Virtual Shadowing as an Effective Approach to Gaining Exposure to the Field of Emergency Medicine

Introduction

Physician shadowing plays a critical role in the education and professional development of medical students during their pre-clinical years. Many medical education programs require undergraduate shadowing as criteria for admission1. The COVID-19 pandemic has severely restricted access to the hospital for medical and premedical students, thereby impeding their career exploration, education, and access to potential mentors. The purpose of this study was to evaluate our novel virtual shadowing program in the emergency department for interprofessional health sciences students.

Medical students, particularly during their pre-clinical training years, rely heavily on physician shadowing to become more familiar with the clinical environment. Shadowing is often used for career development in order to help students foster relationships with potential mentors, explore different fields of medicine, gain experience with patients, and improve their medical reasoning skills through observation2-4. Many medical education programs implement some variation of the Association of American Medical College’s (AAMC’s) Careers in Medicine curriculum to equip students with the information needed to make an educated decision about which field of medicine they will choose to practice in5. The need for a Careers in Medicine program within medical schools is well accepted, with increasingly more schools choosing to formally adopt such programs as part of their curriculum6-9.

Shadowing typically involves a student following a physician for part of a shift. This allows the student to gain understanding of the physician’s role in patients’ medical care and observe the physician performing interviews, physical exams, procedures, etc.10,11. Traditionally shadowing has been an in-person experience however, due to the COVID-19 pandemic these in-person shadowing experiences were severely limited or suspended for pre-clinical medical students. Our institution’s emergency department (ED) was particularly impacted due to it being the front line in managing the pandemic. Thus, student shadowing was deemed too dangerous given the high risk of viral exposure in the ED.

Although the suspension of in-person shadowing was justified, it is also quite possible that restricted shadowing could result in long-term disruptions in student career development. Lack of exposure to fields that are often not required in the clinical years, such as Emergency Medicine (EM), may limit students’ ability to make an informed decision about fields they have not had any exposure to. As a result, it may be difficult for students to make educated decisions about choosing fields such as EM for their clinical experiences or career. Additionally, shadowing has traditionally been an avenue for students already interested in EM to identify career mentors. However, the limitations on shadowing could curtail their opportunities to expand their social network.

To help fill the void left by the suspension of in-person shadowing, our team of faculty and students at a major academic medical center developed a virtual shadowing experience for pre-clinical students in EM with the hypothesis that a structured virtual shadowing experience could supplement or replace the in-person shadowing experience. To test this hypothesis, our team first designed and implemented a virtual shadowing pilot program. We then assessed the efficacy of the pilot program through surveys given to the students who participated. The results of this program are informative and applicable to helping medical schools successfully use virtual shadowing as a supplement to in-person shadowing.

Methods

Design and pilot of virtual intervention

With the approval of the Institutional Review Board, the team first designed and implemented a virtual shadowing pilot program. After a literature review of shadowing best practices, the authors designed a virtual shadowing program with the aims to 1) introduce students to the ED clinical environment and EM as a specialty, 2) reinforce clinical skills through use of a documentation template, and 3) encourage mentoring relationships between students and faculty. Six ED physicians in academic and community settings volunteered to guide small groups of medical students through virtual shadowing experiences for 2-hour sessions offered during October and November of 2020. Once the schedule for the 2-hour blocks was determined, first- and second-year medical students at the team’s institution were invited to register for the sessions via solicitation emails and social media posts. Up to 10 students were allowed per session. Virtual shadowing was conducted using an official University HIPAA compliant “ZOOM” account on an ED issued telehealth monitor or iPad. Prior to each session the students were emailed a copy of Chapter 1 of the Emergency Medicine Residents Association (EMRA) and Council of Emergency Medicine Residency Directors (CORD) student advising guide to read as an overview of what to expect in the field of emergency medicine. Students were also supplied with a “T” sheet (documentation template) for them to fill out during each patient interaction. The “T” sheets were for student use only and were given to help students organize each patient’s history, develop differential diagnosis, and encourage questions. During each session, the physician would bring the telehealth monitor to the location of each patient interaction, obtain permission from the patient, and then proceed to provide care while the students observed through the camera of the monitor. When appropriate and as time permitted, students were able to ask questions using their microphones or the chat feature within the Zoom app.

Evaluation of intervention (instrument design, data collection, data analysis)

Next, to assess the efficacy of the pilot program, surveys were given to the students who participated. Within 24 hours of the shadowing session, each participant was sent a survey about the shadowing experience and was given 1 week to respond. The survey consisted of 15 questions. The first 4 questions were about demographics, while the next 9 questions were Likert scale questions designed to evaluate the student’s perception of the virtual shadowing experience. The final 2 of the 15 questions were free response questions. The survey was designed, collected, and analyzed using the free online access Google Forms resource. All survey responses were anonymous.

Results

In total, 58 students participated in the experience. Survey responses of these students were collected between October 20, 2020, and November 20, 2020. The overall response rate was 96.6% (56/58 surveys completed). Of respondents (N=56), 13 (23.2%) were second-year medical students, 43 (76.8%) were first-year medical students, 35 self-identified as female (62.5%), and 21 (37.5%) self-identified as male. All participants had, prior to COVID-19, shadowed a physician in-person 3 times or more in the past. Of the respondents, 46 (82.1%) rated the virtual shadowing experience as “effective” or “very effective” at providing exposure to EM. Fifty-three participants (94.6%) said they would participate in virtual shadowing in the ED again, and 48 (85.7%) would do virtual shadowing in another specialty were it available. When compared to in-person shadowing, 34 (60.7%) were somewhat less satisfied and 15 (26.8%) were equally as satisfied. Forty-nine (87.5%) participants would “absolutely” or “probably” recommend virtual shadowing to other medical students.

