Building a “webside” manner

I recently conducted a telemedicine appointment for a patient living with a movement disorder. I’ve been doing more of these lately. As the video feed began, the camera appeared shaky, and I had trouble understanding the patient’s garbled voice. I saw trees in the background, children playing ball and it seemed that the patient was taking a walk in the park while conducting his appointment!

The COVID-19 pandemic has propelled adoption of telemedicine at an exponential rate. Due to necessity, restrictions on permitted technologies and locations for conducting virtual visits have been lifted to keep our health system functioning and continue care for patients while reducing onsite visits and maintaining recommended physical distancing. Beyond the current crisis, the benefits to telemedicine are numerous and far reaching. This technology holds potential to eliminate or drastically reduce patient travel time, address rural healthcare shortages and reduce clinical practice overhead.

However, my patient’s attempt to conduct his appointment while taking a leisurely stroll demonstrates a misconception I frequently experience- these appointments are similar to ‘FaceTiming’ with friends and family. A telehealth appointment is not a casual social visit and it needs to replicate the professionalism and accuracy of in-person appointments.

A recent poll report from Sage Growth Partners found 31% of U.S. physicians experience difficulties in establishing the same rapport virtually as they would with an in-person visit. Below I have outlined several key strategies and considerations as we advance telemedicine to a permanent fixture within the healthcare system that will empower physicians to enhance their “webside” manner and deliver the same level of care to patients.

Prior to each appointment, my assistant has a preparatory call with the patient to ensure that they have internet access and explain the use of the technology to try and minimize technical difficulties. I have also started sending letters to patients with upcoming appointments about telemedicine etiquette including conducting the appointment in a well-lit and quiet area with the device secured on a stable surface showing as much of the face and body as possible. I begin every telemedicine appointment by sharing my screen, where I’ve boldly bulleted out instructions for patients, accompanied by relevant icons:

• Unmute your mic (look at the bottom of screen
• Share camera (look at the bottom of screen)
• Let me call you if you are having difficulty with the connection

To make the appointment as seamless as possible, it is key to offer clear and concise instructions that can be understood visually, accounting for potential audio issues.

While telemedicine has immense timesaving potential, both patients and physicians are challenged if the duration and comprehensibility of their appointment is hampered by unfamiliarity with technology. Making telemedicine user-appropriate at both the patients’ and the providers’ ends is vital to ensuring patients receive the same quality of care that an in-person visit provides.

A big takeaway from my experience using telemedicine during the pandemic is that healthcare systems should provide similar IT support and infrastructure to physicians and patients.

My colleagues and I have had to take on a new role as tech support, troubleshooting issues that arise as much of our caseload has gone virtual with little chance for preparation, training or support. However, running a successful telemedicine system requires specialized skills, which hospital administration should support in order to progress this technology from a contingency measure to a standard of care. This means consulting engineers to design and implement telehealth systems that function consistently and smoothly, as well as employing technical support to address day-to-day problems.

While physicians can successfully translate many aspects of an in-person appointment into tests that can be performed virtually, telemedicine is not a “one size fits all” solution. Telemedicine is ideal for follow up visits with patients who are already under my care. This allows me to monitor their progress over video. For initial diagnosis, specifically of movement disorders, a face-to-face appointment is irreplaceable.

For example, there are numerous different types of tremor, including Essential Tremor, that I must consider when evaluating a patient with tremors. This diagnosis is dependent on examination maneuvers that accurately assess tremor amplitude, frequency, exacerbating and relieving factors, and identify neurological diseases that cause tremors. If the connection is choppy, or the camera is shaky, or the patient is not able to position the camera optimally for an examination, it is near impossible to examine the patient and make an accurate diagnosis. In several cases, the telemedicine appointment is a means to an end – an opportunity to implement care until the patient can come in for an in-patient appointment. While telemedicine is a powerful tool, understanding that this technology cannot replace an in-person visit in every situation is essential to ensuring that patients receive adequate care.

Medicine is never just about immediate results—we continue to collect data for years after initial treatments to evaluate long-term safety and efficacy. In the case of telemedicine, especially with movement disorders, we’re in uncharted territory, with virtual appointments never before having been conducted at this scale. The technical chasm between patients and providers, mostly a result of technological inequities and most evident in rural, underserved and poorer communities, must be bridged for telemedicine to work as effectively as in-person care.

Ultimately, we may have to examine the long-term accuracy of virtual exams and compare this data to the gold standard of in-person visits. While we want to be early and eager adapters of telehealth, we cannot sacrifice the fidelity of an in-clinic neurological examination at the altar of virtual care. Telehealth in neurology is here to stay but it requires the same level of scrutiny and rigor as in-person visits for health care outcomes to be optimum.