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Telemedicine

Authors

Alexandra Neumann, MD
Capt, USAF, MC
General Surgery Intern
San Antonio Military Medical Center

Faculty Editor

Neal Sikka, MD
Associate Professor
Chief, Section of Innovative Practice & Telehealth
Department of Emergency Medicine
The George Washington University Medical Faculty Associates

Special thanks to our 1st edition writing team

Krystle Shafer, MD 
Neal Sikka, MD

INTRODUCTION

Description of the specialty
The concept of “connected health” is centered around telehealth and telemedicine. According to the American Telemedicine Assocation (ATA), telehealth and telemedicine are terms that may be used interchangeably to describe an array of patient care provided using telecommunications technology. This may include services ranging from remote patient monitoring to specialty-based consultations such as telepsychiatry, telestroke, or tele-ICU either locally or internationally. It is a tool for providers to offer convenient, efficient, and patient-centered care.

History about the specialty/fellowship pathway
Telemedicine first started in the United States in the 1960s when television was utilized for medical education and consultation. One famous example is the live-streaming of Michael Debakey’s open-heart surgery in Geneva in 1965. Although interest waned during the 1970s-1990s due to concerns about cost and practicality, the progression of technology has opened up new possibilities. Interest in the field was revitalized out of a need for health care delivery to those living in remote places. Corporate industries (eg, military, NASA, off shore oil rigs, Antarctica survey stations, etc.) also began exploring this branch of medicine. By the 1990s, real-time video medical consultation was developed, first used in Norway and later spread worldwide. Many believe that telemedicine can provide greater access to health care and improve the quality of health care services at a lower cost. As this field continues to expand and reimbursement models shift from fee for service to value based, it is no surprise that emergency medicine physicians are taking note of this field. Recently two fellowship opportunities have developed for emergency physicians seeking to become experts in this field.

Why residents choose to follow this career path
Residents choose to follow this career path because they are interested in becoming leaders in developing telemedicine education, research, and services. Through the course, they become experts in bringing together technology and clinical medicine to enhance overall delivery of medical care. Telehealth is considered of emerging importance in new value based payment models and population health and is an expanding field that continues to provide new and innovative ways to improve healthcare worldwide.

How do I know if this path is right for me?
Are you interested in developing new innovative technologies to provide patient care to patients when and where they require it? Would you like to become the director of a telemedicine program? Are you interested in performing research regarding remote biometric monitoring? Are you interested in concierge or direct-to-consumer medicine? Ever considered joining a startup? If your answers to any of the above questions are yes, this may be the fellowship for you.

Career options after fellowship
Options after fellowship include: Chief Medical Information Officer (CMIO), Director of Telemedicine; leader in improving patient access or population health; telemedicine provider; telemedicine researcher; leader of quality improvement teams relevant to telemedicine; program director of telemedicine fellowship, etc.

Splitting time between departments
Physicians typically practice telemedicine under the department of emergency medicine, but other parts of the health system may also be involved, such as internal medicine, speciality services, population health, quality, access, compliance, and accountable care. Thus, physicians do not split time between departments but rather fulfill their telemedicine responsibilities during their administrative time. Organizational leadership opportunities may also exist. The decision about how much administrative time versus clinical time is a personal decision and typically also a negotiation with your employer (example is 25% administrative time and 75% clinical).

Academic vs. community positions 
Telemedicine can be practiced in practically any hospital setting. This branch of medicine is typically hospital or system specific and is geared towards those with an interest in developing their current infrastructure for telemedicine. Of note, academic centers and integrated delivery networks (i.e. VA system or Kaiser) may have more funding and support staff for those interested in research as compared to community positions.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
This is an emerging subspecialty. Currently there are 2 programs, along with a specialized course at another program:

Fellowships:

Courses:

Differences between programs
GWU offers an opportunity to obtain a master’s degree (ie, MBA, MPH, or master’s degree in systems engineering). Fellows are also required to complete 2 research projects during fellowship. Thomas Jefferson offers fellows the opportunity for a certificate or degree from the Colleges of Population, Public Health, or a certificate in Operational Excellence. Both fellowships have their fellows work clinically as telemedicine providers.

Length of time required to complete fellowship 
GWU is a 2-year fellowship, whereas Thomas Jefferson is a 1-year fellowship.

Skills acquired during fellowship 
Skills acquired during fellowship include research, academia, leadership, administrative, entrepreneurship, and clinical skills.

Typical rotations/curriculum 
Typical rotations/curriculum during fellowship include participation in the department’s telemedicine services, opportunity to study advanced coursework, research, clinical emergency medicine shifts, and administrative responsibilities.

Board certification afterwards?
No. However, this fellowship is closely associated with medical informatics. Paths may open in the future that qualify fellows to sit for the Informatics Board by ABPM.

Average salary during fellowship 
Since this is not an ACGME-accredited fellowship, salaries are much more competitive than the traditional PGY-4/5 salaries.

PREPARING TO APPLY

How competitive is the fellowship application process?
This is a reasonably competitive fellowship due to only two fellowship programs currently available. 

Requirements to apply
You must have completed an ACGME residency to apply for this fellowship. 

Research requirements
Research is not required to apply for this fellowship but may certainly help to strengthen your application especially if the research is relevant to telemedicine.

Suggested rotations to take during residency
Suggested rotations to take during your elective time include an administrative month, research month, wilderness medicine, EMS and/or telemedicine rotation, etc.

