So, what do I know about e-health? Not much really. Unlike many of my primary care colleagues, I can count the number of telehealth consultations I have done in the last six months on one hand. There’s a reason for this, and it’s not just because I have grey hair and refuse to move with the times. There’s a bunch of reasons why doing things from a distance is not always a solution, but I’m open to change as required. Having not participated much, but hearing lots about it, it’s made me think about where it might fit in my context.
I think a really important thing to remember is that medicine is a hands-on process and, as many have identified, it can be easy to miss important signs online. In addition to this, general practice is more than just taking a history and examining someone. There’s a connection that you need to make, and I don’t know about you, but I have yet to make eye contact with anyone on Zoom. It’s impossible – if you look at the camera you will look like you are looking directly at them, but you can’t actually see them. On the flip side, if you look directly into their eyes on the screen, you look to the person at the other end as though you are checking your Facebook, or focusing on the lint on their left shoulder. Face-to-face consultations are personal.
I recently started a job in Western Queensland. This is very new territory for me, having spent most of the last 15 years in Arnhem Land in the remote Northern Territory. I’ve never looked after a grazier before. And, actually, I don’t have a lot of experience looking after people over the age of 65. What I already knew and have further confirmed, is that people have a need for connection, and when you live 300kms out of town, or on your own (because you husband of 50 years died last year), a GP is an important connection. Face-to-face contact makes this connection easier to negotiate and means you can get to the important parts of the conversation – like the loneliness, the anxiety and depression due to the drought, or the flood, or COVID-19. I find it is much easier to have those frank discussions about starting insulin, or stopping smoking, and much more fun in congratulating the new pregnancy or starting the long-planned exercise program when you are sitting in the same room.
In-person connection is also how a community gets to know a new face in town. After they have politely answered some of my questions, they feel the need to ask some of their own – do you have a husband, how long will you be staying, *would you like to come out and learn how to shear a sheep? (* note this question has yet to be asked, but when it happens, I’ll be sure to say yes!).
There are also some practical considerations to take into account. Not everywhere in Australia has phone connectivity, let alone internet. Western Queensland is one of those places, as is Arnhem Land, and Palm Island where I worked before Winton. So that can make telehealth tricky. Also, you could do the consultation over the phone, and print out a form for them to have their blood taken for some tests, but as we are also the phlebotomy service, they have to come and see us anyway, so we might as well just do the consultation as well. We all know the importance of examination in formulating and confirming a diagnosis. Sometimes, what may have seemed a simple issue, requires more investigation, and there is no substitute for thorough physical examination.
I think that if you already have a well-established relationship with a patient, telehealth can be an excellent augment to your clinical care. For people in rural and remote areas where a visit to the doctor can be a whole day trip, even half a day, it would be great to be able to offer them the option of telehealth for certain clinical occasions. Which of course we could have always done, but there was no Medicare rebate available to the patient for the service. COVID-19 has given us the opportunity to provide this service, and many of my colleagues are finding they can provide excellent follow-up care to their well-known patients who live a long way from the surgery.
So, I’m hoping that, if I get to know some of my new community well, that this option will remain available for me as an alternative means to provide care to patients. But I will recognise the limitations of the modality and advise patients when I don’t believe that distance care is appropriate.
One new skill I have attained recently, using digital technology is large-scale teaching online. Covid-19 caused some serious difficulties for medical schools, and there was some very concentrated brainstorming about how to deliver interactive and innovative teaching sessions online. I had some really fun and interesting GP teaching sessions delivered via Zoom, either from my house in Townsville or in Winton, to students all over the country. I found that, although not the same as face-to-face interaction, you can have meaningful conversations with people online. I spoke with students about difficulties they were having with their clinical placements, and with coping with COVID-19 overall. In addition, you can still tell jokes (my preferred ice-breaking method) and chat about what else is going on from a study and general life perspective.
I have also been providing regular exam practice for registrars in the district. This was much easier to do once a face-to-face relationship had already been established. As well as expanding my own experience in teaching online, it has hugely expanded my skills and confidence in the different software products that can be used. I can even organise the links myself, invite people to join me, share my screen AND make colourful and entertaining backdrops.
One of the best things that has happened in the last six months has been the improvement in telehealth etiquette. Anyone who works remotely and has been relying on videoconferencing for regular meeting and their own education has long known the effect that paper shuffling and pen clicking have on the ability to hear what is being said. I feel like this has improved considerably, so thankyou to all those ex-clickers who have learned the errors of their ways!
