Canada has a long history of using telemedicine to reach patients in remote areas. Would you be surprised if I were to tell you that we’ve been using this technology for over fifty years? Back in 1998, an article was published to mark 40 years of telemedicine in this country.(1) In case you’re counting back the years, as I did, that was 22 years ago; which means that telemedicine has been used in Canada for 62 years because:
The Canadian climate and geography are particularly well suited to the adoption of communications technologies for long-distance medical care and education.”(1)
Jocelyn Picot, Telemedicine and Telehealth in Canada, 2009
Surprisingly, in light of its long history here, neither telemedicine nor the newer video consultation with clinicians were available to most Canadians prior to the COVID-19 pandemic. With public health insurance and the administration of healthcare falling under provincial or territorial jurisdictions, Canada lacks the consistent ‘public healthcare system’ that many in other countries imagine us to have.
That being said, the federal government is responsible for providing healthcare to certain groups of Canadians; examples include Aboriginal people living in specific areas, members of the military and the Royal Canadian Mounted Police (the ‘Mounties’), and those incarcerated in federal prisons. For today’s post, I’m going to ignore these exceptions and will focus on the situation in my home province; Quebec.
Prior to the current pandemic, most medical consultations for people living in large urban areas in Quebec were conducted in person. Why? Well, like so much of our healthcare, that gap can be traced back to the preferences of physicians – rather than those of patients. In 2002, for example, a study of clinicians found that:
those who practice in hospitals not very far from an urban centre (in our sample: 75-115 kms) would rather have their patients travel to be examined”.(2)
P. Lehoux et al, The theory of use behind telemedicine, 2002
Patients, as you may already have guessed, weren’t consulted as part of that research project. So although telemedicine and video consultations were provided for patients living in remote areas, there had historically been no push from within the realms of medicine or healthcare administration to offer these services to Montrealers. Many city-dwellers, however, would have opted for these alternatives had they been available.
The current coronavirus situation, of course, led to rapid changes in this long-term stalemate between physicians’ and bureaucrats’ preferences and patients’ wishes. Almost overnight, telemedicine and video consultations were suddenly being encouraged by the provincial government. Not only were physicians quickly adopting these newer technologies, other healthcare professional soon realized that they had the potential to help patients from afar; physiotherapists, occupational therapists, psychologists, psychiatrists, and others.
Unfortunately, this rapid adoption of these technological tools in urban settings allowed no time for practitioners to learn how best to adapt their regular practices to an audio- or video-based consultation. The pandemic left clinics, medical centres, and hospital follow-up teams scrambling to fill these gaps during a global health crisis.
With this rushed implementation of computer-based – or even smartphone-based – platforms for healthcare, there was no time to properly train healthcare professionals in how to use these tools to best care for their patients. Not only for the technological aspects of these tools, but also – and perhaps more importantly – for how to tailor their own unique ‘bedside manner’ to a ‘phone-side manner’. How to care for another person, remotely and professionally.
Nor was there any wide-scale patient or caregiver education in how to adapt to these technological changes in their medical care. Video consultations in particular could be problematic, because high-speed internet services remain expensive here: “Studies show that Canada has among the most expensive data costs in the world.”(3) As you probably know, it’s difficult and frustrating to participate in a video consultation if your WiFi signal constantly drops off or lags; for patients as much as for their healthcare professionals.
During this badly-rushed move to both audio and video consultations during the pandemic, another major issue arose for patients in urban areas. Unless a person lives alone, it can be challenging to have a fully private – and quiet – conversation with a healthcare professional from a family apartment or condo. This is true at the best of times, let alone with children at home 24/7 due to pandemic school closures and adult family members being encouraged by the government to work from home.
But, like Canadian patients so often do, we adapted to this difficult situation on the fly. Without any concerted efforts to provide guidance or support from within healthcare, we largely relied on other patients for advice; on each other. Based on many of these conversations with patient advocates, in person and via social media, this post is meant to provide advice for those within healthcare.
Here are some tips on how to quickly improve telemedicine or video consultations skills, to better provide care to your patients – from both my distinct perspectives; as a bioethics and patient privacy protection professional, and as a chronic pain and rare disease patient advocate.
