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Feasibility study of student telehealth interviews

Abstract Background The COVID‐19 pandemic has led to medical students being taught remote clinical communication modalities (telephone and video). Junior students have not generally been included in this and have had less patient contact than previously. This study aimed to examine the feasibility from the junior student viewpoint of conducting both modalities of patient telehealth interviews. Methods An electronic questionnaire was used to discover Year 1 student reasons for their preferred modality after they had conducted one telephone and one video interview in pairs with a patient volunteer. Student views on the challenge and benefits of each were also sought. Findings A total of 55 (32.7% of the cohort) responded, of whom 82% preferred video consultation, 75.6% of those stating being able to see their patient/partner was a key factor. About 5% preferred telephone interview, and 13% had no preference. Telephone interviews were perceived as the more challenging (40% versus 12.7%); however, challenge did not directly link with lack of comfort. There were some technical/connectivity issues with both modalities, and the telephone call system was more complex to set up. Turn‐taking was more difficult by telephone without visual cues. Discussion This is the first direct comparison study in junior medical students of real patient interviews by video or telephone. Students embraced the challenge and, although preferring video and finding telephone more challenging, valued each as an educational experience. Conclusions Telehealth interviews with patients for junior students are feasible, give needed patient exposure, practical insights into remote modalities and consolidate communication skills learnt in the classroom.

elsewhere in the world, [11][12][13][14] alongside an imperative need for clinicians to learn to use it well and for students to gain the related skills they will need in future clinical practice. 9,15,16 Social distancing measures made providing authentic patient experiences for medical students challenging, and senior students were given priority for placements. 13 In light of the limited clinical exposure that junior medical students were receiving, it was important to know whether unsupervised telehealth interviews by video or by telephone would be feasible as a placement alternative for junior students.
It was important to know whether unsupervised telehealth interviews by video or by telephone would be feasible.

| CONTEXT FOR THIS STUDY
In 2020/2021, Keele Medical School newly taught video and telephone interview skills to Year 1 students as part of an innovated curriculum; and as clinical placements were suspended, alternative patient experience was set up in the form of telehealth 9,17 interviews, one by video and one by telephone with a real patient recruited from the School's Patient Volunteer database. The Patients as Educators (PasE) team booked and briefed suitable patient volunteers with chronic illness(es) and provided on-the-day technical support. These formative interviews were conducted in student pairs as we believe that the triadic interview format gives safety, fosters collaboration and encourages effective active listening. The video platform accuRx Fleming is secure and employed in more than 90% UK primary care settings 18 ; telephone interviews were audio only and used Amazon Call Connect. Students were in campus accommodation or at home; interviews were unsupervised, and guidance and training were given to use a standard format (opening, gathering information in biopsychosocial dimensions and closing). A routine online evaluation of this innovation immediately after their first interview was used to monitor student and patient satisfaction and administrative elements. 19 In addition, this study was devised to look at whether the novel experience of telephone and video modality is of educational value to a cohort of Year 1 students and explored the relative strengths, challenges and limitations of each approach.

| METHODS
Ethical approval was gained from the Keele University School of Medicine Student Project Ethics Committee (S-SPEC) for this study. All Year 1 students had two mandatory telehealth interviews. An email invitation was sent in March 2021 to all 168 Year 1 medical students after their second interview with details of the study, links to an electronic consent form and a Microsoft Forms questionnaire (Appendix A). Reminder emails were issued to all students, 2 and 4 weeks after the original invitation. The anonymised questionnaire responses were viewed by the researchers. Students were offered a certificate of participation to recognise their involvement in the study.

| Preferred modality
About 81.8% of students preferred the video call consultation, 5.5% preferred telephone and 12.7% had no preference.
About 81.8% of students preferred the video call consultation, 5.5% preferred telephone and 12.7% had no preference.
All 55 respondents gave open comments on their preference, and 76.4% mentioned that being able to see their patient helped them to build a rapport.
76.4% mentioned that being able to see their patient helped them to build a rapport.
Among the seven students who had no preference, two said the patient made the difference and two felt both were valuable for future practice and that telephone, although harder, enabled the student to think about the modality and adjust their style accordingly

| Overall educational value
A high proportion of students thought each consultation mode was educationally valuable (89% strong agreement/agreement for video, 85.4% for telephone). Agreement strength was higher for video. Of the 34 students (61.8%) who added comments, 55.9% mentioned non-verbal information as enhancing communication and 14.8% cited issues with pair-working complicated the process.

| Ability to develop a good rapport with patient
More students felt that a good rapport was enabled by video (96.4% strong agreement/agreement versus 58.2% for telephone). About 18.2% found establishing rapport more difficult with telephone (disagreed), compared with 1.8% for video. The predominant comment was that direct patient visualisation helped students pick up on nonverbal cues (20 students) and "connect and empathise" better

| Comfort and challenge
Students felt more comfortable with their video consultation than with their telephone consultation (85.5% strong agreement/agreement versus F I G U R E 1 Students' responses on the Likert scales within the questionnaire 76.4%), though two students felt that video consulting was more "intimidating" as they were "observed and visible" ( For those students who found a modality challenging, a similar proportion felt comfortable with the modality (59.1%: telephone; 57.1%: video), but a higher proportion of students that found video challenging was not comfortable with the modality (14.3% versus 9.1%), 'being seen' was a key factor in this for two students.

