Michael: Welcome to Core IM. I’m Michael Shen, a leadership fellow and internist at New York City Health and Hospitals.
Aaron: And I’m Aaron Troy, an internal medicine intern at Beth Israel Deaconess Medical Center in Boston.
Michael: So Aaron, last April 2021, we were at the SGIM Annual Meeting, and there were a ton of great lectures about Telehealth.
Aaron: Yeah, as a medical intern in the COVID era, I know telemedicine is going to be a major part of my career– no matter what I go into or what I practice. But I’ve never had any clinical education on how to best care for patients by video or phone– aside from “have a good wifi connection and probably wear pants.”
Michael: You know Aaron if there’s anything I learned from this pandemic, its to always wear pants during a televisit – but in all seriousness, I remember coming out of the April 2020 surge of COVID in New York City to a whole new world of ambulatory medicine. 100% telemedicine, converting all visits to phone or video calls, etc. At this point, two years later we’ve realized the power of tele visits and the overall landscape of outpatient care. So, Aaron and I are going to consolidate a few tips for our listeners.
Aaron: Thankfully, SGIM brought the best minds in the biz together for some incredible sessions, so we decided to pick their brains and collect their top 10 tips for telemedicine visits.
Michael: Top ten tips. Is that like an alliteration?
Aaron: Top ten telemedicine tips, forgot a T.
Michael: Oh, 4 T’s, top ten telemedicine tips, not the 4Ts score. So we’re going to talk about the previsit, the history, the physical exam and kind of a few big picture telemedicine tips. And I promise you a few of these Physical Exam tips – you have never heard before, because I certainly didn’t. We’re going to get pretty creative. Alright Aaron, take us into the pre visit – preparing for the televisit – what’s Tip #1?
Aaron: One does not simply walk into a televisit…
Michael: Haha, okay… any Lord of the Ring fans there?
Aaron: We can’t make a good listicle without some quality memes.
Michael: Never walk into a tele visit without preparing. But, before we dive into this one – I want to introduce our experts – whom we actually invited back from SGIM to speak on our show today. They had a great talk titled “We’re going to need a longer stethoscope.” First up, Dr. Nadine Pardee.
Dr. Nadine Pardee: I’m Nadine Pardee. I’m an Assistant Clinical Professor of Medicine at UCSF and a primary care doctor at the VA.
Michael: Dr. Amy Lu
Dr. Amy Lu: I’m Amy Lu. I am also an Assistant Professor of Medicine at University of Colorado School of Medicine. My main role is the medical director for a Federally Qualified Health Center.
Michael: And Dr. Juliana Macri
Dr. Juliana Macri: I’m Juliana Macri. I’m an Assistant Clinical Professor affiliated with UCSF and I work out of the San Francisco VA.
Michael: Dr. Pardee, Dr. Lu, and Dr. Macri were actually in the telehealth game long before COVID – and the thing they all decided was one of the most important aspects of the televisit was this – to “begin with the end in mind”. Aaron what exactly do they mean by this?
Aaron: What they’re saying is – you need to decide what the goal of the visit is, you can’t wing it as much as an in person visit.
Michael: Hmm, why do you feel like it’s more challenging to wing a televisit than it is an in person visit?
Aaron: There are lots of reasons. When you walk into the clinic room you probably have the patients’ vitals and a chief complaint, which you might not at the start of a televisit. At the end of the televisit, your diagnostic and therapeutic options or more limited. In clinic, you can easily get lab work, an ECG, or even an X-ray. To get any of that data after a televisit you need to decide whether each peace of information is worth asking the patient to leave their house or workplace.
Dr. Amy Lu: You sort of have to think about clinical reasoning before you even get on the call…is this a follow up call, is this an acute visit…what kinds of things are available to the patient?
Michael: So I think it would be useful to have an example. Let’s look at MSK complaints. They are very common and can be quite intimidating on televisit. But, if you use this idea of “keeping the end in mind,” you can plan out your management ahead of time.
Dr. Juliana Macri: With most MSK visits, you are sort of going to divide your management into two buckets – one is going to be this is some kind of an emergent or surgical issue. For the vast majority of other issues though, you’re going to be doing conservative management if you feel comfortable in the visit that you can rule out the urgent things, you sort of end up in that other bucket and those sort of things are very amenable to talk about over a televisit.
Aaron: Right – hence one does not simply walk into a televisit.
Michael: Okay, so Aaron, can you sum up some take-aways for us?
