The COVID-19 pandemic has created a powerful impetus to move entire organizations toward remote e-work. However, even prior to the pandemic, remote e-work had already emerged as common practice outside of academic medicine, with 70% of individuals globally working remotely 1 day of the week and 53% working remotely for more than half of the week.1 National US data from 2018 previously showed that roughly one-fifth of all students were taking at least 1 class online.2 Despite the increasingly common integration of remote e-work practices in other industries, academic medicine has yet to fully utilize advancements in information and education technology.3
Although several terms are currently used to describe this concept, we have chosen the term “remote e-work” in this article to refer broadly to work completed digitally outside of the traditional office, whether from home or another location. Several other related terms include telecommuting, telework, mobile work (or M work), working from home, remote work, working remotely, and alternative workplaces.4–7 While subtle differences between these terms exist, a detailed review of these nuances is beyond the scope of this article. We acknowledge that remote e-work can occur in varying degrees, such as for some or all team members, for part or all of the work week, and for limited periods of time or permanently.
The Academic Life in Emergency Medicine (ALiEM) organization has engaged in high-level remote e-work for more than a decade. The authors of this article include members of this team of virtually based clinician educators who collaborate and accomplish tasks primarily via remote e-work mechanisms. Drawing from our experience, we share applications of remote e-work for academic physicians, including a consensus-based list of advantages and disadvantages. We hope our insights help others working in graduate medical education (GME) to explore remote e-work, both during shelter-in-place periods and as we look beyond to the post-COVID-19 era.
Background
The dawn of information technology (IT) and the internet challenged workplace norms, including the wholesale dependency on physical offices and in-person interactions. Remote e-work has become commonplace in many sectors; particularly in the IT industry, where IBM (which piloted remote e-work in 1979) has reported that 40% of its workforce (nearly 154,000 employees) now have no office space at all.8 Today, a simple Google Scholar search yields innumerable articles and studies trumpeting the advantages of remote e-work.9,10 The professional services industry has the highest overall percentage of those who work remotely (17%), followed by health care (12%), finances and insurance (10%), manufacturing (8.5%), and educational services (7.5%).11
Why, then, is this not the case with academic medicine? Medical schools still cling to the lecture or in-person small group experiences as their main methods for educational programming. Recently, due to the COVID-19 pandemic, many national graduate and postgraduate organizations, perhaps due to a lack of familiarity or faith in new technologies, have taken drastic measures affecting training. For instance, the decision to cancel or reschedule end-of-training and qualifying board certification examinations in the United States12 and Canada13 will result in a paucity of new board-certified specialist physicians and surgeons across the country, with thousands unable to become fully licensed. This pandemic has highlighted some of the key vulnerabilities that health care organizations face in their overreliance on in-person events and processes.
Potential Applications of Remote e-Work in Academic Medicine
From our perspective, there are 5 areas (summarized in table 1) where academic medicine can benefit the most from applying new technologies to enable and enhance remote e-work. These include: (1) improving project collaboration; (2) creating virtual meetings; (3) fostering digital mentorship; (4) forming virtual communities of practice; and (5) advancing online learning.
Improving Project Collaboration
Cloud computing involves the use of online storage and bandwidth on a pay-for-what-you-use basis.14 Many large institutions offer free cloud storage for trainees, faculty, and employees. These platforms allow for multiple editors based in various locations to concurrently edit documents saved in the cloud.
Creating Virtual Meetings
Conducting meetings virtually can facilitate scheduling and negate the need to commute and travel between sites. As an example, a program's core faculty or clinical competency committee may elect to meet virtually.
Fostering Digital Mentorship
Despite numerous established benefits of mentorship in academic medicine (research productivity, grant success), studies demonstrate many in the academic world still lack mentors.15–17 Remote technology allows us to facilitate more potential mentorship connections. Mentors and mentees sharing professional and personal interests can connect without limitations often imposed by geographic location.18 Similarly, senior trainees may also find these platforms useful in their own peer mentorship or studying, without teachers present.19
Forming Virtual Communities of Practice
A community of practice (CoP), a term originally coined by Lave and Wenger20,21 and modernized by Bourhis et al,22–24 can be a powerful tool for developing academicians. Remote e-work can allow for the development of online CoPs that promote social learning among teams of individuals who share a particular interest. Removing geographic barriers through technology also allows the most relevant experts around the world to collaborate on a given task.25,26 The ALiEM Faculty Incubator, which annually invites approximately 30 early-to-mid-career scholars (with individuals from diverse locations such as Australia, India, Chile, Canada, and the United States) to engage in online faculty development is one example of a successful and efficient CoP.27
Advancing Online Learning
Learners everywhere have access to the courses of their choice, from any location and at any time, transcending geographic and scheduling barriers, and increasing reach and accessibility.3,27,28 Content is saved as a permanent file that is easily accessible for future use and review. Learners can review content at their own pace, including rewatching portions of a lecture that were difficult to understand. Although this has not been well-established in the GME learner population, asynchronous reviewing of content has been shown to improve retention of knowledge on tests in some learner groups.29–31 The same approach might be applied to small group teaching, which can similarly be recorded and viewed by trainees who were not present and rewatched by trainees who were present.
