You’ve Got Mail: a Case-Based Curriculum to Teach Patient E-mail Communication to Internal Medicine Residents
J Gen Intern Med
DOI: 10.1007/s11606-020-05999-5
© Society of General Internal Medicine 2020
INTRODUCTION
An ever-increasing portion of patient care across nearly all medical specialties is provided virtually via telephone, e-mail, and video encounters.1When physicians render care via se- cure e-mail, it is necessary to be mindful of clinical challenges, legal considerations, and the possibility that technology may worsen disparities among patients with limited health or tech- nological literacy.2,3
In the Kaiser Permanente Oakland Internal Medicine (IM) Residency, a community-based residency training program within a large integrated healthcare organization, resident physicians provide primary care via office, telephone, and e- mail encounters. In 2018, our 44 IM resident physicians received a total of 7,773 patient e-mails. These patient e- mails are sent from their empaneled patients as well as from those for whom they have provided care, starting as early as the first day of internship. However, there is not a standardized approach to e-mail encounters, and the basic skills to conduct these are not universally taught in graduate medical education curricula, which can impact patient safety and quality of care.
METHODS
We performed a literature review and root cause analysis to systematically identify gaps in resident physician education.
Subsequently, we interviewed key stakeholders including pri- mary care providers with high patient e-mail volumes as well as our local patient advisory council. Using this information, we developed and implemented a new case-based curriculum and measured the effectiveness in pre- and post-intervention surveys of reported self-perception of proficiency.
INTERVENTIONS
We designed a 2-h curricular innovation highlighting the top five common clinical scenarios identified by our stakeholder
interviews. The simulated cases included a patient-generated e-mail message, medical history, and relevant data. The topics covered an itchy rash, medication side effects, request for lab results, active depression symptoms, and an appointment re- quest. A learner’s guide included prompts to discuss commu- nication, clinical decision-making, and electronic medical re- cord technical skills. A facilitator’s guide specified learning objectives to discuss with participants. Each case concluded with instructions to compose a response to the patient- generated e-mail message. Our repeat post-intervention survey assessed the efficacy of the curriculum and resident self- perception of secure e-mail proficiency.
RESULTS
Thirty-two resident physicians and medical students were divided into five small groups and participated in the interven- tion curriculum with an attending physician facilitator. Each group was assigned an individual case. After completing the curriculum, group members presented a summary of their assigned case, group discussion, and e-mail response to all learners. All residents in the training program received a 9- question survey prior to and after the curriculum (response rate 59% and 75% respectively). Surveys showed increased self- perceived proficiency with respect to domains highlighted in the learner’s guide.
CONCLUSIONS
We developed and piloted a novel curriculum with case-based simulations of common patient-physician e-mail encounters to teach resident physicians the unique skill set to provide virtual care as part of a quality improvement project. The curriculum encourages learners to develop a shared framework and stan- dard approach to secure e-mail. Following the simulation, small groups of experienced and novice physicians discussed workflows, documentation, when to seek supervision or rec- ommend office evaluation, and communication etiquette. Our survey data demonstrated increased self-perceived proficiency in e-mail virtual encounters suggesting that this curriculum has utility as a quality improvement and educational tool. Al- though our curriculum featured clinical scenarios most useful for IM resident physicians, it could be modified to highlight teaching objectives across medical specialties, practice set- tings, and learner experience levels. As telemedicine
Received May 28, 2020 Accepted June 15, 2020
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Published online July 6, 2020 36(9):2886–7
Luxenberg et al.: Curriculum to Teach Patient E-mail Communication JGIM
utilization increases, it will become increasingly important for physicians across the continuum of experience levels to hone their telemedicine skills through formalized curriculum. Since designing this curriculum, it has become integrated as a core component of our residency program’s yearly course work.
Adam Luxenberg, MD MS1 Leslea Brickner, MD1,2 Stephan Lee, MD1
Nirmala D. Ramalingam, MPP2 H. Nicole Tran, MD PhD1,2
1Department of Internal Medicine, Kaiser Permanente Oakland Medical Center,
Oakland, CA, USA
2Graduate Medical Education, Kaiser Permanente Oakland Medical Center,
Oakland, CA, USA
Corresponding Author: Adam Luxenberg, MD MS; Department of Internal Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA (e-mail: Adam.A.Luxenberg@kp.org).
Compliance with Ethical Standards:
Conflict of Interest:None of the authors have any conflicts of interest to disclose.
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3. Emani S, Peters E, Desai S, Karson AS, Lipsitz SR, LaRocca R, Stone J, Suric V, Wald JS, Wheeler A, Williams DH.Perceptions of adopters versus non-adopters of a patient portal: an application of diffusion of innovation theory. BMJ Health Care Inform. 2018;25(3):149-57.
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