Aaron: When you pre-chart, come up with concrete red flags that you can find out during a televisit that would make you want to send them to a higher level of care. And at the same time, think about where you might send them, and with what level of urgency, if any of those red flags turn out to be positive.
Michael: So that’s tip #1… how to keep the end in mind before you head into a televisit.
Michael: Okay onto Tip #2. Aaron, what do you have for us?
Aaron: Seriously, where are you though.
Michael: This tip, is quite literally to remind you to ask your patients where they are.
Aaron: Dr. Macri has some stories about patients being in surprising locations.
Michael: Like the patient who called Dr. Macri from a boat, in the middle of a lake. Or the patient who called Dr. Pardee from vacation.
Dr. Nadine Pardee: The plane was taking off and the flight attendant was like “Sir, you need to turn off your electronic device.” I’ve had calls from birthday parties being like “Doc, have a drink”… soccer games.
Michael: Literally, you have to be prepared for anything! You might just have to make the visit a quick med check visit and plan for the patient to come in or to reschedule – I’ve done all of these before. But actually one really important thing to follow up is not just where they are, but if they are in a private are and if there are other people in the room.
Aaron: It’s actually important for several reasons – the first is a serious one – patient privacy.
Dr. Nadine Pardee: The patient was very reassuring, no I want to talk to you … now I really need to get these things resolved… and then as his visit goes on we’re not just talking about his knee issue… we’re talking about depression and anxiety and we’re in a ..not a private setting.
Michael: So there’s a challenge here. Feeling the need to provide care to that patient, but also making sure you;re providing it in a respectful and appropriate way. Another reason it’s important to know who’s in the room is that family members and caregivers can be great sources of collateral!
Aaron: I’ve heard this called this the tattle tale phenomenon- one patient told me they take their amlodipine every evening, then I heard his wife off screen saying “He hasn’t taken that in weeks!”
Michael: Hahaha. What a tattle tale!
Aaron: But seriously, a caregiver or loved one in the room can be super helpful.
Michael: And that extra person can often help with the telehealth medium itself- I know my grandma often has trouble navigating her iPhone, so my mom’s always there to help her and tell her what buttons are what. But, that extra person in the room could be your safety net for a technical challenge.
Aaron: So practically – Tip#2 – always ask
Aaron: And also who else is in the room?
Michael: Okay, we’re on to our next section – the History. We’ve got two tips for you here. Tip #3 in our list is the history is the same!
Aaron: True that, the history is the part of the visit with the fewest differences between in-person and telemedicine. You can ask all the same questions, and your patient can give you all the same answers.
Michael: Yeah this is classic intern report type stuff. Aaron, I’m sure you get this all the time. Know your clinical scripts.
Dr. Nadine Pardee: As with most things, I have found the history provides the vast majority of the information that I need and the physical exam supports it. Examples are, patient coming in with insidious chronic hip pain with limited ROM, on chronic steroids with HIV. I’m already thinking about osteonecrosis before I have even done the physical exam. And limited range of motion and gait is starting to push me in that direction verses someone coming in with risk factors for a septic joint and telling me it’s red hot and they can’t bear weight… I’m done, right? I can do that over the phone. A video visit can give me more information, but I have already triaged based on those red flags.
Michael: So that makes a lot of sense. Focus on the red glads, that is paramount in these cases…
Michael: Tip #4, BEST. MED REC. EVER.
Aaron: This one’s pretty simple guys. We all know the struggle with the Med Recs – sometimes in clinic it’s hard to know what your patient is or isn’t taking. It’s actually the best proxy for whether or not they’re taking their meds– ask them on a televise to show you their morning meds. If they can walk to their pill box or cabinet and you see everything the EMR says should be there, you have way more information than you could possibly get in the comfort of your exam room.
Michael: And you know there’s some important takeaways here – once you know exactly what the patient is taking – a televisit is actually a really convenient setting to do some really great med management. Here, I’m going to bring in another clinical expert from SGIM, Dr. Tim Anderson.
Dr. Tim Anderson: So I’m Tim Anderson, I’m a general internist and an Assistant Professor of Medicine at BIDDM and Harvard Med School.
Michael: Dr. Anderson has written a lot on using telemedicine as an avenue for deprescribing in the geriatric population, and he gave a great lecture at SGIM about this.