For the last 3 questions, students were asked to rank the likelihood of each of the 3 following scenarios to occur because of the virtual shadowing experience when compared to in-person shadowing: (1) finding a mentor (2) strengthening rapport with a fellow student with similar career interests (3) connecting with a more senior student with whom I could ask questions about the field. Twenty-three (41.1%) students rated scenario 1 as less likely, 25 (44.6%) rated scenario 2 as less likely, and 24 (42.9%) rated scenario 3 as less likely. The entirety of the student responses and results are included in Table 1.

Wheelwright_Table_1

Themed student feedback is shown in Table 2.

Wheelwright_Table_2_983

Discussion

This novel pilot study of a virtual shadowing program for pre-clinical medical students found that virtual shadowing can serve as a feasible, easy to implement, and positively viewed program for medical students. The program was utilized as an alternative to in-person shadowing during the COVID-19 pandemic but could also be utilized as a supplement to in-person shadowing in non-COVID times. The experience allowed for students to interface with EM physicians, residents, and classmates; all of whom the participants may not have interacted with otherwise. During many of the virtual shadowing experiences contact information was exchanged between the students and the physicians. We are hopeful that the students’ exchange with the physicians via Zoom will help them to feel comfortable contacting them in the future for the purposes of mentorship and research.

Based on the student responses, the use of virtually shadowing appears to be a viable supplement to the career development of 1st and 2nd year students. Appropriate incorporation into the career development curriculum has the possibility to enhance the student’s ability to make educated decisions regarding what type of medicine they want to practice5.  With most medical programs requiring career development7, there is potential space for required virtual shadowing to ensure students have a larger breath of exposure prior to rotations and residency selection. Though the mode of observation is different during virtual shadowing compared to traditional shadowing, the goals of shadowing (mentorship, clinical experience, and enhanced medical reasoning) as outlined by Burgess and Zink can still be achieved through the virtual setting.

As a result of this study, we recommend increasing student and physician participation in virtual shadowing. The pilot program proved to be an accessible and effective way to allow a considerable number of students to gain exposure in a small amount of time. One benefit of virtual shadowing is that up to 10 students were able to gain shadowing experience by being virtually present within the examination room without overfilling the space. Another benefit of virtual shadowing is that it is more time efficient than in-person shadowing. For example, in this study using the virtual shadowing approach for 30 days, nearly 60 students were able to shadow an emergency room physician. While student evaluation responses were overwhelmingly positive, to more adequately assess the effectiveness of the virtual shadowing program there needs to be long-term implementation with greater student and preceptor participation. The participation should preferably come from multiple academic centers to increase the cohort diversity. The pilot program for virtual shadowing was easy to set up and required relatively little commitment and demands for both the attending and the student. These characteristics of the program will allow for it to be easily implemented into the career development curriculum at other programs without significant investment of time or resources.

Another appropriate progression of this study is the application of virtual shadowing to other specialties.  Because this study only assesses the use of virtual shadowing within the ED, it would be advantageous to apply the virtual shadowing program to other specialties to assess its viability in other areas. The ease of access for students could attract more students to shadow different medical specialties and may be an attractive primer even in the post-pandemic setting. When implemented, students no longer have to go through the cumbersome task of identifying their own shadowing opportunities. Using a virtual shadowing shift calendar, as was implemented with this pilot, it is very easy for students to be able to gain access to shadowing experiences. One exciting application of the program is the use of virtual shadowing to increase the ease of access for students to gain exposure to rural and otherwise difficult to access areas of medicine. This has the potential to foster more interest/exposure and career development in areas of medicine that desperately need more physicians. 

Although there are numerous benefits of virtual shadowing, there are also some challenges. Certain aspects of the shadowing experience are poorly portrayed through a virtual setting. For example, a shadowing student most likely cannot fully comprehend the atmospheric setting of busy ED or a frustrated patient through a virtual setting. This lack of atmospheric comprehensiveness could lead the student to perceive the field of medicine which they are virtually shadowing to be less interesting than they would have perceived it if they were shadowing using the traditional, in-person approach. Additionally, the lack of personal connection could be negatively perceived by the patient. Although, there were no negative comments made by any of the patients who consented to have the students virtually observe the interaction, it is likely that some patients would dislike virtual observation.

Some students also commented on the lack of personal interaction they felt with the physician and patient during the virtual shadowing experience when compared to their previous in-person shadowing experiences. These findings suggest that virtual shadowing may be an effective supplement for in-person shadowing but should not be considered as a replacement.

The most common area of critique by students for the pilot program was regarding technical difficulties during the sessions, including audio and video quality. These barriers could be addressed by having the attending physician wear a portable microphone or equip the monitor with a higher quality microphone and ensuring that the camera is angled correctly. Although the patient interviews were often easily visible, the visualization of procedures was often more difficult. Using portable stands made this easier. However, if the angle of the camera changed during the procedure the student’s view could end up being disrupted for the entirety of the procedure because the attending or resident were unable to adjust the view until after the procedure was completed. One possible solution is to have an in-person shadowing student be in charge of controlling the camera angle and video quality during the session.

Limitations

This study is limited by its small sample size and single center design. A greater number of student participation and the participation of additional academic centers would allow for greater analysis of the effectiveness of virtual shadowing. Additionally, students who participated were self-selected which may introduce bias in their survey responses in that these students may have already been interested in EM. Finally, the pilot program did not include an attending physician survey, which could be beneficial for receiving more feedback on how to improve the experience for both physician and student.

Conclusion

Virtual shadowing utilizing mobile telehealth monitors in the ED is an easy way to implement, positive experience for preclinical medical students. Virtual shadowing may be a viable supplement to help students gain exposure to the field of emergency medicine and other specialties.

References

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