Similarly, online peer learning likewise transcends geographic barriers and eliminates commutes and associated expenditures. Finally, GME learners and teachers can leverage asynchronous communication tools to discuss complex topics as they are encountered32,33 ; increased ease and convenience may also augment the willingness and frequency with which peers utilize each other for learning. Examples of new methods to deliver asynchronous content include the ALiEM Chief Resident Incubator program28 and the CanadiEM Digital Scholars program.34
Dedicated research of digital learning environments and how they might be effectively harnessed more in GME are certainly warranted.35 While there is an obvious opportunity for innovations in point-of-care resources that allow for just-in-time learning at the bedside,36 these same resources might allow for asynchronous review. Videos featuring standardized patients, previously recorded simulations, or simple written fictionalized cases could all be augmented by asynchronous discussion similar to our ALiEM Medical Education in Cases Series.33
Best Practices
Remote e-work enables a number of new opportunities and applications for academic medicine. Moving away from traditional, hierarchical team structures benefits both individuals and the larger group. Non-hierarchical teaming can foster psychological safety, which in turn may have significant positive effects on the work environment. For instance, prior studies of health care teams have demonstrated that those lower in the hierarchy perceive themselves to have less knowledge relative to those higher up, and are thus less likely to share their opinions.37,38 Junior members of non-hierarchical teams may suggest ideas and provide honest, constructive feedback related to the team's dynamics, processes, and products more readily in a remote setting.
At the same time, movement away from primarily in-person interactions has generated new challenges that leaders and individual members must navigate to build a successful and productive team culture. The online supplemental material lists some potential benefits and downsides of introducing remote e-work compared to the more traditional in-person methods.
Bearing in mind the advantages and disadvantages with remote learning (as listed in the online supplemental material), we want to emphasize that remote e-work may not look the same for all teams, nor should it. Teams are unique. Based on our selected review of the literature both within and outside of academic medicine, we developed some best practice concepts that are important to consider when implementing (or improving) a remote working environment. Table 2 details some of these best practices.
Virtual platforms can fundamentally change the nature of communication, collaboration, and teaming. Institutions and companies utilize remote e-work to varying degrees. These 3 types of groups include: remote-friendly, remote-first, and remote-only.
Remote-friendly organizations allow certain employees to work remotely at certain times, all employees to work remotely at certain times, or certain employees to work remotely all the time, etc.50 Others are remote-first, whereby the bulk of the team works remotely, but some do not. Github (an IT company that allows groups to host and review computer code, acquired by Microsoft in 2018) takes a remote-first approach, where employees are encouraged to work wherever they are happiest, so long as they can get their work done. Github now has a portion of its 1000 employees working from some 15 countries.51 Finally, remote-only organizations46 have no physical office at all, such as Automattic (parent company of Wordpress), which has 1176 employees in 76 countries.52 Readers should consider to what extent a team, course, or organization is to be remote, and for whom and in what cases it is appropriate to support remote e-work.
The best practices highlighted in table 2 can facilitate the transition to remote e-work. Creating cultural norms, implementing proper onboarding processes, and providing clear standard operating procedures are all key to enabling a successful remote team. However, each team will require adaptation of such practices according to its unique needs. Certainly, remote e-work cannot replace face-to-face interaction for all tasks and all teams. For instance, tasks that require physical contact, such as certain medical procedures and demonstrations thereof, may require one's physical co-location.
Conclusions
Remote e-work comes in multiple forms, each with its own benefits and challenges. Outcomes depend substantially on the method of implementation of remote e-work. Spurred by the COVID-19 pandemic, academic medicine has rapidly and suddenly integrated remote e-work. However, the ultimate long-term success of remote e-work will require strategic and responsive adjustments. Faculty, staff, and students are learning quickly to change their prior workflows to accommodate this shift. As this represents a transition from our traditional norms and practices, we anticipate leaders will encounter challenges associated with implementation, followed by a significant increase in positive outcomes and satisfaction once all team members accept and adopt remote e-work practices. We have great hope that this transition will open up many exciting avenues and methods to enhance research, scholarship, and education within medicine.
