Telemedicine continues to make waves in ophthalmology

Special to Ophthalmology Times®

The COVID-19 pandemic is transforming the way medicine is practiced throughout the country and the world. New alternatives to the modus operandi of traditional health care delivery have been necessary during these uncertain times. 

One transformative alternative has been the use of telemedicine and virtual visits. The American Academy of Ophthalmology’s most recent guidelines recommend televisits for all routine and nonurgent ophthalmologic care.

Although telemedicine is currently primarily designed for the delivery of health care, we believe that telemedicine can and should be extended to teaching and learning for medical students as an alternative for the traditional apprenticeship model, direct face to face, bedside, and chairside graduate medical education (GME).

On March 17, the Association of American Medical Colleges recommended that medical schools pause all student clinical rotations due to the COVID-19 pandemic.

The Association of American Medical Colleges has provided schools with recommendations and guidelines on how to develop online education, including virtual learning resources, web-based modules, and simulations.

However, medical students traditionally also learn from observing and participating in clinical duties in the hospital or clinic alongside physicians, residents, and fellows.

At Houston Methodist Hospital, we have transitioned to online teleconferencing for our educational sessions, and we are using HIPAA-compliant platforms for telemedicine patient care.

Although multiple platforms (eg, WebEx, Zoom, Skype, FaceTime) have been used, clinical rounds may be more challenging to implement with learners.

We briefly describe our use of telemedicine for our GME activities at the neuro-ophthalmology service at the Blanton Eye Institute at Houston Methodist Hospital.

In the first part, I describe our use of the video platforms as a teacher; in the second part, our medical student, Arko Ghosh, describes his individual learner experience; and in the third part, our neuro-ophthalmology fellows describe the balance in the clinic between social distancing and chairside teaching.

Video conferences
These video-conferencing platforms allow the teacher to see the students, but it takes some dexterity to navigate the slide sharing (with the left hand) and toggling among the video streams for the individual learners to gauge interest, enthusiasm, and understanding of the material.

“I [Andrew Lee, MD] try to rotate in a Socratic method the questions and answers for cases based upon the PowerPoint slideshow that is being shared with the participants.

Although not as good as face-to-face interactions, I have learned to judge facial expressions and body language among video participants and to determine levels of interest and understanding as well as opportunities to probe the knowledge base and improve interactive learning.

At Blanton Eye Institute, Houston Methodist Hospital, we have typical (but small) eye lanes. On some of our neuro-ophthalmology rotations, we might have up to 6 or 8 learners at a time (eg, medical students, eye residents, neuro-ophthalmology fellows, international visitors, and residents from other services).

“Social distancing requirements will mean disruptive innovation for proximity and teaching at the bedside and at the chairside in the eye clinic even after the COVID-19 restrictions are loosened or removed. We are working on using video technology (with appropriate patient informed consent) for teaching and learning remotely in real-time even in the eye clinic lanes.”

Student experience
“As a student, I have personally experienced groundbreaking medical education on a neuro-ophthalmology rotation during the COVID-19 pandemic,” Arko Ghosh said. “Despite my absence from traditional patient care scenarios, I was still able to have a very stimulating and educational rotation.” 

“Through daily Zoom lectures, I participated in the morning report, and I collaborated with the team on multiple research projects. Additionally, although I was unable to participate in direct patient care, I was able to approximate that experience by researching and writing up unique case reports. These opportunities were not only made possible by telemedicine but were actually enhanced by it.

“As medicine continues to accommodate the evolution of technology, it is important for future clinicians to be well versed in telemedicine. This unique setting offers medical students an unprecedented opportunity to learn and experience telemedicine, carrying with them a valuable and unique skill set into residency training and beyond.”

“The current COVID-19 pandemic is certainly a challenging time for everyone, with constant change in every facet of life, including the delivery of health care. But during a time largely consisting of darkness, there is light to be found in medical education. It is possible for students to gather a challenging and fruitful education, despite being unable to participate in clinical activities.” 

