To continue providing patient care, the Rowan Department of Family Medicine shifted to a telehealth model that included provider training, virtual patient visits, and electronic information sharing to facilitate patient care. ⁵ During this transition process from bedside to “webside,” Rowan SOM faculty made a conscientious effort to adapt the Family Medicine clerkship to include third-year medical students as a way to continue their education. 

In the traditional clerkship paradigm, medical students often start by shadowing the attending or resident physician from start to finish of an office visit. This experience includes obtaining the patient’s history of present illness (HPI), performing a physical examination, precepting, and discussing the management or treatment plan with the patient. By the second week of rotation, medical students are expected to progress to independently seeing patients before presenting to their preceptor and completing the visit with the attending or resident physician. Transitioning to a digital telehealth model presented barriers that needed to be surmounted (Table 1). 

Switching to telehealth offered an opportunity to ensure continuity of education while minimizing patient care disruption. Students were given the opportunity to conduct telemedicine visits via real-time audiovisual meetings from their own homes instead of conducting in-person office visits. Rowan SOM had an existing business associate agreement with a video conferencing platform that allows for multiple parties to interact on web or mobile applications, in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If patients were unable to set up or log into this platform, the Centers for Medicare and Medicaid Services had issued guidance allowing for common “non-public facing” remote communication products to be used for patient encounters:  

Given patients’ varying levels of technological literacy, medical students leveraged their communication skills to walk patients through this process. If patients were still unable to connect or did not have access to a smartphone/internet, the interaction was switched to a telephone visit. Educating medical students on how HIPAA guides regulatory parameters of telemedicine exposed them to aspects of medical care they may not have appreciated or had access to in a normal physical context, such as directly observing a patient’s living situation, home environment, or even the patient’s pantry if nutrition was a concern. 

The “rooming” process not only accomplished data-gathering and physical examination components for presenting patients, but also also prepared students for future COMLEX-Performance Evaluation by teaching them fundamental skills such as physician-patient communication, professionalism, and interpersonal skills. This telehealth version of the clerkship program was made possible by technological capability, patient willingness to comply, and authorization of billing codes. Wireless monitoring, mobile health applications, and smartphone video capabilities, among other technology platforms, offer innovative possibilities to extend care relationships well beyond the traditional in-patient visit. ⁷  

The students also learned a new skill—conducting a virtual examination via video conference. This included, but was not limited to, checking patient pulse, obtaining data from patients’ wearable devices, and asking patients to palpate problematic regions in the body to gauge tenderness. They also learned important patient interview skills such as maintaining eye contact and engaging effectively. 

Prior to the COVID-19 pandemic, the Rowan SOM comprehensive clerkship curriculum included in-person lectures; two case presentations by students; subjective, objective, assessment, and plan (SOAP) note submissions with individual feedback sessions from course directors; and review of journal articles. Students were also required to complete virtual clinical learning modules and oral case presentations. During the COVID-19 pandemic, students were still able to complete all these milestones by interacting virtually with faculty members and submitting their assignments online. The Family Medicine clerkship is typically eight weeks in length; however, this was altered to only six weeks to allow for two weeks of in-person experience at a later date, as recommended by Rowan SOM’s curriculum committee. At the end of this telemedicine clerkship, the Comprehensive Osteopathic Medical Achievement Test examination was administered remotely. Table 2 shows a direct comparison between activities in the traditional clerkship and those undertaken in the virtual model during the pandemic. 

The family medicine specialty embraces continuity and patient-centered, competent care within the context of family and community. ⁸ This approach has proven to be paramount amidst the current public health crisis, when there is a need to decrease the spread of COVID-19 through measures like social distancing and quarantine. The emergence and integration of telehealth into care-delivery systems during this pandemic has lent itself to not only health promotion and disease prevention, but also continuation of medical education. Family medicine clerkships provide patient care knowledge necessary for all medical students, regardless of their ultimate career choice. ⁸ During this time, we feel that telehealth gave Rowan SOM a platform to expand these skills beyond traditional medical competencies to include active listening, expressing empathy, and working in teams that included certified medical assistants, residents, attendings, and technology support personnel. 

Rowan SOM did not include telehealth as part of the traditional curriculum prior to the pandemic. However, this proved to be a relatively insignificant barrier because the existing tools are user-friendly; a redesigned workflow was quickly developed by the faculty. Replicating this program requires flexibility and a clear goal of how medical students would be integrated. Successful implementation of the six-week virtual family medicine clerkship model at Rowan SOM allowed students to seize a rare opportunity in the context of critical practical experience. 

Although telehealth is useful, it is also important to recognize that there are elements of osteopathic medical education that cannot be replaced virtually. These elements include the ability to use our hands to not only diagnose structural and functional concerns but also to provide treatment with osteopathic manipulative medicine (OMM). Additionally, the doctor-patient connection can be enhanced with a physical presence to provide support and ensure that patients’ concerns are eased. While telehealth cannot truly replace an in-person clinical experience, students can still gain invaluable clinical knowledge while learning a new modality for delivering healthcare that will likely remain a major part of medicine for years to come. 

The clerkship team and the Department of Family Medicine at Rowan SOM executed a substantial overhaul to the clerkship curriculum to implement telehealth and continue osteopathic medical students’ education during the COVID-19 pandemic. While seemingly daunting, it is possible for other clerkship sites to use similar changes, especially for office-based rotations. Students should stay involved in patient care during this pandemic so they can see how public health crises can affect a medical practice and how physicians can respond. The profound effects of COVID-19 will impact medical education for years to follow. The key learnings from this worldwide pandemic can be distilled into a necessity for academic communities to prioritize a forward-thinking approach. Digital literacy is a critical aspect of future medical pedagogy. Telehealth has shortcomings such as limited physical examination capability and lack of options for hands-on management like OMT, but mastering telemedicine early in training will prepare future physicians for known and unknown challenges their patients will face.