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  • Writer's pictureDr Andy Raffles

Remote Video Consulting – The New Mode of Delivering Healthcare – A Guide

Over the last few weeks everyone’s real world has been turned upside down, and inside out – and replaced with virtual worlds in a way no-one could have predicted and at a rate that would have been unthinkable just a few weeks ago. Many things we all took for granted have either disappeared completely, or had to change to reflect the new order of life and living.

One of the biggest changes in the medical world hasn’t only been the pandemic we are experiencing, but the impact on the traditional way parents, patients and carers consult or interact with doctors, nurses and health care workers. Suddenly we no longer have relatively rapid access to a face to face consultation or interaction, and we have had to find new ways of ensuring safe, effective and empathetic healthcare advice and care. Well, it may not surprise you that the traditional face to face - hands on consultation can be effectively replaced for the majority, but not all of our patients and parents. Up to early March our practice undertook some email and virtual consultations – especially for follow up patients, but since the end of March this has increased to 100% of consultations!! and this includes developmental assessments, assessment and diagnosis of rashes, concerns regarding weight gain and loss, feeding challenges, bowel related and digestive problems, sleep challenges, head shape problems and the whole range of children’s health and well being conditions we usually encounter in the traditional consulting room practice. 1. Role of video/telephone consulting As well as our Consultants’ clinical competence, worried parents and sick patients also need to feel understood and cared about. The way we consult by video can go a long way towards reassuring you that your child is in safe hands. Of course it may not always be appropriate to deal with your problem remotely and in such cases, for example where your child needs to be examined, we will arrange to do this in a suitable safe environment. The following points in this guide will help you get the most out of this type of consultation - please do not worry if not all of the suggestions can be implemented or if it seems complicated, our priority as always, will be to do our absolute best to work with you to achieve this

2. Pre-planning If you have booked a video remote consultation for the first time, our Practice will give you some helpful information about what you can expect, including:

  • when and how to establish the video connection o this is best done via Face time, WhatsApp, Google Duo, Zoom or Skype – our preference is any of the first 3 o If you do not have access to this technology, a simpler telephone only consultation, is also a very effective method

  • any types of problem that may be unsuitable for remote consulting o examples such as those clearly requiring a physical examination although we have successfully instructed parents to successfully examine their child’s abdomen via a video call!! o If in doubt arrange the remote consultation and we can discuss how to proceed

  • any details of the problem that we could have in advance of the consult to help us prepare o most recent or even better current weight o photos of skin rashes or lesions can prove helpful o videos or audio of any unusual behaviours e.g. tics and snoring o a list of any medications trialled or taken in recent days prior to the appointment

  • try to have your child’s Red book or child health record to hand as we may need to look at any previous recordings by other care providers such as GPs or Health Visitors.

  • if you have a tape measure and thermometer in the house, perhaps have these in easy reach too

  • have the details of your local pharmacy prepared, including address, telephone number, fax and email – just in case a prescription needs to be arranged

  • babies should be dressed for the consultation in easy to remove clothing and toddlers similarly, with older children especially girls, we would advise they wear a loose t-shirt or a vest