“I believe that a virtual, telemedicine-like structure can provide the experience that students need to acquire, and, in some cases, enable students to return to active helpful roles on the health care team. I have personally experienced the power of virtual education, and while it certainly cannot entirely replace the clinical experience, I hope that other students get to experience it, as well.”

Challenges with social distancing
Shruthi Harish, MD, and Nita Bhat, MD, neuro-ophthalmology fellows said, “Social distancing measures in the wake of the pandemic have had an impact on all specialties of medicine. However, with the eye exam needing to be carried out at close proximity, ophthalmology faces a unique challenge.

“In our neuro-ophthalmology practice, we have developed a workflow where we triage patient charts to determine which patients need to come into the clinic for an in-person visit (usually reserved for urgent and emergent cases) and which ones can be conducted via telemedicine or managed by telephone. 

“For our in-person visits, we limit the number of physicians in the room to 2 at maximum. The patient is seated in the examination chair, and we have 1 physician at the computer (appropriately distanced from the patient), and the fellow or resident is positioned 6 feet away from both the patient and the attending physician, from where they are able to present their findings to the attending.

“Both doctors wear a surgical mask throughout. There is a plastic ‘shield,’ fashioned out of plastic folders, installed on each slit lamp, which serves as a makeshift face guard. Additionally, we request the patient to hold their questions until after the slit lamp exam is completed to avoid droplet production as much as possible while in close proximity. We dilated all our patients and use the indirect ophthalmoscope, which is more conducive to social distancing than the direct ophthalmoscope.

“For our virtual visits, we have 2 physicians in the room, usually 1 attending and 1 resident or fellow. Each eye lane is equipped with 2 computers. One computer is used to set up the patient’s video call and to put in a resident or fellow note. The other is assigned to the attending to be able to access the patient’s chart and to type, dictate, or otherwise edit the note. Having 2 computers in the room helps the 2 physicians to not only be able to maintain adequate distancing but to also avoid having to share keyboards and a mouse, which themselves can be fomites.

“The keyboards and mouse are wiped down with alcohol wipes at the end. With patient consent, from both in-person as well as virtual visits, we are able to keep the door of the eye lane open in many cases. This enables a second learner to be positioned at the door, thus being able to observe and learn while still maintaining social distancing.

“Change is always hard. When we started this fellowship, we would never have expected to be engaging in tele-neuro-ophthalmology. Now, however, we have not only gotten used to it, but having been able to diagnose superior oblique palsies, thyroid eye disease, myasthenia gravis, and—in 1 case—a downbeat nystagmus that turned out to be secondary to glutamic acid decarboxylase, we feel that telemedicine indeed has a role in ophthalmology.” 

Conclusion
The COVID-19 pandemic has created chaos and disruption of both clinical care and for teaching and learning. This disruption has created a unique opportunity for innovation and more rapid adoption of tele-neuro-ophthalmology. 

In addition, telemedicine might also prove to be a suitable or even superior alternative to face-to-face morning report, grand rounds, journal club, and lectures.

Further work is necessary to determine the impact of this disruption on the quality of the GME experience for our residents and fellows. We believe that telemedicine will play an increasingly important role in GME long after the COVID-19 pandemic ends.

Andrew G. Lee, MD
e: aglee@houstonmethodist.org

Contributing authors: Arko Ghosh,a Nita Bhat, MD,b Shruthi Harish Bindiganavile MD,b and Andrew G. Lee, MDa,b,c,d,e,f
Affiliations:
a Texas A&M University College of Medicine, Bryan, TX.
b Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX.
c Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY.
d Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX.
e University of Texas MD Anderson Cancer Center, Houston, TX.
f Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa.

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References
AAO COVID-19 Guidelines: https://www.aao.org/headline/alert-important-coronavirus-context

AAMC COVID-19 Announcement: https://www.aamc.org/news-insights/press-releases/important-guidance-medical-students-clinical-rotations-during-coronavirus-covid-19-outbreak

AAMC Virtual Education Resources: https://www.aamc.org/coronavirus-covid-19-resource-hub#medicaleducation

AAMC iCollaborative Link: https://icollaborative.aamc.org/collection/covid19-alternative-learning-experiences/