"One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Joshua Stein.
Joshua Stein, MD is the clinical director and an attending clinician at Minnesota-based psychiatric health system, PrairieCare’s partial hospitalization program (PHP). He also operates a clinic that serves as a bridge for patients leaving PHP until they can see their outpatient provider. Dr. Stein practices with a focus on patient centered care to improve his patients’ functioning at home, in school and in social settings, with the goal of not only addressing immediate obstacles and gains, but improving long term trajectory as well. Dr. Stein completed medical school, a general psychiatry residency and a child adolescent psychiatry fellowship at the University of Minnesota.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
Medical school was always on the table, but somehow, I had no idea I would end up in psychiatry. I was raised by a talented clinical social worker; and in hindsight, our dinner table conversation shaped my awareness of psychology, attachments and character. During my required core clerkship in psychiatry, it clicked, and I realized the connection between medicine and those dinner table conversations of emotional awareness would lead to a career in the field. Since then, I am honored to have numerous mentors who shaped my path and led me to child psychiatry. Currently I am lucky enough to teach, work in the hospital, consult to pediatricians and have a long-term continuity clinic. Also looking back, I did a bit of theatre growing up. My comfort on stage has led to teaching and lecturing as a physician. It has become an increasingly joyful part of my career.
Can you share the most interesting story that happened to you since you began your career?
Although there are of course unique or eye-catching stories, I think generally the most interesting aspect is the aspect of time. Time allows growth and development. Patients have gone from crisis to having families, careers, and vast talents. It illustrates the striking importance of treatment and the value of time.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Life deserves purpose.” My grandfather who survived the holocaust told me this in high school and it stuck. The seriousness of his life built this perspective, but it many ways it applies to all of us. In my life I interpret it to mean — whether with family, work or play — be thoughtful and aware. Exploration of self or world can be purpose. Developing can be purpose. In the therapy side of my practice, this concept shifts care from: “I want to feel better,” to “my hope is to graduate high school” or “learn to love again,” or “play baseball again.” It moves care past “just be healthy” to regaining specific functioning in areas of meaning.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
Drs. Joel Oberstar and Jonathan Jensen at the University of Minnesota were mentors in child adolescent psychiatry that demonstrated how joyful this field could be. They both showed how to engage patients through humor and play, allowing treatment to be silly. The moments learning from them have allowed me to bring play and silliness to my interactions that in many ways defines how I build rapport. Awful “dad jokes,” running football routes, Pokémon trivia and Harry Potter house assignments are examples of how my career gets to be goofy and fun, which it should be, when you work with children.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Similar to the experience many have had after the world has moved to virtual, with telehealth, there is the loss of connection that can only occur in person. In psychiatry, an extensive exam takes place called the “Mental Status Exam.” While the physician does not palpate the stomach or utilize a stethoscope, we do pay extensive attention to aspects of interaction and functioning. It is hard to complete this or build rapport in the same way virtually.
Additionally, there is an affective feel to a visit that speaks wonders. By meeting in person, the family dynamics are palpable, the stress levels are evident, and conflict is hard to ignore. This can be lost when meeting virtually.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
At times, virtual visits can lack the necessary formality of a doctor’s appointment. Patients can try and squeeze in an appointment from the car or a crowded restaurant. As your doctor, my goal is to give you my utmost attention and help care progress. Situational informality can lead to wasted time often to the detriment of care.
Additionally, diagnostics become difficult. Children are appropriately shy and may not like to see themselves on the screen. Many grandparents have found this fact frustrating as they have tried to maintain a virtual relationship over the pandemic. In medicine avoidance, lack of engagement and why those things are occurring help to understand the clinical diagnosis of the patient. When the patient is in the office these abstract aspects are readily clear. Virtually, it becomes quite difficult to understand why they “won’t come to the screen.”
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need to Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)
- Set effective ground rules before care: While this has always been necessary, it is strikingly important in virtual health. This includes arrive on time, no driving while in an appointment and be in a private area that feels comfortable for candid discussion. The physician needs to know who is in the room ahead of time. In my practice when I have not taken these steps it leads to lost time, risks confidentiality, or at worst — a patient may not disclose what concerns them. An example from my practice is when a mother of an anxious patient presented for a virtual appointment from the public pool. The child was embarrassed and uncomfortable. The session was ended after a review of appropriate formats for meeting. Future appointments were much more successful.
- Both patient and provider should prepare internally for the appointment ahead of time. Often given the ease of technological access means there is not the classic preparation time in the car or even walking through a clinic during which the patient may center and focus on goals for the appointment. Take a few minutes to reflect prior to appointment to make sure it is worthwhile. The switch to virtual has led to many appointments where patients arrive without awareness of direction or needs.
- Prepare externally for the appointment: The same screen that provides access for the clinical connection is a site of constant distraction. Shut off email, alerts, etc. These distractions can at best undermine therapeutic connection and at worst render an appointment useless. In my practice I regularly ask patients to shut off email reminders, social media, etc. My teenage patients often reflect that it is a relief not to have constant alerts and have space to connect.
