Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 
  • Users Online:1228
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 12-15

Digital health, learner competence, and a pandemic: The storm I had been waiting for

Associate Dean, Educational Innovation & Academic Technologies, Faculty of Medicine & Dentistry, University of Alberta; Neurodevelopmental Pediatrician, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada

Date of Submission06-May-2021
Date of Decision08-May-2021
Date of Acceptance10-May-2021
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Lyn K Sonnenberg
1-128A, Katz Group Centre for Research, 11315 87 Ave NW, Edmonton, Alberta T6G 2H5
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_107_21

Rights and Permissions

How to cite this article:
Sonnenberg LK. Digital health, learner competence, and a pandemic: The storm I had been waiting for. Arch Med Health Sci 2021;9:12-5

How to cite this URL:
Sonnenberg LK. Digital health, learner competence, and a pandemic: The storm I had been waiting for. Arch Med Health Sci [serial online] 2021 [cited 2022 Oct 6];9:12-5. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/12/319370

  The Perfect Storm Top

As I reflect on where I find myself as a clinician-educator and administrator today, I cannot help but draw parallels to the blockbuster movie by the same name. It has been more than 20 years since I watched it in theater upon its release, but the metaphor came back all too quickly. Based on a true story, the storyline unfolds as a group of fishermen seek out one final catch of the season, only to be caught at the confluence of two powerful weather fronts and a hurricane. For me, the two powerful weather fronts are digital health, using technology to help improve individuals' health and wellness, and learner competence, the possession of required skill, knowledge, qualification, or capacity. And the hurricane? You guessed it. The COVID-19 pandemic.

We need competent health-care professionals who, upon graduation, are ready to transition into the world of clinical practice and deliver quality health care, safely and compassionately. We thought we had the educational tools we needed for this task. Then the world changed. Isolation measures drove the need for virtual health care at a rate that was previously unprecedented, shifting in-person visits to online delivery practically overnight. This was particularly striking because change and adoption procedures are typically well calculated and planned prior to delivery (at least in principle). While telehealth/virtual health infrastructure was present prior to the global pandemic, it lacked integration with our clinical practices and regulatory barriers created challenges.[1],[2] The pandemic changed all that. Even emergency medicine, a specialty that in my mind is pseudonymous with face-to-face delivery, has remarked that the pandemic has brought forth “the dawn of mainstreaming virtual care.”[3],[4] It seems unlikely these innovations will simply disappear postpandemic.[5] Our patient community is not interested in returning to the prepandemic status quo, with its access limitations, now that the proverbial “genie is out of the bottle.”[6],[7] So, as medical educators we have to ask ourselves, how are we preparing to meet these changes and preparing our learners for digital health integration into clinical practice?

  Driving Home the Issue Top

Health professions education is well steeped in the apprenticeship model. But what happens when the medium of health delivery is new to both the teacher and the learner? The old adage, which makes many an educator shudder, “see one, do one, teach one,” is based on the premise that we learn by seeing, then doing, and finally by passing that learning along to the next learner. What happens, however, when there is no one after whom to model ideal care? What are the knowledge, skills, and attitudes needed to deliver basic virtual care, never mind exceptional care? It is not as simple as transferring in-person clinical skills to the virtual environment. By analogy, just because I can drive a car in rural parts of Canada doesn't mean I can drive it well in Delhi, India. The conditions are different. The fact the two countries drive on different sides of the road is challenging in and of itself, but sources of cognitive load will also vary, from having children arguing in the back seat (a hypothetical example, of course) to reading unfamiliar street signs in a more congested environment.

Now let's extend this model to the clinical learner. As practicing clinicians, we assume that our “Millennial” learners are technology literate and, therefore, will know how to manage the technological aspects of the clinical encounter easily

Contrary to popular opinion, Millennials are not all tech-savvy, a socially constructed and unfortunate myth that continues to be perpetuated.[8] As educators, we must take into consideration the need for contextual competence, the ability to adjust to new settings, which is often overlooked in current training models.[9] Merely thinking that by moving a learner, who is competent in an in-person clinical encounter, to a virtual environment, without any preparation or support, downplays the complexity of the situation. Too often as educators, we fail to realize that the learner's cognitive load, the multiple demands on one's working memory, is heavy. The weight of a new virtual health environment must be considered, when intertwined with the medical expert, communicator, and other roles they are learning to master and stresses they are carrying. We must further acknowledge that there may be even greater complexity when considering technology such as fluency with apps, wearables, and digital exchanges with patients through registered portals or other digital means, which may also require mastery and integration beyond the traditional clinical encounter/appointment. As a seasoned clinician-educator, who specializes in the intersectionality of technology and learning, I find myself overwhelmed, so I can only imagine how difficult this would be for those whose career is less focused in this area. Therefore, we need to carefully determine which competencies are needed to successfully navigate a virtual health-care encounter, while promoting a healthy learning and working environment.