3. Setting Up Location - If you are working from home and your video consultation is in your home, try to choose a neutral setting and background, a child’s bedroom if available, is often a quiet safe place for the consultation, but in truth, if you and your child feel comfortable, any room will do. Privacy - Make sure you will not be interrupted, and that background sounds are not intrusive. At present with schools closed it isn’t always possible to keep other children out of the consultation – this is fine as it gets them used to this new way of working. In fact involving them is also a great distraction for them. Some siblings, particularly older ones – prefer to stay out of the way – watching TV, reading or drawing or even doing home schooling!. Framing – We think landscape (wide) format is better than portrait. Landscape feels a little more natural, and gives a feeling of a comfortable separation between you and us; portrait view can feel too much ‘in your face’. Adjust your position so that you are central to our view and don’t be afraid to ask us to do the same!! As in any human interaction we need to be able to see each other’s facial expression without straining, and preferably also your hands, as hand gestures are an important part of communication. If using your phone or iPad try using a stand or propping up so you can feel more relaxed Lighting - Make sure you are well lit, and avoid having a source of bright light, such as a window behind you as this may either cause a glare making it difficult to look straight at you. 4. Getting Connected (WIFi,4G etc) and Video Devices – Cameras , Tablets and Phones Make sure you are familiar with how to adjust picture quality and sound level on the equipment you are using for the remote video consultation, and if you need us to adjust/optimise our own settings, please just say. We have found that modern phone and tablet cameras have really sensitive cameras – usually high definition which is excellent and sometimes better than a human eye at detecting skin rashes, enlarged tonsils, as well as lumps and bumps caused by enlarged glands especially in the neck if the child is positioned well. With some video platforms, or if bandwidth is an issue, there may be a small time delay in the system, or picture and sound may be out of synch, or the picture may periodically 'freeze'. Be aware of the danger of missing significant information because of these distractions, which may result in a certain amount of repetition to ensure adequately conveyed. Make sure you know how to reconnect if the connection is lost. If possible the connection used, be it phone, tablet or computer, should be on a cabled or WiFi connection. 4G also works well. Be aware, if you are using WIFi at home and a partner is doing office work, or a sibling is streaming TV or Music, and if a microwave is being used for cooking, this can affect the connection quality. If at all possible try to ensure exclusive access to the network connection, more easily achievable of course if you are lucky enough to have more than one network at home. For the technically minded try to use 5Ghz preferable to 2.5Ghz – although you might need to be a bit closer to the WiFi Access point with 5Ghz

5. Introductions When we call you we will introduce ourselves and ask you and your child what you would like to be called. We will need to confirm who we are talking to. If not identified as the child’s carer or parent, there may be issues of confidentiality and written consent will be required from them to speak with you. 6. 'Visual and Vocal cues' Verbal and non-verbal signals show we are listening to each other or wanting to interrupt. They include nods, facial expressions, noises like ‘uh-huh’ or ‘mmm’, and words like ‘right’ or ‘OK’. Remember you know your child best and if they are vocal, then actively encourage them to take part in the consultation, as they have their own important contribution. On a video link, these cues may not have their usual effect. Visual cues may be harder to see on screen. The other person’s speech over the link may not be as loud or as distinct as we are used to. If there is even a slight time lag between vision and sound, our ‘uh-huh’s and ‘mmm’s may become distracting interruptions. To minimise the effect of these problems:

  • where possible try to make sure only one person is talking at a time

  • keep your vocal cues to a minimum – a slow nod or a smile is better

  • show your interest and attentiveness by eye contact and facial expression

  • if you need to interrupt, try a visual signal such as raising your hand

  • rapid gestures or body movements can be distracting – try to slow them down

7. Eye contact If you want to make eye contact, remember to look at the webcam, not at the face on the screen. 8. Signpost In the slightly unfamiliar circumstances of a video consultation, it helps if you ‘signpost’, i.e. tell the us what you want to do or say next and why. e.g. ‘These are the foods my child is currently eating’ Keep a written list of issues you want to cover and please don’t hesitate to ask for things to be repeated 9. Check for understanding Before finishing, there will be an opportunity for you and us to summarise the consultation’s main points and ask if there are questions, or if there is anything you would like explained again such as:

  • follow-up arrangements

  • what to expect in the next 48hrs, 1 week or as appropriate

  • agree “Red Flag Symptoms” or changes which should trigger a further consultation or visit to an emergency GP or Department or a call back to the Practice

  • any Investigations and how they will be arranged

  • letters and who to send to

  • prescriptions and how to arrange they get to a pharmacist i.e email of signed copy with copy to parents, hard copy in post

We want you to get the most out of the remote consultation and if you remain concerned, please do not hesitate to contact us for further assistance. Ref: Greenhalgh T, Vijayaraghavan S, Wherton J, et al Virtual online consultations: advantages and limitations (VOCAL) study BMJ Open2016;6:e009388. doi: 10.1136/bmjopen-2015-009388

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