Finally, I think like many of my Rural Generalist colleagues, I hope that those who make decisions, will concur that rebatable telehealth should be considered a permanent option for patients whose access to quality primary health care remains restricted.
I think a really important thing to remember is that medicine is a hands-on process and, as many have identified, it can be easy to miss important signs online. In addition to this, general practice is more than just taking a history and examining someone. There’s a connection that you need to make, and I don’t know about you, but I have yet to make eye contact with anyone on Zoom. It’s impossible – if you look at the camera you will look like you are looking directly at them, but you can’t actually see them. On the flip side, if you look directly into their eyes on the screen, you look to the person at the other end as though you are checking your Facebook, or focusing on the lint on their left shoulder. Face-to-face consultations are personal.
I recently started a job in Western Queensland. This is very new territory for me, having spent most of the last 15 years in Arnhem Land in the remote Northern Territory. I’ve never looked after a grazier before. And, actually, I don’t have a lot of experience looking after people over the age of 65. What I already knew and have further confirmed, is that people have a need for connection, and when you live 300kms out of town, or on your own (because you husband of 50 years died last year), a GP is an important connection. Face-to-face contact makes this connection easier to negotiate and means you can get to the important parts of the conversation – like the loneliness, the anxiety and depression due to the drought, or the flood, or COVID-19. I find it is much easier to have those frank discussions about starting insulin, or stopping smoking, and much more fun in congratulating the new pregnancy or starting the long-planned exercise program when you are sitting in the same room.
In-person connection is also how a community gets to know a new face in town. After they have politely answered some of my questions, they feel the need to ask some of their own – do you have a husband, how long will you be staying, *would you like to come out and learn how to shear a sheep? (* note this question has yet to be asked, but when it happens, I’ll be sure to say yes!).
There are also some practical considerations to take into account. Not everywhere in Australia has phone connectivity, let alone internet. Western Queensland is one of those places, as is Arnhem Land, and Palm Island where I worked before Winton. So that can make telehealth tricky. Also, you could do the consultation over the phone, and print out a form for them to have their blood taken for some tests, but as we are also the phlebotomy service, they have to come and see us anyway, so we might as well just do the consultation as well. We all know the importance of examination in formulating and confirming a diagnosis. Sometimes, what may have seemed a simple issue, requires more investigation, and there is no substitute for thorough physical examination.
I think that if you already have a well-established relationship with a patient, telehealth can be an excellent augment to your clinical care. For people in rural and remote areas where a visit to the doctor can be a whole day trip, even half a day, it would be great to be able to offer them the option of telehealth for certain clinical occasions. Which of course we could have always done, but there was no Medicare rebate available to the patient for the service. COVID-19 has given us the opportunity to provide this service, and many of my colleagues are finding they can provide excellent follow-up care to their well-known patients who live a long way from the surgery.
So, I’m hoping that, if I get to know some of my new community well, that this option will remain available for me as an alternative means to provide care to patients. But I will recognise the limitations of the modality and advise patients when I don’t believe that distance care is appropriate.
One new skill I have attained recently, using digital technology is large-scale teaching online. Covid-19 caused some serious difficulties for medical schools, and there was some very concentrated brainstorming about how to deliver interactive and innovative teaching sessions online. I had some really fun and interesting GP teaching sessions delivered via Zoom, either from my house in Townsville or in Winton, to students all over the country. I found that, although not the same as face-to-face interaction, you can have meaningful conversations with people online. I spoke with students about difficulties they were having with their clinical placements, and with coping with COVID-19 overall. In addition, you can still tell jokes (my preferred ice-breaking method) and chat about what else is going on from a study and general life perspective.
I have also been providing regular exam practice for registrars in the district. This was much easier to do once a face-to-face relationship had already been established. As well as expanding my own experience in teaching online, it has hugely expanded my skills and confidence in the different software products that can be used. I can even organise the links myself, invite people to join me, share my screen AND make colourful and entertaining backdrops.
One of the best things that has happened in the last six months has been the improvement in telehealth etiquette. Anyone who works remotely and has been relying on videoconferencing for regular meeting and their own education has long known the effect that paper shuffling and pen clicking have on the ability to hear what is being said. I feel like this has improved considerably, so thankyou to all those ex-clickers who have learned the errors of their ways!
Finally, I think like many of my Rural Generalist colleagues, I hope that those who make decisions, will concur that rebatable telehealth should be considered a permanent option for patients whose access to quality primary health care remains restricted.