As a result of these changing times, there is a growing gap between what learners need to do upon entering practice and the training we provide them.[10] The concept of adaptive expertise, “the flexible use of knowledge and the ability to generate new solutions and learn from daily problem solving,” is helpful here because it is based upon the premise that individuals will learn and innovate in response to practice challenges.[10],[11] To foster adaptive expertise in our learners, we need to shift their learning beyond retention and direct their application toward preparation for future learning.[12] As educators, therefore, we need to challenge learners to go deeper in their learning by asking the harder questions of why and what if, allowing them to embrace struggle and discovery in their learning to help them develop the capabilities of a Master Adaptive Learner.[11] This will allow learners to thrive in the ever-changing health-care environment upon entering practice, of which technology will play a significant role. So how do we manage when both mentor and protégé are feeling their way through uncharted waters? We navigate these changing times together.

  The Eye of the Storm Top

The learner and teacher are essential components to the learning process, both playing an active role; for the teacher that means no longer needing to be the “oracle who speaks from the platform of authority, but rather the guide, the pointer-out, who also participates in learning.”[13] Because this learning occurs in the context of health-care provision, patients must also play a key role in the equation, with their health-care needs being balanced with the needs of learners, who must grapple with the learning process to reach their full potential. Herein lies the inevitable tension between clinical service delivery and learning; how can the priorities of both the learner and the patient take center stage? Situated learning theory, “where learning is situated within a specific place and time and involves interacting within a community of practice,” may provide new ways of thinking.[14] Here, the importance of social interactions, and active participation in learning, centers around the mutual goals, objectives, and interests of community members. The tension is not seen as good or bad, but rather part of the learning experience. Recognizing that patients are equal partners in this learning experience changes the dynamics from being in competition to now being in partnership. This notion of partnership is highlighted in both social accountability, “the obligation [of medical schools] to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve,” and person-centered care, “a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs.”[15],[16],[17] This means putting patients/people at the center of decisions and seeing them as experts, working alongside learners and teachers, to get the best outcomes, thereby resolving the tension.

The therapeutic relationship between a health-care provider and a patient is the cornerstone of compassionate care, the human connection between patient and clinician, and technology can introduce a new space between them.[18] Digital health alters communication, boundaries, and privacy/confidentiality, placing that essential relationship at risk.[19] Digital tools introduce barriers, distractions, and distances that prevent clinicians from being physically present with patients.[20] Virtual health initiatives may further amplify existing health disparities experienced by those living, for example, in communities with limited internet connectivity or digital access.[21],[22] Yet at the same time, they have also afforded opportunities to improve the connection between patient and clinician, overcoming barriers and eliminating distances for those in rural and remote areas, where access to care was previously limited or, in urban areas, where travel to medical appointments was challenging. While continuing to keep compassionate care at the forefront, we need to weigh the consequences of our actions from multiple perspectives and ensure that digital compassion, the relationship between emergent technology and compassionate care, permeates all programs, services, and platforms, as we make our way forward through this storm.

  Competence on the Horizon Top

As medical educators, we are going to need a new approach to address the gap that remains between where our digital competence rests now as a profession and where it needs to be for our learners and patients as we continue to move into an uncertain future. Paulo Freire, an educator of the 20th century, advocated that teachers and students together initiate and sustain a process of dialog on issues that are real in the lives of both, and I would add that patients must be a part of that same dialog.[23] He spoke to the transforming role of human reflection and action, of social reform and advocacy. That call has not changed. So how are we going to shape the future of health-care delivery postpandemic? How are we going to navigate this transition to the “next normal?” There is no question in my mind that we need digital health-care clinicians who can deliver person-centered care using the most appropriate digital tools and technologies available to them, inclusive of understanding the security and privacy of digital information. Digital technologies will need to be seamlessly integrated into the full clinical experience, in a way that is professional and respectful, including before, during, and after the clinical encounter. This will likely be a steep learning curve for most of us, as we work to close the gap in a socially accountable way.

