Training docs on 'webside manner' for virtual visits

When Kaiser Permanente's emergency room wait times began rising three years ago, Dr. Dennis Truong and a colleague launched a telemedicine program to provide faster access to care for their patients.

At the time, there weren't many training programs for telemedicine or for developing good “webside” manner, which can greatly improve patients' adherence to treatment. Instead, Truong had to learn on the fly.

“We essentially created our own webside manners through experience and through inter-regional sharing with our other KP regions,” said Truong, telemedicine director for the Mid-Atlantic Permanente Medical Group, McLean, Va.

Like its cousin “bedside manner,” webside manner is a key skill for clinicians involved in telemedicine, experts say. Physicians must proffer an empathetic and compassionate presence to calm fears and provide hope for patients who may be suffering from serious or even not-so-serious illness. Medical schools have always included training in bedside manner in their curricula.

And that's not just because they want to make a patient feel better about an encounter with the healthcare system. According to a 2014 study published in PLOS One, bedside manner can have a statistically significant impact on patient health, affecting the incidence of obesity, asthma, diabetes, hypertension and osteoarthritis. It can also affect weight loss or blood sugar levels in patients.

But clinicians are going to have to rethink how they deliver this important element of their craft as medicine moves deeper into the digital age. Telemedicine is booming, with startups and new applications springing up constantly.

Approximately 71% of employers say they will offer telemedicine consults through their health plans by 2017. Investment is growing too; the telemedicine market was worth about $500 million in 2014, but that is expected to balloon to $13 billion in 2020, said Fletcher Lance, managing director and global healthcare lead of North Highland, an Atlanta-based global consulting firm.

That's why experts and consultants are encouraging physicians to prepare for virtual visits with appropriate equipment and a well-developed “webside manner,” which includes all the same skills as bedside manner but has a number of its own requirements. Just like during a traditional office visit, clinicians must juggle paying attention to the patient with filling out electronic health records and other forms. It's as important to put patients at ease in a virtual environment as it is in an office.

“I think that people forget sometimes in healthcare when we're very focused on the profession, the data, the latest and greatest of science, we forget that healthcare has two words in it. One is health, one is care,” said Ron Gutman, CEO and founder of HealthTap.

HealthTap has amassed a network of 120,000 physicians providing virtual care via video visits, an online query center and answer library. The Palo Alto, Calif.-based company also developed a series of training programs to help physicians prepare to enter the telemedicine world, including a free certification class that offers a level 1 continuing medical education credit. The class started a couple months ago.

While HealthTap and other groups offer certification and training courses for physicians who want to use telemedicine, preparation classes are only starting to take hold at medical schools. The University of Arizona has incorporated some telemedicine into its medical school, according to Elizabeth Krupinski, a University of Arizona professor and associate director of evaluation for the Arizona Telemedicine Program. But there are no formal requirements for telemedicine education in medical school curricula yet.

It may not take considerable formal training to get comfortable with telemedicine practices, though. In many cases, it simply requires common sense. According to Gutman, starting a virtual visit off right with proper webside manner is a key element to a successful telemedicine episode. “Every consultation starts with a smile and ends with a checklist,” he said.

That checklist could involve using proper intake documentation and following a framework to determine whether a virtual visit diagnosis is appropriate or a follow-up in-person visit will be necessary. By making patients comfortable during their telemedicine appointments, physicians can improve patients' confidence and the likelihood they'll adhere to treatment regimens, Gutman said.

But doctors need to be confident in their own abilities, according to HealthTap's chief medical officer, Geoff Rutledge. Rather than erring on the side of not diagnosing patients, Rutledge encourages physicians in telemedicine to follow their checklists. “There is a presence that you project through the virtual channel and you should be conscious of it,” he said.

That presence can be improved with good patient communication, whether it's explaining that they'll be looking at a patient's record on a screen for a moment rather making eye contact or asking a patient to provide more information with a blood pressure cuff.

While good bedside manner easily translates into good webside manner for most doctors, experts encourage physicians to get some training before they start seeing virtual patients so they understand the differences between telemedicine and face-to-face consultations. Just as in the office, physicians should present themselves professionally in virtual settings, paying attention to their office layout, surrounding equipment and their dress.

“When you're conducting a videoconference with a patient, it's not the same thing as getting up Saturday morning, going on FaceTime and talking to your best buddy,” Krupinski said. “It's not that simple.”

Lighting and background are key elements of getting webside manner right, Krupinski said. If a physician sets himself up in front of a window, he'll look like a dark shadow. If he has a cluttered or shabby backdrop, it may not sit well with patients.

In addition, physicians should be aware of their internet connection, camera resolution and audio equipment to make sure their stream won't cut out in midsession. “If someone has a first bad taste, that's not good for anything,” said Dr. Jim Marcin, head of pediatric critical-care medicine at the UC Davis Health System, Sacramento, Calif.

In Northern California, Marcin and his colleagues use telemedicine to provide virtual support to other hospitals and physicians and curb unnecessary transfers in their emergency departments. Specialists can appear remotely in ICUs to speak with patients, their parents or their local doctors and help determine a treatment regimen.

So far, Marcin says specialists, patients and local doctors have appreciated the live interactive video consultations. Studies have shown they're capable of providing the same care and diagnoses via telemedicine as they can deliver in person.

“It's a win-win-win,” he said. Marcin believes telemedicine also performs well in delivering mental health, endocrinology and other specialty services that require more thinking and talking. It works less well for specialties that require more physical examinations.

According to Marcin, even 15 minutes of basic video etiquette training can help clinicians become comfortable with using telemedicine and develop a better webside manner. The UC Davis system provides training and does extensive equipment testing at its remote sites before setting up its virtual consultation systems.

“It's just a different medium in providing care,” Marcin said. “Once they have basic pointers on what to do, those with good interpersonal skills are well-received, and it goes well.”

But Marcin and several other experts voiced concern over the direct-to-consumer model that some telemedicine providers have taken, which allows individuals to have one-off visits with doctors rather than build relationships with their medical providers.

“That's the first problem in relationship-building or engagement,” said Arman Samani, chief technology officer at AdvancedMD, an EHR and practice-management software company. “If you don't know somebody, if you're going to have one transaction with them, how can you engage with them effectively?”

Samani and his AdvancedMD colleagues encourage physicians to start using telemedicine with their existing clients before considering expanding to new clients or a larger geographical market. Even then, doctors should discourage using telemedicine as a one-off solution in favor of developing relationships with their expanding clientele.

That could include sending marketing messages to patients to let them know about telemedicine offerings and making it as easy to set up a virtual visit as an in-house appointment, Samani said.

However, there's a convenience factor—for both doctors and patients—who use broad telemedicine networks such as HealthTap. Dr. Dariush Saghafi, a neurologist in Parma, Ohio, has been using HealthTap's virtual platform since 2013, first by answering questions on the platform's public Q&A board before conducting full-fledged consultations.

Saghafi acknowledged that doctor-patient relationships generally start with a physical visit since it can be difficult to adapt to a fully virtual relationship or refer far-flung patients to providers in their area for follow-up visits. “You kind of learn how to work around that,” he said. “You learn where the safe zones are to tread in when you're recommending interventions, treatments and prescriptions.”

Kaiser's Truong noted that his system encourages clinicians to “up-triage” patients for physical examinations when needed. Kaiser, which has made a major commitment to telehealth and projects it will log more telehealth visits than office visits within a few years, offers telemedicine training and live demonstrations for physicians.

“Remember that the patient on the other side, this may be their first time receiving care by video, too,” he said. “You're both experiencing this newly together.”