2020 IPEP CONFERENCE
Welcome to IPEP Conference 2020! In these extraordinary times, we have organised the conference to be held online. The theme this year is: "Communication", which covers two very relevant topics - Telehealth and First Nations Health. There are two parts to this conference:
Part 1 - Recorded videos, podcasts, and transcripts of insightful interviews conducted with experts and professors working and researching in Telehealth and/or First Nations Health which are available to you from Monday 14 Sept to Thursday 8 Oct (AEST).
Part 2 - A live Zoom session on Thursday 8 Oct, 7:30-9:30pm (AEST) to delve deeper into case studies with some of these experts.
Please head over to this link to register - https://forms.gle/djdp5gUGjzDre6wv8
If you have any questions, please email us: firstname.lastname@example.org
DR. DAVID LIU
Dr. David Liu is a first-year General Practice registrar in the Eastern Victoria General Practice program. He was the co-founder of the Melbourne med_hack hackathon, previously held a medical advisory role in shaping the design of Monash Health’s Electronic Medical Record system, and is the founder of Nintendo Switch news website Switchaboo. David was also previously involved in consulting businesses on digital marketing paid acquisition strategies, as well as developing/running his own eCommerce and GP clinic websites. His main active project is his currently tiny YouTube channel ‘Dabido’ which focuses on productivity and tech, as well as the associated blog www.dabido.com.au.
Telehealth in the Medical Setting [Video Transcript]
Presenter: Dr. David Liu, first-year General Practice registrar in the Eastern Victoria General Practice program
Hello! Welcome to this talk on telehealth. My name is David Liu. I am a doctor in Melbourne, Australia doing my first year of general practice training and, um, prior to that I’ve done three years of other doctor stuff like emergency medicine, general medicine, and I worked on the electronic medical records at Monash. So the other, sort of, background that I have is that I’m a bit of nerd and had worked on websites and design and a bit of coding stuff and blah blah blah.
What telehealth, sort of, introduced was this- two interesting perspectives of just like, this is the technology side of things and this is the medical side of things coming in as a junior doctor.
I guess I wanted to try to give a snapshot of what medicine was like before telehealth, what medicine was like after telehealth and, um, the different implications that telehealth might have. The first thing I’ll start with is that, contextually, as a first year general practice registrar, uh, we got thrown into the deep end of the coronavirus stuff just as much as anyone else. So, um the- the world was a very interesting place and there was often days where we would be just checking the DHHS website, the department of health website, pretty much every single morning to see if there was an update to the covid triage criteria. And who you could swab and who- what you had to do about people and, you know, we didn’t know how dangerous coronavirus was. Um, everyone was scrambling to try and get their isolation practices in place and um, so I guess with that transition period, it was quite rocky. And I think that, um, the interesting thing I suppose about general practices is each general practice is a separate business in itself. So it’s not one coordinated gigantic hospital network, which means that every single practice had very much different paces at how they adopted telehealth. For example, I was at a clinic called Rosanna Medical Group before and because we had some really good GPs there, we adopted telehealth pretty quickly. Like pretty much as soon as it became a thing we adopted it. That wasn’t the case for every registrar. Actually there were some- there were some friends of mine that, for example, had troubles with their clinics and, you know, the clinics would often still be seeing lots and lots of patients and this was sort of in the early days, maybe the first two months of telehealth and everything coming in.
I guess the interesting thing is that everyone had this fear that a coronavirus patient could come in. But some people had decided to answer that fear with genuine, like, quick, genuine, good responses. They were great. People that adopted telehealth and adopted, like, remote- remotely chatting to patients early on, uh, they sort of were very, very well prepared and there were other clinics that tried to do this “oh I’ve never done this before” and you know “we’ve never done this” and “it doesn’t really matter”, “coronavirus is not that bad” that sort of thing. But often those clinics were a bit slow on the uptakes. So you just had this different pacing. Um I think eventually, especially with lockdowns and stuff like that, people became much more up to speed; pretty much out of necessity. And I think that nowadays, that problem is more or less rectified.