Dr. Tim Anderson: My own practice has been that telemedicine has actually helped with the follow up of deprescirbing and its somewhat hard to convince patients to come back in physically to a clinic to talk to me about stopping a medication or to be honest, the flip slide of that sometimes is dose escalating medications in chronic disease management.
Michael: And I think televises really help in this area, especially in clinics that don’t have the resources or pharmacists to do this kind of work.
Dr. Tim Anderson: I think honestly, a quick telephone visit whether it is billed or not, has been a really nice way to follow up on people. I can think of a few folks where I’m tapering there benzos slowly and gradually with once every 2 month phone check-ins and I think its worked a lot better than I thought in the past when I could only get people in to come see me every 6 months or so.
Michael: And I know a lot of you out there can really relate to that. Okay Aaron, those were tips #3 and #4 related to history taking over tele visits. Remind us what those were.
Aaron: Tip number 3, the history is the same. And tip number 4, best. med rec. ever.
Michael: Okay, onto the physical exam. Hit me with Tip # 5 Aaron!
Aaron: I’ve got gadgets and gizmos a plenty.
Michael: Throw back to Disney and VHS tapes.
Aaron: I was just thinking a couple days ago about that Disney/VHS intro.
Michael: Dude, that was so classic.
Aaron: Seriously, patients have so many gadgets and gizmos these days… if they have it, you might as well use it!
Dr. Juliana Macri: Especially if I find myself getting a little flummoxed about how can I assess this particular complaint. Okay, if I had this person in clinic what would I want I want to do? And then, how can I adopt that to video.
Michael: Hmm, I love that approach.
Dr. Juliana Macri: So, some basic but specific things. Really, remembering vitals are important. More and more patients have peripheral devices at home.
Michael: Okay Aaron, pop quiz… name all of the peripheral devices, go.
Aaron: Apple Watch, iPhone, iPad…
Michael: nonono….well….actually I’ve asked a patient to tell me their resting heart rate from their Apple Watch before. But what else is out there?
Aaron: BP cuffs. As useful as these can be, they’re unfortunately restricted to patients with more disposable income. Just so you know, on Amazon or at a local pharmacy, you can get home blood pressure cuffs for as low as $20.
Michael: Oh and patient’s sometimes have those wrist BP cuffs – just an FYI – they’ve studied it and generally they’re not that reliable.
Aaron: Good to know. Michael, the bargains won’t stop for your peer-reviewed studies. Pulse oximeters $10!
Michael: As we were writing this, Aaron looked up all the prices of all the things.
Aaron: Gotta get that shopping on
Michael: During COVID pulse oxes were THE way I triaged. I worked on the COVID hotline for a bit and definitely sent a few patients to the ED for hypoxia. Okay Aaron, what else?
Aaron: Scales, even ones that connect to smartphones, calculate BMI, and estimate body fat percentage, start at $10.
Michael: That’s actually a really great way I have my patients trend there weight volume status if they have heart failure.
Aaron: In sum, for an initial investment of $40, patients can measure all their vitals every televisit, and between visits too!
Michael: Then, you have to add tax in there so… That’s pretty good though. I think the only vital sign we’re missing though is respiratory rate. I think Dr. Macri has a way to measure respiratory rate over tele visit. She sometimes has the patient do something distracting, then counts there respiratory rate. Probably more useful, if the patient is complaining of dyspnea. Again, this was useful during COVID – I could hear people be tachypneic over the phone cuz they were huffing and puffing.
Aaron: Alright, tip # 6 – it’s all about the camera angle
Michael: Is this an all about that base reference
Aaron: No, its all about the selfie stick. That camera light… you gotta get your good angles.
Michael: This tip comes from Dr. Pardee.
Dr. Nadine Pardee: An example of something that was really striking to me that I felt that I missed was a patient coming into me with skin nodules and at the end of the visit… they wipes there face and I saw they have significant RA changes on there hands, that was not even on my differential for the nodules and that’s ultimately what it was and it reminded me that you need to really think about… what is on my differential, but what can’t I see.
Michael: This goes back to the point that there is a lot of stuff we take for granted during an in person visit… being able to see the entire person and there body is one of those things.
Dr. Nadine Pardee: Some important tips for success are to make sure you can actually see there knees in the frame and that might require either moving the patient, having them change there clothes, making sure you can demonstrate for them, stand up, showing them you’re wearing pants and/or coaching them on actually putting the camera on a lower object, “Can you put the camera on the coffee table in your house so that I can actually see that area.” So, this is sort of another area that’s different and not being limited by the initial framing.