| Allowed effective communication
Significantly more participants felt video allowed them to communicate more effectively than with telephone (87% strongly agreed/ agreed for video; 63.6% for telephone). About 21.8% felt communication was ineffective (disagreed/strongly disagreed) with telephone compared with 5.5% for video. One student felt it was more intimidating handling a sensitive mental health topic by telephone; another felt the difficulties in communicating via telephone led to a longer consultation. Again, non-verbal information featured predominantly in student comments (12/25 students); five were centred around pairworking.
F I G U R E 2 Full quotes from selected students

| Preparedness
More students felt prepared for their video consultation (80% strongly agreed/agreed) than for telephone (58.2%). The key factor was experience related to students' prior classroom teaching (21/26), which was less for telephone: "I didn't really know what to expect, and because I hadn't used the different software I felt even more nervous" (Figure 2: 2.9). Ordering of modalities was a factor: Two of the three students who preferred telephone had completed their video call first, all of whom found video more challenging (when they were less experienced). Also, the interview format was different from prior simulated interviews: "I think because there was no 'presenting T A B L E 1 Main themes and number of students making comments complaint' and the consultations were more of a general conversation" (Figure 2: 2.9).

| Best aspects and what could have improved the experience of that modality
The best aspect of video call was the non-verbal factors (25 students), with the next two aspects-better rapport (12)  Video felt "more intimate and realistic like in real life".
I believe the telephone consultation was just as valuable as the video call consultation as it is vital we get experience from patients without visual cues.

| DISCUSSION
The high educational value found in our study mirrors that found by Budako glu et al. 2 in more senior medical students. Unrue et al. 20 is the only other study of the effectiveness of telemedicine training for a cohort of Year 1 students (in osteopathy) but used a simulated patient rather than a real patient encounter. They reported improved student self-confidence and satisfaction with telemedicine.
Ours is the first direct comparison study of two remote modalities in a whole cohort of Year 1 medical students. Rush et al. 21 found that such comparisons have been 'surprisingly limited' in the world literature. Hammersley et al. studied this in general practices where telephone consultation was found to be more useful for managing patients' problems than video (78% versus 65%). Our students preferred video, and this may reflect differing purpose and time frame of the calls.
The value of non-verbal information is widely recognised in video consultation. 4,22,23 Our students found that non-verbal communication allowed them to better read emotions and display empathy and establish a stronger rapport. Others have found in consultations with a heavy psychological component that non-verbal communication matters more. 6,24 The extra challenges that we found with telephone interviews were similar to final year students' experiences in Mulvihill et al. 4 ; however, that study did not contrast the two modalities specifically nor comment on rapport building, comfort or preference. Our students noted that for telephone, they had to use more specific questions and clarify more, which led to a more accurate and comprehensive history. Mulvihill et al. 4 similarly identified this challenge as being a useful opportunity to advance verbal communication skills.
Explanations for telephone being less favoured, apart from absence of visual cues, are less classroom exposure and the more complicated set-up combined with the triadic format. For video, many students are already familiar with setting up video for chat and teaching.
Our finding that students who feel challenged do not necessarily feel uncomfortable may be explained by the fact that students, as they learn a new skill, push themselves out of their comfort zone; this performance anxiety is inherently uncomfortable, 25 but the related confidence building brings comfort.

| Strengths and limitations of the study
The study addressed the previous absence of published work relating to remote interviews in Year 1 students. Our students embraced and valued the new educational opportunity, validating this as a new and 'entrustable professional activity'. 26 The large number of open-text comments proved helpful in giving texture to student responses, especially outlying ones.
Our students embraced and valued the new educational opportunity, validating this as a new and 'entrustable professional activity'.
The 32.7% survey uptake, despite using proven measures to increase response rate (participation certificate as an incentive and reminders), 27 is not unusual for an emailed survey 28 but raises the question of non-response bias. 27 The parallel evaluation 19 after the first patient interview may have led to survey fatigue, and such clashes will be avoided in any future study. Preference bias for one or other teleconsulting methods in responders more than in nonresponders is not anticipated in our study, however, as all students experienced both modalities. It is also noteworthy that in the evaluation that had a better response rate of 75% after one interview 19 (50% telephone call; 50% video call), all students found each telehealth interview a good use of their time and would repeat the experience. 19 We use non-standardised patients, reflecting real life, and some individual patient characteristics such as friendliness/chattiness may have made some interviews feel easier, possibly confounding the impact of modality. In line with this, Darnton et al. 29 found that patient selection influenced the value of student telehealth encounters. The complexity of call set-up may have biased respondents in our study against telephone.
Studies in primary care have found telephone and video calls to be shorter 5 and less 'information rich' than F2F. 5 We did not collect information regarding the length of each interview, though know from student evaluations that they ranged from 20 to 70 minutes. 19 If the study is repeated, call length will be recorded.
We set up these telehealth interviews in response to educational pressures in a pandemic. The usual timescales needed to design and pilot a research study of an educational innovation were contracted to fit within the ethical approval window, and the main method-a questionnaire-was chosen to give data on the first run through. Further research could examine the impact of ordering of modality on student comfort/preference and the relative and comparative educational value of remote consultations undertaken by students later in their training and as a singleton.

| CONCLUSION
This study demonstrates that, in a pandemic, unsupervised telehealth interviews are possible, educationally valuable and safe alternatives for junior students, which develop not only their general communication skills but also their telecompetence (Turner 1999, cited in Matusitz and Breen 30 ), which is vital in an ever-evolving and heavily technology-reliant environment.
Unsupervised telehealth interviews are possible, educationally valuable and safe alternatives for junior students.
Vital in an ever-evolving and heavily technology-reliant environment.
Both video and telephone consultations with patients are of high educational value to Year 1 medical students. Once technical factors and set-up are taken into consideration, video call is preferred as it parallels F2F consultation. Telephone three-way consultations are more challenging, as they are less familiar and rely only on verbal information.