and future experts from other health care professions to work with patients without the risk of infection. The teachers also consider the seminar to be useful outside of pandemics. Likewise, the participating students within the online survey agreed with the statement that the seminar should also be offered after the COVID-19 pandemic (median: 101, max: 101, min: 85).
The teaching method could lead to more inclusion. In particular, students with children, part-time jobs, and long travel distances may benefit from remote patient instruction from the students’ perspective. The core points of the teaching concept (patient contact, family medicine, digitalized medicine, local flexibility, and study in small groups with debriefing) can also be implemented in alternative formats, according to the teachers. One possibility is to conduct the patient discussions as before and to integrate them into a learning context, e.g., in the form of an internship following a lecture series or eLearning unit on chronic diseases, in order to practice what has been learned theoretically. The internship could be carried out as a digital family medicine internship, in which a student accompanies a family physician during (video) consultations. This is also possible as a classroom method or blended learning concept. Getting to know the participants in presence could simplify the cooperation.
The implementation of the video consultation could be distributed among several family physicians. The digital format means that universities are not limited to collaboration with teaching practices in the immediate vicinity and can expand their network. However, according to faculty, collaboration with familiar teaching practices could facilitate exchange on didactics and content.
Another idea for the modification of the previous seminar concept is the graduation in difficulty levels. Depending on their previous knowledge, the students could first practice anamnesis in video consultation, then practice digital examination methods, and in a further step they could be taught how to interpret long-term values from digital health data. It would be possible, for example, to integrate newly developed apps into the teaching concept.
The teaching concept offers the opportunity to apply the skills learned for conducting a video consultation in other disciplines as well. The seminar concept could also be applied in a modified form in other medical specialties to teach telemedical competencies to medical students.
As a team, students, teachers, and patients can further develop the concept and motivate other physicians, patients, and students to conduct video consultations. The joint use of video consultation hours and the exchange of suggestions for improvement as well as corresponding research could lead to a qualitatively better health care of the patients. For example, by improving the technical conditions and developing emergency checklists.
There are gaps in research, particularly with regard to the didactic format, the implementation of high-quality video consultation hours, and the sensible use of digital medicine in general. The use of digital medicine is less widespread in Germany than in some other countries. Video consultations would offer the chance to relieve the shortage of specialists in rural regions of Germany. Through the described teaching method, future physicians could decide whether they would like to use digital medicine or not.
3.3.4. Risks
The teachers see the risks of the teaching method in the integration into the curriculum of the respective universities. This requires commitment, money, and time, which is not available in every project group. If the participating lecturers, students, or patients are not motivated, there is a risk that the seminar will not take place or that the learning success will be lower. It remains uncertain whether other patients, teaching practices, and students are willing to cooperate in the teaching project. Especially patients without experience with distance learning. Performing family medicine under the observation of several students and other specialists is an unusual way of working. Therefore, the willingness of teaching physicians to participate is questionable.
In the case of professional differences between two specialists participating together, team-building and the learning success of the students are endangered. Another risk is the focus on telemedicine instead of using it only as a tool for family medicine.
The use of technical aids in teaching could lead to communication problems.
The flexibility of the workplace presents the risk that people from the public sphere participate and thus data protection is not guaranteed.