Specialists’ learning from facilitating group peer telementoring: a qualitative study

Abstract

Background

Group peer telementoring supports interprofessional learning through multi-directional and synchronous engagement where experienced and knowledgeable individuals exchange guidance and support with differently experienced and knowledgeable individuals. A leading example of group peer telementoring among medical specialists and medical generalists is Project Extension for Community Healthcare Outcomes (Project ECHO), a rapidly spreading program with demonstrated learning outcomes among community-based medical generalists. Yet the multi-directional exchanges that characterize group peer telementoring interactions suggest that specialists facilitating sessions may also learn from the group experiences. We explored what medical specialists learn from community-based medical generalists and from other specialists as a result of facilitating and participating in group peer telementoring.

Methods

Pairs of ECHO administrative staff and researchers interviewed medical specialists who facilitated Project ECHO work. Using interview transcripts, we identified 129 learning episodes in which 53 specialists discussed what they learned from their Project ECHO experiences. An inductive multi-phase thematic analysis was used to identify what medical specialists were learning and from whom.

Results

Three primary themes emerged from the data. Specialists learned about community-based health care, including learning about unique and novel community-based treatments and patient needs. Specialists broadened and deepened their knowledge of patient care, including taking an interprofessional view and learning more about their own specialty area. Specialists also learned about learning, including revelations about power hierarchies, the importance of opening space for learning, and practicing humility.

Conclusions

Project ECHO’s emphasis on group peer telementoring brought the realities of community-centric care to the attention of medical specialists, deepening their knowledge about patient care and about learning. Specialists learned from community-based medical generalists, other medical specialists within their discipline, and from medical specialists with other expertise. The "all teach, all learn" space that medical specialists endeavored to create in Project ECHO for community-based medical generalists created a safe space for specialists to admit what they did not know. Continued facilitation and participation in group peer telementoring may provide medical specialists with feedback about diagnoses, treatments, and community-based resources for low-income rural and inner-city patients that contributes to their continued development and medical education.

Background

In 2021, the U.S. National Institutes of Health convened a Pathways to Prevention Workshop to explore how to best improve rural health via provider-to-provider telehealth. Telehealth was defined as the use of information and telecommunication technology to provide care across time or distance, with “care” defined as encompassing tele-consultations, telementoring, and continuing education. The focus was on specialists providers sharing their expertise with generalist providers so they can manage care locally [1]. A possibility overlooked by participants in the workshop is that provider-to-provider telehealth may also include specialists learning from generalists, thereby shifting roles so that a specialists who is ostensibly a mentor becomes a mentee as a generalists takes on the role of an expert. In effect, provider-to-provider telehealth can be a form of group peer telementoring.

Mentoring has traditionally been defined as an experienced and knowledgeable individual (a mentor) providing guidance, support and personalized advice to a less experienced person (a mentee) [2]. This definition changes when we move to group peer mentoring which is distinguished by two concepts, power-distribution and the flattening of hierarchies. Power is distributed as authority is shared and every member has leadership and mentoring responsibilities. Hierarchies are flattened as each participation, regardless of their status or stature in the community, is valued and seen as a valuable contributor [3]. Thus, we define group peer mentoring as experienced and knowledgeable individuals exchanging guidance, support, and personalized advice with differently experienced and knowledgeable individuals.

A principal benefit of group peer mentoring is its broad network of collaborative input as each member has a responsibility to provide and be provided mentoring [3, 4]. The multi-directional nature of group peer mentoring can support interprofessional learning, where members of two or more professionals learn with, from, and about each other to improve collaboration and quality of care [5]. For example, nurses, primary care physicians, and social workers can learn together and from each other. If group roles are informal and influx, however, there can be confusion about who facilitates the group which can lead to getting-off-track as well as loss of sustained interest and benefit. Peer group mentoring stays more focused and engaging if someone has the explicit responsibility to facilitate the session [6].

