Rural physicians often express frustration with their professional isolation and lack of collegial support. Their limited access to specialty consultants and their very limited access to continuing professional development (CPD) opportunities are particularly concerning in small communities with very few or no peers in close proximity. Rural physicians who are prepared to leave their communities to participate in CPD can only do so infrequently because their absence impacts negatively on their patients’ access to care. They also suffer financially from lost income and the expense of travel and accommodation. These situational factors, substantiated by the College of Family Physicians of Canada in a national family physician survey,[1] can precipitate professional dissatisfaction and lead to difficulties recruiting and retaining rural physicians. Overall, the situation can negatively affect the delivery of health care to rural patients.

Videoconferencing (VC), one form of modern information and communication technologies (ICTs), can elegantly help rural physicians obtain CPD opportunities in their own communities and augment clinical service delivery, providing solutions that are both timely and welcome.

Telelearning

Traditional face-to-face conferences and workshops create communities of learners who can interact with each other and with the instructor or presenter. While telelearning does not replace this traditional medium, it can create communities of learners across distance and even over time. These “borderless e-learning communities” can thrive when committed learners from different geographic areas are unable to assemble for face-to-face meetings but are able to share their passion to learn through ICTs. VC can easily connect physicians from two or more geographically separate areas. For example, urban and rural specialists can be linked visually with their family physician colleagues for educational discussions. This encourages learning between rural and urban physicians as well as between general practitioners and specialists. Urban and rural physicians can learn from each other about applying literature-based evidence in different clinical settings and discuss the availability of clinical resources. As well, rural and urban specialists and family physicians from various communities can exchange perspectives on patient management. Finally, all physicians can discuss how medical evidence can be practically applied to their patient population.

Bridging communities

While traditional workshops allow lively exchanges between individual participants who come from different communities, VC is able to enrich the learning experience by bridging two or more physician communities for validation and comparison of practice patterns. For example, during a UBC Division of Continuing Medical Education VC round on hypothermia that connected Vancouver with two rural communities, the rural physicians exchanged practice tips and information about innovative techniques for warming intravenous fluids without the expensive equipment available in an urban centre. As well, the urban physicians were able to see the benefit of these innovative approaches in the absence of specialized equipment and came to appreciate their colleagues’ problem-solving abilities. Without VC, this exchange would only be possible if all participants were transported to one place for an expensive face-to-face meeting.

High-quality VC permits another layer of necessary reflection when compared with traditional face-to-face instruction. In traditional classroom interactions, learning delivery methods (e.g., lectures, small-group discussions, case-based activities) need to be considered in relation to learners and the content to be covered. Instructors who use videoconferencing not only need to consider how learners, the content, and the VC delivery method all interact, they need to be aware of the strengths and limitations of this new medium. While VC brings together participants who are not in a single physical setting, instructors must understand the impact of this “distributed classroom” in terms of how material is presented and how learners absorb that knowledge.

Reducing “transactional distance”

Many first-time VC presenters and participants report that the experience is different from face-to-face instruction. Michael Moore’s concept of “transactional distance,” a distance education theory,[2] describes the communications gap between the instructor and his or her learners. This gap can create a psychological space of potential misunderstanding between the instructor and the learner during their interactions.[2] The balance between “program structure” and “dialogue” during a VC session determines the degree of transactional distance. Dialogue describes the kinds of interactions (learner-content, learner-instructor, learner-learner, learner-media, and learner-environment) occurring during instruction. Program structure refers to the flexibility of the educational objectives, the teaching strategies used, and the program’s evaluation methods—all of which determine the extent to which an education event can respond to each learner’s individual needs and learning styles. A highly structured program limits the opportunities for dialogue and the active engagement of learners, thereby increasing transactional distance. A less-structured program encourages dialogue and meaningful interactions between participants and content, thereby reducing transactional distance.

Minimizing transactional distance is vital when using VC for educational purposes, as VC itself exerts much more influence on transactional distance than the geographical separation between the instructor and the learner. A lecture-style presentation is less effective for a videoconference audience than for a live audience. The key challenge for a VC presenter is to use teaching strategies that strike a balance between dialogue and program structure, leading to engaging and content-rich experiences that involve a high degree of interaction for participants.

Engaging learners

Videoconferencing in and of itself is a technologically synchronous activity. Learners need to meet at specified times and locations in order to interact with one another. While VC education can bridge distance in the creation of borderless e-learning communities, it cannot bridge time. Therefore, web-based interfaces have been created to allow physicians to interact with knowledge not only in their own space but at their own pace. This technology can provide asynchronous solutions for learners that do not limit the e-learning communities in terms of common meeting times. One of the best examples is rounds-based material provided on the Internet. From video clips and audio files to journal articles and self-tests, web-enabled rounds-based materials provide a wealth of information that is available at any time to all physicians with an Internet connection.

Involving the learner during any type of technology-enabled educational session maximizes engagement and learning. For example, instructional developers need to keep web materials relevant and communicate clear instructional goals to learners. As with any distributed education technologies, web-based education should be chosen based on its appropriateness, especially regarding its use of the multimedia environment for presentation of materials. Finally, offering learners a variety of learning modalities—short video clips, interactive questions, gaming and simulation—will keep them engaged. Facilitating quality interactivity when designing content provides the best opportunities for learning and reflection.

Telemedicine

Using VC for peer-to-peer clinical services, such as collegial exchanges or case consultations, can be divided into three broad categories: store-and-forward consultation, scheduled consultation, and just-in-time consultation on demand.

