Virtual reality

Telehealth is a broad term defined as serving patients remotely or at a distance, and it can encompass different types of technology, including telephone, texting, emailing, and videoconferencing. Virtual visits fall under the umbrella of telehealth and have been defined by some as a secure two-way Internet-based communication between physicians and patients, and this would include emailing and videoconferencing. Since COVID-19 announced itself to my practice in March 2020, I have “seen” a few thousand patients, and of those visits, 20% were office visits, 80% were via telephone, and one was a videoconference visit. This does not capture the numerous emails that have been sent, but the emailing was done only between my staff and my patients.

In my opinion, the office visit has always been the gold standard for assessing a patient’s physical and mental well-being. The office visit encompasses seeing the patient’s expression (may it be of happiness or pain), hearing the joy or anguish in their voice, and making that ever-so-essential eye contact. COVID-19 changed all of that. Although I do still see patients in the office, it is a different interaction. The eye contact is through my sometimes fogged-up glasses, the examination is with a latex-free gloved hand, and the smiles and frowns are now masked. 

I have realized that although the office visit remains essential for any symptom that requires an examination, the telehealth visit has come to play a very important role. Whether it be to avoid a Handy Dart or taxi ride, missing work, or having to drag young kids along, I find that the telehealth visit is the obvious choice for most of my patients. For those who are immunocompromised, it decreases exposure to COVID-19, influenza, and other communicable diseases. For me and my staff, it saves greatly on the oh-so-scarce personal protective equipment and time spent disinfecting the clinic after each patient interaction. The telehealth visit is convenient, accessible, and less costly. 

Patients are more than ready to come into the office if an examination is necessary, but otherwise they always choose the telephone visit over the videoconferencing visit, which I will refer to as the virtual visit. The virtual visit seems to be the most comprehensive option during this pandemic but the least desired by my patient population. I have offered virtual visits to patients and only a few have accepted the idea, and of those who did, one patient forgot about the appointment and another had a failed Internet connection. I had one virtual visit regarding acne and, unfortunately, I couldn’t see the patient’s skin very well at all. When asked why they refuse the virtual visit, some say they feel self-conscious, others say that it is easier for them to talk on the phone while at work rather than setting up for a virtual visit, and some just don’t have the technology or are intimidated by the thought of what’s involved.

A drawback of the telephone visit is that occasionally it lacks the patient’s focus on the seriousness of the issues at hand. Some of my patients are busy doing other things (e.g., driving, shopping, hiking) during the telephone visit. And sometimes I feel that the message isn’t getting across; it becomes just a formality. A patient’s lack of interest could lead to potential for the physician to become less meticulous with the telephone visit, thereby compromising the quality of care to the patient. 

Telephone visits are also touted to provide more timely care, and although this is true for the patient, it has put added pressures on my schedule. My patients now expect a return phone call within a few days for non-urgent medical issues that normally would have been addressed within a few weeks.

I have asked many of my family physician colleagues about their patient-visit preferences, and most of them have adjusted to this new norm and are quite satisfied with delivering health care via office visits or by telephone. Some of them have tried virtual visits but just didn’t find any added benefit at this time.

A recent study published by the BC College of Family Physicians in their Tools for Practice resource states, “diagnostic accuracy/agreement of virtual care seems similar to in-person visits.”[1] They defined virtual care as videoconferencing and telephone visits. The study had a small sample size and many limitations so we can’t draw any definitive conclusions from it, but I’m sure it will spark other studies on this topic. 

How can we entice physicians to do more virtual visits? Currently the remuneration for office visits and telehealth visits is fairly equal. Should we reevaluate how physicians are compensated for the different types of visits? Compensation for a telephone visit could stay the same as it is currently, compensation for a virtual visit could be somewhat higher due to the time required for the setup, and compensation for an office visit could be the highest as it requires the use of PPE and also poses a higher risk for the patient, staff, and physician.

Yes, the virtual visit is more time consuming for everyone involved, but overall I think it would be a more thorough and rewarding interaction for the patient and for me compared to the telephone visit. My electronic medical record offers a simple and inexpensive option to book and start a virtual visit from within a patient’s chart. And on the patient’s end, it is also only a few clicks away.

Many of my elderly patients find technology inaccessible or intimidating, but I think they are the ones who would benefit the most from the virtual visit, especially during a pandemic. I have proposed a quality improvement project with the help of the Practice Support Program through the General Practice Services Committee. I plan to educate my patients on virtual visits. For patients who have the technology, I am going to host a webinar on virtual visits. For patients who do not have access to the Internet, I plan to use the concept of patient partners. Patient partners may be able to present themselves to my patient’s home with a laptop and help conduct the virtual visit. In future, virtual visits may also be incorporated for patients who already receive home care visits.

Pandemics may come and go, but telehealth is becoming an integral part in the standard of care in my practice.
—Jeevyn K. Chahal, MD 

References

1.    BC College of Family Physicians. Virtual visits versus face-to-face: Diagnostic accuracy in primary care. Accessed 5 October 2020. https://gomainpro.ca/wp-content/uploads/tools-for-practice/1601913617_tfp273virtualvisits.pdf.