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Telemedicine is forcing doctors to learn ‘webside’ manner


NO ONE KNEW exactly when the girl would die, but everyone knew it would be soon. A 12-year-old with end stage cancer, the child’s parents had recently moved her from the hospital to her home in the suburbs of Los Angeles. Some days later the girl’s breath quickened, and her father phoned the family’s hospice nurse. Please come, he said. He was worried about her breathing.

The nurse knew the visit would require more than four hours of her time: a two-hour drive in each direction, plus her time with the girl. Why don’t we connect over FaceTime, she asked. The father agreed, and they connected.

The nurse asked the father to move his daughter gently to her side. Then to her back. To lift the child’s shirt. To show her the expansion and contraction of the girl’s rib cage. The nurse would ask: What do you see, what concerns you, and the father would explain. Then the nurse would do the same. In this fashion the pair examined the girl—the nurse on her computer, the father his iPad. Together they decided that the nurse’s presence was not necessary, that the child had more time.

Later, the father reported feeling comforted by the nurse. He appreciated her availability, the fact that she could see what he saw, and their ability to discuss it in real time. “It’s so unique, the visual image, and knowing that everyone is seeing and talking about the same phenomenon,” says pediatrician David Steinhorn, director of palliative care at Children’s National Medical Center—and the head of the telemedicine pilot the girl’s family had been part of.

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An expert in the burgeoning field of telemedicine, Steinhorn believes in the power of digital tools to connect clinicians with their patients. But more important than the technology, he says, is what clinicians in the field have taken to calling “webside” manner. It’s a modern twist on bedside manner—a physician’s ability to relate with a patient and convey their desire to help. “My experience is that, once you get past some initial hurdles, you can maintain an intimate, immediate connection with patients that in some cases may be more therapeutically useful than even in-person interactions,” Steinhorn says.

But getting there isn’t always easy. As anyone who’s spent time on a video call knows, communicating via telepresence is very different from communicating in person. “It’s all the little things,” says experimental psychologist Elizabeth Krupinski, associate director of evaluation for the telemedicine program at the University of Arizona. “I mean, there’s the technology bit, obviously. Webcam resolution, internet connection, and so on. And you have to think about your backdrop, your lighting, what you’re wearing as well. But what you’ve really got to monitor is your behavior.” Krupinski should know: U of A is one of the first schools in the country to incorporate telemedicine instruction into its medical school curricula.

“It sounds strange, but when you’re on camera all your actions are magnified,” Krupinski says. Sitting six feet away from your doctor, in person, you might not mind or notice her slouching, fidgeting, or gesticulating. But a webcam’s intimate vantage point augments these actions in ways that patients can find distracting or off-putting. “You take a sip of coffee and your mug takes up the whole screen, and all they hear is the sound of you slurping,” she says. “Or you turn away to make a note, and now all your patient sees is your shoulder. Maybe you disappear from the frame entirely.”

If these all sound like awfully little things for physicians to concern themselves with, well, you’re right. But that’s kind of the point. The considerations are so small and numerous that they can wind up overwhelming otherwise competent clinicians, interfering with their ability to connect with patients. “There are some people who are great in person and you put them on camera they’re a dead fish,” Krupinski says. Some physicians are camera shy. (For others, the physical isolation can actually help them be moreempathetic—Krupinski says she’s seen it both ways.) Telemedicine students are often instructed to disable their video chat’s picture-in-picture feature. “Turn it off and look at the patient,” Krupinski says. That’s also kind of tricky: To appear as though they’re making eye contact, clinicians are taught to look not at the patient on their screen, but directly into their device’s webcam.

Some hospitals have gone so far as to design telemedicine clinics, purpose-built to address the peculiarities of virtual examinations. “We try our best to control as much of the environment as we can, so the doctors can be doctors,” says Jim Marcin, director of the pediatric telemedicine program at UC Davis. The room is staged like an office but with better lighting. There’s a nice desk for the clinician to sit behind, a computer situated stage left, and books in the background. A physician taking a video call from home, or somewhere in the ICU, might wear a gaming headset—a pair of brawny headphones, equipped with a mic—to ensure whatever the patient says isn’t broadcast to anyone off-camera (a clear violation of patient privacy, Marcin says). But in the secluded confines of the telemedicine clinic, the whole room is mic-ed. The clinician can forego the gaming rig and focus on projecting a natural, empathetic presence.

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