Over four years post-pandemic it feels almost antiquated to refer back to the Covid-19 health crisis of 2020-2022, but it was a turning point for many people and also for telehealth.

Prior to Covid, telehealth did have strong support by many in healthcare, but it was still very much a very small group on the fringes of care delivery. The world-wide pandemic changed that literally overnight and soon everyone in healthcare was scrambling to figure out how to make this “telehealth thing” work for them and their patients.
 
The lucky ones had already started to invest in telehealth prior to 2020. The not so lucky ones rolled out telehealth by telling physicians “here’s a video chat license and a webcam, go see your patients over video”.
 
As we now know, that approach did not work very well and soon much of telehealth, especially in primary care, ended up being telephonic, audio-only care. The two primary reasons were challenges on the patient side (connectivity or figuring out the technology) and challenges on the provider side (feeling uneasy on video and also having challenges with the technology).
The Myth of the Patient Who Does Not Like Telehealth
Over the past years, anecdotally but repeatedly, I’ve heard clinicians in both rural and urban areas declaring that either “my patients don’t like telehealth” or that their patients did not have the right devices, or no reliable connectivity.
 
Yet, 85% of all Americans now have a smartphone (that’s 5 out of 6) and 97% have some sort of cell phone, though in the over 65 age group, those numbers drop to 61% and 92%, respectively. Access to 4G cellular connectivity is available to 96.3% to 97.7% of subscribers to AT&T, T-Mobile/Sprint, and Verizon and low-cost cell phone providers run their service over the backbones of the big players.
 
So while statistically speaking there are some challenges (and I get that not everyone is on an unlimited data plan), it is definitely not the majority of patients that are limited in their access to technology.
 
I think the underlying motivation behind those “self-fulfilling prophecies” lies somewhere else.
Do You Like Being on Camera?
Think back to March, April of 2020 before the onslaught of video meetings. How much did you like seeing yourself on video in the occasional Webex, Zoom, or Google Meet?
 
If you were quite new to the world of video conferencing, probably not so much. I have been using Zoom meetings since about 2014, first a few times a week, then a few times a day and now about 8-10 times a day. But I still remember being quite particular (and distracted) about how I looked “on camera”.
 
As multiple Zoom-fatigue guides explain: Seeing your own video can be very stressful, as you are constantly evaluating what you look like and the recommendation is to turn off or hide your self-view as quickly and as often as possible.
 
I remember that for my first designs of telehealth services in rural clinics in the early 2010s, I made sure that the technology we were using at the time had the patient’s self-view disabled while the patient was waiting for the physician to join. I did not want patients to get distraught by having to stare at themselves which — unless you are a narcissist and naturally spend hours in front of a mirror — can make you feel self conscious.
 
So yes, having to be on video can be very disorienting.
The View from the Clinician Chair
Clinicians, by their own understanding of their profession, are trained to appear to be in control of the situation. They strive to instill trust in patients by exuding confidence and sometimes having to make difficult decisions in split seconds.
 
Over the course of their education, their training, and their career they become masters of intuition. As they arrive at their confidently stated orders, diagnoses, or treatment, they consciously and subconsciously take into account at least a dozen of different inputs: the medical history, the latest test results, the previous visit notes, the family history, the gait of the patient, the speed and agility of the patient’s movement, their dress style, their smell, their choice of words, their emotions, etc.
 
Over years, they have acclimated themselves in carefully designed exam rooms or, for some, in offices that reflect their personality. That is their home turf, that is their playground, here is where they are royalty, reigning over and purposefully controlling the experience for the benefit of the patient.
 
Now, enter a webcam. And a patient who is miles away, in an environment unfamiliar to the clinician.
 
Suddenly, clinicians are no longer in their own element. A fish out of water. In unchartered waters. They are neither at the patient’s home nor with the patient in their own office. They are somewhere in between.
 
There is no smell, there is no touch, there is very little body language to pick up on.
 
A warm, yet confident face-to-face presence is replaced with a cold, harsh video stream. Oftentimes with a connection that on the patient side is marred with connectivity problems, technical issues, bad lighting, distorted or muted audio, awkward camera angles and sometimes “TMI insights” into the patients’ home life.
 
Next, add to that telehealth technology on the clinician’s end that does not always work as smoothly as it should.
 
So it’s no wonder that most physicians very much dislike having to care for patients using this modality. The old, proven, established ways of an in-person visit do no longer apply in the same way. Very few physicians have experienced house calls and are therefore not accustomed to the mindset of visiting patients at home.
 
Very few, even those who make good use of it, would prefer it over an in-person visit. Sure, telehealth beats “no visit” anytime, but when given the choice, many would prefer sticking to their comfort zone.
A Cure for Video Vertigo

Given that telehealth is something that many patients demand (and other, non-traditional care providers are happily providing), we have to figure out how we can support clinicians in getting the most value out of this care delivery modality.

The answer is quite simple. For many years now, as part of a well-planned rollout of a new telehealth services we provide some 20-minute 1:1 training on what is cutely referred to as “webside manners” – proper bedside manners in a web-enabled environment.

There are a dozen or so simple, easy to learn, easy to remember, and easy to apply techniques that clinicians can be introduced to that vastly improve their experience being on video. Here’s a three-part Telehealth Tuesday series on Webside Manners providing more detail about those techniques.

And this training makes a measurable difference: In March of 2020, at the onset of the Covid-19 health crisis, I was on ground zero at an FQHC rolling out telehealth in 36 hours to 25 primary care clinicians across 5 sites. About 12 of the clinicians took me up on the offer to do a 1:1 training and those who did, reported a 4.3-4.5 satisfaction rating of their visits on a 5-point Likert scale. The satisfaction ratings of those who either did not want or did not make time for the 30-minute training, ranged from 2.7 to 3.3.

Over the past years we have added Telehealth TechChecks to prepare patients for their first ever telehealth visit and additional training for clinicians on the idiosyncrasies of the telehealth technology, on the telehealth workflows, on properly conducting effective virtual exams, and on adequate documentation of virtual visits.

So the cure is known and proven — but it has to be administered and followed, just like a carefully devised care plan.

A Hurray for Clinicians
Having now intensively worked for more than 20 years for and alongside physicians, psychologists, and advanced practice providers I know that each one of them is 110% committed to their patients getting the best diagnosis, the best care.
 
We also know that as a human species we are initially always nervous when we are outside of our comfort zone. Asking physicians to “practice medicine at a distance” is putting them quite a way outside the comfort zone they carefully crafted for themselves over the course of at least the last 5, 10 years of their career.
 
Thus one well-kept secret of telehealth is that from the physician’s point of view a telehealth visit is mostly NOT like an in person visit. While a telehealth visit can definitely be as effective or even more effective than an in-person visit, it is a new skill that needs to be learned and should be introduced and treated as such.
 
And as with all skills, they need to be trained and practiced. Because not to train your clinicians on a new skill, that would truly be disrespectful.
 
My favorite quote is Dr. Paul Batalden’s quote that “Every system is perfectly designed to get the results it gets”. And if you don’t like the results, you need to change the system. You can only change people’s behavior when you change the system they are operating in.
 
If you would like to set up your own “webside manners” training program, set up a call with me to discuss the next steps you can take.

To receive articles like these in your Inbox every week, you can subscribe to Christian’s Telehealth Tuesday Newsletter.

Subscribe to Telehealth Tuesday

Christian Milaster and his team optimize Telehealth Services for health systems and physician practices. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.

Contact Christian by phone or text at 657-464-3648, via email, or video chat.

Connect with Christian