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Virtual Care With Presence

Learning Objectives
1. Apply strategies to “Prepare with intention” and center oneself prior to conducting a telemedicine visit
2. Incorporate strategies to “Listen intently and completely” while on a virtual visit with a patient
3. Determine goals and priorities with the patient during the virtual visit by “Agreeing on what matters most”
4. Engage virtually with the patient's family, friends, and home environment by “Connecting with the patient's story”
5. Recognize and respond to body language, facial expressions, and changes in tone by “Exploring emotional cues”
0.25 Credit CME

Internet Enduring Material sponsored by Stanford University School of Medicine. Presented by Primary Care and Population Health at Stanford University School of Medicine. Healthcare systems are rapidly scaling up telemedicine to reduce risk of infection and protect clinicians and patients in light of the pandemic. In the outpatient setting, many visits are taking place by video, introducing a digital barrier to the human connection that is central to patient care. This training video covers strategies to foster humanism and meaningful connection during virtual visits, as guided by the Presence 5 model.

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Activity Transcript

Speaker 1: This training video covers strategies to foster humanism and meaningful connection during virtual visits, as guided by the Presence 5 model. In the outpatient setting, many visits are taking place by video, introducing a digital barrier to the human connection that is central to clinical care. Presence 5 developed by Stanford Medicine's Presence center offers a toolkit of simple evidence-based practices that can help clinicians forge meaningful connections with patients. The Presence 5 practices are to prepare with intention, listen intently, and completely. Agree on what matters most. Connect with the patient's story, and explore emotional cues.

This video will highlight how clinicians who are conducting telemedicine visits can adapt these practices during a virtual visit. Even though telemedicine presents certain challenges for patient care, adopting specific humanistic practices can help clinicians foster meaningful connections with patients. The first practice is prepare with intention. When practicing telemedicine, clinicians may have back-to-back video visits. In this context, physical and psychological preparation before a virtual visit is foundational to a high-quality and meaningful interpersonal interaction. One best practice around preparing with intention is to take a moment much between visits to reset. For example, stand up and take a deep breath between visits.

In video visits, clinicians no longer have natural moments of transition like knocking on the exam room door, crossing the threshold into the patient's room, or washing their hands. Instead, clinicians often remain seated as they navigate back-to-back visits to keep up with high volumes and don't have organic chances to pause and refresh before their next appointments. Standing up and taking a deep breath or a sip of water between visits helps break up the physical and mental monotony and helps clinicians recharge and focus their attention on the next patient. Another recommended strategy is to perform a brief chart review highlighting important aspects of the social history.

Familiarity with key psychosocial factors about a patient provides clinical contextual information and allows the clinician to convey that he or she understands and cares about the patient's history and life circumstances. Lastly, to prepare with intention, clinicians should check audio-visual equipment before initiating the visit. In order to minimize distractions and technical frustrations check that the audio and video functions work before initiating a visit. Remove potential distractions to help maintain a focus on the patient and the conversation.

The second practice is to listen intently and completely by exhibiting engaged body language and actively listening, clinicians give patients space to tell their stories. To listen intently and completely during a virtual visit, clinicians should sit up, lean forward, stay in the frame, and use the camera to maintain eye contact. One tip for maintaining eye contact is to position the image of the patient as close to the webcam as possible and periodically look at the web camera when talking to the patient. Minimizing the screen and screen video function can also help clinicians focus on the patient and reduce distractions presented by their own face on the monitor. Clinicians should also nod to signal listening and verbalize offscreen activities, telling the patient that you may look away from the camera to take notes during the visit. Video lag times often impede natural conversation flow. So account for lag time and pause after the patient speaks before responding.

The third practice is: agree on what matters most. To do this, a clinician should establish a virtual visit agenda that incorporates a patient's priorities and goals. Be sure to check in frequently with open-ended questions. Because patients vary in experience and comfort with telemedicine, clinicians should ask the patient about priorities and expectations for the visit. Clinicians should also educate patients about possible courses of action while minimizing medical jargon. Over the duration of the visit, keep in mind that patients talk less on average during video visits compared to in-person encounters. Use open-ended questions as patients may be in to speak up on video. If a patient has more concerns that can be addressed on one video visit, create a plan for continuity or follow up to address unresolved patient priorities. Explaining virtual aspects of the healthcare system that remain functional as patients stay at home can offer reassurance. When possible clinicians should also send educational materials or after visit summaries electronically or by mail emphasizing the plan for the patient's top priorities.