Michael: I like that, don’t be limited by the initial framing of your patient. I think that applies to life in general somehow. Okay Aaron, what is tip #7.
Aaron: Okay tip #7 – The Uncanny Virtual Shoulder Exam. This one is a really creative tip, and it’s from a study titled “The Virtual Shoulder and Knee Physical Examination” published in the Orthopedic Journal of Sports Medicine.
Michael: Yeah I think MSK exams are one of the most challenging things over televisit because it’s hard to feel like you did a good exam when you’re not able to palpate or maneuver the joint yourself. Well, this paper is probably one of the first I’ve seen to tackle a comprehensive shoulder and knee tele-exam.
Aaron: Yeah it’s got a ton of great tips, and we would encourage you to read it.
Michael: For the sake of the podcast, though, we decided to pick out one of the most creative aspects – using daily household items as weights – so you can add a resistance component to your physical exams exam. So Aaron – we’re gonna try this.
Aaron: Oh, we’re doing this?
Michael: Yeah! I want you to go grab two bags, and a bunch of canned goods. Or you can use a few water bottles. Okay so…let’s say you have shoulder pain.
Michael: Haha. Okay before we use the bags for resistance – what are some things you might ask the patient to do first?
Aaron: Well, I’d probably try to do what I would do in the office. I observe their joint. So I’d ask them to position their camera so that I can see at least the top of their body. And ideally I’d be able to see the skin around the shoulder.
Michael: Great, so another tip is to ask the patient to dress appropriately for the physical exam. Okay, so I’m looking at your shoulder, no deformities that I see.
Aaron: Then you know, maybe some range of motion, and I can ask the patient to palpate in certain key areas depending on their chief complaint.
Michael: Great, so let’s say I’m thinking rotator cuff – most common injury right. Okay, let’s show our audience how to put those bags to use!
Aaron: Alright, what do I do?
Michael: Let’s just do the empty can test. DO you remember what that is?
Aaron: Great, so this one tests just the supraspinatus muscle and tendon which is one of the 4 rotator cuff muscles.
Michael: Right, so I would start with two bags. You’re gonna put a few cans into each bag or alternatively 2 water bottles into each one. Next, hang one bag on each wrist. Now we’ll do the empty can test – put your arms out to each side with the bags on your wrist, your arms will be parallel to the ground, and point your thumbs down. And that’s the empty hand test.
Aaron: I’m so glad our listeners can’t see me doing this.
Michael: You look great haha. Now I think there’s a few things to notice here. Having one bag, one on each hand, is pretty useful because you can compare between shoulders. The other thing you want to do is to ask your patient if they are feeling pain.
Aaron: Alright, no pain.
Michael: Nice! There you have it. Your supraspinatus is probably OK.
Aaron: Alright do we have another one?
Michael: Okay we’ll do one more example. We’ll test two more muscles of the rotator cuff – the infraspinatus and teres minor. So usually in the office I do this by putting resistance against external rotation. But here, you are going to have the patient lay down so you can use gravity and the bag to act as that resistance. So w’ere going to do one arm at a time here. So, say I’m testing your right shoulder. Aaron, I’m going to have you lay down on your right side in lateral decubitus. Then, I’m going to have you bend your right elbow at 90 degrees and then you’re going to place the bag on that resist. So when you externally rotate that arm you’re adding resistance.
Aaron: Wow, so with a bag and some canned goods, you’ve tested most of my rotator cuff! And virtually!
Michael: Pretty creative way to do an exam. Onto tip #8 – the functional physical exam.
Aaron: This tip is a call to brainstorm outside of the box ways to examine patients when they’re at home. Think about it. What kinds of things can we assess just as well if not better than we can in the office?
Michael: So we did some brain storming already. You can assess METs, have someone their stairs or two. NYHA class for heart failure. What kind of symptoms they have at rest or when walking.
Aaron: You can assess fall risk! Throwback to the Geriatrics Assessment five pearls episode with Shreya and Minali– ask patients to simply cross their arms and stand up.
Michael: Please please don’t do this if the patient is by themselves. I don’t want to encourage dangerous patient maneuvers. You don’t want your fall risk assessment to be so specific that they fall.
Aaron: Yike, agreed.
Michael: Mobility! With the timed get up and go test. You remember how to do this one Aaron?
Aaron: Ask the patient to get up, walk ten feet away from their chair then 10 feet back from their chair and time how long it takes until they sit down again.
