Telehealth Best Practices: Dr Geoff Rutledge Of HealthTap On How To Best Care For Your Patients When They Are Not Physically In Front Of You

“[Authority Magazine’s Jake Frankel] can you articulate for our readers a few of the main benefits of having a patient in front of you?

[Co-founder and CMO of HealthTap Geoff Rutledge] The most important point to emphasize is that the essential physician–patient interaction is direct face-to-face communication that allows a doctor to connect with their patient, engage with them, and enable them to share in detail what is going on with their lives and their health. And that this critical face-to-face communication can occur equally well either in an in-person, in-office setting or via high-resolution video and audio consultation.

It’s worth noting that when doctors see and engage patients in face-to-face communication, they also are observing their patients, whether they are in the same room or communicating via remote video consultation. This is a physical examination that occurs by inspection, without touching the patient. It is highly revealing of many aspects of a patient’s condition — an experienced clinician often knows the most likely diagnosis for a patient’s problem based on observation even before hearing in their own words what their symptoms are. Key observations that help with this assessment include appearance, attire, affect, posture, gait, motor movements, eye movements, pupil size and reactions, facial symmetry, skin color or rash, voice tone and tenor, speech quality, and more.

[Frankel] 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?

[Rutledge] The good news is that the vast majority of patients who need outpatient primary care services can be served as well or better by virtual consultation than they can be via in-office care. This is demonstrated by the fact that office-based primary care doctors do not routinely do physical exams unless there is a specific concern or medical reason to do so. Even when they do perform a physical examination, it is often cursory, because it is expected rather than needed. Many people do not at first realize it’s possible to choose and meet a doctor, get to know them, and then turn to them for advice and guidance when new medical issues arise. The virtual care doctor should anticipate and understand these prior notions that people have, and address them directly during their visit, reassuring their new patients that they really can expect their virtual primary care doctor to be there for them in future.

The main challenge for virtual care is how to manage patients who need more than is possible to do via virtual consultation. [..]

For example, when a patient arrives at a doctor’s outpatient office with shortness of breath and substernal chest pain, that is beyond the scope of practice for an office visit, and the doctor will call for an ambulance to transport the patient to the emergency department. They may also provide guidance to the patient immediately, by offering an aspirin or starting an IV.

A less extreme example is a patient with moderate to severe abdominal pain, when a physical examination of the abdomen is an important component of the evaluation. When such a patient presents for a virtual consultation, the virtual care doctor will assess the need for hospital-based evaluation (for example, if the doctor recognizes that even after an in-office physical examination, a CT scan of the abdomen will be needed) and arrange with the patient for transportation to the hospital for further evaluation. If hospital-based care is not likely to be needed, but the diagnosis and treatment requires a physical examination, then they may refer the patient for a visit with an office-based primary care physician. The virtual care doctor may also order initial laboratory testing to be performed so that the office-based doctor will have important test results to guide the evaluation at the office visit. [..]

[Frankel] 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?

[Rutledge] Patients often are under the impression that a doctor must perform an in-person physical examination to evaluate them. The most important — and often the only — information to support a doctor’s diagnosis is a thorough patient history, including all the relevant past medical history, social history, risk factors, details and the presenting complaint(s). In fact, for routine in-office visits, doctors do not usually perform a physical examination. When doctors do examine the patient, it often is little more than the “laying on of hands.” It’s done to connect with the patient and establish a rapport — and because it is expected. In routine practice, and when there is no suspicion of a specific problem, the percussion, palpation, and auscultation elements of the physical examination are rarely done in a thorough manner, and almost never provide information that has any impact on the care delivered.

Another common misconception is that doctors have to meet a patient in person and perform a physical examination in order to develop a trusted, caring relationship. It is counterintuitive, but it turns out that when a doctor’s only contact with their patient is via video, the doctor actually pays increased attention to their patient, hyper-focusing on details of their patient’s appearance and attire, mannerisms, affect, mood, voice, verbal tone, intonation, facial and eye movements, skin color and complexion, posture, and motor movements.”

Full interview, Authority Magazine, 2023.1.11