|
|
 |
Telemedicine Precepting
It has been suggested that use of this technology could be expanded to permit “telemedicine precepting,” or the supervision of a resident in a remote site by a preceptor who is not physically present.
From the perspective of the ACGME Program Requirements for Residency Education in Family Medicine (effective July 2006), supervision of residents is assumed to occur in a setting where the physician is physically present and can confirm the resident’s findings, review pertinent information and options, and guide the management of the patient. Although telemedicine would permit a supervising preceptor to view the patient, review records and X-rays, “see” superficial lesions, and perhaps converse with both patient and resident, s/he would be unable to verify most physical findings and would similarly be unable to assist/support the resident in the event of an emergency. In fact, given the realistic risk of a “lost connection,” the supervising preceptor would not actually be able to ensure any support to the resident. That assurance of support is central to the role of the preceptor, and is explicitly defined in the Program Requirements, as follows:
Supervision of residents:
"... on site supervision by an appropriately qualified member of the program’s faculty when the services or procedures …. “(PR – V.B.3)
Faculty Supervision:
"Whenever residents are performing clinical duties in the FMC, there must be an appropriate number of family physician faculty who, without other obligations, are engaged in active teaching and supervision of the residents.”(PR – V.B.2.b)
The RRC-FM has been flexible and supportive of curricular experimentation, as is evident in the accreditation of the rural programs that function in the 1-2 format or longitudinally structured programs. There are, however, several issues that require discussion if the RRC is to consider accepting the use of supervision by telemedicine. Some of these are as follows:
- Ensuring adequate supervision of a resident in a remote location would require the availability of a qualified physician on-site who would respond promptly if the remote telemedicine preceptor were unavailable or unable to provide the necessary depth of supervision. Such arrangements might be considered sufficiently safe to permit experimentation with telemedicine precepting.
- Immediate availability of the supervisor, rather than having to rely on contacting a local consultant, is more likely to encourage a resident to seek a collegial consultant which enhances learning and often uncovers insecurities or the need for fine-tuning of procedures, physical examination technique, etc. Residents would be reluctant to interrupt a consultant who is with his/her own patients.
- The absence of a physically present supervising physician could make it impossible for patients to receive those services requiring the action of an appropriately licensed physician. For example, in some states residents are not eligible for licensure until completing the three years of a family medicine residency. A supervising physician is needed to sign outpatient prescriptions, orders for durable medical equipment, and other items requiring authorization by a licensed physician.
- The issue of risk management in a telemedicine precepting situation would need to be addressed by the residency’s sponsoring institution. Appropriate liability protection for residents in training is an ACGME Institutional Requirement (IR III.D.1.g)
- Other interactional precepting activities may be permissible and allow fulfillment of educational and administrative activities of a program without long distance travel to remote sites. Examples include teleconferencing, e.g., lectures, seminars, and support groups; participation in faculty meetings, as well as in clinical teaching/supervision situations in behavioral medicine/psychiatry; and teleradiology.
- Careful monitoring and evaluation of the arrangements by the program director, preceptor, and residents would be needed.
Anyone proposing the use of supervision by telemedicine should address these issues in the appropriate sections of the PIF or in a separate proposal to the RRC. The Committee will judge whether the arrangements ensure compliance with the intent of the Program Requirements regarding resident supervision.
|
|
|
