FEMALE SPEAKER: Welcome to Mayo clinic COVID-19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer, Inc, and is in accordance with a ACCME guidelines.

SARA BONNES: I'm Sara Bonnes, and I am here to discuss webside manner during telemedicine. I appreciate Dr. Carl Anderson's input in this presentation as well. I have nothing to disclose, and during this discussion, I hope to update you about what is webside manner, how to use some of these skills involved in website manner to manage emotions of patients, and how to help summarize or wrap up a visit so that patients feel that you're addressing all of their care needs.

As we were all taught about bedside manner during our training, webside manner it's our interaction via telemedicine. It's considered the new bedside manner. We were all taught various skills during our training about how to make patients feel comfortable and how to conduct an effective visit. Webside manner, though, is starting to be a new art form, and with the transition to telemedicine, is increasingly important.

As folks have studied webside manner, they have learned about patient and provider listening and communication. And we know that it's important to promote adherence, decision making, and outcomes. But some of the skills needed to conduct telemedicine visits are different than those that we use when we're physically with a patient.

As discussed in other presentations, the digital divide has the potential to worsen existing disparities. Not all patients are able to access telemedicine visits. Not all patients are able to communicate via telemedicine, particularly, those with limited English proficiency or those who may have visual or hearing limitations. In addition, the communication during a webside visit may require some modifications of your skill set.

The components of webside manner, as with bedside manner, are similar. Communication is still key. However, when you're not physically with a patient, verbal and particularly nonverbal communication are different. The types of encounters selected for virtual care will also impact your webside manner and how you behave during these visits.

Your presentation-- you want to make sure that you still look professional, that you have an appropriate background, and that you're focusing on looking at the camera and making an eye connection with the patient as opposed to looking elsewhere in the room or focusing on the electronic medical record. Privacy and security are of the utmost importance. We need to make sure that you, as the provider, have a secure connection and a secure location to conduct these visits, but that the patient also has a place where they can have a secure conversation with you that will allow for the best care possible.

Technology and connections are wonderful when they work, but can certainly cause much frustration if they aren't working appropriately. The Academy of Communication and Health Care further classifies some of the key factors in webside manner. During telemedicine, because we can't be physically present, it's very important to still let the patient's know that you are present and ready to meet with them. It can be challenging to identify the patient needs when the verbal and nonverbal communication is limited by distance.

Make sure that you're listening to the patient and that the patient feels heard, empathy. Whatever is causing the telemedicine visit, whether it be the current pandemic or whether it's just patient convenience, make sure that you still let the patient know that you're there for all of their care needs. And sharing information can also be different. In our clinic, we have many resources to help patients. We have booklets on exercises that they can do or a handout sheet regarding an immunization. The nurses can even come in and follow up with additional information. With telemedicine, we don't have all of those options available, so make sure that you as the provider are doing a great job sharing the appropriate information with the patient.

Some strategies to optimize your effectiveness at being present. It starts even before the visit. Make sure that you've optimized your space, that you have your camera angle appropriate so that you can be in the center of the screen or at least easily visible to the patient. Also, it's important to do a speaker and microphone check before you connect with the patient. You've probably been on a conference call and heard the, can you hear me, can you hear me now, discussion. It's great if you can do that check before you actually include the patient in your discussion.

Consider your setting. If you're working from home or from an off-clinic site location, make sure that you have a secure, private location so the patient is comfortable having this personal discussion with you. I would encourage caution with virtual backgrounds as it may be difficult for the patient to know where you are and if you are in a secure location, so that they can speak freely. In addition, some of the virtual backgrounds can be distracting or may have information that you didn't pick up on but that the patient may not feel is appropriate.

Don't forget the introduction, especially when you're not seeing a patient in a clinic setting. Be sure to introduce yourself with your appropriate credentials and acknowledge that this is different for both of you. Although you're in a different environment, you can still have an effective clinic visit and take care of the patient. It's also important to plan so that you can minimize distractions and disruptions. Maybe it's hanging a sign on your door so that others know that you're not just in there ready and waiting to take a knock or a drop-by conversation. Let them know that you're in with the patient, and so putting a note on your door, letting them know that you're conducting clinical visits may be appropriate.