As a form of telehealth, group peer mentoring typically takes place via electronic and social media platforms [7]. Mediated communications are synchronous or simultaneous, meaning that the interactions occur in the same time and space for all participants [2]. Group peer telementoring can accelerate and amplify knowledge sharing because participants across geographic areas and with varied sources of knowledge may provide guidance and pose questions to each other, creating a multi-directional telementoring professional development experience.

A leading example of group peer telementoring in medical education is Project Extension for Community Healthcare Outcomes (Project ECHO, or ECHO), a rapidly diffusing telementoring platform used in more than 200 countries and areas across North American, South America, Africa, Europe, Asia, and Australia. ECHO uses a facilitated group peer telementoring model. Programs are facilitated by single medical specialist or a panel of medical specialists who have additional training and education in a specific area of medicine. Participants are community-based medical generalists, typically primary care or family physicians, nurse practitioners, and others who are seeking to learn more about a condition, treatment, or process to better meet the needs of their patients. A typical ECHO session begins with a brief didactic led by a medical specialist. Then a community-based medical generalist presents a patient case. After a case is presented, the specialist invites participants to comment or ask clarifying questions and then asks for their impressions and recommendations. Frequently, considerable informal discussion ensues with many participants learning and teaching.

The multi-directional conversation between and among specialists acting as facilitators and community-based medical generalists flattens status hierarchy and ensures that ECHO meets its underlying principle that when “all teach, all learn” [8, 9]. The roles of mentor and mentee change throughout the session. Community-based medical generalists are learning and offering advice, and so too are the specialists who facilitate ECHO sessions. What is constant, however, is that the specialist continuously acts as the facilitator.

Several scoping reviews about Project ECHO have documented learning by generalist primary care providers, family physicians, and other community-based health care practitioners [10,11,12]. The conversational dynamic and connectiveness of ECHO programs can also enhance participant motivation to engage in lifelong learning [13]. Detailed studies have focused on how this learning takes place via interactions between specialists and generalists [14,15,16]. However, similar to an emphasis in continuing medical education on assessing learning by trainees and not on learning by those who train them [17], very little is known about if or what medical specialists who facilitate ECHO sessions learn from their participation.

If the ECHO experience delivers on its promise that when “all teach, all learn,” we would expect medical specialists who facilitate and participate in ECHO sessions to learn from participating medical generalists who often work in diverse and under-served communities and who see patients with conditions and constraints that differ from those typically encountered by specialists. We might also anticipate interprofessional learning as ECHO encourages multidisciplinary teamwork to ensure comprehensive and effective treatment for patients with complex conditions [18]. The objective of this study is to identify what, or if, medical specialists learn from facilitating and participating in group peer telementoring.

Methods

Selection of hubs and programs

In a larger investigation, we studied the implementation dynamics of Project ECHO programs at hubs in the U.S. and Canada. An ECHO hub is an organizational unit that coordinates and offers multi-session ECHO programs. We studied hubs perceived as influential within the Project ECHO community as these are hubs that others might look to for advice or ideas to improve their own operations. To determine which hubs were influential, we asked Sanjeev Arora, MD, founder of Project ECHO at the ECHO Institute in New Mexico, to generate an initial list of influential hubs. To this list, we added hubs whose leaders had made presentations at international MetaECHO conferences in 2014, 2016, 2017 or 2019, or published peer-reviewed journal articles about ECHO through 2018. We limited inclusion to hubs that had been in operation for at least one year. This process yielded 57 influential hubs, 54 in the U.S. and 3 in Canada.

We contacted leaders of each influential hub, inviting them to be a study site. After repeated outreach efforts, 34 hubs agreed to participate in this study. Of the 34 hubs, 17 were affiliated with universities, 11 were in clinical or medical centers, and six were in nonprofit or government affiliated organizations. To learn about ECHO program implementation as well as hub implementation, we selected programs within each hub to participate in the study. Programs had to focus on health care and have completed at least one multi-session cycle within the prior year. In six of the hubs, only one ECHO program met these inclusion criteria; from each of the remaining 28 hubs we selected two ECHO programs that differed from each other in terms of health topic or other program parameters including if the program was facilitated by one specialist or a panel of specialists, program maturity, and the number of sessions per program. By selecting ECHO programs which were diverse yet within the same hub we maximized differences and then in analysis attended to similarities in outcomes [19]. Our study included 31 hubs in the U.S. and 3 in Canada, with 62 programs.