- Find a quiet, confidential space. A cubicle or the kitchen table often limits the discourse due to concern for who can hear. Countless times patients will present from an inappropriate place and then be hesitant throughout. By picking a private room or a locked car, the normal disclosure can occur, leading to the necessary treatment and healing. I have had patients try and whisper about the family member across the room or imply concerns without saying them while at a coffee shop. A confidential place of focus is needed.
- Let patients share their life: Classically, appointments occur in the formal medical setting. Home virtual appointments allow a chance to meet the furry friends, see trophies, meet the other siblings, and see favorite possessions.
- Recognize when virtual is not working and an in-person appointment is needed. In my practice, autism and ADHD evaluations are much more effective in person. As we move into year three of the pandemic, every provider has a different comfort level with when to meet in person. If the virtual appointment is stagnating care, consider shifting patient back to an in-person setting whether in the same clinic or not.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
Access to care no longer requiring physical proximity is a huge advantage of telehealth. Child psychiatrists and many other specialized physicians commonly live and practice in larger cities or their suburbs. Rural patients have always struggled with the choice of long drives or not being able to see the most appropriate clinician for their symptoms. In my practice I see many children right after a hospitalization, but then they return to their home and cannot be seen further by a child psychiatrist due to distance. Over the last two years telehealth has allowed the care to conclude based on illness course rather than physical proximity.
Additionally, there is a large “time cost” of doctors’ appointments. This includes: the interruption to school, the drive time, potentially a parent needing to take the whole day from work, etc. Telehealth can allow less disruption in the day as there is little extra time needed other than the appointment time.
Telehealth also allows numerous parties to be present that may be hard to gather in person. In my practice, this allows case managers, therapist, separated parents, and/or complex families to be present all at the same. That “coming together” can happen in person, but often rarely. With telehealth, this occurs with greater frequency.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
As simple as it sounds, good lighting and a couple books to prop up the phone or tablet being utilized. Handheld devices in poor lighting can make the entire experience frustrating. By removing the camera from the hands, patients can speak freely and use body language effectively. It allows a shift towards forgetting the virtual nature of the visit and getting down to business. Overall appointments via desktop computers with built-in cameras seem to be the most effective overall. Finally, good Wi-Fi is needed. If patient has struggled with connection issues in the past, consider encouraging them to use a private room at the local library.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
A screen a few feet from the patient would be helpful to allow them to settle into the conversation without the overt issues a cell phone or tablet presents. Often the camera is facing the ceiling or aimed at the chin. If a parent is present, they may only be half in the screen. The device that captures the image often starts to take up its own space in the appointment. The simpler the device, that allows connection without dominating the interaction, all the better.
Also, the potential for a noise deadening microphone would be beneficial. Although the patient may not realize, many steps are taken in the therapist’s or physician’s office to maintain confidentiality. Thick walls, white noise and other tools are used to maintain privacy. Virtual care often requires a patient sneaking away to their car for a confidential visit. A tool to increase confidentiality would be helpful.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
- Prepare briefly ahead of time, focus on what you would like to accomplish in the session.
- Find a quiet, confidential space.
- Plan ahead. Virtual appointments allow numerous people across numerous settings to be present. Would it be beneficial if a social worker, a therapist, a teacher, or a family member join the appointment? This new tool allows for a more collaborative appointment.
- Children need to be present for their appointments. This is a regulation, but also allows the completion of the mental status evaluation which informs psychiatric care.
- Used a fixed-point camera. Handhelds shift and often end up filming chins, ceilings, floors. By setting the camera down, it allows increased engagement and comfort.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
Recently, both Amazon and Facebook released devices that sit on a table and allow virtual connection at the highest degree. Sound quality and imaging are excellent. The camera will follow a pacing patient. A shift to make these devices covered for mental health would be appreciated.
Also, schools and offices may consider new confidential virtual health rooms. Patients could book these for appointments to allow easy access for a setting that allows earnest communication without the risk of being overheard.
Is there a part of this future vision that concerns you? Can you explain?
While technology allows improved access to individual interests it comes at the cost of actual interaction. We need real interaction to develop. Humans need to learn to be flexible, compromise and build resilience. This growth comes through faced obstacles initially small and then larger. First, we learn the alphabet, next we learn to read and then perhaps understand the rhetoric of Shakespeare. Virtual life certainly has some advantages, but I am fearful that it limits real life stress tolerance.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I would say, a push to allow “growing up” to be expected allowed and appropriate. We need to let children, adolescents and young adults make mistakes. Growing pains will occur but help them learn what they are capable of. A push to allow children this space and time is warranted.
How can our readers further follow your work online?
https://www.mnpsychconsult.com/ is the home website of the Psychiatric Assistance Line. We offer education, and in real time psychiatric consults to primary care physicians. I regularly blog on this site and future trainings are available in the calendar.
https://www.prairie-care.com/ is the website for my clinical practice. Additionally, numerous PrairieCare Education Series links are available including my past and future lectures.
Thank you so much for joining us. This was very inspirational, and we wish you continued success in your important work.