Michael: You can assess another ADL by asking patients to put on and take off a sweater or jacket.
Aaron: Oh and Dr. Lu had another good one.
Michael: She was shadowing a neurologist and they were taking about how to do near exams over telemedicine.
Dr. Amy Lu: One of the most interesting/creative ones was testing for proprioception. And he has to get eye drops for his chronic eye condition. And she asked him can you give yourself eye drops without any help. And the ability to do that already suggested that his proprioception is intact. So, she’s like that is better than any other specific neurologist test that I can do even over video.
Aaron: We could go on and on, but really this is a call for active brainstorming. Having your patient at home should inspire you to think outside the box about what we’re really trying to assess, and whether there’s a non-textbook way to check it.
Michael: So now, let’s zoom out a little bit. We’re in a world now where we have in person visits and tele visits. I think its important to think about how we use these different types of visits to optimally care for our patients. That brings us to tip #9!! Almost there folks! This is one of the best ways to utilize telemedicine, in my opinion. It’s the virtual home visit.
Aaron: There’s a lot you can learn about a patient medically from their home. You can assess for cleanliness and for there ability to keep things organized. You can see if they can actually use there kitchen and do things around there. You can assess for fall risk and see if patient has hand rales, and if they have there walker around and if they have rugs that can increase there risk of falls.
Michael: And cords or stuff like that that can increase there risk for falls.
Aaron: Absolutely! It’s a key way to frame the telemedicine visit act you just can’t otherwise do.
Michael: Tip #9, using the telemedicine visit as a home visit. And now, tip #10.
Aaron: Let’s be honest, no patient should get 100% of their care virtually.
Michael: For sure. So this tip is about how we can use our televisits to complement the in person care we provide?
Aaron: First up, if you’re working on the wards, think about scheduling patients with close interval televisits if you don’t think they can make it into clinic within the week!
Michael: I love that. One of telemedicine’s greatest benefits is its accessibility, and we should harness that whenever we can to keep patients well-monitored and plugged in during high risk times.
Aaron: One last point that Dr. Anderson raised was for patients who you realize, mid-visit, need that in-person level of care. Rather than punting everything to that visit, you can do a lot during your televisit to tee yourself and the patient up for that clinic appointment.
Michael: I love that, feeling yourself up. Next time I end a televisit, I’m going to think about what I can do to make my next visit more productive. And next time I discharge a high-risk patient, I’m going to ask myself whether a close interval tele-visit would improve their care.
Aaron: Wow… I’m both pooped and super stoked after diving into those top 10 telemedicine tips.
Michael: Couldn’t agree more. For this episode’s “take home points,” let’s run through the tips one more time.
Aaron: Remember, the more you test yourself, the greater your…
Michael: Aaron, that doesn’t make sense here
Aaron: Sorry, sorry, couldn’t help myself. Let’s run the list. Our first tips are for your pre-visit.
Michael: Tip number 1, one does not simply walk into a televisit… without a concrete plan.
Aaron: Number 2, where are you… and who are you with?
Michael: Our next tips are about your patient history.
Aaron: Number 3, the history is the same
Michael: Number 4, Best. Med rec. Ever.
Aaron: The next tips are about your physical exam.
Michael: Number 5, Gadgets and gizmos aplenty
Aaron: Number 6, It’s all about the camera angle
Michael: Number 7, The Uncanny Virtual MSK Exam
Aaron: Number 8, The functional physical exam
Michael: Our final tips are about the unique roles televisits can play in the overall primary care of a patient.
Aaron: Number 9, the virtual home visit.
Michael: And number 10, the transitional visit.
Aaron: And that’s a wrap. Can it, double bag it, and lift it with your thumb pointed down.
Michael: Alright Aaron, I’ll leave you to your workout.
Aaron: Thanks man.
Lamplot, J. D., Pinnamaneni, S., Swensen-Buza, S., Lawton, C. D., Dines, J. S., Nawabi, D. H., … & Taylor, S. A. (2020). The virtual shoulder and knee physical examination. Orthopaedic journal of sports medicine, 8(10), 2325967120962869.
Casiglia, E., Tikhonoff, V., Albertini, F., & Palatini, P. (2016). Poor reliability of wrist blood pressure self-measurement at home: a population-based study. Hypertension, 68(4), 896-903.
Tags: devices, home visit, interview, physical exam, questions, virtual