Store-and-forward consultation

This consultation model is commonly used to transfer digital images along with a description of a case from one location to another. These packages of digital information are captured “stored” and then transmitted “forwarded” to another location.[3] The consultant then accesses both the digital images and clinical information, interprets, and sends a report back to the original location. Teleradiology is the most common telemedicine application. In a typical scenario, a hospital in a small town without local expertise sends X-ray images over the Internet to the radiologist in a larger urban institution. The radiologist views the images and then sends a diagnosis back to the requesting institution. Images of X-rays, CT scans, and MRIs are all now routinely stored-and-forwarded at hundreds of health care facilities. Images of pathology slides, skin conditions, and the retina are also being transmitted using this telehealth model for diagnostic consultation.

Although the store-and-forward model was initially used by a number of medical specialties (for example, a physical examination or interview of the patient by the local health care professional was recorded and forwarded to a consultant), this type of application is now less common. One exception is the Memorial University of Newfoundland’s Telehealth and Educational Technology Resource Agency (www.med.mun.ca/telemed/Default.htm [11]), which is involved in a number of international initiatives using low-cost store-and-forward technology.

Advantages of this consultation model include reduced dependency on bandwidth and expensive customized networks and equipment, and increased flexibility for consultants in terms of accessing images at their convenience. Disadvantages include inappropriateness for emergency situations where consultant opinions cannot be delayed, and lack of real-time interaction between the patient, the local health care professional, and the consultant.

Scheduled consultation

This consultation model involves a prearranged, real-time, two-way interaction between the consultant in one location and the patient and care provider at another location. VC equipment is present at both locations and can range from relatively inexpensive personal-computer-based and stand-alone desktop systems to elaborate, dedicated VC suites. Network options also vary dramatically, from relatively inexpensive Internet and intranet options, to terrestrial public networks such as ISDN or satellite systems. Nearly all clinical specialties now provide this kind of consultation. For example, in a number of small BC communities without resident psychiatrists, mental health clinicians and family physicians now schedule consultations for their patients with psychiatrists based in Lower Mainland teaching hospitals. Patients are interviewed, most often with the local mental health clinician present, and recommendations concerning ongoing management are immediately provided to the relevant local health care provider. Similar scheduled consultations now occur in the fields of internal medicine, rehabilitation, cardiology, pediatrics, obstetrics/gynecology, and neurology, although these specialties may require the presence of a local care provider to perform any physical examinations required. Increasingly, many peripheral devices, such as stethoscopes and otoscopes, can be attached to the VC equipment to aid in the interactive examination.

The advantages of this consultation model include its capacity to:

• Match the usual consultation approaches, which facilitates more ready acceptance by consultants and referring physicians/health care professionals.
• Improve access to specialty consultations by rural patients.
• Reduce cost and stress of travel for the patients and/or consultants. 
• Provide immediate clinical feedback to the patient and referring physician/health care professional.

The disadvantages include:

• Dependency on appropriate bandwidth and customized networks and equipment, which can significantly increase cost. 
 • Limitations in audio and video quality, potentially compromising the accuracy of the consultation.
• High cost of transmission. 
• Labor intensiveness of scheduling consultation times.
• Difficulty recruiting consultants because of inflexible timing and location of consultations.
• Dependency on the remote primary care physician/health care professional to perform part of the patient evaluation.
• Need for expensive peripheral equipment for some specialties.
• Lack of the bandwidth required for more sophisticated uses in many rural areas.

Just-in-time consultation on demand

Just-in-time consultation on demand (JITCOD) differs from both store-and-forward and scheduled consultations in that the consultation occurs unexpectedly, at the time the need arises. JITCOD is most commonly used to treat a critically ill patient in need of immediate intervention. In a typical scenario, the consulting physician triggers a telehealth consultation at his or her discretion and makes contact with a consultant ready to provide synchronous discussion of management recommendations. For example, when a trauma victim could not be evacuated by air from a regional BC community recently because of fog, a neurosurgeon in an urban centre used VC to guide a general surgeon in the community during the performance of a procedure to relieve an intracranial hematoma.

The advantages of JITCOD include real-time provision of consultation, immediate co-management of critical cases when minutes count, and the immediacy of management feedback to the consulting physician when the consultation need arises.[6,7] The disadvantages of JITCOD include the high cost of ensuring the availability of consultants on a 24/7 basis, and not knowing yet whether the volume of cases requiring JITCOD justifies the cost.

Conclusion

Videoconferencing is a rapidly evolving and viable way to provide rural physicians with close-to-home educational opportunities (telelearning) and clinical support (telemedicine). The essential first step for telehealth in BC is to build an ICT infrastructure to facilitate timely education and health service delivery. This enhanced connectivity will serve to equalize access to information for rural physicians, which can increase their professional satisfaction and reduce their sense of geographic isolation. As medical instructors and consultants become more aware of the unique nature of VC and design content specifically for this medium, effective telelearning initiatives and telemedicine approaches will merge into an innovative environment where learning and consultation become mutually complementary and inseparable, and where rural patients and health professionals alike benefit from the same access to services and educational opportunities that their urban counterparts enjoy.

Competing interests
None declared.

Kendall Ho, MD, FRCPC, Harry Karlinsky, MD, FRCPC, Sandra Jarvis-Selinger, PhD, and Jeff May, MDE

Dr Ho is associate dean and director of the Division of Continuing Medical Education, and assistant professor in the Department of Surgery, UBC Faculty of Medicine. He is an emergency physician practising at Vancouver General Hospital. Dr Karlinsky is director of continuing medical education and professional development, Department of Psychiatry, UBC Faculty of Medicine. Dr Jarvis-Selinger is director of research, Division of Continuing Medical Education, UBC Faculty of Medicine. Mr May is a consultant, Division of Continuing Medical Education, UBC Faculty of Medicine.