Dr Owen's tips for on-line consultations

14 months ago by Dr David Owen

This is both for those of you who are patients but reluctant to do video calls and for those of you that are happy with video appointments but might like to reflect on making the most of consulting this way using platforms like zoom, Doxy, Teams, Whats-App, Skype etc.  I have found lots of patients are very happy to consult this way and many have chosen to keep consulting this way.  In the early days of the Covid pandemic, it felt a challenge to change the way I was working from in person to video consultations.  Now it feels it is working really well offering a blend of face-to-face and video appointments.  It has been an interesting challenge for the practice to see how to make the best of consulting this way.  Currently about two thirds of my consultations are by video and I thought it might be interesting to share some of our learning, particularly to encourage those of you who currently like using phone consultations to try adding video through our preferred online consulting platform called ‘Doxy’.  While this piece is mainly about one to one consultations it is also informed by the one to one coaching sessions and many small groups I facilitate using video meetings.

One of my first impressions having to stop in person appointments during Covid was the amount of information we gain from nonverbal clues and how important the physical environment is for patients (and doctor) to feel at ease.  Recognising how important this was led me to explore how we can best recreate the ‘magic’ of the consulting room online.  Sometimes it can be difficult to objectively assess the quality of a consultation, although mostly the patient and doctor have a good sense of how things have gone, how easily things have flowed, the depth of conversation and the order and meaning leading to a clear assessment, agreed plan, clear advice and useful prescription.

I have really enjoyed developing new skills to maximise the opportunities and manage the challenges to both the patient and doctor during online consulting.  The relationship online has some fundamental differences from face-to-face consulting.  Some obvious such as saving travel time, consulting from the convenience of home or office, to not being able to easily examine a patient or use physical therapies or take a blood sample or treat with acupuncture.  Others are less obvious such as patients who are feeling relaxed and trusting often revealing more pertinent information, or having to manage the loss of travel time to and from an appointment which often helps patients order their thoughts ahead of an appointment and review any advice after an appointment.

Sometimes working by video the visual focus can reduce the attention to how you are feeling both for the doctor and the patient.  I find this less of a problem if I hide my self view when I notice I’m more in touch with my feelings.  Doing this, I also notice I’m often less tired after a number of video appointments.  Perhaps it is linked to being able to concentrate and focus on the patient.  In video consultations I find I often ask patients how they are feeling and as they arise I’m more likely to share my own feelings as a way of giving permission to look at and use our emotions.

Mostly microphones give good audio and cameras are well positioned. When a patient logs on through a phone however, often the view is not as good as from a laptop or desktop.  I find a phone and some tablets held close don’t show enough of the participants face, shoulders and hands because the patient has to sit closer to the device.  This makes it harder to read body language although it can offer more detail of facial expressions.

I remember how in my early days, during an occasional home visit, how much information could be gleaned from a patients home and how often they would, in the security of their home, open up and tell you things at a first appointment that might otherwise not be talked about until they and you had otherwise met several times.  These personal bits of information really help in giving a holistic picture – so important in finding the right approach and treatment for a patient.  After all we treat patients who have an illness – to help them heal.  Not just the illness the patient has ‘caught’.  Given the benefits of the extra information the environment a patient is talking from, I prefer it if patients don’t blur their background when they set up for video calls. (It is a feature a number of programmes allow.)  If blocked or blurred it feels like part of them is hidden.  I appreciate there are times, in more open meetings when a view of a patient's home or workplace might not be something to ‘broadcast’ but I'd hope that’s rarely the case for a medical consultation.  Unless there are very good reasons I assume a patient's microphone and camera will stay on throughout the consultation.  If a patient turns their microphone off or hides their image I like to explore why they are doing this, maybe they have background noise or are finding it hard to find a safe quiet place to talk in confidence.  Still useful to know.

One of the things reduced when consulting on video is some of the body language. How we sit and move in relation to each other and what is being talked about gives important information.  One of the consultation tools I use, especially when talking about more difficult things is sometimes referred to as ‘matching, pacing and leading’.  This builds rapport and confidence to explore a topic in more detail.  Here the non-verbal clues help gauge the progression and if it is not possible to see arm and hand movement then subtle eye movements and changes in voice can help navigate this process.

Ideally you can set up your camera and sit back enough so there is a clear view of your face as I find eye movements communicate a great deal and are especially helpful when working virtually and hand movements and body language are hard to see.  I also find it is even more important to check out how the person is feeling emotionally which can link to paradoxical statements, amplified or spontaneous comments, changes in voice and eye movements which can all point to strong feelings surfacing.  Like body language, eye-movements are partly personal but can also be a useful pointer.   For example, I often find people look to their right when thinking ahead or wanting to plan their future actions and more to the left when they want to talk or reflect more on the past , perhaps wanting to share something.  When we look up we are looking for inspiration and when we look down we are often starting to feel uncomfortable or less safe.

One of the differences working virtually is the ‘power’ positioning.  That can be indicated and reinforced by seating, desk position etc.  This can be unsettling for a doctor or patient but when recognised gives new opportunities for a more equal relationship.  I’m very interested in patients perceptions of strengths and weaknesses of video consulting so do please feedback to me what you find works well and of course what you feel doesn’t work well.