So I guess the real important lesson from that one particular thing that happened was especially when it’s novel problems, you have to try to think about doing things from first principles because doing things as you’d always have done them is not a good method to dealing with problems that are brand new. So, um, I guess I would have likened it to saying, if the only tool that you have is the hammer then every problem looks like a nail, right? And the clinics that operated from first principles did a lot better, a lot quickler, heh quickler, a lot more quickly than, um, the clinics that didn’t. So, so that’s the sort of macro level on the general practice level.
But what about in the level of the individual clinician? So this is something that me and my friends had soon discovered for ourselves. There’s a few perils of communication. So if you take the first original paradigm of medicine – history, physical examination, investigations, management and, I suppose within management, education to the patient. Um, there’s a lot of different alterations to that when you are doing telehealth and when you are almost forced to do telehealth. For the history, your history’s going to be altered. For the physical examination, well your physical examination’s almost the- ahh I think their voice sounds okay over the phone, or even sometimes, uh like, you know, there’s that particular thing ‘if you press it, does that hurt’. Um and then- the other thing about physical examination, I suppose, is that you could do video consultations but then that had its own peril because not everyone knew how to install apps or not even everyone knew how to physically get that technology there so that you could just enable these people to video call you. It’s very surprising, especially in this day and age where everyone has a mobile phone. But that doesn’t necessarily necessitate that they know how to use that mobile phone.
So altered history, altered physical examination, altered investigations. Sometimes if there’s an investigation that you wanted but you couldn’t get because this patient might have had suspected covid, but they may also have pneumonia or something like that and, you know, you can’t necessarily go to examine them because they might give you covid if they’ve got like, you know, a cough and, sort of, productive cough symptoms and, um, that sort of thing. So you’ve got this big dilemma as to what you do for investigations because you can’t also just order test x-rays straight away. Um and the problem with a lot of the illnesses is that some- is that a lot of them do present kind of vaguely. Especially with coronavirus, where there really is a pretty big range of symptoms. A lot of people already know the viral easy ones, like sore throat, cough, fever, shortness of breath, those things. But then there’s all these other manifestations that can come up and whilst- especially when it was new, like um, there was a lot of uncertainty about whether something was perhaps an indicator of coronavirus. A good example is that right now a lot of people are getting chilblains, which is where, um, you get some vasoconstriction to the toes, for example, in other words the blood vessels to the toes are just getting very narrow just because it’s really cold and then that causes a bit of pain, discolouration and stuff. But like, that thing which happens, um, to people anyway, there’s a thing called covid toe which is related to, I think, microthrombosis and that can present also with a discolouration of your toes and stuff like that. Most likely like it’s still going to be chilblains in the overwhelming majority of cases, but now there’s just this like, this added layer of diagnostic uncertainty.
So with management, it was also kind of interesting. You would have to sometimes um- because if you are relying on your physical examination… Your physical examination can really tell you a lot. Physical examination became something that, um, was a tool that we thought we would always have. And so we learned medicine that way. We learned medicine in a way that was like, oh okay, you know, this thing, this headache that you’ve got, if you’ve got temporal artery tenderness, maybe it’s something like temporal arteritis. Or if you’ve got, for example, this- this child with a sore throat, what’s the chance of them having a streptococcal throat infection. Well you need to use a thing called the centor criteria, but um, the centor criteria relies on you knowing whether they have exudate at the back of their throat. And it also involves you seeing whether there’s any lymphadenopathy or tender lymph nodes or big lymph nodes around the neck area.