During elective time, it is worth considering attending conferences, such as those through the American Telemedicine Association. This is a great way to help network and increase your knowledge about the specialty.

Suggestions on how to excel during these elective rotations
During your elective rotation, be careful not to fall into the trap of treating this as a “lighter month” and cruise through the month. Instead, make it a point to work hard, come in early, and stay late. Be courteous to all and seek out opportunities to be part of the care team. Read every day and expand your knowledge base. Find mentors in the field of telemedicine during your elective months if possible.

Should I complete an away rotation?
Since there are only 2 fellowships available, it may be helpful to arrange an away rotation at either GWU or Thomas Jefferson. This would be a good way for both you and the program to get to know each other better. Assuming you perform well, it may give you an advantage when you apply for fellowship. 

What can I do to stand out from the crowd?
The best way to stand out from the crowd is by creating an application that through your CV, personal statement, and letters of recommendation clearly demonstrates an interest in telemedicine. Leadership and/or research activities will also help you build a strong application. Becoming chief resident, while not required, can certainly strengthen your application as well. 

Should I join a hospital committee?
Joining a hospital committee and/or quality improvement team would be an excellent opportunity to expand your management and leadership skills. Seek out opportunities where you would have meaningful involvement in the committee.

What about publications other than research?
Publications other than research – such as blog posts, podcasts, case reports, magazine articles, etc. – can be a great opportunity for you to educate yourself and the emergency medicine community about telemedicine. Such publications would certainly be supportive on your application about your interest in this field.

How many recommendations should I get? Who should write these recommendations?
Contact each program regarding their requested number of letters of recommendations. Typically, the traditional number is 3 letters, one of which is from your program director or department chair and one of which is ideally from someone within the field of telemedicine. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes, you can still be competitive if you decide to work as an attending before applying for this fellowship. The key is to continue to be involved in leadership and other academic activities while working as an attending and to list them on your CV. Be prepared to explain your decision to work as an attending when interviewing for fellowship.

What if I’m a DO applicant? 
There are no barriers to DO applicants. 

What if I am an international applicant?
International applicants are encouraged to contact the fellowship directly. Applicants will at minimum need to have completed their USLME steps as well have obtain the appropriate visas.

APPLICATION PROCESS

How many applications should I submit?
Apply only to those places you would seriously consider attending if offered a fellowship position. 

How do I pick the right program for me?
Choose a great fit academically while also in a location that fits your personal and family needs. 

Common mistakes during the application process

Common mistakes that applicants make during the process include:

  • Missing application deadlines.
  • Grammatical errors on personal statement.
  • Having a CV that does not demonstrate a clear interest in telemedicine.
  • Weakly supportive letters of recommendation.

Application deadlines
Interested applicants are advised to contact each program regarding deadlines. 

Tips for writing your personal statement
The best personal statements do not simply repeat what is on your CV, but rather explain your interest in this fellowship and your career goals afterward. This is the time to let your personality shine through and try and set yourself away from the other applicants. If you have a certain life experience that led to your interest in this field, now is the time to write about it. Have multiple people read your statement to make sure it reads well and is without grammatical errors.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
If you do not obtain a fellowship position, take a look at your application to identify areas of weakness. It may be worth asking the programs that rejected you for tips on how to improve your application. Also, consider having your residency program director reviewing your application. Once you identify these weaknesses, spend the next year addressing them and apply again. Practice your interview skills. Worst-case scenario, there are other avenues to pursue education and practice in the telemedicine field.

INTERVIEW PROCESS

How do I stand out from the crowd?
The best way to stand out from the crowd during your interview is by having a clear vision about why you are interested in this fellowship and how this fellowship will help you achieve your career goals. Be personable and friendly with everyone that you meet. Be careful not to be overly shy nor overly chatty. Make sure you are prepared to ask the program thoughtful questions during your interview that cannot be easily found on their website.

What types of questions are typically asked?

  • Why are you interested in telemedicine?
  • Why are you interested in our telemedicine program specifically?
  • Tell me about “blank” that you list here on your CV.
  • What are your 5- and 10-year career goals?

How many interviews should I go on?
Since there are limited fellowship opportunities available, it is recommended that you attend all interviews offered. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Understanding Telehealth 1st Edition by Karen Schulder Rheuban and‎ Elizabeth A. Krupinski; McGraw Hill Education 2018.
  • Latifi R. Telemedicine for Trauma, Emergencies, and Disaster Management. Norwood, MA: Artech House; 2010.
  • Eren H, Webster JG. Telemedicine and Electronic Medicine. Milton Park, UK: CRC Press; 2015.

Important skills to practice while in residency to prepare for fellowship
First and foremost, residents should focus their energy towards becoming the best emergency physician they can possibly be. Other skills to consider developing include administrative, leadership, organizational, educator, and technological skills. 

Tips on how to succeed as a fellow
Take advantage of all opportunities that are offered to you during fellowship. The next 1-2 years is a chance for you to develop your niche under the guidance of mentors. Arrive early, stay late, and read every day. Strongly consider completing advanced degree programs if offered. Seek out opportunities to become involved in quality improvement projects, research projects etc.

CONCLUSION

Additional resources

Journals/Journal articles

Blogs/Podcasts/Websites

National organizations

Conferences

How to find a mentor
Unfortunately, there is no central website that connects interested physicians with mentors within this field. We suggest turning to faculty within your current department, national telemedicine organizations, and/or telemedicine conferences when searching for a mentor.