7 Lessons in Communication from a teleNeurology Practice
By Tamika Burrus, MD
One of my first remote consults as a teleNeurologist involved a case where a psychiatry patient stated someone was talking to him through the television. The patient had had a stroke, seen incidentally on a scan the day before, but he also suffered from depression, and the on-site care team had requested neurology clearance, which was provided remotely.
When the patient told the team about the person talking to them through the TV the following morning, the nurses put in another stat consult, citing acute mental status change, and that’s where I came in. After evaluating the patient I determined that he had indeed seen someone talking to him through the screen. But, it had been the remote teleNeurologist who’d given the neurology clearance the day before.
Other than the stroke, the patient was fine. The communication about how he was being cared for, by whom, and how, was, on the other hand, not so fine. This was one of the first big lessons in communication from a teleNeurology practice I learned.
Lesson 1: Tell the patient about telemedicine
Patients need to be informed beforehand how telemedicine works and how a teleNeurology encounter is performed. If you are a nurse, you might walk them through it in simple terms: a doctor is going to come onscreen, they are going to evaluate you, and I’m going to remain here to help.
Patients can easily be confused by the technology, as was the case with my stroke patient, so it’s important to tell them not only what will happen and how it works, but to be an ally for the remote physician about to come onscreen.
Lesson 2: Explain the why of teleNeurology
When I come on screen with a new patient, I always take a moment to say why I’m there in this medium, rather than in person. Here’s what I say: the hospital is so invested in your care and making sure you have access to care as fast as possible, that they’ve invested in having me here to see you quickly rather than waiting.
Just that simple explanation can go a very long way toward setting the patient more at ease during a teleNeurology encounter.
Lesson 3: Pay attention to the handoffs
Handoffs are important in telehealth generally, but particularly in teleNeurology. In the case of my stroke patient, the nurse hadn’t told the care team that the previous day’s neuro consult had occurred, and they hadn’t looked at the patient note.
When everyone is new to the process, as many are right now, the handoff needs to be a smooth transition so everyone involved is on the same page.
Lesson 4: Be Camera Ready!
I confess that in the early days of teleNeurology it was not uncommon to simply be on call waiting for consults while also taking care of other personal business. On another one of my early consults, I rushed to the computer from my bedroom, connected to the hospital, and when I saw my face come up on the Zoom, I realized to my horror: I still had an avocado mask on my face.
The patient was intubated, and the nurse didn’t seem to notice, but the whole time I was self-consciously rubbing it off my face.
The point is visual cues are magnified on screen. As teleNeurologists we’re not there in person, so we can’t rely on our body language or bedside presence. Nowadays we are always busy when on shift, so the avocado peel incident will never happen again, but still: remember that you have to rely on your face for visual communication.
Lesson 5: Implicit bias is magnified
Similar to above, not being there in person can magnify the visual and verbal cues that patients do see: namely your perceived age, your race, and your accent. I’ve been asked if I’m really a doctor, what country am I from, and similar questions which signal implicit bias coming at me through the screen.
It is important to remember that biases work both ways. I have a sticker on the side of my computer that says “minority” to remind myself to check my own implicit biases for the patients I’m seeing.
TeleNeurologists see patients in every corner of the country, from the deep South to New England. You’ve got to be prepared to communicate effectively with a very diverse mix of patients.
Lesson 6: Medications before past medical
My standard training taught me to ask for patient history before medications. But for the sake of the patient’s privacy, I’ve found it’s better to reverse this when you’re on a camera.
In a teleNeurology consult, you have a limited view of the hospital room and can’t always tell who is nearby or hearing the conversation. So if, for example, I were to ask for medications and the patient gives me an HIV or a psychiatry medicine that helps me protect patient privacy. If need be I can always get the true past medical history from the doctor on the phone.
Lesson 7: Know when to acknowledge when video isn’t ideal
When all you have is your voice and your face, you need to find words of empathy when it really matters.
Once after evaluating a brain injury, I had to communicate to the patient’s parents just how serious the injury to their child was. I told them I was sorry I had to deliver the information through a screen. That was a time when it was clear it would have been preferable to be there in person.
TeleNeurology truly is the way of the future. It will help more patients get access to expert care faster. But there are times you have to convey empathy with just your words and deliver them through a screen. Simply acknowledging the gravity of a diagnosis may be enough. A little can go a long way.
Ultimately, teleNeurologists must both have excellent clinical acumen and be highly effective communicators. Without that skill both you and your patients may become frustrated and it could reflect in the quality of their care. Communication throughout the entire teleNeurology consult is important because you never know when you may just get called in a second time because the patient reported someone talking to them through the television!
Tamika M. Burrus, MD FAAN, is a fellowship trained vascular neurologist with special expertise in telemedicine. Via teleNeurology, she provides care within a critical window of time to hospitals throughout the country including many where this otherwise would not be available. In addition, through her roles in hospital management she has helped transform hospitals into stroke centers throughout Southern California.
Dr. Burrus has authored numerous publications around stroke and health care disparities. She has presented at national and international conferences. She currently serves on the Stroke Council of the American Heart Association and is a member of the American Academy of Neurology. Providing access to quality neurological care to the most underserved has been a passion of Dr. Burrus since medical school.
Dr. Burrus is a graduate of Vanderbilt University and obtained her medical degree from the University of Iowa Carver School of Medicine. She completed her Neurology residency at the Mayo Clinic and her Neurovascular fellowship at the University of California, San Francisco.
If you would like to learn more about our teleNeurologists, check out TeleNeurology Offers Real-Time Clinician Collaboration by Dr. Susanna Horvath, or Practicing Neurology in America: From Solo Practice to Telemedicine by Dr. Elaine Jones.