So those things- the tools that we used before telehealth, and before we had to do everything remotely, um, those were tools that are now taken away from us. Which means that we have a limit- like less information and means that our decisions have to be altered. We don’t necessarily like over-treating people with antibiotics, for example. But if someone’s got a genuinely productive cough, and you know, you feel like ‘oh they’ve got a bit of a fever, they sound like they’re not doing too well’ you know, you’re- you want to prevent antibiotic resistance, for example, and not prescribe people that just have a viral URT (upper respiratory tract infection) with like, um, amoxicillin or whatever. But um now if this, especially there’s like an 80-year-old person and you can’t even listen to their chest to hear if they’ve got pneumonia and you can’t send them to a chest x-ray because they might have covid. Then, you know, the temptation to just be like, oh yeah, take some amoxicillin, that temptation is definitely there. And sometimes it’s actually necessary to overtreat just because you now have that risk harm benefit thing going on.
With telehealth specifically, one of the bigger problems is that not everyone knows how to use their phone. Even if they have a phone, that doesn’t necessarily mean they know how to use it. I think one of the biggest problems initially was that, people were scrambling to try to figure out, okay, like I can call the patient on their mobile phone, but I also want to do video calls. And so video calls was something that was, uh, almost like, like you know, trying to get someone to install Zoom or install Skype or go to a Zoom. Very, like, easy for younger people, oh sorry not even all younger people because some young people are bad at technology too. Um, it’s just easier for people that are good at technology and then somewhat surprisingly difficult for people that aren’t good at technology. And the result was that you would try to explain at the start maybe how to install a particular app on a phone or something. You had privacy issues. So for example, you know on FaceTime if you tried to call someone via FaceTime, as far as I know, um, you’d have to expose your contact details which is obviously not something that you’d want to do because your patient, uh, may become your private patient. They may, um, like want to call you back on the mobile number that you now send them via phone. So that’s why we tend to, you know, use private caller IDs and stuff like that of course. Um so it was just difficult, basically, to try to set up.
Thankfully then came this software called GP Consults, which was one where they didn’t have to install an app on their phone. That was the biggest one issue- was that people had to install an app on their phone and they had to know how to do it, they had to actually do it. Umm but with the GP Consults thing, which is I think, gpconsults.com.au, you could actually just, um, put in the patient’s number into that particular website, they would text the patient a link, so on their messenger, and then it would actually send them to a web browser page that could access video and you’d do a video call through that. So that was really good. And basically that solved a massive issue which is that you can’t expect, um, other people to necessarily know how to onboard themselves with technology.
Another obvious problem that came about with telehealth is that a lot of the patients doesn’t have a phone. And you’d be surprised about how many people don’t actually have mobile phones in the community. Um, they would sometimes have to come in person. But if they came in person, it was kind of like, they might have been a bit of a trojan horse, but you don’t know whether they are a trojan horse or not. You don’t know whether they are completely covid free, such as viral symptoms free, or whether they have some other complaint that they actually really need to see the doctor for. So, um, try to do remote work like that, almost every patient that you saw was going to convey a certain amount of risk. And this risk is something that we never had in general practice before. It was kind of like you had this new layer of decision making and the old layer, the old way that decisions were made was just the same question, am- is what I’m doing going to be safe for the patient? But now you have this new layer of thinking, is what I’m doing going to be safe enough for me to do it as well. And then compare that safety with the actual potential risk of a patient deteriorating or having a serious medical condition that really does need treatment.
So often, you would come across these situations where, where you’d really want to see the patient but it poses certain risks to you. And then you had to do things like either get a covid swab first and then see him, or you would have to send them to the emergency department immediately which you always feel quite bad about as GPs because you don’t want to overload the system. And um, it was just a bit of a mess, basically. Um, you know, when the stakes are personal, that’s a different kind of decision making layer altogether.