We have been thrust into this digital landscape due to the pandemic, in one crashing wave, rather than being able to dip our toes gently into the waters to acclimatize gradually. We may find ourselves now either trying to keep our heads above water, still trying to stay afloat and wait out the storm, or treading water in circles, not really knowing what to do next. We know that virtual health delivery is going to change postpandemic. We will need to transition from the “virtual models adopted in response to COVID-19 to those that will be relied on as permanent features of the health delivery system.”[24] While we have been predominantly fixated on survival, a good interim strategy, I would challenge that we now need to shift our focus to the critical assessment of how we thrive, rather than merely survive, by looking at digital health through the lens of both digital compassion and digital competence. Why? Because “despite the growing enthusiasm and use of virtual care, there has been limited discussion of its quality and the principles that should inform its development and assimilation.”[25] And, while there has been focus on how to integrate learners into the virtual health encounter and on how to assess existing competencies, we know too little about the actual clinical competencies needed to deliver effective virtual health care.[26],[27]

When I was asked to create digital literacy objectives for my clinical specialty of developmental pediatrics, I naively proposed this simple, one-line approach: Identify and integrate appropriate virtual health opportunities into the provision of person and family centered care. While this may have been a great place to start, this objective was anything but directive. Thankfully, best practices in learner competence continue to emerge, which will help guide the process, and I would be remiss not to help chart a way forward. Having reflected and grown since my aforementioned approach, and drawing from the work we have explored together, I suggest the following guiding principles for digital health when creating entrustable professional activities, key tasks clinicians are trusted to do every day:

  1. Ensure the importance of trust, transparency, human centeredness, and compassion in the development and delivery of digital health technologies[19]
  2. Be mindful of security, confidentiality, accuracy, and clarity in digital information that is created and used[28]
  3. Establish and maintain appropriate competence in selecting and operating technologies for clinical use or, more simply put, select the right technology for the right time[28],[29]
  4. Maintain a professional online presence by behaving professionally and respectfully with all media, always[28]
  5. Model positive and effective digital behaviors to others[28]
  6. Maintain an emphasis on equity, diversity, inclusivity, and access when implementing digital health services[19]
  7. Ensure the implementation of digital health technologies aligns with a health-promoting learning environment.[30]

These seven points of practical focus should be able to steer educators in the right direction. Yet, this is no small task we are being asked to accomplish in continuing to shift the health-care culture into uncharted waters. As a result, it cannot be a task that falls solely on the shoulders of medical educators. It calls for organization-level barriers to be removed and replaced with digital compassion standards, the standard of care for the experiences provided in digital environments.[31] We have an incredible opportunity to support these approaches through education, training, and coaching, affording a more balanced approach to health-care delivery, while ensuring an equal seat at the table for all. If we are going to get to our destination of providing compassionate care in the digital age, I don't think we have any other choice but to learn how to navigate these waters that are churning thanks to digital health, learner competence, and a pandemic. It was the storm I had been waiting for to hoist the anchors that stagnated our progress forward and I am grateful we have adopted new strategies and adapted our practices. Let us not lose sight in doing so, however, of the opportunities that remain, and holdfast to the wave of momentum we have been riding, for we have not yet arrived at our final destination.


I would wish to thank Drs. Kevin Eva, David Wiljer, and Victor Do for having read and commented on a draft version of this manuscript.

