Traditionally, medical residents and fellows learning from a supervising practitioner had to be in the same physical location while caring for patients. But since the pandemic, temporary flexibilities from the Centers for Medicare and Medicaid Services as well as accrediting bodies have extended their definitions of “direct supervision.” This allows supervising attending physicians to observe learners from anywhere through real-time audiovisual technology, used at least for the critical parts of a medical service.
The practice (for now) is in place through the end of this year, and has big benefits especially in rural health settings, speakers said during a recent webinar hosted by the American Telemedicine Association. Journalists could find several interesting story angles by following the trend of virtual direct supervision and its potential for further expansion in patient care.
How it works
Direct supervision used to mean that a supervising practitioner had to be physically present in an office suite (though not necessarily in the same room) and immediately available to furnish assistance in case something happened, said David Newman, M.D., chief medical officer of virtual care for Sanford Health in Fargo, N.D., during the webinar.
During the COVID-19 public health emergency, CMS temporarily revised their view of “direct supervision” to allow supervision through real-time audiovisual technology rather than in-person or on-site presence.
Last November, as part of the 2024 Medicare Physician Fee Schedule final rule, CMS extended virtual direct supervision through Dec. 31, 2024, according to the Bass, Berry & Sims law firm. The extension allows practitioners to continue using virtual direct supervision while CMS considers the future of this capability.
There are multiple ways in which virtual direct supervision can work, Newman said. For example, an attending physician can be in one hospital but supervising a resident in a different hospital treating a patient there or at home. Or for less critical situations, a patient could be at work while the resident and attending physician can be at each of their homes.
“This has really been great for patient care as well as really been a good lifestyle situation for the residents and the attendings,” he said. “And it is becoming an expectation for young doctors coming through that they can do these things and there can be quite a bit of flexibility with this.”
In rural areas
Virtual direct supervision has been particularly helpful in rural settings, where specialists in urban areas can share their expertise remotely with trainees and patients who lack those types of experts nearby, sometimes due to hospitals and clinics closing, Newman noted.
For example, an expert could provide tele-ICU care to support very ill patients in critical access and smaller hospitals. For less urgent situations, there could be asynchronous supervision where trainees read a chest X-ray or CT scan and discuss with an attending later.
Newman’s medical center has been conducting a lot of remote supervision for mental health visits. Knee injections for arthritis are fairly routine, he said, and trainees in physical medicine and rehabilitation are permitted to give these while under virtual supervision.
“I used to say this was the future of medicine but it’s really the present of medicine now,” he said. “This is something that everyone should be expected to do by the time that they’re done with medical school and residency.”
To participate in the process, attending physicians and trainees must have the appropriate licensure in the state where a patient is located and must document on the medical record whether the teaching physician was physically or virtually present.
CMS will continue to evaluate whether to make virtual direct supervision a permanent policy and, if so, how best to balance quality, patient safety and program integrity concerns against the benefits resulting from expanded access to care and preserving the workforce capacity of medical professionals, according to Bass, Berry & Sims.
Remote direct supervision is not limited to medical trainees, Newman said, noting that social worker or respiratory therapist trainees also can benefit, provided they are following guidelines from their governing bodies.
It’s not for all areas of medicine
Virtual direct supervision is not necessarily appropriate in all areas of medicine or for all residency or fellowship programs. The Accreditation Council for Graduate Medical Education releases a document each year spelling out what procedures are and aren’t allowed to be completed through direct supervision using audiovisual technology for each medical specialty. For example, under obstetrics and gynecology, virtual direct supervision may not be used for the management of labor and delivery, or during invasive procedures.
Some areas where virtual direct supervision is not permitted, Newman said, include general, vascular and thoracic surgeries; critical care, obstetric and pediatric anesthesiology; and these specialties:
- Dermatology.
- Neurosurgery.
- Sports medicine.
- Addiction medicine.
- Ophthalmic plastic and reconstructive surgery.
- Orthopedic surgery.
- Osteopathic neuromusculoskeletal medicine.
Allowable services potentially could evolve, Newman said. There are some parts of surgery residencies and fellowships such as follow-up visits that could lend themselves to virtual direct supervision going forward, he added.
The Veterans Health Administration has slightly different rules, he said. Supervising faculty must be in the general vicinity and available to provide direct supervision when required, so they can’t work from home or a remote clinic.
Story ideas
There are several related story angles journalists could pursue, including speaking with patients, trainees and supervising physicians at health centers about what they like and don’t like about this type of setup. Reporters also could follow the legislation this year to see what will happen beyond Dec. 31.
Assuming these capabilities will be extended into future years, it may be worthwhile to look into areas like dermatology or sports medicine to see what procedures/conditions within those specialties lend themselves to virtual direct supervision.
Resources
- Revitalizing rural health care using technology – a webinar from the American Telemedicine Association.
- CMS extends virtual direct supervision through 2024 – a backgrounder from Bass, Berry & Sims law firm.
- Recommended telehealth competencies across the continuum of medical education – a report from the Association of American Medical Colleges.
- Specialty-specific program requirements for direct supervision – a guidance document on direct supervision using telecommunication technology, from the Accreditation Council for Graduate Medical Education.