Participatory research approach

We framed our work as participatory research. That is, some of the people whose work was the subject of the research actively took part in the research. Participatory research engages community stakeholders to work alongside researchers in all stages of the research process, from problem identification and developing research questions to participating in interviews, analysis, and writing [20]. As U.S. social science researchers, we recognized that those working in ECHO hubs and with ECHO programs would have lived experience in ECHO implementation that would deepen our knowledge and improve the study. At 25 of the 34 ECHO hub sites, we recruited individuals to participate in this study as Implementation Fellows (Fellows), of which 23 were from the U.S. and 2 were from Canada. All had multiple years of experience supporting ECHO programs. Fellows were recruited by asking hub leaders to identify the day-to-day administrative leaders of ECHO work at their site. We reached out to these administrative leaders and told them about the study, clarified the role of a Fellow, and discussed time commitment, as well as the potential benefits of participating as a Fellow. To offset the costs of participation, we provided a stipend to each of the 25 ECHO hubs. Fellows attended six workshops led by the authors that focused on implementation science, qualitative interviewing, case study analysis, and cultural competence. Fellows worked with the research team to design the interview protocol (Additional file 1). Each interview was led by a Fellow along with a research team member.

Data collection

For each ECHO hub and program, we invited two to four people who were instrumental in leading, organizing, and implementing Project ECHO work to participate in a group interview. One Fellow and one researcher (RSL, JWD, NR) jointly led each interview via Zoom from September 2020 through October 2021. Interviews lasted from 60–90 min and were audio recorded and transcribed. The study protocol was reviewed and approved by the Heartland Institutional Review Board (HIRB Project No. 200803–296). Consent statements were shared with all respondents in advance of the interview and read prior to beginning the interview. All respondents gave verbal informed consent which was recorded.

We asked interviewees the same open-ended questions about the adoption, implementation and sustainability of Project ECHO. A subset of questions asked interviewees to define the ECHO principle of “all teach, all learn.” Specifically, we asked each respondent to tell us what the phrase “all teach, all learn” meant to them. In advance of the interview, we sent an email to interviewees stating that we would be asking them to describe a time when they experienced a strong sense of “all teach, all learn.” We wanted interviewees to have an opportunity to reflect on this question in advance. During the interview, we asked interviewees to tell us about the event, including what was taking place, who was involved, what specifically happened, and what, if anything, happened as a result of this experience. At the conclusion of the interview, the Fellow and researcher conducting the interview shared their insights about the interview, provided feedback to each other, and both completed and uploaded reflective field notes (Additional file 2).

Data analysis

Two researchers (RSL, JWD) led the coding of transcripts. One researcher (RSL) has a background in adult learning and the other researcher (JWD) has a background in diffusion of innovations. Both are trained in qualitative research and conducting interviews and both took part in the majority of the interviews. The researchers independently reviewed each transcript to identify learning episodes – descriptive chunks of information or statements [21] – from medical specialists who facilitate ECHO group peer telementoring (specialists). In each learning episode, specialists talked about what they were learning from their ECHO experiences. The two coders then met and reviewed all learning episodes to discuss and resolve differences in the coding of learning episodes. They agreed on 129 learning episodes from 53 specialists. The medical specialties of these 53 respondents are listed in Table 1.

