By Pierre Elias,
In June, as the on-call cardiology fellow, I treated a man who was having a heart attack in the emergency department. He had “a sudden pang of what felt like terrible indigestion,” he said. The patient made a full recovery, and later we joked that he would think he was having a heart attack every time he had heartburn.
In prepandemic times, a worrying symptom would have meant a long wait to see a doctor in person at an office or a visit to urgent care. But with telemedicine’s growing popularity and easy access, this patient and others can now book a quick 15-minute video visit with a doctor to get some peace of mind when we all could use it.
One in 3 adults below age 65 have used telehealth during the pandemic. While telehealth has its advantages, it has some drawbacks, too. Even the most brilliant physician cannot listen to your lungs through a webcam or make a diagnosis when a poor connection cuts off every other word. Whether it’s your first consultation or for long-term care, here’s how to make the most of any telehealth visit.
With medical appointments available anywhere with reliable Internet connection — and some services such as Teladoc available 24/7 — scheduling ones for follow-ups, preventive care and non-urgent questions is more convenient than before. A new patient in my clinic had gained over 100 pounds of excess water weight as a side effect of heart valve problems, but she had been scared to come into the clinic during the pandemic. A telemedicine appointment and a scale could have helped us address the problem much sooner.
Check your tech
Because of patient privacy laws, health systems may use proprietary videoconference systems that operate differently from consumer applications. Test that the system works on your device — that you can log into your account, check into the appointment, and join the call with high-quality video and audio. Don’t do a virtual visit while commuting — choose a quiet, private place with no TV or radio in the background. Consider using earphones. Lighting should be in front of you. Use landscape mode for better visibility. Plug in devices or charge them beforehand. Hiccups can still happen in good conditions, something my deaf patient, her American Sign Language interpreter and I discovered when the video froze at inopportune times during our conference call.
Manage time well
Create an agenda: Start the appointment by listing issues, then ask your doctor if there’s anything the physician would like to add. As a favor to a colleague, I squeezed a new patient into the only available 15-minute slot. He wanted to address new chest pain, high blood pressure and diabetes. Having this list helped me clarify that we’d only have time to thoroughly assess the chest pain, but would examine the other two properly in a follow-up visit.
Be very detailed
The lack of a physical exam means that the most valuable thing you can do is catalogue your symptoms very well. Take good notes and clear, well-lit photos of visible symptoms such as rashes or bruises. It is rare for me to meet patients who can confidently recount all the details I’m going to ask about if they haven’t written some of them down. And the less time spent on data gathering, the more time can be spent on finding solutions.
Almost all doctors use one of two standardized note-taking systems: the history and physical (H&P) or the subjective, objective, assessment and plan (SOAP). Both are designed to concisely communicate a patient’s history, exam findings and plan of care to the entire medical team.
The mnemonic that many medical students learn, and that I still use every time I interview patients, is OLDCARTS. When a friend called with coronavirus concerns, we listed her symptoms of fatigue, fevers and shortness of breath. Then, we organized her thoughts before a telehealth visit with her physician:
Onset (When did symptoms begin?): Fatigue and fevers, three days ago. Shortness of breath and chest pain, 24 hours ago.
Location (Where is the symptom?): Pain between the ribs.
Duration (Is it episodic? How long do they last?): The pain, fever and fatigue have been constant.
Characteristics: Felt short of breath when walking up the stairs, but for the past few hours also while walking on level ground.
Aggravating Factors (What makes it worse?): It gets worse with deep breaths or when I push between my ribs.
Relieving Factors: Pain improves if I’m sitting down or not exerting myself.
Treatments: Took some Tylenol, didn’t help.
Severity: On a scale of 1-10, the pain is a 2. The shortness of breath is like jogging a few hundred feet.
Since the chest pain was musculoskeletal, it was probably soreness from heavy breathing rather than something more ominous. Knowing fever and fatigue clearly preceded shortness of breath meant that the culprit was probably a viral illness rather than a potentially life-threatening blood clot in the lungs. The preciseness of the symptom severity and timeline allowed her doctor to list specific changes that would warrant a trip to the emergency room, if they occurred. Fortunately, she felt better the next day.
Doctors do this, too. If I am a patient seeing a new doctor for the first time, I’ll make sure to provide my medical history. I always have this in an electronic form, so that it’s ready to be emailed if requested. Ask your doctor if it would be helpful to send it along before the appointment.
Research this, not that
Search engines can answer broad questions that apply to the general population, such as “Who can get vaccinated right now?” Use time with your doctor to navigate your unique circumstances: “Since I have rheumatoid arthritis, do I meet the immunocompromised criteria to be vaccinated early?”
Speaking for the entire medical profession, please don’t search the whole Internet for your symptoms. There are better resources such as UpToDate, a subscription-based encyclopedia of articles written by doctors for doctors, and one of the most-used medical references at the top 20 hospitals on the U.S. News & World Report’s rankings. Ask your doctor if there’s a “for patients” article pertinent to your situation, which can be an excellent way to understand what might happen next and why certain tests are ordered.
“Is that your final answer?”
I rarely think to tell patients how complex their issues are, yet it’s sometimes the most useful thing they hear from me in the entire visit. Some of the best questions you can ask your doctors are how certain they are about the cause of your symptoms and the next steps, whether the issue is complex or atypical, and whether the plan of care is widely accepted, highly controversial, or a complete judgment call because guidelines don’t exist.
Before hanging up, ask your doctor if they felt that they had enough time to evaluate the issue.
Discovering a diagnosis, managing symptoms, dealing with relapse — these are all roads best traveled together. At a time when many of us yearn for such kinship, telemedicine can make it easier to be in lockstep with your physician. These tips will better the journey.
Pierre Elias is a cardiology fellow at NewYork-Presbyterian/Columbia University Irving Medical Center in New York.
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