With Montreal’s number of COVID-19 cases still rising during this second wave of the coronavirus, I expect that we’ll return to ‘Red Zone’ status any day now.(4)
Before that happens, please take a few moments to ask yourself whether your distance-doctoring skills could be improved. If your response was yes, please read this tips from a patient and bioethics professional.
Some points to remember, for telemedicine consultations with your patients:
- Begin any telemedicine or video consultation by asking your patient whether it’s their first experience with telemedicine or video for a ‘doctor’s visit’
- If so, reassure them that it can be just as personal; a fun way to do this is to tell a joke, to show that you can still share human ‘moments’ without an in-person consultation
- Explain what they should do if the call/feed is cut off (e.g. Will you call them back? If they should call, which number should they use?)
- Ask your patient if they’re in a location in which they can speak to you privately; in a crowded home, you might suggest that other family members all go into one other room for the duration of the consultation
- You may wish to remind your patient that, even if they’re wearing earbuds or a headset, anyone nearby can still hear them
- Focus on your patient as they speak; if you’re shuffling papers on your desk, talking to someone else in the background, or using a keyboard, your patient will hear this – and feel as though you aren’t ‘really’ listening to them
- If you need to use your keyboard to take notes as they speak, or will be flipping through a paper chart for their history, tell your patient at the start of the consultation that you will be doing this – and that anything they hear relates only to their care
- Show your patient that you’re listening
- a) for telemedicine, this means leaving pauses for delays in message transmission, and prompting a patient to speak because they may not want to interrupt you (i.e. they will be lacking the body language clues from you that they would rely on during an in-person consultation); and
- b) for video calls, lean towards your camera when the patient is speaking – and look into your camera to create eye contact on the patient’s screen
- Summarize what your patient has told you about their symptoms, then ask them if they have anything to add – or to clarify; you may have misheard or missed some of their words due to poor connection
- Pause for at least 30 seconds at this point; it’s often difficult for a person to explain their symptoms when they’re nervous, and patients unused to these virtual technologies may be feel stressed by this new experience
- After this 30 second pause, begin to ask guiding questions to narrow down your patient’s symptoms
As stressful and difficult a situation this pandemic is for you as a healthcare professional, it’s important to remember that it’s also a challenging and fear-inducing period for your patients. They may be struggling with their unplanned stay-at-home households, financial burdens linked to the coronavirus, fear of this illness, and more. They may also be worried about the health of loved ones in assisted living centres.
All of this added life stress, particularly for patients already living with chronic illness and/or chronic pain, can make it more challenging for them to focus on you during a consultation – particularly when they’re trying to do this from their home rather than in clinic.
We’re all trying our best, in trying times.
As always, thanks so much for dropping by. If you’d like to comment, or have any suggestions, feel free to reach out via Twitter or Instagram; I’ve had to disable the comments feature of the blog because it’s too much for me to handle with my CRPS-related mild cognitive impairment.
Stay safe, keep well, and try to do something ‘just for you’ today ‘-)
References
(1) Jocelyn Picot. Telemedicine and Telehealth in Canada: Forty Years of Change in the Use of Information and Communications Technologies in a Publicly Administered Health Care System. Telemedicine Journal. Vol 4, Issue 3, Jan 1998. 199-205. ePublished 29 Jan 2009:
http://doi.org/10.1089/tmj.1.1998.4.199
(2) P. Lehoux, C. Sicotte, J.-L. Denis, M. Berg, and A. Lacroix. The theory of use behind telemedicine: how compatible with physicians’ clinical routines? Social Science & Medicine. Vol 54, Issue 6, 889–904. Mar 2002. Online:
https://www.sciencedirect.com/science/article/abs/pii/S0277953601000636
(3) Jonathan Lamont. Canada among top five highest costs for 100Mbps internet speed.
MobileSyrup (“an independent resource on mobile technology in Canada”).18 Dec 2019. Online:
https://mobilesyrup.com/2019/12/18/canada-top-five-highest-costs-100mbps-internet/
(4) Jillian Kestler-D’Amours. Montreal and Quebec City move to orange ‘moderate alert’ COVID-19 level. The Canadian Press. In The Globe and Mail. ePublished 20 Sep 2020. Online:
https://www.theglobeandmail.com/canada/article-quebec-reports-462-new-cases-of-covid-19-five-additional-deaths-2/