Other ways to let your team member know is also beneficial so that the patient can feel that you're totally focused on them. It's important to identify the patient needs. We typically have an agenda that we want to get covered during the clinic visit, but it may be more difficult for the patient to bring these up. It's important even before the visit to consider the purpose of the visit. It's long been discussed that it's not optimal to deliver bad news via phone or letter, or even via a telemedicine visit, but instead to do it in person. However, we don't always have that option, and there are great resources on how to help deliver bad news even via a telemedicine visit. But if you know the patient and you know what your limitations are, consider whether it's truly best to use this as a telemedicine visit or an in-person visit.

Again, be cautious with sensitive topics. Make sure that the patient is in a location where they can speak openly and freely with you so that you can ensure that you're providing appropriate recommendations and care. If the patient is in agreement, it's fine to involve significant others. It can be difficult if you're invited to the family reunion and everybody wants medical advice, but it's important that the appropriate family or friends are involved in the discussion just as they would be in a clinic setting.

Setting the agenda is incredibly important. People may not have the same time restrictions such as I have to get back to work after this visit, and so it can be important to let them know the limitations not only of the technology and what you can accomplish, but also what your duration of time will allow. Make sure that you both work to agree on covering what you and what they consider the most important. Open-ended questions continue to be very important, but don't forget to use probing questions to clarify further concerns.

Empathy and listening are much more challenging via a telemedicine visit. While we frequently rely on nonverbal responses when we're in person, studies have shown that both verbal and nonverbal responses tend to be less in telemedicine visits. It may require some intentional intervention on your part to offer verbal or even non-verbal reassurances to the patient to let them know that you are listening and that they have been heard. This is a great way to help deal with some of the emotions or challenges that come up. Letting the patient know that they are heard can help identify and de-escalate some situations.

Verbal responses may have to replace non-verbal actions. When a patient is tearing up or crying, you can't hand them the box of tissues, but it is important to acknowledge the challenge and the struggle that they're having. Similarly, identify and name the emotions that come up. It may be harder to pick up on some of the nonverbal cues, but helping patients identify and label how they're feeling and how they're responding to the situation can certainly help with some of the tension when you can't have that face-to-face discussion.

Again, due to the limitations of the physical interaction, it's important to use summary statements so that the patient knows what you understood from their discussion and to let them know that they were heard and their concerns are going to be addressed. As we may have a greater role in sharing information because we don't have some of the educational resources we frequently rely on, make sure that you're using bite-sized chunks of information so that the patient can hopefully retain it better.

Provide time in your agenda for questions. It can be challenging for patients to pick up on everything that we have discussed, particularly if we don't have physical information for them to take home or read. Ask patients to teach back, again, verifying that they know and understand what you talked about. Again, when you're setting your agenda, make sure that you've allowed adequate time for each topic, and it may be important to schedule another visit if the patient's concerns can't all be handled in one visit.

At the end of your visit, make sure that you summarize. So after you've shared that information and have verified that the patient has learned, don't forget to summarize the overall visit and how they would like to proceed. Let them know that you're care doesn't end at the end of this telemedicine interaction, but that you're still there for them in the future, and how they can reach out to you. Ask if they would like summary information via portal or a letter, or whether the discussion has been enough.

Frequently, it may be beneficial to plan for that next visit. Discuss when and how. Will it be face-to-face? Or will it be another telemedicine visit? It can be helpful for the patient as they're planning that agenda and those next steps when they know what they can look forward to in the future. Also, offer a follow-up method if they have other questions or concerns, whether it's reaching out via a patient portal or electronic communication, whether it's a phone call, and the contingency planning on when to seek emergency care.

So in summary, be aware of the nuanced communication needed to conduct a telemedicine visit. The preparation comes even before the visit, as you're considering the topic to be discussed, as well as the setting where you're at. Planning ahead to make sure that you have a contingency plan in case you get disconnected and the patient knows how to reach out will be important, just as setting your background and making sure that you and the patient are in a private setting.

Given all of these changes, it takes effort to improve our verbal and nonverbal communication via telemedicine. So consider how you could continue to improve your webside manner. These are some of the references that were utilized as this presentation was prepared. They're all excellent if you want to continue to look for additional resources on how to conduct an effective telemedicine visit. Thank you.