During your rotation, some clinics may be virtual. Telemedicine is a very different way of practicing medicine than we may be used to, but it is a nice alternative for patients who do not necessarily need an in-person visit and/or are worried about infectious exposure. Though the platform is different, many aspects of a “normal” clinic visit are the same, and you can definitely still learn a lot from these sessions.
Getting set-up and general telederm etiquette:
- Download and set up the Doximity app on your phone (you should be sent instructions for how to make an account) or make a Google Voice number so that you do not have to use your own personal number when contacting patients.
- Find a private spot to conduct visits that is quiet with a good WiFi connection where you won’t be interrupted.
- Your background ideally should be plain and professional without distracting elements. Make sure you have adequate lighting so that you can be seen on video.
- Position the camera so that you can look into it when talking to the patient to simulate eye contact.
- Dress professionally.
- Keep chargers for devices on hand.
Format of Virtual Visits:
Most virtual visits will take place over Zoom, FaceTime, phone call, or Epic Zoom pilot (for Partners). Your level of involvement may vary by attending and situation. A couple common formats you may encounter:
- You join in the visit by 3-way Zoom, FaceTime or telephone call and listen in as the attending takes the history and gives the plan. You can mute yourself if that feels appropriate.
- Taking the history with the attending
- You 3-way Zoom, FaceTime or telephone call the patient with the attending and take some of the initial history, then the attending takes over.
- Contacting the patient somewhat real time
- Prior to clinic, the attending will give you a list of patients to contact.
- While the attending is doing other virtual visits, you call the patient 15-20 minutes before their scheduled appointment to gather the history, then either call the attending to present quickly or 3-way Zoom/FaceTime/call the patient and present with the patient on the call (think of this like “bedside rounds”).
- Contacting the patient in advance of their appointment:
- Prior to clinic, the attending will give you a list of patients to contact.
- The day before the patient’s appointment, you call your assigned patients to gather the history, then either call the attending to present right before each patient’s appointment or 3-way Zoom/FaceTime/call the patient and present with the patient on the call (again, like “bedside rounds”).
There may be other variations of the above that attendings prefer. They are also figuring this out and sometimes there may be technical difficulties or patients don’t pick up, so stay flexible! As you work more with an attending, you can ask to take a more active role by suggesting some of the formats above. Another way to be active and helpful if you are shadowing is to offer to jot down some of the history in the note while the visit is happening, but learning, not scribing, should be your priority during clinic!
Communicating with the attending:
- Sometimes the attending you are working with will proactively reach out to you with their contact information/phone number/Zoom meeting ID and logistics for the virtual clinic, including patients that they think would be good for you to contact, if appropriate.
- If you do not hear from them in advance (e.g. by the day before the clinic is scheduled), it is okay to email the attending to introduce yourself. You can ask how they would prefer to run the clinic and if they have any suggestions for how to prepare, such as reaching out to patients beforehand if they are comfortable with that.
- Make sure to provide your contact information (phone number and/or FaceTime contact) to the attending and ask how they would like to 3-way call the patient/any other logistics. Let them know if you do not have an iPhone and cannot do FaceTime.
How to prepare:
- It is helpful to review patient charts beforehand, just as you would for in-clinic visits.
- Unique to virtual visits, check the “Media” tab (if using Epic) to see if the patient emailed in any photos.
- If pre-assigned patients to contact, focus on those patients and take a good look at their past notes, history, and last visit with the attending or other dermatologist. Because you know which patients to focus on, this is a great opportunity to dive deeper into topics you come across that you are unfamiliar with.
- Start a note in Epic (see “Documentation” below).
- If reaching out to patients beforehand, take advantage of the extra time after gathering the history to think through your plan and practice your presentation if you would like to really impress!
Reaching out to patients:
Depending on attending preference, you may contact the patient right before their appointment or the day before (see above for various formats).
Before reaching out, it is helpful to have the following information on hand:
- The office phone number for the site coordinating this VV clinic, in case the patient has questions for the office.
- Time of appointment and format (FaceTime/Zoom/telephone/EPIC Zoom pilot – this will be documented next to the patient name on the attending’s clinic schedule page in Epic).
- The physician’s Zoom ID, if applicable (can usually find this by checking the notes section of the attending’s schedule page or as a documented “encounter” in the chart communicating this information to the patient, or if you can’t find it ask the attending) and phone number.
- Remember to use the Doximity app or Google Voice to call patients.
- Check Epic for the patient’s phone number (under demographics in the “Snapshot” tab). Sometimes the preferred phone number is also listed in the “notes” section on Epic next to the patient’s scheduled appointment time.
