Strategies to foster meaningful connection during telemedicine visits [PODCAST]

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“The COVID-19 pandemic has upended health care, with telemedicine emerging as a strategy to reduce risk exposures for patients and clinicians. Video visits, in particular, can be effective for many types of clinical care and offer convenience and savings for patients. As care shifts to this virtual modality, however, there is a risk of jeopardizing the meaningful human interaction that is critical to clinical care and impactful to patients and clinicians alike.

The communication challenges of telemedicine, further compounded by COVID-19 related stress, call for strategies to help clinicians forge meaningful interactions with patients during virtual visits. The Presence 5, published earlier this year in JAMA, comprises evidence-based guidelines to foster humanism and connection in clinical care. Reconceptualizing this framework for video visits offers several strategies aligned with the Presence 5 practices: prepare with intention, listen intently and completely, agree on what matters most, connect with the patient’s story, and explore emotional cues. Prioritizing explicit humanistic practices can help clinicians foster meaningful virtual connections with patients amidst this challenging pandemic and in the future as telemedicine becomes more widely integrated into clinical care.”

Megha Shankar is an internal medicine physician.

She shares her story and discusses the KevinMD article that she co-wrote, “Strategies to foster meaningful connection during telemedicine visits.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Megha Shankar. She’s an internal medicine physician in California, and she co-wrote the KevinMD article “Strategies to foster meaningful connection during telemedicine visits.” Welcome to the show.

Megha Shankar: Thank you so much.

Kevin Pho: All right, we’ll get into your article in a little bit, but first off, tell me your story and your journey to where you are today.

Megha Shankar: Yeah, so I grew up in Chicago and actually spent a good amount of my childhood in Tokyo. My dad’s job brought us over there, and so we spent the first seven years of my childhood there and then came back to Chicago. I completed my undergrad and med school there, then my residency at UW in Seattle, and then came down here to the Bay, where I am now. And I think throughout all of that, going from Chicago to Japan and kind of throughout the West Coast here, it’s been a great way to learn about people, how different people act, and how I can connect with them.

Kevin Pho: Fantastic. So how has the pandemic affected you and your practice?

Megha Shankar: Yeah, so I think a lot of us have switched over to telehealth, and that’s been a really, really big change in our practice, not only in terms of how we practice, like the logistics of not being able to ask the nurse to help out with the BP or other things that may happen in clinic, but it also changes the way we interact with patients and the way that we really make that rapport with them strong. And so that’s been a really, really big change.

I’ve seen that in the inpatient floors as well, where we oftentimes do the H&P over the phone so that we reduce exposure as much as we can. So I think it’s happening everywhere, which is definitely not a thing that I could have thought of five years ago.

Kevin Pho: Sure. Now, you co-authored the KevinMD article “Strategies to foster meaningful connection during telemedicine visits,” and let me start by reading a short excerpt from that article. Your group writes, “The communication challenges of telemedicine, further compounded by COVID-19 related stress, call for strategies to help clinicians forge meaningful interactions with patients during virtual visits. The Presence 5, published earlier this year in JAMA, comprises evidence-based guidelines to foster humanism and connection in clinical care.” Now, before you get into talking about that and the Presence 5, tell me the problem that you’re trying to solve that this framework addresses.

Megha Shankar: Yeah, definitely. So I think oftentimes, when we have a screen in front of us and we have another person on the other side, it feels like there’s a barrier to the kind of connection that we can make there. And so I think oftentimes in clinic we use that presence, that physical being in the same place, to kind of help us build that rapport. Without that there, it feels like the whole patient-physician rapport is jeopardized. And so we wanted to ask: Is there a way to maintain that as we do a lot of telehealth now?

Kevin Pho: All right. Now, what is the Presence 5?

Megha Shankar: Yeah, so the Presence 5 is practices for fostering humanism in health care. This really all started because of just the increase in demands of health care, trying to see more patients in a shorter amount of time, and all the documentation that goes with that. And so these were created through formative work that involved patient-physician observations, interviews with patients, interviews with physicians, a systematic review, and then, after all of that, using a Delphi panel to create the five that we came up with.

