Video calling your doctor

26 May 2020

Interview with 

Lucas Seuren, Oxford University

DOCTOR_ONLINE

image of a stethoscope and a laptop computer

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The coronavirus pandemic is obviously having an enormous impact on hospitals. And lockdown is also changing the way community health workers communicate with patients. Many doctors and nurses are doing phone calls, or video calls, to dramatically limit how many people come into surgeries. So what’s it like to go from waiting room to webcam? Local GP Sarah and her patient Wendy invited Katie Haylor to listen in on an appointment, conducted over an Internet video link, and here’s a taster of what went on...

Wendy - I've got a rash up here on my abdomen, at the top, just above the belly button.

Sarah - And what day did that start?

Wendy - About Sunday.

Sarah - Right. Okay. So you think it's been going on for about five days now?

Wendy - Yes, it has. Yes. And it's quite itchy as well.

Sarah - And can you describe to me Wendy, what it looks like?

Wendy - Yes. So it's red, and it started off as small dots and then gradually got bigger. So now the redness has sort of gone into one sort of mass, if you like, with little spots on top.

Sarah - It looks very much like shingles.

Wendy - Oh, okay.

Sarah - Just want to check Wendy, have you ever had chicken pox before?

Wendy - Yes. Yes I did. As a child, yes.

Sarah - Right. Okay. When we've had chicken pox, the virus lives in our nerves forever, and then it can reactivate itself along one nerve. And I think that's what's happened here. For the itch, if we give you an anti-histamine to help that, and then the second thing we need to do is to give you some acyclovir tablets.

Wendy - Okay.

Sarah - If it's a little bit hot and burning. You can just pop a little bit of calamine lotion or cream on it. And then the final thing just to be aware of with shingles, is sometimes people can get a nerve pain afterwards. If that happens, you need to let me know and then we'll look at painkilling treatments to try and help that.

Wendy - Okay. Yep.

Katie - After the consultation, I caught up first with Wendy, and then with Sarah about how they found it.

Wendy - It was a positive experience. It's not something that I've done before, but I feel my doctor has met my needs in this current difficult time.

Katie - Were there any aspects of that communication you felt were better than if you'd gone to see Sarah in the surgery?

Wendy - I don't know if it was better. It was just very useful. Got into what we needed to do. It takes away the risk and anxiety of leaving home, because I'm shielding at the moment, so that was very useful.

Katie - Was there anything actually you felt was missing in terms of not being able to go and your GP face-to-face?

Wendy - No, not at all. Because I was able to show my doctor the actual rash that I had on my abdomen.

Katie - Sarah as a GP, how was it for you?

Sarah - I think it was really helpful in Wendy's case because, particularly with a rash, it's so useful to have these video consultations, so that you can have a good look at the rash and get an idea of what the patient's describing to you verbally as well. It does have some drawbacks. Sometimes if the camera's perhaps not as clear as seeing someone face to face, it can be a little bit difficult to see some things. But in general it works very well I think. And this new technology has great advantages when you're not feeling well, it's nice to just be in your own home and be able to chat to your doctor or nurse like this. It's useful from the point of view of infection control. So lots of patients aren't mingling in the same waiting room, spreading their infections from one to the other.

Katie - Have you had any circumstances in which actually it's really difficult to get in touch with people this way, this video conferencing way, or just over the phone.

Sarah - It can crash sometimes. We had a thunderstorm recently and it just stopped the electricity for a while and everything went off. But in general we found the majority of people we've spoken to, it's worked very well.

Katie - What about in terms of managing time? I know that GPs are really pressed for time. Do you find that video conferencing is better or worse?

Sarah - Yeah, I'm finding it a lot better actually. Because I have my list of perhaps 15 or 16 patients to speak to in a morning, and I can scan down the list and deal with any urgent things first. And then, you know, I'm finding that if someone needs a five minute consultation or a 15 minute consultation, I can be more flexible. I also think it makes you less stressed because you're not having people waiting and running late in the same way that you do running a normal surgery. General practice does seem to be moving to this telephone triage system, where we're talking to everyone on the phone first and then we're sorting a lot of problems out over the phone. We can send electronic prescriptions across for people to the local pharmacies to collect. I think it's probably going to be the future of general practice.

Katie - What about patients who might not feel comfortable doing a video call or might not actually have the kit necessary to facilitate it?

Sarah - Yes. I think that's particularly the case with perhaps some of our vulnerable, older patients who perhaps don't have the technology. We've been getting around that with some of them by just telephoning them, and then deciding if we need to see any older people, and also people's daughters, sons and their carers, can often work the technology on the older person or the vulnerable person's behalf.

Katie - Thanks very much to Wendy and GP Sarah. So could this be the new normal? Well, Lucas Seuren researches exactly this kind of communication at Oxford University. He's analysed the whole of the consultation and he's down the line, hi Lucas. What did you make of the consultation?

Lucas - I thought it was very similar to what we expect video consultation to be compared to a face to face consultation. But if you look at how the consultation works, in terms of moving from a problem presentation towards getting a diagnosis, and determining on treatment that goes in exactly the same way as it would have gone probably in a face to face consultation, which is good because you want the quality of healthcare over video, that you'd also get in a face to face consultation. And it works in the allotted time period. It's a quick alternative and it's a good alternative. In that case.

Katie - Do people behave the same way though, both patient and doctor, or are there any differences?

Lucas - So what we find in our research is that patients can, and are allowed to be a little bit more assertive, if you will. So because they are in their own home and they have to, some do more self management in terms of their own care. They also take that responsibility towards themselves. So where normally if for example, you think about a physical examination, the clinician lays hands on the patients and the patient undergoes, so to speak, that examination. In a video consultation, we find that patients take more responsibility and want that responsibility for themselves actually.

Katie - So Wendy and Sarah were reflecting on their experience, and they mentioned a few positives, maybe a few negatives. Are there any other obvious advantages or drawbacks?

Lucas - So an obvious advantage would be, for example, in terms of mental health care. We've talked to mental health providers and what they say is that video consultations for them are a great opportunity, because sometimes patients are uncomfortable with leaving the house, or they may forget their appointments. And then when they have the opportunity of a video consultation, they can have that from the comfort of their own home. They don't have to worry about the stress of going outside, or of meeting their appointment. At the same time if they forget it, it's easy to dial in at the last minute. The flip side is that because there's a lot of sensitive issues that people have to talk about, we aren't always comfortable doing that over video. So for example, in the consultation we just heard patient has a rash on her abdomen. And we typically fine with showing that over video, but not all parts of our body we like to share over the internet, and similarly there are issues we might rather not discuss online. We prefer to talk to somebody face to face, but this also varies from patient to patient. So it's hard to determine what kind of care is appropriate for whom, and that's still an issue that needs to be worked out.

Katie - What is the current situation in terms of privacy concerns?

Lucas - One of the main concerns is whether a consultation is appropriately secure. We've talked to lots of patients over the last year about what they worry about when they have a video consultation, and one of the things is the system security. Can somebody listen in to my consultation when it's online? And we've had a lot of security issues with consumer software like Zoom that makes people more worried about that. In reality, the software that GP practices normally use are secure. So there shouldn't be issues around that. But whether that works in practice, like taking those concerns away from patients is an issue. But with appropriate security measures, that typically works out fine.

Katie - And very briefly, do you think this could be the new normal, say if you don't need to actually have a procedure?

Lucas - Yeah. So if you don't need a procedure done, almost always a video consultation, maybe even a telephone consultation will be all you need. In some cases, telephone might be easier to set up, but video can offer some reassurance.

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