  References Top

Webster P. Virtual health care in the era of COVID-19. Lancet 2020;395:1180-1.  Back to cited text no. 1
Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. Mhealth 2017;3:38.  Back to cited text no. 2
Ho K. Virtual care in the ED: A game changer for the future of our specialty? CJEM 2021;23:1-2.  Back to cited text no. 3
Reid S, Bhatt M, Zemek R, Tse S. Virtual care in the pediatric emergency department: A new way of doing business? CJEM 2021;23:80-4.  Back to cited text no. 4
Foulds J, Burkle M, Sonnenberg L. From spark to flame – Radical innovations from cataclysmic events in medical education. Med Educ Publish 2020;9:132.  Back to cited text no. 5
Reed T. UnitedHealth Exec on Telehealth Use, Reimbursement: 'The Genie is Out of the Bottle'. Fierce Healthcare; 2020. Available from: https://www.fiercehealthcare.com/tech/unitedhealth-exec-telehealth-use-reimbursement-genie-out-bottle. [Last accessed on 2021 May 6].  Back to cited text no. 6
Khairat S, Lin X, Liu S, Man Z, Zaman T, Edson B, et al. Evaluation of patient experience during virtual and in-person urgent care visits: Time and cost analysis. J Patient Exp 2021;8:1-8.  Back to cited text no. 7
Jauregui J, Watsjold B, Welsh L, Ilgen JS, Robins L. Generational 'othering': The myth of the Millennial learner. Med Educ 2020;54:60-5.  Back to cited text no. 8
Teunissen PW, Watling CJ, Schrewe B, Asgarova S, Ellaway R, Myers K, et al. Contextual Competence: How residents develop competent performance in new settings. Med Educ 2021. doi: 10.1111/medu.14517.  Back to cited text no. 9
Mylopoulos M, Kulasegaram K, Woods NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract 2018;24:674-7.  Back to cited text no. 10
Cutrer WB, Miller B, Pusic MV, Mejicano G, Mangrulkar RS, Gruppen LD, et al. Fostering the development of master adaptive learners: A conceptual model to guide skill acquisition in medical education. Acad Med 2017;92:70-5.  Back to cited text no. 11
Mylopoulos M, Steenhof N, Kaushal A, Woods NN. Twelve tips for designing curricula that support the development of adaptive expertise. Med Teach 2018;40:850-4.  Back to cited text no. 12
Lindeman EC. In: Glessner R, editor. The Democratic Man: Selected Writings of Eduard Lindeman. Montreal: Harvest House; 1956.  Back to cited text no. 13
Cleland J, Durning SJ. Education and service: How theories can help in understanding tensions. Med Educ 2019;53:42-55.  Back to cited text no. 14
Boelen C, Heck JE. World Health Organization. Defining and Measuring the Social Accountability of Medical Schools. World Health Organization; 1995 (No. WHO/HRH/95.7). Available from: https://apps.who.int/iris/handle/10665/59441. [Last accessed on 2021 May 6].  Back to cited text no. 15
Jandoo T. WHO guidance for digital health: What it means for researchers. Digit Health 2020;6:1-4.  Back to cited text no. 16
Health Innovation Network South London. What is Person-Centred Care and why is it Important? Health Innovation Network; 2021. p. 1-7. Available from: https://healthinnovationnetwork.com/. [Last accessed on 2021 May 6].  Back to cited text no. 17
Cole MB, McLean V. Therapeutic relationships re-defined. Occup Ther Ment Health 2003;19:33-56.  Back to cited text no. 18
Strudwick G, Impey D, Torous J, Krausz RM, Wiljer D. Advancing E-mental health in Canada: Report from a multistakeholder meeting. JMIR Ment Health 2020;7:e19360.  Back to cited text no. 19
Wiljer D, Strudwick G, Crawford A. Caring in a digital age: Exploring the interface of humans and machines in the provision of compassionate healthcare. In: Hodges BD, Paech G, Bennett J, editors. Without Compassion, There Is No Healthcare: Leading with Care in a Technological Age. Montreal, Canada: McGill-Queen's University Press; 2020. p. 34.  Back to cited text no. 20
Hirko KA, Kerver JM, Ford S, Szafranski C, Beckett J, Kitchen C, et al. Telehealth in response to the COVID-19 pandemic: Implications for rural health disparities. JAMIA Open 2020;27:1816-8.  Back to cited text no. 21
Crawford A, Serhal E. Digital health equity and COVID-19: The innovation curve cannot reinforce the social gradient of health. J Med Internet Res 2020;22:e19361.  Back to cited text no. 22
Elias JL, Merriam SB. Philosophical Foundations of Adult Education. Malabar, FL: Krieger Publishing Company; 2005. p. 156.  Back to cited text no. 23
Hardcastle L, Ogbogu U. Virtual care: Enhancing access or harming care? Healthc Manage Forum 2020;33:288-92.  Back to cited text no. 24
Herzer KR, Pronovost PJ. Ensuring quality in the era of virtual care. JAMA 2021;325:429-30.  Back to cited text no. 25
Rashid M, Foulds J, Forgie S. Practical tips on incorporating learners into virtual clinical care. Med Educ Publish 2020;9:167.  Back to cited text no. 26
Hall AK, Nousiainen MT, Campisi P, Dagnone JD, Frank JR, Kroeker KI, et al. Training disrupted: Practical tips for supporting competency-based medical education during the COVID-19 pandemic. Med Teach 2020;42:756-61.  Back to cited text no. 27
Ellaway RH, Coral J, Topps D, Topps M. Exploring digital professionalism. Med Teach 2015;37:844-9.  Back to cited text no. 28
Hilty D, Chan S, Torous J, Luo J, Boland R. A framework for competencies for the use of mobile technologies in psychiatry and medicine: Scoping review. JMIR Mhealth Uhealth 2020;8:e12229.  Back to cited text no. 29
International Conference on Health Promoting Universities & Colleges. Okanagan Charter: An International Charter for Health Promoting Universities & Colleges [O]. 7th ed. Kelowna, BC: International Conference on Health Promoting Universities & Colleges; 2015.  Back to cited text no. 30
Wiljer D, Strudwick G, Crawford A. Caring in a digital age: Exploring the interface of humans and machines in the provision of compassionate healthcare. In: Hodges BD, Paech G, Bennett J, editors. Without Compassion, There Is No Healthcare: Leading with Care in a Technological Age. Montreal, Canada: McGill-Queen's University Press; 2020. p. 51-6.  Back to cited text no. 31


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
The Perfect Storm
Driving Home the...
The Eye of the Storm
Competence on th...

 Article Access Statistics
    PDF Downloaded250    
    Comments [Add]    

Recommend this journal