Table 1 Medical specialties of interviewees (n = 53)

Our next step was to conduct an inductive multi-phase thematic analysis [22, 23]. The coders (RSL, JWD) began by reviewing field notes recorded by Fellows and researchers immediately following the interviews to identify potential learning codes. The coders then individually reviewed each learning episode and inductively assigned it an initial learning code. In addition, we coded the learning episode for the source of the learning – learning that was primarily from community-based medical generalists or other specialists. A single learning episode could have multiple codes. The coders then met to review initial learning codes. This review entailed listing all codes, looking for similarities among codes, combining codes, and developing and defining new codes. The two coders then re-coded the learning episodes and met to discuss and resolve differences in coding. This process was repeated one additional time when the coders reached an intercoder reliability of 0.80. In addition, the two coders (RSL, JWD) reached agreement on who the specialists were learning from – either medical generalists or medical specialists.

To reduce bias, the third and fourth authors (NR, CEM) reviewed the coding. The third author (NR) specializes in intercultural communication in health care settings and conducted multiple interviews with Fellows for this study. The fourth author (CME) is an expert in organizational communication and was not involved in the interviews, but did participate in the development of the interview protocol. Both are trained in qualitative interviewing and analysis. The four authors discussed and resolved differences during the final coding, and defined and named themes.

Results

We identified three broad themes: (1) Learning about the practice of community-based health care, (2) deepening specialist knowledge about patient care, and (3) learning how to help others learn. We then identified subthemes within each of the three themes. Themes and subthemes are summarized in Table 2.

Table 2 Learning themes and subthemes

Theme 1: learning about the practice of community-based health care

Specialists described learning about the knowledge gap between what they experience in academic medical centers and specialty settings compared to what is happening in the community, in rural clinics, and in health clinics that provide primary care services to underserved populations. Community-based medical generalists educated specialists about what does and does not work in low-resourced community settings where protocols can diverge from standard practice and where patients have conditions and constraints perhaps rarely seen in academic medical centers. Two subthemes emerged when specialists talked about community-based health care: Learning about community-based treatments and about community-based patients (Table 3).

Table 3 Theme 1: learning about the practice of community-based health care

Learning about community-based treatment

Specialists learned about testing, protocols, and programs in communities. They learned about challenges in ordering tests and having access to testing equipment, such as MRI machines. While specialists generally expressed surprise at what was not available in the community, some were surprised by what was available in the community such as resources for applied behavioral analysis in a rural part of the state or peer navigator programs. One specialist shared, “We are learning what community practitioners are able to do. And when I say able, I don’t mean based on knowledge, but empowered to do; what they have access to.”

Learning about community-based patients

Specialists talked about seeing different types of patients than those seen by community-based medical generalists. Specialists may not see patients without health insurance or patients who are screened-out before they can be seen by a specialist. That specialists and community-based generalists may see different types of patients and therefore have different examples and experiences to draw on may enrich the learning for specialists and community-based generalists alike. One specialist said, “I learn more from our [community-based] participants than I do from our hub team because they [the generalists] see people in the front line, and they have different perspectives. I think it's a case of we're all able to teach each other because we have diverse patients.”

Theme 2: deepening specialist knowledge about patient care

ECHO sessions provide an opportunity for specialists to deepen their knowledge of patient care. Sessions are sometimes led by a panel of specialists with complementary expertise. Guest speakers who are experts in their field are frequently invited to make brief presentations. Very occasionally, patients and families participate in ECHO sessions. In short, many “experts” bring new or different perspectives to session didactics and case discussions that can enrich a specialist’s understanding of patient care, support, and adherence. As one specialist said, “ECHO has been a pleasant surprise. The work in this space had helped me to be a better primary care doctor. I’m learning about working with my patients.” Two types of learning emerged from analysis of these episodes (Table 4): Interprofessional learning, and a deepening of specialty knowledge.

Table 4 Theme 2: deepening specialists knowledge about patient care

Interprofessional learning

Respondents said that they learned about diagnosis, treatment, and care from other specialists, community-based generalists, and members of their ECHO teams. One specialist described this as “interdisciplinary learning” while another described this effect as “learning things outside of our own discipline.” For example, a hepatologist presented a case where the patient had severe bipolar disorder and had previously been incarcerated for threatening to harm others. A psychiatrist on the panel helped the presenting specialist develop contingency plans and modifications to the patient’s pharmacologic regimen. A particularly interesting interprofessional learning experience was shared by a specialist:

“We did one of our earlier ECHOs on opioid diversion, combining that with how you prescribe opioids for high-risk individuals who have a need for opioids, and how we can best manage those situations. And we had a lot of good ideas on what to look for inside the home, mainly from the hospice community, giving us ideas on how to manage and control the flow of opioids.”