And I think a lot of times it feels like these should be things that we just do on our own, but I think a lot of times we need that real intentionality in what we do, and that can help wellness.

Kevin Pho: All right. So I’m a primary care internal medicine physician, so let’s go into a little bit more detail in terms of exactly what those five entities are as part of your framework.

Megha Shankar: Definitely. So the first is to prepare with intention. I think in person, a lot of times that means pausing at the door, taking a deep breath, and kind of resetting yourself before you walk in. For telehealth, that may mean some of the same things. You’re not going to be pausing at the door, but you might pause before you turn on the screen. You still might take a deep breath. And I think here there are a lot of back-to-back appointments, so standing up can be really helpful just to break up the day. So that’s a big one to start off with.

The second one is listen intently and completely. A big part of this here was, in the data, we found that physicians tend to interrupt patients a lot. I think the statistic was just in the first almost 10 seconds of the appointment. And so a big thing here is body language, so sitting up, leaning forward, and then avoiding interruptions as much as we can. I think here, with telehealth in particular, there might be lag time, and so that’s a really important time to just kind of pause, let the patient complete their thought, and make sure that you’re not allowing the technology to get in the way of that.

And then the third practice is to connect with the patient’s story. And so here, a big part of it is really seeing what the context is in which the patient lives and works and has friends, and how that affects their health. And I think with telehealth in particular, this is an invitation into their home. It kind of goes back to the olden days, when we had house calls and could really see what their home environment was like and who was around them to help them in their health care. How safe are they at home? What’s in their fridge? Are they elderly, and do they have a lot of steps? So I think some of those things we can actually see now, and that’s great.

The last one is to explore emotional cues, and that can be really challenging with telehealth, because I think that oftentimes we use a lot of nonverbal communication to express that we care. That might mean a hand on the shoulder, or, if they’re not feeling well, we might offer them a tissue or something like that. And I think in this case, with telehealth, it becomes really important to choose words really closely and then just ask how they feel. I think especially during COVID, everyone is tense, and so that kind of overlays the appointment regardless. And so it can be helpful just to check in: “Hey, I think there’s a lot of stress right now. How are you doing with all of this?”

And I think I forgot the middle one, which is agree on what matters most. Here it’s really the same as in person, really thinking about what the shared goal is and thinking about what we want to talk about during that particular appointment.

Kevin Pho: Fantastic. And I think it’s a wonderfully systemic way for us to maintain that connection with patients. Primary care doctors are often so busy with a lot of bureaucratic requirements, and now with the pressures with COVID, so I think this framework gives us an organized way where we can maintain that connection with patients. If you can give one tip, what’s your number one tip that physicians can use to maintain that connection with patients?

Megha Shankar: Yeah, that would definitely be “listen.” I think it comes down to something that feels very simple, but allowing the patient to tell their story and really hearing what they have to say, I think, can go a long, long way.

Kevin Pho: Wonderful. And let’s take a step back. Is there anything that you’ve been curious or passionate about in the last few months?

Megha Shankar: Yeah, I think that racial justice has definitely been on my mind, and I’ve been thinking a lot about how, even just in the words that we use and how we talk to each other, we can kind of promote that. And so that’s been a big topic that I’m thinking about and reading about, and hopefully we can come up with a good strategy to make that work for all.

Kevin Pho: We’re talking to Megha Shankar. She’s an internal medicine physician in California. She co-wrote the article “Strategies to foster meaningful connection during telemedicine visits.” Megha, what’s your take-home message for the KevinMD audience?

Megha Shankar: Yeah, so I think the big thing, again, is to listen, not only to your patients but to everyone around you. We can learn so much from everyone, and that’s how we all learn.

Kevin Pho: Fantastic. Well, thank you so much for your insight and your time, and thank you so much for being on the show.

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