- If reaching out to patients beforehand, even if it is scheduled to be a Zoom or FaceTime, call the patient on their phone first to avoid a “surprise FaceTime.” Once they are okay with talking, you can either continue the conversation by phone or ask if they are comfortable switching to FaceTime if they have an iPhone, but this is not necessary if they have sent in photos.
- Sometimes you may not be able to reach patients on the first try. Feel free to leave a message and/or try again at a different time. You may have more luck getting in touch if contacting patients at the end of the work day or around lunchtime when patients may be more free to chat. If contacting patients for an afternoon clinic, you can try to reach out the morning of the clinic, but your chances of getting in touch may be higher if you try the day before, as patients may call you back the next day.
- If patients haven’t sent in photos and photos would be helpful for their chief complaint, encourage patients to send them in through Patient Gateway as a “Non-Urgent Medical Question” message to the attending. Instructions for BWH patients if they do not know how to do this:
- Direct them to https://www.brighamandwomens.org/dermatology -> Click “For Patients and Families” (on the left) -> Scroll down to “Patient Instructions” and click “How to attach a photo in Patient Gateway” Or https://www.brighamandwomens.org/assets/BWH/dermatology/pdfs/How-to-attach-a-photo-in-Patient-Gateway.pdf
- For BWH specifically, if absolutely necessary, you may recommend the derm email inbasket (email@example.com), but there can be a lag in receiving these, and up to a two-day delay in uploading these to EPIC.
Sample script for reaching out to patients (courtesy of Dr. Buzney):
- Hi Mr/Mrs ________, I’m _____, a ______-year Harvard medical student. As part of my dermatology rotation, I’m working with Dr. _______, from the Brigham and Women’s Hospital Department of Dermatology.
- I know you have a telemedicine dermatology appointment coming up with Dr. ______ at ______ am/pm today/tomorrow, over FaceTime/Zoom/telephone.
- Dr. ______has asked me to call in advance to ask some questions about your skin concerns, in preparation for your visit. Then I will be present during the virtual visit.
- Would this be OK with you?”
- If no: “No problem, I completely understand. Dr. ______ will be looking forward to seeing you for your appointment.”
- If yes:
- “OK, great. Thank you!”
- Proceed with asking CC/HPI, confirming medications/allergies/problem list/FH/SH as appropriate.
- At the end of the call, confirm that the patient is set for Zoom (do they have the instructions/meeting ID?) or FaceTime (do we have the right phone number?)
- “Great, thank you so much, I will look forward to speaking with you and Dr. _____ at ______ am/pm, today/tomorrow.”
- If you don’t want to use the above script, make sure you communicate who you are, date/time and format of their appointment, and obtain verbal consent for calling them in advance and for participating in the virtual visit.
- After talking to patients, jot down the history you gathered in your templated note for the visit so you don’t forget, especially if reaching out the day before.
- It is often hard to see skin lesions on video. Sometimes the easiest and clearest way to visualize a lesion is through photos, which is why we encourage patients to send these in.
- Because you are not able to actually physically examine the patient, you may need to figure out other ways to assess properties of lesions/rashes. For example, you can ask patients if the lesion feels raised or flat if they close their eyes and run a finger over it, or ask if the lesion turns white when the patient presses on it to get a sense of blanching.
- If the patient’s rash is in a sensitive location it may be best to defer the exam until the attending is on the call with you and you can both do the exam together.
- Notes are generally the same as in-person clinic visits. The attending may include some billing-related language when they sign and attest the note. You may ask the attending for any specific preferences. When documenting the exam, do your best to describe findings from the video call or photos. If unable or it is difficult to examine the patient, you can include the line “Unable to examine patient due to telephone format” or “Exam limited due to virtual format.”
- When signing your name, include the following sentence: “_____ consented to medical student participation in this virtual visit.”
Other tips for getting the most out of virtual sessions:
- Clear communication with the attending is extra important for the virtual format. Make sure you and the attending have a plan for how you will be participating in clinic.
- It might feel awkward to reach out to patients beforehand and sometimes they are also confused by this, but this is a great opportunity to take a longer history than you normally would in clinic! You may find that patients will also warm up to the idea and appreciate being less rushed than in clinic.
- You will likely find your own flow that fits with the attending’s style for virtual visits, these tips are just a starting point.
- Though format is different, the same principles of in-person visits apply regarding thorough but focused presentations, being attentive and respectful to the patient during the visit, and thinking through the differential and plan.
- While you should stay attentive, you can real-time quickly Google anything you are unfamiliar with during the visit.
- Ask the attending for some time at the end of the clinic, even if just for a few minutes, to ask questions and discuss cases, as there is not always time to do this in between patients.
- Be flexible and have fun! 🙂