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We agree that prioritising patient care in the response to the COVID-19 pandemic has led to justifiable disruption to medical education, prompting innovative and adaptive methods of teaching from medical educators.1 In a July 2020 address to the Royal College of Physicians, the Secretary of State for Health and Social Care stated general practioner (GP) consultations in the UK should be delivered remotely by default for the foreseeable future. As final-year medical students, we would like to share our experiences of the recent changes to undergraduate medical education and primary care delivery, particularly the rapid increases in the use of telephone triage and remote primary care consultations during the COVID-19 pandemic.
Medical education can shape and influence a student’s career choice,2 so appropriate exposure to each speciality is crucial in this decision-making process. Primary care placements typically allow students a unique opportunity to practise history taking for a wide range of presenting complaints and communication skills in the management of chronic conditions. This environment also provides time to safely perform clinical examinations during student-led consultations and allows for immediate feedback from the supervising clinician to facilitate effective learning. However, face-to-face patient encounters across both primary and secondary care have been significantly limited by COVID-19, resulting in reduced diversity of clinical learning experiences. Although remote consultations differ from in-person care, they have bridged the current gap in clinical education.
After receiving training from our medical school, we were immersed in the world of remote primary care. This included leading telephone or online triage consultations. Depending on the presentation of the patient, we could either invite them to a video consultation, ask them to send digital photographs via an opt-in encrypted electronic messaging service or request their attendance at the GP surgery for a full face-to-face history and examination.
During our primary care clinical placements, we identified several patient groups for whom the long-term universal adoption of telephone triage and remote consultations may be problematic. It was particularly challenging to take histories remotely from patients where there was a language barrier, from those with hearing loss, and from those less able to use digital camera technology. Furthermore, online triage questionnaires did not always evoke adequate or specific detail regarding patient signs and symptoms, especially for chronic or complex presentations. In face-to-face consultations, patients less able to verbally articulate their symptoms could have better communicated their problems with additional non-verbal communication. In-person consultations also offer the opportunity for the clinician to act upon visual cues, such as those associated with psychological problems, or signs deemed unimportant by the patient. We also observed greater potential for miscommunication between the person consulting and the patient during telephone appointments. Questions were sometimes misinterpreted by the clinician or patient, leading to further in-person consultation to clarify the disclosure of potentially dangerous signs and symptoms. Furthermore, sustained reductions in the number of UK 2-week-wait referrals have been reported in recent months. Such trends may be due to patients delaying presentation to GP practices with symptoms. However, less opportunities to identify important visual cues and signs unnoticed by patients when consulting remotely may also be exacerbating diagnostic delays and longstanding health inequalities.
Consulting via telephone highlighted to us the importance of taking a more comprehensive history, including questions on specific signs in the absence of visual cues, and the benefits of incorporating more open questioning throughout. This allowed patients greater opportunity to share symptoms they might not initially mention, but may have the biggest impact on their current health and well-being, such as psychological symptoms. Therefore, although telephone triage proposed a unique challenge to adapt to, it aided in advancing our verbal communication skills, a beneficial competency we can use throughout our careers.
For those presentations that can be managed via a single telephone consultation, the widespread adoption of telephone triage has eliminated some barriers to accessing NHS healthcare, including physical, geographical and occupational barriers. For patients who can interact with healthcare remotely, this has significantly reduced the time required to travel to and from a face-to-face appointment. However, the need for several remote consultations (eg, online, telephone triage and then video) sometimes made for a more inefficient and timely consulting process. The widespread adoption of telephone triage is likely to have increased barriers to healthcare for those with reduced access to technology or poorer knowledge in using it. For example, restricted access to a telephone while at work or insufficient bandwidth to support a video consultation. Arguably, the rapid adoption of telephone triage and video consultations may have worsened barriers to healthcare for some of our most vulnerable and in need populations.3 4
The reduction in opportunities for students to examine patients during the COVID-19 pandemic has implications for both students and patients. Clinical examination is important for learning and building a diagnostic thought process; furthermore, non-verbal communication is an important aspect of the primary care consultation.5 As William Osler proclaimed, ‘to study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all’. This is therefore a component that will need to be addressed within medical education under the current circumstances, perhaps through making greater use of patient simulations.
The widespread adoption of telephone triage within primary care during the COVID-19 pandemic has provided medical students an opportunity to further develop verbal consultation skills. As a result, the future primary care workforce will be more prepared to make use of technology in facilitating remote consultations when appropriate. Despite this rewarding outcome, there remain unanswered questions regarding the impact of this rapid change in how patients access primary care services, particularly on patient care, patient experience, and medical education. In reference to the latter, we are most concerned by the potential negative impact of reduced opportunities for current medical students to practise their clinical examination and non-verbal communication skills. It must also be acknowledged that for clinicians and patients, face-to-face appointments were considered superior prior to COVID-19.4 Thus, maintaining remote GP appointments as the default consultation option after COVID-19 may be unrealistic.
Twitter Jean Pierre Laake @JPSLaake.
Acknowledgements The authors would like to thank the academic primary care teaching staff at Warwick Medical School and the teams on our GP placements for providing us with clinical learning opportunities and support during our placements.
Contributors CM and JPL conceived the idea for this letter and drafted the manuscript, which is based upon formal reflective pieces of writing completed as part of our MBChB course and a facilitated group discussion involving all authors at the end of our final year primary care clinical rotation. CM, JC, JP and JPL revised the manuscript for important academic content and approved the final version for submission. JPL is the guarantor of this work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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