The Art of a Telemedicine Visit

In this episode of the PedSpace, Dr. Aaron Martin dives deep into the art of a telemedicine visit. Dr. Martin explains how to set the stage before your appointment: Hardware set-up, environment, background, and sound as well as how to maintain your professionalism while on camera with your patient. This insightful conversation will leave you with some helpful tips to make the most of your next telemedicine visit.

Dr. Aaron Martin completed his urology residency at Mayo Clinic Arizona and pediatric urology fellowship at Children’s National in Washington, DC. He practices at Children’s Hospital New Orleans where he also serves as Telemedicine Medical Director. His research interests focus on the intersection of medicine, technology, and healthcare delivery with several projects involving telemedicine and surgical device innovation. 

Transcript

Welcome to the PedSpace, sponsored by Palette Life Sciences. My name is Simone Howell. Many of you know me but for those of you who don’t: I have had the privilege of working with Deflux development, education and training for over 20 years. I am currently Head of Medical Affairs for Palette Life Sciences.

We envision The PedSpace to be your resource for sharing best-practices and compelling conversations across a wide variety of pediatric urology and VUR topics.

On today’s episode we will be speaking with Dr. Aaron Martin, a pediatric urologist at LSU Children’s Hospital New Orleans. He’s speaking about the art of telemedicine and tips on how to improve patient trust.

In this uncertain time of Coronavirus, telemedicine has become a vital tool for the medical community to better serve their patients and enhance the patient experience.

The content in this podcast is solely the opinion of Dr. Martin and we so appreciate his willingness to share his expertise.

And now, it is my pleasure to introduce - Dr. Aaron Martin.

First I would like to thank Palette Life Sciences for providing this educational forum, so we can better serve our colleagues and patients. I was thrilled to be asked to record this podcast and given the general topic of telemedicine, which has definitely become the socially distance Healthcare delivery modality of choice over the last month for most of us. Our system just like everyone else was forced to quickly get our Virtual game into gear, but fortunately this is been a project of mine for the last six years and our children's hospital already had rapidly expanding telemedicine program up and running and this gave us a sizable jump to be able to quickly expand to all five hospitals in our system and all providers without many of the usual hiccups,so we were very fortunate in that sense.

That being said there's essentially two overarching aspects of telemedicine and the first is basically the practice of telemedicine or the ‘practical stuff’ meaning the: infrastructure, the scheduling, the workflow, the charting, the billing-- all the headaches that everybody's been going through hasn't done this before. Those I'm not going to talk about today because that's the topic of basically every other talk that's out there -- there's thousands of talks out there there's thousands of newly found ‘experts’ in the field just in the last few weeks and so we certainly don't need another talk on that and there's many out there that you can find and I'm certainly happy to point you to any of those if you wish, but I want to talk about today is the next piece what I referred to as the art of telemedicine.

This is no different to what in our medical school, in probably all the medical schools around the nation called something like clinical skills integration-- this encompasses the art of good history taking, reading visual cues, presenting yourself as a caring person that the patient can trust, and forming that sacred bond that allows patients be completely honest. In my case a trust that allows a patient to hand me their precious child for surgery with the understanding that the next however long it takes I'll look over that child as if they're my own. That's a special trust that's unique to medicine, that's why a lot of us got into this. 

When I started doing telemedicine I'll never forget the physician leader who first went to looking for some support and he declined to fund my project because he said, “I don't understand how you can form of patient-physician relationship over a computer screen”. Needless to say I politely left, looked for a different supporter and fortunately found one. But he did bring up a valid concern, clinicians in the art of healing are intimately tied with touch and of course you can't touch over telemedicine, at least not physically. There are countless quotes and examples of this, even in the Bible and other ancient texts. It should not be surprising that some struggle with the idea of practicing medicine over a camera. 

Or should it be surprising? We are taught in medical school that the most important aspect of our ability to diagnose and heal is our history taking. Multiple studies have calculated over 80% of diagnosis can be determined by a good history alone, and in fact in some cases if clinicians are presented with diagnostic information before the history they're more likely to be fooled into wrong diagnosis. So this podcast will focus on just that, and hopefully give you some practical skills and set up needed to form that relationship and trust that we so easily do in the office.

