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Telehealth, COVID-19, Medical education, Virtual, IntroductionTelemedicine or &,ldquo Telehealth&,rdquo has grown exponentially in the U.S. over the past few decades and current trends in the healthcare environment fuel this expansion into the future ( 1, , 2, ). Telehealth involves the use of telecommunications and virtual technology to deliver healthcare outside of the traditional brick and mortar healthcare facility. This platform has been shown to reduce inefficiencies in the delivery of healthcare by improving access for underserved and rural populations ( 3, , 4, ). Telehealth has also been shown to be cost-effective, improve health outcomes, and enhance patient social support ( 5,- 8,). Kansas, is one of the longest running practices of its kind worldwide. The practice began in 1995 and connected an oncologist at KUMC with a rural medical center in Hays, Kansas. Fifteen years later, the practice continues to thrive at Hays Medical Center and has also expanded to include two additional sites within the state-the Northeast Kansas Center for Health and Wellness in Horton and Goodland Regional Medical Center in Goodland-that offer regularly scheduled teleoncology clinics. While the KUMC practice has witnessed an expansion in service sites throughout its history, the practice has seen a significant decrease in the costs associated with providing such services since its inception. The cost decrease can, in part, be attributed to an increase in the number of teleoncology visits conducted through the practice since it began (In Fiscal Year 1995). Recently, telehealth has also proven to be rather dynamic as it has been applied in both primary care settings and for specialty consultations ( 9, ).Despite the multiple innovative applications of digital technology in healthcare, telehealth is not readily adopted by all healthcare providers and many medical schools still do not include telehealth in their curricula ( 2, , 10, ). Additionally, the American Medical Association (AMA) recommends telehealth training of medical students and residents. However, a recent survey by the Association of American Medical Colleges (AAMC) found that only 58% of medical schools currently provide telehealth training ( 11, , 12, ).Due to the new challenges faced by medical schools during the COVID-19 pandemic, novel curricula must be considered ( 13, , 14, ). Medical schools have been challenged with adapting and innovating new curricula aimed at creating clinical experiences for students that are remote from the hospital ( 15, ). To ensure the delivery of quality clinical education despite the pandemic, we created a Telehealth Education Curriculum (TEC) for the Obstetrics and Gynecology (Ob/Gyn) third year clinical rotation at New York Medical College, which was implemented in April 2020. The novel TEC included medical student telehealth encounters with real patients and a virtual OSCE (vOSCE) with standardized patients to resemble a telehealth encounter. We chose to incorporate an OSCE into the TEC curriculum as they have been shown to improve clinical skills in educational settings ( 16, ). Students were asked to complete surveys on their perceptions of the TEC and responses were used to assess its educational value.The objective of this study was to measure student perceptions of a novel Telehealth Education Curriculum for the virtual obstetrics and gynecology core clerkship during the COVID-19 pandemic and evaluate best practices for future telehealth curriculum implementation. A secondary objective was to contribute to current medical education literature on telehealth curricula, and their utility, to continue finding new innovations in medical student education during the COVID-19 pandemic and beyond.MethodsStudy Design/ ParticipantsThis prospective mixed methods study of 52 medical students was conducted at New York Medical College School of Medicine (NYMC SOM), located in Valhalla, New York. It is one of the nation&,rsquo s oldest private health sciences universities (est. 1860) and provides a comprehensive educational program with the goal of developing well-rounded medical students who will become resilient, compassionate, and skilled physicians. The SOM is proud of its strong foundational science education, diverse affiliated clinical training sites, and the commitment of its faculty and administration to medical student education.In light of the COVID-19 pandemic, which provided a significant barrier to undergraduate medical education, and specifically clinical education, the third year Obstetrics and Gynecology (Ob/Gyn) medical student core clerkship was converted to a four-week virtual format in April 2020. The students originally scheduled to complete the standard Ob/Gyn clerkship in April and May 2020 were automatically enrolled in the virtual Ob/Gyn clerkship. This put the onus on faculty to rapidly develop and implement a new virtual curriculum that allowed for clinical learning and interaction in this new digital era. This new curriculum featured didactic sessions, case-based presentations, and interactive learning workshops via Zoom. Didactic activities included presentation of video-based surgical cases, interactive board question review, and discussion of general obstetrics and gynecology topics. Additionally, a novel Telehealth Education Curriculum (TEC) consisting of virtual Observed Structured Clinical Examinations and actual telehealth patient encounters was implemented as part of the virtual Ob/Gyn third year clerkship. We evaluated the student perceptions of the novel TEC following their successful completion of the virtual Ob/Gyn clerkship.To be considered eligible to participate in the study, the students were required to be in their third year at NYMC SOM, enrolled in the virtual Ob/Gyn clerkship, and participating in the virtual Ob/Gyn clerkship and TEC. Students were provided with explicit information explaining that their participation in surveys was voluntary and their responses would be utilized for research purposes only. They were also informed that responses would be de-identified and accessed only by the research team data handlers with no impact on their grading. Two authors, JM and LF, were responsible for all data handling and were not involved in any aspect of medical student