Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Insights From Practicing Telemedicine

"Many of us made unfair assumptions about the ability or willingness of older patients to embrace telemedicine, and have been humbled in recognizing our biases."


To make the most of video visits, stay attuned to your patients' nonverbal cues and avoid any background distractions in your environment.

Though telemedicine isn’t new, the COVID-19 pandemic abruptly made it our predominant way to give care in many specialties. Now that we’re reintroducing in-office visits, it’s valuable to reflect on insights from our unexpected, rapid foray into virtual care, and how this can inform us going forward.



The digital divide

While Zoom, FaceTime, Skype, and other video chat functions have been available for some time, many doctors and patients hadn’t used them much, and there was a steep learning curve this spring. In preparing patients for video visits, we encountered many who were unfamiliar with terminology such as “app,” “download,” and “WiFi.” Additionally, some patients—for socioeconomic reasons or personal preference—don’t have access to digital devices or a fast internet connection. This digital divide restricts some of our patients’ access to care.



Care disparities

Low-income communities and communities of color, already struggling with a disproportionate burden of COVID-19 cases and deaths, are most affected by lack of internet access. This includes patients who are constrained by long work hours, caregiver responsibilities, and transportation challenges that would make telemedicine an ideal option. With no other options for these patients, this can result in visits to overcrowded emergency rooms with greater risk exposure. We must view access to internet connectivity as a social determinant of health, and advocate for funding and initiatives to make it available to all.



Virtual care of elderly patients

Many of us made unfair assumptions about the ability or willingness of older patients to embrace telemedicine, and have been humbled in recognizing our biases. The unique needs of the elderly should be considered as we develop platforms for future virtual care, such as simplified sign-on processes and instructions, limited jargon, and allowing for simultaneous log on of a patient’s advocate to assist. Along with falls risk, diet, and ADLs, we should include questions about access to a digital device and WiFi during annual wellness visits.



When is an office visit necessary?

Notwithstanding the emotional value of touch and importance of physical examination, pandemic limitations have forced us to question how often we need to see patients in person. With the wide availability of home monitoring of vital signs, glucose, INR, and oxygen saturation, virtual visits are a convenient option for many patients to connect with their caregivers for assessing acute symptoms and monitoring chronic conditions. Further study is needed to understand the long-term impact of virtual care on clinical outcomes, as well as on patient and clinician satisfaction.



Building strong relationships

Finally, the shift to virtual care has spurred us all to take a closer look at building strong doctor-patient relationships. The value of handshakes, hugs, offering a tissue for tears, helping patients on and off of the exam table, and the simple laying on of hands for physical examination are easily taken for granted, until they are not allowed. Caring clinicians have taken note and aspired to translate this to the virtual realm. Hopefully, this increased focus on relational communication will improve all modalities of care.



Finally, here are the top 3 things I’ve learned about connecting with patients virtually: 


1. Ask staff to schedule and conduct a dry run to be sure the patient is comfortable with the telemedicine platform.


2. Be attuned to facial expressions, vocal tone, and other nonverbal communication cues.


3. Stay focused and avoid distractions.



COVID-19 has challenged us to quickly adapt the ways we give patient care. The pandemic will at some point recede, and we’ll have to reckon with how to integrate the new with the ways of old. Clinicians must seize this moment to  explore new ways of connecting with patients via telemedicine.