Perhaps, the best person to teach this course would be your local news anchor. Everyone has their favorite, perhaps the most famous American broadcaster of all time-- Walter Cronkite was labeled by Time Magazine as the man with America's trust. Now think about it, would a patient open up to Walter Cronkite about their intimate health issues? Maybe. That just shows how good we clinicians need to be on camera or more accurately how human we need to come across.

This start is your basic telemedicine set up-- regardless of your specific platform all require a camera and  microphone. Obviously, higher quality webcams and professional microphones enhance the fidelity of your output. Before you break your budget remember the quality on the patient's side is determined by their receiving device which is typically a smartphone via Wi-Fi or cellular signal--and if you're like my practice sometimes it's not so good. Some recommend a headset with an attached microphone-- and while certainly this probably better sound quality on your end, I'm not really a fan of these I never have gotten into them. Mainly because it makes me look like an air traffic controller or a phone operator and definitely not like a doctor. And anyone who knows me, knows I need all the help I can get.

More importantly it's how you stage yourself, remember you're trying to mimic the perfect in-person clinic encounter. Except you don't have the advantage of having all the ‘clinic stuff’ behind you that makes you look good. First, you need to be in a private quiet room without the risk of an inadvertent person walking in on you. That’s key, basic 101 of privacy. There is no quicker way to lose a patient's trust than for them to think others could be watching or listening in. 

Your background should be neutral not cluttered, you can have your practice logo behind you if you want to get fancy. But avoid the goofy or comical backgrounds of some programs. While some patients may appreciate it, some may just think you're being a little too silly. Especially if it's your first visit with them that's not the impression you want to give.

There needs to be good lighting coming from ideally in front of you. Think of it like when you take a picture, backlighting is going to make you appear to be coming down from heaven. And unless this is your intention, you probably want to avoid that. I find having two screens is ideal, so you can have one with the video on it and one with the chart. And this allows you to kind of go back and forth seamlessly during your visit and review things. It also lets you look at imaging.

I recommend wearing your white coat with the name tag visible even if that's not your practice in person. I don't normally wear a white coat in person because I don’t want to scare the child and I find it helps. On the camera, it’s a totally different situation. You want to look as professional as possible. It lends that extra sense of professionalism and elevates the conversation beyond just a FaceTime chat that you’re having with your buddies.

You also want to pay attention to your clothing underneath your white coat as well, which sometimes you forget and this is a mistake I made early on. In one of my first telemedicine  encounters years ago I discovered something known as spatial aliasing. I didn't know anything about it then, but this is a phenomenon that occurs when wearing narrow thin stripes on camera. All the news guys know about this when you do it, it causes a very distracting wavy psychedelic pattern to come alive on your picture and this can be very distracting.  Not only to your patient, but to you if you see yourself in the picture. It's not the best impression to give, so sick solid colors -- light colors make sure it doesn't match your background for those kind of things.

Your camera should be as close to eye level as possible, this is one of the most important things that people forget about. You need to frame yourself in the image with the top third of your chest visible so they can see on your shoulders in your head. You want to avoid the floating head look or the extreme close-up. This just looks unprofessional and looks like you set it up overnight. 

Probably the most overlooked and hardest skill to master is you must look directly into the camera. This is kind of an awkward thing at first because we’re not used to that we’re used to looking at the patient's eyes. But, if you look at the patient’s eyes depending on where it is on your screen-- you’re either going to be looking away from them or staring at their neck or the chest. Depending again on the relation of your camera and where you have them on your screen. So what I did in the beginning was I moved the patient's video as close to the camera attached to my screen as possible to limit my eye movement away from the camera itself and this helped remind me to look into the camera. So now most of my visits I'm looking directly into the lens of the camera and ignoring the picture completely unless there's something they need me to see on on the picture itself. 