grading for the clerkship. NL and JP were able to access student data after it was processed and fully de-identified without the ability to re-identify students given their roles at the School of Medicine. All study procedures were approved by and compliant with the New York Medical College Institutional Review Board (protocol #14323).Novel Telehealth Education Curriculum (TEC) Design and AssessmentThe novel Telehealth Education Curriculum (TEC) consisted of two components, the telehealth encounter and the virtual Observed Structured Clinical Examination (vOSCE). For the telehealth encounter, each student completed at least one telehealth visit via a 3-way video conference call with an Ob/Gyn patient and attending physician, before the end of the 4-week virtual clerkship. Following the telehealth visit, students completed a clinical note in the Subjective, Objective, Assessment, and Plan (SOAP) note structure and a survey entitled Telehealth Evaluation for 3rd year Ob/Gyn Clerkship. Students then virtually met with their attendings for a telehealth debrief in which verbal and written feedback was provided.The second component of the novel TEC was the virtual OSCE designed to mimic a telehealth patient encounter, conducted via Zoom Video Communications, Inc. The blueprint for the vOSCE included completion of a standardized patient encounter with a physical exam and history (20 minutes), a post-encounter note that included a differential diagnoses, assessment, and plan (15 minutes), followed by two debriefing sessions with faculty focused on communication skills (15 minutes) and clinical reasoning (40 minutes). Students also had the opportunity to collaborate with another student who had independently completed the same case, while individually writing their assessment. The standardized patients presented with a common obstetric and gynecologic complaint (i.e. primary amenorrhea, postmenopausal bleeding, antenatal visit). Faculty observed the vOSCEs, reviewed post-encounter assessments, and evaluated students using the following criteria, medical knowledge, interpersonal skills and communication, empathy, and development of a differential diagnoses. Following the vOSCE, students completed the Virtual OSCE Evaluation Form for the 3rd year Ob/Gyn clerkship to provide feedback about their experience with the vOSCE and its value as an educational tool.Data CollectionTo assess student perceptions of the novel TEC curriculum, students in the first two cohorts of the virtual Ob/Gyn third year clerkship were asked to complete two 4-point Likert surveys consisting of nine student perception questions and four free response questions. Possible answer choices for the Likert survey questions were as follows,1=Strongly agree, 2=Moderately agree, 3=Moderately disagree, 4=Strongly disagree. Free response questions for both surveys asked the following, 1) What was most successful about the session? 2) What was most challenging about the session? 3) What were my top takeaways from this session (clinical and communication skills based)? 4) Any Additional comments or suggestions for improvements?The two surveys were distributed to students at the conclusion of their virtual Ob/Gyn clerkship. One survey corresponded to the telehealth encounter and the other to the virtual OSCE. Responses were de-identified upon completion and stored in a secure database.AnalysisWe conducted all analyses using the Statistical Package for the Social Sciences (SPSS IBM version 19). Likert data were analyzed by computing means, and response distributions, for each question to compare self-reported student agreement with survey statements.For qualitative analysis of free response questions, the research team reviewed all qualitative data individually to identify salient themes. The research team then met as a group to resolve discrepancies in interpretations and reach final theme interpretation. Qualitative data was reviewed until no new themes emerged from the analysis. Illustrative quotes were collected to represent all salient themes. ResultsA total of 52 students participated in the virtual Ob/Gyn clerkship with 25 in the first cohort and 27 in the second. The telehealth encounter component of the TEC was still being piloted with the first cohort of students, so their participation in the telehealth encounter was optional. Based on faculty availability and student interest, 9 out of the 25 students in the first cohort completed the telehealth encounter. However, all 25 participated in the vOSCE because it was not optional. All 27 students in the second cohort completed both components of the TEC, the telehealth encounter and vOCSE. Of the 52 students who participated in the first two cohorts of the virtual Ob/Gyn clerkship, 36 completed the Telehealth encounter and 52 completed the vOSCE. Of these students, 33 completed the Telehealth survey (92%) and 48 completed the vOSCE survey (92%) (Tables 1, and 2,).Telehealth Evaluation Survey StatementsStrongly AgreeModerately AgreeModerately DisagreeStrongly DisagreeThe physician instructor explained medical history and other pertinent facts prior to the Telehealth patient encounter.28 (84.9%)2 (12.1%)1 (3.0%)0 (0%)This Telehealth experience provided me with a valuable patient interaction.21 (63.4%)11 (33.3%)1 (3.0%)0 (0%)The content of the physician debriefing played a useful role in my clinical skills training.24 (72.3%)9 (27.3%)0 (0%)0 (0%)I felt that it was a good use of my time to participate in a Telehealth encounter.25 (75.8%)8 (24.2%)0 (0%)0 (0%)The telehealth activity helped develop practical skills for effective communication with patients.22 (66.7%)8 (24.2%)3 (9.1%)0 (0%)This session increased my confidence in interviewing a patient presenting with a gynecological complaint.22 (66.7%)9 (27.3%)2 (6.1%)0 (0%)The educational value of a telehealth patient interview was similar to an in-person patient interview.11 (33.3%)14 (42.4%)7 (21.2%)1(3.0%)Telehealth encounters/education should be part of the medical student clerkships during social distancing secondary to COVID-19 restrictions.26 (78.8%)6 (18.2%)1 (3.0%)0 (0%)Telehealth encounters/education should be part medical student clerkships going forward (post COVID-19).14 (42.4%)13 (39.4%)6 (18.2%)0 (0%) TEC, Telehealth Education Curriculum vOSCE, virtual Objective Structured Clinical Encounter |