Guest speakers, family members and patients, along with social workers and community health workers, extended knowledge as well.

Deepening specialty knowledge

Specialists deepened their specialty knowledge through interactions with community-based medical generalists who participated in ECHO sessions. Specialists also learned from their colleagues practicing in the same academic medical center or clinic and from invited guests. One specialist said of their disciplinary colleagues, “I could go on and on about all the things I’ve learned from my faculty that I didn’t know.” In addition, questions generated during case presentations and discussions could lead a specialist to additional research or reading in their specialty.

Theme 3: learning to help others learn

Specialists learned about effective instruction and how to teach, how to, in effect, help others learn by understanding the dynamics of learning and strategies to create learning environments. When specialists described “learning about learning,” three subthemes emerged (Table 5): Identification of power hierarchies in a learning environment, the need to open up space for all to teach and to learn, and the importance of being humble – recognizing and stating what one does not know. These themes are interrelated. Reducing hierarchies was sometimes discussed alongside learning to be humble; being humble helped to open up space for others; and opening space was a way to reduce hierarchies. Specialists learned how to help others learn from ECHO community-based generalists, other specialists, and from ECHO staff and administrators.

Table 5 Theme 3: learning to help others learn

Learning about power hierarchies

Engaging in ECHO helped specialists to see that the power differentials inherent in many teaching or mentoring environments can be reduced and that leveling perceived differences in status can encourage learning. Specialists described how they were learning to reduce hierarchies or status differentials and to increase, in essence, “feeling like a community.”

Learning to open up space

Specialists learned that yielding the floor – opening the discussive space – is an effective strategy to facilitate learning. Stepping back was a learning strategy mentioned by several respondents. Stepping back was not always easy. A developmental behavioral pediatrician said that learning to hold themselves back and open up the discussion remains a “work in progress.”

Learning humility

Across many interviews, specialists described being humbled or practicing humility, largely born out of the recognition of what others know and what they themselves do not. This was a powerful, eye-opening form of learning for many specialists we interviewed. Showing humility can be an intentional action, and several specialists said they were learning to model humility for others and admitting when they don’t know something. A specialist shared, “I’ve learned so many things that I would have to send you a list. But the most important thing is being humble. Being humble about what we know and do not know. That’s been a great teaching from ECHO”.

Discussion

During the 2021 Pathways to Prevention workshop, participants provided evidence about provider-to-provider telehealth. Project ECHO was called out by participants as providing benefits to community providers including enhanced knowledge, increased satisfaction with training, and improved skills and capacity to screen, counsel, prescribe, and treat patients with a wide range of complex conditions [1]. Research and evaluations of ECHO programs mostly bear out this conclusion [10, 12, 24, 25]. As we learned in our study, ECHO can also provide benefits to the specialists who facilitate program sessions.

Specialists learn that the patients, procedures, and resources in rural clinics and in health clinics that provide primary care services to underserved populations are different from what they experience in their practice settings which can impact the recommendations that specialists make to medical generalists with whom they interact. Specialists expand their knowledge about patient care via interprofessional case-based learning while deepening their knowledge of their own specialty – both of which may change how specialists think about and provide care to their own patients and how they train future physicians. This learning appeared to be serendipitous and was often expressed as having an element of surprise. But specialists, as mentors and mentees, had agency to admit what they were learning without losing face. Further, they valued their learning experiences even in advance of the learning itself as they chose to facilitate ECHO sessions again and again. Agency, surprise, and value are conditions necessary for serendipitous learning [26] which occurs most readily under conditions when individuals with a common base of knowledge are self-motivated to organize around a commonly shared objective or challenge. Our study suggests that it is possible to intentionally cultivate serendipitous learning for specialists by positively reinforcing curiosity around specific practices and disciplinary knowledge, while also inoculating against the assumption that specialists are not open to new learning.