The fourth practice is to connect with the patient's story. In many ways, a video visit is an invitation into a patient's and offers a unique opportunity to engage virtually with the patient's family, friends, and home environment. At the beginning of the visit, the clinician has the opportunity to greet the patient and ask accompanying individuals to introduce themselves, taking a moment to comment on visible personal items, such as pets, photos, and furnishings can offer valuable insight about the identity of the person in your care. A video visit offers an opportunity to inquire about the patient's home environment, social support, and safety, if appropriate. In certain situations, it may be appropriate to assess a patient for housing instability, food, and medication insecurity, or substance abuse. Clinicians should be prepared to provide resources if a patient indicates that one of these factors is an issue.

A final best practice is to explore emotional cues by looking for and validating emotions in facial expressions, body language, and changes in verbal tone and volume. While it's impossible to offer a tissue or a comforting hand on the shoulder over video, clinicians can assess body language, tone, and volume and ask a patient how they are feeling about their health concerns and other stressors. It is important to name and validate emotions that you hear from a patient and reassure the patient that it is normal and understandable to experience stress and worry in the current situation. The end of the video visit presents an opportunity to further build trust and solidify the diagnosis and treatment plan by asking for patient teach-back.

Closure of a visit can include a reference to the patient's family, health and social concerns, and priorities. In this way, clinicians convey to the patient that they listen fully and want to provide care that is aligned with the patient's circumstances and goals, even though virtual care inhibits the physical contact that is fundamental to the practice of medicine, the Presence 5 practices for telemedicine can help clinicians foster meaningful connections with patients during video-based encounters.

Activity Information

All Rights Reserved. The content of this activity is protected by U.S. and International copyright laws. Reproduction and distribution of its content without written permission of its creator(s) is prohibited.

Accreditation

In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation Statement: Stanford Medicine designates this Enduring Material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Financial Support Disclosure Statement: Stanford Medicine adheres to the Standards for Integrity and Independence in Accredited Continuing Education.

The content of this activity is not related to products or the business lines of an ACCME-defined ineligible company. Hence, there are no relevant financial relationships with an ACCME-defined ineligible company for anyone who was in control of the content of this activity.

Donna M Zulman, MD

Assistant Professor of Medicine (General Medical Disciplines)

Stanford University School of Medicine

Course Director, Faculty

Juliana Baratta, MS

Project Manager

Stanford University School of Medicine

Faculty, Planner

Sonoo Thadaney Israni, MBA

Executive Director Stanford University Presence and The Program in Beside Medicine

Faculty, Planner

Abraham Verghese, MD

Linda R. Meler and Joan F. Lane Provostial Professor of Medicine and Vice-President of Education

Stanford University School of Medicine

Faculty, Planner

References:
1.
Maitra  A, Kamdar  MR, Zulman  DM,  et al.  Using ethnographic methods to classify the human experience in medicine: a case study of the presence ontology.  J Am Med Inform Assoc. 2021;28(9):1900–1909. doi:10.1093/jamia/ocab091Google Scholar
2.
Zulman  DM, Haverfield  MC, Shaw  JG,  et al.  Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter.  JAMA.2020;323(1):70–81. doi:10.1001/jama.2019.19003Google Scholar
3.
Haverfield  MC, Tierney  A, Schwartz  R,  et al.  Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review.  J Gen Intern Med. 2020;35(7):2107–2117. doi:10.1007/s11606-019-05525-2Google Scholar
4.
Brown-Johnson  C, Schwartz  R, Maitra  A,  et al.  What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection.  BMJ Open. 2019;9(11):e030831. Published 2019 Nov 3 . doi:10.1136/bmjopen-2019-030831Google Scholar
5.
Schwartz  R, Haverfield  MC, Brown-Johnson  C,  et al.  Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields.  J Gen Intern Med. 2019;34(7):1251–1257. doi:10.1007/s11606-019-04913-yGoogle Scholar
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