Tricky telemedicine communication

Most of my readers will have figured out how important communication is in Medicine. It is key. Well, maybe in some areas more than others. Yes, a dermatologist has to explain a rash, a neurosurgeon an operation, a pathologist, eh, might relate to a grieving family. Mostly communication is verbal (an interrogation around chest pain, for example), but clearly benefits from visual input (you see bruising, or tremor, or alarm). In fact, communication covers all the senses, and works both ways. That is why telemedicine is so challenging. You are down to one sense: hearing. And the clock is ticking…. Read: A perspective on liquor They say it is all about first impressions. Can they (a) hear you (b) understand your accent (c) confess their deepest concerns to this stranger on the phone? They have read on an Internet rating site that you are aggressive and uncaring, so you have a narrow window of opportunity to gain their trust. “Hi, Ms Elmes,” you chirp in an engaging way. “It’s Dr. Robinson calling. Your GP asked me to contact you about your chest pains.” There is an embarrassing silence, then a gruff male voice says “Is this a spam call? We get a lot of these you know.” You reset. I remind him I have gotten through call-control, and know his wife’s birth date and PHN number. At least it isn’t Xenobia Zelinskivaskya with presbycusis and a stammer. “No, no, Mr. Elmes, it’s Dr Robinson. Can your wife come to the phone?” You hear Jack shout to Agnes. There is some rustling of pots and pans, the dog yelps and a door creaks open. Maybe these are of some importance, but by now you are five minutes behind. “Allo?” she says. You imagine her cradling a smartphone on speaker, something she does rarely. Read: The struggles of compliance Confession at church must share similar themes. First, you comment on the weather, the latest political scandal, or the state of local healthcare. I let her know this call might last 30-40 minutes, and we will review her heart health. I’ll go over her test results, and see her in the office for an exam if needed. By now you know she’s tachycardic, sweating and bug-eyed. Soft questions like “How are you keeping these days?” are preferable to “When was your last Pap smear?” Well, at least not until you have established some sort of professional relationship. “How old are you, are you retired, do you have children?” are usually rhetorical. You probably know the answers. They permit an opening up to occur, you know, when they tell you about their vacation in Mexico, and sister Betty’s allergies, or the wonderful marrows at the farmer’s market. You are eager to move on to hard facts, like “What drugs do you take?” If you think the medication list on your referral note is accurate, think again. She tells you she takes Tecta once a week, and pops one of her husband’s Indocid at bedtime. Might be important. She doesn’t see your eyes roll back when she mentions ‘Happy Hour’ (2 martinis and a few glasses of wine) that make COVID-19 monotony more tolerable. You share some wisdom (“red wine is good for you, ha, just an old wives’ tale”) or a joke (“I remember when liquor was cheap, you could have a bottle in each hand and might be mistaken for a conjurer”). What you are doing, in this telephone conversation, is difficult. You need to adduce evidence for disease, understand the patient’s primary fear, prepare for an explanation in simple terms, and deliver a probable diagnosis and treatment plan. Remember, they didn’t take anatomy 101. They haven’t realised OTC drugs might be toxic. Their UpToDate may be Norman, the neighbour, who was cured by saw-palmetto and coQ10. Or worse, sister Betty got a rash from her COVID-19 shot and fell down 12 stairs. “Never the same afterwards.” Getting into a confrontation doesn’t bode well. Answers become truncated: “Yes. No. Maybe. Why do you need to know?”—and sometimes “ok, right, bye!” On the other hand, you can ask what sort of dog is barking in the background, and its name. I have sometimes documented the dog’s name in my consult letter, not because it is important, but boy it gets you mileage on call two. How is Rusty? This is a trick to be used carefully, in the absence of patient dementia or significant dog-illness (“buried last week”) followed by inconsolable sobbing. There are times when the tables are turned. They might ask “How would you know what endometriosis feels like?” or “Are you retiring soon?” or “COVID vaccines magnetise you, isn’t that so?” Most times, a reversal of questioning is a positive sign, they are trying to put ME at ease. “You must be very busy.” or “Is that a Scottish accent?” or “Gosh, are you Ms. Nicholson’s doctor?” There are times when you genuinely feel emotional distress. “Hey doc, it’s Jack here. Can you prescribe those ED pills, you know, the little blue ones that put pep back into your love-life? Since my bypass and carotid surgery, I’ve been less active that usual.” I engage a short-response answer (good grief, I’m a WASP and blush easily). “Eh, yes, these medications were designed to treat angina, but were found to have a useful side-effect. Your GP can….” And you live to discuss another day. Finishing a discussion is an art. You know, you are 20 minutes behind, have three forms to fill out, and a pharmacy to call. They are telling you about their grandchildren or their house renovation, you realize they are more socially isolated than you thought. How do you wrap up without seeming abrupt? By this time the history, medication review, report on tests and plan of management have been covered. I often say “Now here is what I said, in case you wanted to write it down. 1. Less alcohol. 2. Less alcohol. 3. Daily Tecta. 4. No Indocid.” You hear the drawers open and close, the pencil being taken out and the scratch on the nearest scrap of paper. “I’ll write your GP and talk to you again before long. Bye.” We part as friends. Medicine is like that. I meet 10 strangers a day, and make 10 friends. It’s great. Sometimes you need spider-sense to help you figure out what they are NOT telling you (a bereavement, a psychotic delusion, a fear of your medication, or most commonly lack of understanding brought about by age, poor hearing and misinformation). The richest information comes when you stop talking, and just listen. You can’t listen when you are talking, so there has to be a break scheduled in the interrogation. This should be part of every conversation: silence. “Well, I’ve been under a lot of stress since Jack lost his job, and my son got caught peddling narcotics……” “Right…….” “And stomach cancer runs in our family.” “Right…..” Lastly, there are patients who teach you, entertain you, and delight you. You look forward to a yak with Marvin, the old car collector, restoring his 57 Chevy. Or Wendy, the landscape painter, who shares a passion for seascapes. Brian, the retired firefighter-come-comedian, who makes any situation a laugh. They see your humanity, and your willingness to share frailty, empathy and compassion. They ask about your health, and thank you for your care. Most times, you are tired at the end of the day, but keen to start the next. It’s communication—an art and a science after all.

Tricky telemedicine communication

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