Specialists also report learning about learning—of becoming more effective teachers. They shared stories about reducing interpersonal power hierarchies, trying to create safe spaces for learning, and practicing humility by disclosing their own learning – frank admissions about what they had not understood before facilitating a particular session. Project ECHO appears to reduce the tension between promoting credibility and hiding vulnerabilities. The "all teach, all learn" space that specialists as facilitators endeavor to create in ECHO for generalist learning also fosters a safe space for specialists to share what they did not know and to be mentored by others. Our results show specialists “leaning into” generalists – listening closely and posing questions with the desire to both help the generalist and the other session participants and to inform themselves, thereby modeling professional humility. In other words, specialists were practicing “intellectual candour” [27] where specialists and generalists, often alongside interprofessional others, were speaking aloud their thought processes, dilemmas and failures [28]. Such learning can lead to cultural humility where specialists engage in self-reflection and self-critique and are open to being wrong and ready to learn new ways of thinking, being, and doing for the benefit of patients [29].

Serendipitous learning and intellectual candor occurred during patient case discussions. Case-based learning is not new to ECHO participants. Multiple studies have found case-based learning to be effective and well received by students in health professions [30, 31]. Yet case-based learning is underused in continuing medical education [32]. Continued participation in group peer mentoring may provide specialists with the type of feedback about diagnoses and treatments of actual patients that motivates their continued development of medical reasoning and error correction [33].

There are limitations to our study. We sought a purposive sample of influential hubs in North America and the resulting set cannot be considered representative of the many hundreds of ECHO operations. Ours is a somewhat elite sample of well-resourced well-known hubs that included a number of Project ECHO’s largest distributed operations at universities and academic medical centers. Our larger study did not focus on how specialists changed or planned to change how they care for their own patients or provide instruction to peers and residents in the future. We did not ask specialists if their ECHO experience impacts research they plan to conduct or any spillover effects of their ECHO experiences on their behavior in other virtual or face-to-face groups in which they take part. Further study might explore such learning and work outcomes. Further, we did not collect information from specialists about their breadth or depth of experience within their specialty, their extent of interprofessional practice, or their experience with ECHO. Such factors could explain who learns what and when. We encourage this as a future area of study.

Health care in the U.S. and Canada faces multiple challenges, from projected shortages of physicians [34, 35] to a hollowing out of physicians and access to medical services in rural areas [36,37,38]. Project ECHO has shown promise for creating a sense of community among far-flung community-based providers who live and practice in socially isolated circumstances. The present study looked at the other participants in Project ECHO program sessions: Medical specialists who facilitated ECHO sessions. If the ECHO experience delivers on its promise that when “all teach, all learn,” then group peer telementoring learning interventions such as Project ECHO that level the playing field and recognize the knowledge held by providers across the continuum of care may help to transition medical centers into learning health systems [39] not just narrowly conceptualized on the basis of data integration through electronic health records [40], but as intrinsically motivated case-based learning health systems for medical specialists, whose insight into and understanding of everyday practice conditions in rural clinics and in health clinics that provide primary care services to underserved populations can be slight.

Conclusions

Project ECHO’s emphasis on group peer telementoring brought the realities of community-centric, non-specialized care to medical specialists facilitating sessions and deepened their knowledge about patient care and about learning. Specialists were learning from community-based generalists, other disciplinary specialists, and interprofessional specialists. The safe space specialists endeavored to create in Project ECHO for community-based medical generalists also created the conditions for medical specialists to share what they did not know. Multi-directional telementoring can result in serendipitous learning and intellectual candor where specialists continue their development of medical reasoning. ECHO and ECHO-like interventions may offer an additional means of continuing medical education for personal and systemwide improvement, one that brings the realities of non-specialized care to the attention and appreciation of those in academic medical centers and elsewhere.