As with most introductions you want to start the visit with a smile. Introduce yourself ask them to recite the patient's name and date of birth, so that you can confirm everyone is on the same page. You want to make sure you have the right patient that you're looking at on the screen because you don't have your nurse to tell you this on the telemedicine visits typically. Pay attention to your facial expressions,remember they're looking directly at you so your expressions are what conveys everything. Your personal skills and ability to show empathy are magnified, but don't let this paralyze you. Just be yourself and have a conversation.

It’s also a good idea to tell the patient when you're looking away at the chart on the other screen or if you're just reading the chart to let them know because your eyes are going to be moving and they're going to see that. It's going to look like you're ignoring them; you don't want that to happen so if I'm ever looking away from the chart for an extended period of time I make sure I mention that, something you don't have to do in person. 

Our platform also allows us to share images and draw directly on them, so this helps a lot when I'm looking at an image. Instead of looking at it by myself, I pull it up and share with a patient I show them exactly what I'm looking at and annotate on it. It makes the visit a lot more interactive and something that they enjoy a lot more.

Also encourage the patient to share or send in pictures ahead of time of sensitive genital exam findings for better quality than a live shot and to decrease the awkwardness of an on-screen genital exam. It puts the patient much more at ease than asking to do it during real time or trying to focus on the patient’s genitalia while they're holding the camera at the same time it can be quite clumsy.

It's also a good idea to finish the visit by sending them a summary shortly after any educational materials that can be helpful and follow-up recommendations, just like you’d hand them in the office. 

And that's it, that's the art of a telemedicine visit-- we already do it everyday it just needs to be modified to be suitable for TV so to speak. It's important also remember that it's okay that telemedicine isn’t appropriate for all conditions. Our program is set up with the caveat that it is to be used to enhance not replace care. It should be led by physicians and clinicians looking to improve the experience with their own patients, to reach them when they need it, where they need it, and to guide them back to the office when that is more appropriate.

We need to be very careful this is not taken away from us by insurance companies or private ventures looking to offer quick fixes without continuity of care. This always has been and always will be our responsibility as physicians or clinicians.  I ask that you please, now that this has become widespread embrace it, take control of it and make it a part of your practice.

 I'll leave you with a quick example of enhanced care via telemedicine. A 16 year old young woman with spina bifida returned to my office with her mother for follow up. She was about two years overdue for a follow-up and hadn't followed any of my recommendations from our previous visit. Long story short, they were scared. Her prior visit-- things weren't going well, she was having trouble coping with the transition of becoming a teenager. She didn’t want a catheter. She was angry at her condition and being different so they just withdrew.

The recommendations from my end at the follow-up visit were the same, but she wouldn't even speak during the visit she just sobbed the entire time. It was not a good encounter, and it was an in-person encounter but I didn't really know what more to do. She had been told what would happen if she didn't do these things and I couldn't seem to comfort her even get her to express what her real fears were. I just started up our telemedicine program, so I set up a visit in two months which they could do for their home which was 3 hours away. So it's much more convenient for them and I was really hoping to not loose them again.

To my surprise they logged on that day and we had a great visit. In her own home she was a completely different child, she's smiling, she's interacting, she is open with her struggles. She even agreed to give catheters a try. This really is enhanced care and so the naysayers out there who say you can't give the same amount of care when you're doing it virtually vs. in person they're just wrong. Sometimes you need that change of venue, sometimes you need to have them in a comfortable setting an order for them to open up. And this is that special trust allowing you into their home to share in their intimate needs. This is why telemedicine will continue and this is why I encourage you to be a part of that in your practice. So don't be afraid to enhance the care you give your patients. Embrace this opportunity and change your practice for the better

Thanks for joining us this week on The PedSpace!

We hope you enjoyed Dr. Martin’s perspective. Feel free to share with your colleagues while we deliver more pediatric urology-focused content in the coming weeks. There are some great resources for you and your patients for Deflux on www.Deflux.com .  Additionally, you can learn more about our company and our products on www. Palettelifesciences.com