Novel Telephone Medicine Curriculum Reduces Unnecessary Diagnostic Testing by Medical Students on Their Comprehensive Clinical Skills Exam

From the 2019 HVPAA National Conference

Mr. Joshua Prudent (Johns Hopkins School of Medicine), Dr. Daniel Hindman (Johns Hopkins Department of Medicine), Dr. Suzanne Kochis (Johns Hopkins Children’s Center), Ms. Ariella Apfel (Johns Hopkins Department of Medicine), Dr. Julianna Jung (Johns Hopkins Department of Emergency Medicine), Dr. Christopher Golden (Johns Hopkins Children’s Center), Dr. Amit Pahwa (Johns Hopkins Hospital)

Background

Telephonic and digital patient encounters are increasingly common, and physicians need the skills to triage and manage patients not physically present in their offices. In pediatrics, twenty eight percent of patient encounters now occur in this manner [1], and while potentially reducing unnecessary healthcare visits [2], telemedicine also can lead to excessive testing [3]. However,  telephone triage curricula are not required or utilized universally in undergraduate or graduate medical education. To augment the future practice of high value telemedicine, we implemented a telephone medicine curriculum (TMC) as part of the Core Clerkship in Pediatrics (CCP) at the Johns Hopkins University School of Medicine (JHUSOM), in August 2017. Using students’ encounter notes from a telemedicine case on their end-of-third-year Comprehensive Clinical Skills Exam (CCSE), we assessed the TMC’s effectiveness in improving students’ diagnostic testing practices in a telephonic patient encounter.

Objectives

  • Reduce unnecessary diagnostic testing by medical students in telemedicine encounters

Methods

This prospective cohort study evaluated third-year medical students at JHUSOM during the 2017-18 academic year after implementation of the TMC. The curriculum includes an introductory lecture, two simulated patient phone interviews, and a post-encounter note. Students’ later performance on the CCSE’s telephonic standardized patient case (based on test selection and cost) was compared between those who had participated in the TMC prior to the CCSE 2018 (Intervention Population [INT]) and those who had not (Concurrent Control [CON]), as well as to students who completed the CCSE in 2017, which predates the curriculum (Historical Control [HIS]) (Fig. 1). CON and HIS are also combined into a non-INT study population. Cost of testing was determined using the 2018 Medicare Fees Report from the CMS. The non-normally distributed cost data is compared via Kruskal-Wallis tests, and the categorical data from grading students’ testing is compared via chi-square/Fisher exact tests.

Results

The diagnostic tests selected by the students varied, and included highly expensive tests such as CT scans. Students who took the TMC ordered fewer tests (2.6 per student, versus 3.9 [CON] and 3.3 [HIS]) with a lower total cost ($63.11 per student, vs $92.97 [CON] and $80.55 [HIS]) in the setting of a benign telephonic patient encounter (Table 1, Fig. 2). A few tests were ordered more commonly by INT (bolded). When grading the student documentation, INT more often scored points for ordering appropriate testing (52.3% vs 24.0% [CON] and 37.7%[HIS]), with a statistically significant difference for INT vs CON (p-value: 0.002) and INT vs non-INT (p-value: 0.009). Additionally, the difference in total costs for INT vs CON was statistically significant (p-value: 0.011), as well as for INT vs non-INT (p-value: 0.040).

Conclusions and Clinical Implications

Medical students who participated in our telephone medicine curriculum ordered fewer and less costly diagnostic tests on their CCSE telephonic encounter. This study shows that such medical school curricula can improve high value practices by students in telemedicine encounters, with the potential to reduce costs and improve the quality of their future healthcare practice.

References

1) Curtis P and Evens S. Doctor-Patient Communication on the Telephone. Can Fam Physician Vol 35; January 1989.

2) Vyas S, Murren-Boezem J, Solo-Josephson P. Analysis of a Pediatric Telemedicine Program. Telemed J E Health Vol 24; Dec 2018.

3) Ray KN et al. Antibiotic Prescribing During Pediatric Direct-to-Consumer Telemedicine Visits. Pediatrics April 2019.

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