So something that was really important, I think, to think about in terms of what the benefit of seeing someone in person is versus doing it over the phone is, is that you- it’s not just for diagnostic purposes. Of course like history and physical examination are two components that are really important. But the physical examination is also a big, big, big component in reassuring a patient. An example would be a parent that comes in with their child, and then their child has some sort of rash which has been there for a week and the parent’s really worried about it and they don’t know what it is. And you know, if it’s just something via telehealth, you try to get them to send a picture to you over the phone and they send it via the clinic email and then you look at that picture and the picture is like all pixelated because they probably have an Android phone. Sorry, iPhone and Apples are better. So the real problem with not seeing those patients in person is that you can try to reassure them and say, look based on the picture, um, it seems like it would be a viral exanthem, in other words it just seems like it would be a usual viral rash and you don’t need to worry about it at all, it will go away by itself. But sometimes the parents will just come back and say, can I have- can I get you to have a look? And if you’re thinking, well, I guess so, but you know, your child might have covid, or like the parent might have covid or something like that. It’s difficult. You can’t just reassure necessarily over the phone, always.
Even talking to people as well, is something. You know, I had a very angry patient once. He was very, very upset. I can’t go into the specifics of why he was upset, but he was dreadfully upset. And trying to calm him down over the phone is really hard. I mean, you can bring your best calm voice and try to say, yeah I see, like you know, I get what you mean and that’s really horrible, I’m sorry. But it’s just not the same as physically being there, physically paying attention to them, looking at them. So in that particular case, that patient just continued to, sort of, yell at me over the phone and stuff like that. You can’t even like, you can’t make a signal to go out of the room. Sometimes if your patient, um, is talking for too long, you may want to strategically try to give some sort of body language to say okay, like, I have to move away and I have to see my next patient, I have to talk to my next patient and stuff. Traditionally the way I’ve done it is just physically stand up and open the door and then when it’s time for the patient to go, you know, surely you standing with the door open is like an indication for them to go. And they usually get the picture. You can’t do that over the phone. Like you sort of just have to try to interject and be like uh uh uh sorry. So it’s kind of- um, it’s harder, it’s just harder. There’s a lot of stuff that you can do physically which you can’t do over the telephone.
So I suppose I can talk a little bit about some of the businesses that came up as the result of telehealth. So basically for a little while, telehealth was something that was just thrown wide open to anyone that had doctor’s ed (education) to do. And what had happened was, you would see these Facebook ads for these new, like, ghost clinics I suppose, for lack of better word, that would pop up. And these clinics were just ones where it’d be like, oh our doctors will be happy to give you your scripts and be happy to write you a covid referral and that sort of thing. Um, but those clinics existed almost purely online. They weren’t actual physical clinics and um, or at least, you know, they may have been physical clinics but it was just something where they clearly weren’t interested in keeping an ongoing relationship with the patient. They were just trying to do this money grab. And so there were a lot of websites like that that popped up. I don’t have any specific names, um, but they would often try to do things like Facebook advertising and stuff to get people in. And it was kind of- it was an interesting thing to see that, how the government reacted to that. Um the government had done these things whereby you had to see a- the, you had to have seen the physical doctor in person in the last 12 months, or 24 months or whatever it was, in order to get a telehealth, um, paid out from Medicare to the doctor. But that actually became something that worried and worked against us to some degree because then we did have patients that hadn’t seen us in just three years, or four years or so, but they were genuinely patients of the clinic that wanted testing or had other stuff, and then you couldn’t bill them. And it was kind of like this, this unsteady stage of whether you could actually see these people or not. At the same time, the government was also trying to counter that- those pop-up clinics, basically. So thankfully now it’s stabilised a lot and yes, you have to actually have seen the patient within a certain period of time before. But it’s just a bit better in terms of what it is now. So those pop-up clinics, um, will hopefully be out of source to some degree because they’re pretty bad.
So I want to take a step back out of the doctor role and then talk about it from a technology role. Because I think that that’s really interesting too. So I think that when telehealth first started, um, a lot of people weren’t really sure how to go about it. They were, luckily, and you know, rightly so, trying to think about how they could repurpose existing tools to try to do the actual telehealth thing. So people like, I remember my old clinic had a lot of phones and I was installing Zoom on every single phone and then I had to go into some settings to make sure that people could enter via link and stuff without having to, um you know, of essentially having Zoom on their phone. So repurposing existing stuff is one way to solve a physical problem. I think that one of the problems of repurposing is now, if you’ve got this data, that’s video data, on some external company’s, um, some external company’s thing, then that might become a privacy issue especially if like, it’s not, a technology that was necessarily built for medical security in mind, for example. So that sort of is a little bit of an issue. But overall, the idea of just taking something that you already have and trying to use it for a new purpose – that will solve a lot of problems by itself and often you just have to go looking a little bit, or just be a bit creative with the stuff that you use.
