By Abby Rhoads, DO

COVID-19 has emerged and infected every aspect of our lives and well-being. With changes in billing and HIPPA regulations, utilizing telemedicine has allowed us to adapt in a short period of time, to protect our most vulnerable patients. It also offers protection for our safety on the frontlines as primary care physicians.

Of course, as a wife and mother, I was relieved to protect my family. However, I can’t help but wonder: Why did it have to take a global pandemic to protect our most vulnerable populations? For many Americans, access to care as well as health insurance is challenging, leaving them vulnerable to adverse outcomes.

Patient and Physician Perspectives

My first experience with telemedicine was in November 2019. My daughter had to see a specialist, and I had the choice of taking a telemedicine visit or waiting another five months. The choice seemed obvious.

I picked my daughter up early from school; we drove for an hour to the pediatric office. We checked in at the front desk, waited 10 minutes in the waiting room and were then taken to an exam room with a laptop on a cart. Within a few minutes the provider appeared on the screen and disclosed, they were in their home office, no one else was in the room and the door was closed.

By the end of the appointment, I had one question: Is there a way to have these appointments without driving an hour? The answer at the time was “no.” However, I was not aware this would become my everyday practice in a few short months.

Fast forward to March 2020. In a single week, I had converted from doing all in-person visits to 100% telemedicine visits. My practice entered into the telemedicine pandemic era, after several meetings and training sessions. Now with a single video call, I was reaching out to my patients, visualizing them through a screen and calming their fears in the comfort of their homes. The first two weeks seemed to move in slow motion with meeting after meeting, connectivity problems and low patient volumes.

Challenges of Billing and Technology

Telemedicine has the potential to fill in certain care gaps; however, it comes with its own obstacles. My first concern was the office manager receiving an array of phone calls from patients over their telemedicine bill. As Medicare’s guidelines were clear, commercial insurance was a grey area. I remember when a patient abruptly ended the conversation, after I communicated this was a billable service. They had just been furloughed from their job, and their health insurance was gone.

A big concern for physicians and medical practices, of course, is sufficient reimbursement and relative value units (RVUs). Unfortunately, we have not seen the entire detrimental impact of this yet.

In the beginning, another challenge was connectivity, as millions of Americans were utilizing video calls to stay connected. This has improved, and I have utilized many differed platforms to conduct these visits. Here are two lists of telemedicine platforms with highlighted features: VSee Telemedicine Platform Reviews and TechRadar’s Best Telemedicine Software of 2020.

Ease of Care

One main objective for using telemedicine is to make the visit easy for the patient. The best way to learn how telemedicine works from a patient’s perspective was to try it out myself. I was due for a specialist follow up and had planned to cancel this appointment due to time consumption of driving and waiting in an office, but I chose to keep it. I worked on my computer until the moment the provider came on the screen. We conversed during the appointment for 16 minutes and then it ended. I resumed my work instantly. I thought about how not only is telemedicine beneficial for our patients, but this could positively improve access to self-care for providers, who often forget to take time for themselves.

Digital Empathy

When utilizing telemedicine, we lose physical touch—something that osteopathic and primary care physicians foster on a daily basis. Even though we cannot reach through the phone to examine our patients, which can be frustrating, we can still show our patients empathy in the virtual encounter. We can foster a supportive environment by active listening and portraying nonverbal displays of empathy. I recently enhanced these skills during an online education module entitled, “Empathy in Telemedicine.” 1

Research shows that physician empathy can positively impact patient outcomes, improving their self-efficacy, participation in treatment and decreasing their psychological stress. Nonverbal displays of empathy are also a major aspect of our everyday communication and can still be displayed on a screen.  As providers, we can demonstrate these nonverbal displays by maintaining eye contact, showing emotional concern through facial expressions or demonstrating active listening with an occasional head nod. Patients will display nonverbal cues by changes in their facial expressions, and verbal cues by stating words of emotion such as “worried” or “afraid.”

It has been shown that providers who have an empathetic relationship with their patients can lower their risk of burnout, which is so important during this time of crisis. I am particularly appreciative when my patients ask me how I am doing, if I have enough protective equipment and conclude the conversation with “be safe.”

Teaching OMM to Patients

One of the hardest parts of telemedicine for me is not providing OMM, which is deeply imbedded in my everyday practice.

I was talking care of a mother and her adult daughter who were quarantined at home together. They were both tearful after 10 days of COVID symptoms with persistent cough. The mother verbalized rib pain from coughing so frequently; this is usually when I reach for OMM to utilize counterstrain to help relieve the symptoms. I thought to myself, “What can I teach them to do on each other?”

In less than 10 minutes, I was able to effectively communicate how to perform five techniques on each other at home on their couch. The key to success was using simple language that they understood. The daughter was able to hold the phone as I provided guidance and critique on each technique to the mother. To my surprise, after two days of utilizing these techniques on each other, both patients were feeling tremendously better. I felt incredibly connected to my patients in that moment and no longer felt helpless.

Post-Pandemic Vision

In the future, I foresee having a blended practice, seeing mostly in-person visits with scattered telemedicine appointments in my schedule. This will improve access to care and compliance to treatment while reaching a much larger pool of patients. Telemedicine is now integrated into family medicine to improve patient care for the better. As osteopathic family physicians we must embrace it and stand up together to ensure adequate reimbursement.

ACOFP Webinar
Telemedicine for COVID-19 Patients: Making OMT Accessible

On Monday, May 18, ACOFP held a webinar in which I discussed a case about teaching OMT with telemedicine technology to two patients who tested COVID 19 positive. Attendess learned about common somatic dysfunction found in respiratory tract infections, evidence-based medicine in teaching OMT to laypersons and utilization of OMT in respiratory infections. 

We discussed five simple techniques including sub-occipital release, pectoralis traction, thoracic outlet release, seated rib raising and pedal pump. For each technique, she will describe the steps and benefits of each in language that a layperson can understand.

This session was recorded and is now available as an on-demand session for CME, at no cost to ACOFP members. (The members-only discount will be applied on the registration page.)

Sign up for the on-demand session.

Resources

The Emerging Issue of Digital Empathy  https://www.ncbi.nlm.nih.gov/

3 Ways to Add Empathy to Telemedicine – PatientPond Blog

Virtual Bedside Manner: Connecting with Telemedicine – PPC, Pediatric EHR Solutions

References

  1. Defenbaugh, Nicole Phd. “Empathy in Telemedicine.” Online learning module, April 2020.
  2. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract, 2013;63(606):e76-84. doi: 10.3399/bjgp13X660814
  3. Hojat M, et al. Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust, and compliance. Int J Med Educ, 2010;1:83-87.
  4. Hojat M et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med, 2011;86(3):359-64. doi: 10.1097/ACM.0b013e3182086fe1
  5. Thirioux B, Birault F, Jaafari N. Empathy Is a protective factor of burnout in physicians: New neuro-phenomenological hypotheses regarding empathy and sympathy in care relationship. Front Psychol, 2016;7:763. doi:10.3389/fpsyg.2016.00763
  6. Hooper EM, Comstock LM, Goodwin JM, Goodwin JS. Patient characteristics that influence physician behavior. Med Care, 1982;20:630-8.

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