To talk about one of the anecdotes from the transition period, it was very entertaining for some people, evidently. Because, you know, we’d have to vaccinate people in like, outside of the clinic and try to do it inside the carpark, essentially, but then, you know. First of all, if you’re vaccinating kids, that’s a whole dilemma because, you know, the kids are running around everywhere and um, they’re- they, you don’t realise how nimble they are until they climb literally from the front seat- uh from the back seat, through that gap in between the two driver seat and the other seat, and then into the driver seat and they’re just like really, really quickly like a rat. So um, that was hard because, you know, you’re this dude that’s like got a mask and gown and you got a needle and you know, it’s just not a good sight to be chasing a kid that’s screaming. And rightly so, because if some guy came to your house and, you know, was threatening you with a needle, nah you’d be a bit scared.
The other thing about doing things outside, for example, was that you know if someone is coming up to you with their phone and they’re just like, you can tell they’re on their phone, they’re slowly bringing their phone up to you, you know they’re up to no good because you just know that they’re recording you or something like that. So that’s another peril of being outside. But anyway, I’m getting distracted, I should probably talk about more telehealth.
I think telehealth did have its benefits. I think that, um, obviously preventing people from coming in and out of the clinic is a really huge benefit to society because of the fact that you’re encouraging social distancing, you’re preventing places which could otherwise become niduses of infection, perhaps. And you’ll just try to mitigate as much as you can. So I’m glad that telehealth was something that actually came in and was something that was, um, that was actually practical from a business sense.
I think another really good thing about telehealth is that – really, doctors could now get paid for doing things that they were doing before anyway. Uh for example- but that they weren’t getting paid for. So for example, calling patients about their results, um, was something that was an unpaid task and if the patient happened to want to talk for longer, really the doctor, umm to get any benefit from that, from the business perspective, if anything it made things worse because there’d be other patients who are behind and stuff. Obviously talking with patients and trying to communicate well involves time and involves effort. And sometimes, um, if you’re at least reimbursed for the effort, then it makes it practical to do. You don’t feel like, by being a good doctor, you have to be a bad communicator. And so I think that’s a really good thing about telehealth.
So thank you for listening to this talk. I hope that this talk on telehealth has given you some insight into what telehealth has been like for us as general practitioners and, um, if you’re interested in other stuff that I talked about then I have my blog and my YouTube channel which is called Dabido, d-a-b-i-d-o. Otherwise, you can reach me at an email that that I will provide Michelle later (email@example.com). My personal opinion is that if you’re someone that’s really interested in innovating, being in a field that is something that you’re good at, for example, maybe nursing, maybe medicine, maybe pharmacy, maybe physiotherapy, maybe music therapy, maybe like any sort of combination of, uh, certain fields. I think that the most important thing is to be great at that particular field, but also to have a secondary interest and um, for me, that interest has been technology. And uh you know, doing a bit of coding, designing and all that sort of jazz. But it can be another thing. And that’s actually something where you can create a lot of value. Not only for yourself as your own person navigating through the world, but also that, that ability to talk in two languages will be something that will make you an incredible asset to building stuff that’s really important.
I hope that you found this talk interesting. It’s been kind of fun to talk about, and ahh, sorry about- if it’s a little choppy in different places because I’m actually doing a fair bit of video editing because I said a lot of stuff which probably shouldn’t be in the talk so… Have a great rest of the conference and, again, any questions or any burning thoughts, please feel free to contact me. The email will be here, or something. So have a good rest of the conference and stay warm, stay safe and uh, do good things. Okay, catch you later!