Telehealth is everywhere, and both doctors and patients are adjusting to its ubiquity. Helen Ouyang is an emergency physician and an associate professor at Columbia University, and she joins host Krys Boyd to discuss why she initially objected to telehealth shifts but now believes the tool can further public health objectives – plus, she’ll offers tips on how to get the most out of a remote doctor-patient visit. Her essay “How Virtual Appointments Taught Me to Be a Better Doctor” was published in The New York Times.
Can telehealth save you a visit to the E.R.?
By Madelyn Walton, Think Intern
Telehealth continues to be a normal approach for those seeking care in a virtual setting and it also seems to be improving the doctor patient relationship.
Dr. Helen Ouyang is an emergency physician, associate professor at Columbia University, and a contributing writer for The New York Times Magazine. She joined host Krys Boyd to discuss her initial hesitations to provide care via telehealth, why some patients prefer it, and tips for more effective virtual care appointments. Her essay “How Virtual Appointments Taught Me to Be a Better Doctor” was published in The New York Times.
The shift to virtual care started during the pandemic. Patients with limited mobility and worries of catching an illness favored this approach.
“When I first started, I was a little taken aback by it because it’s just the two of you staring at each other,” Ouyang says. “But it’s quiet, it’s calm. They have all of my attention.”
Many patients call just to talk to a physician one on one and get clarity about their symptoms. But high-risk patients suffering from a heart attack, or a stroke are urged to go to the E.R.
“These are people who maybe have a symptom and they Google it and they come across our virtual urgent care and they call in. It could be a wide range of symptoms and severity,” Ouyang says.
Ouyang found people are willing to share more about their condition from the privacy of their homes and the doctor-patient relationship is stronger. Doctors can follow up with their patients in a virtual setting, whereas in the E.R. you’re on the move.
“I have people who pull me away to see other patients that they think might be more sick,” she says. “In every way you can imagine, I’ve been interrupted in an emergency room and my interaction with the patient has been interrupted.”
Also, telehealth can save a patient from a long visit in the waiting room.
“I think a lot of people can benefit from calling virtual urgent care if they’re not sure, because I can talk them through it and help them figure out if they need to go,” she says.
The E.R. sees all medical conditions, from physical health to mental health crises, physicians are there to treat them all.
“Since I’ve had these connections on virtual urgent care, I think I’ve been a lot less frustrated in the emergency room or realized that even if I can’t give a patient a medical answer, just being able to talk to them often is enough,” Ouyang says.
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Transcript
Krys Boyd [00:00:00] If the pandemic taught us one thing, it is that video calls are a decent option when in-person meetings are off the table. But what about when we feel sick enough that we need to see a doctor? Can a Zoom exam room ever work as well as a trip to a clinic? From Kera in Dallas, this is Think. I’m Krys Boyd. My guest, Dr. Helen Ouyang, is an emergency physician and associate professor at Columbia University. She’s also a contributing writer at The New York Times magazine. When her hospital started ramping up virtual E.R. visits as a way of reducing people’s exposure to the Covid virus, she had real concerns. How could a doctor and patient possibly connect through a screen? What she discovered was not just surprising, but illuminating. She wrote about this in a New York Times essay titled “How Virtual Appointments Taught Me to Be a Better Doctor.” Helen, welcome back to Think.
Helen Ouyang [00:00:53] Thanks so much for having me on.
Krys Boyd [00:00:55] So we all heard about virtual medical visits during the pandemic. I did not realize these were ever used by emergency departments. Were you surprised when your hospital made the decision to start experimenting with these?
Helen Ouyang [00:01:09] Yeah, I was definitely surprised, Krys. We had done a smaller version of this in the beginning, before the pandemic, but we had not expanded to virtual urgent care, so I was really surprised. As an emergency room doctor, I would be seeing patients over video. It was a big surprise to me.
Krys Boyd [00:01:27] You share that as an E.R. physician, you started your training with one fundamental question in mind. What was that question?
Helen Ouyang [00:01:35] Well, what does this patient have? So every time I see a patient, I walk into the room, I listen to their story. I examine them. And then I try to figure out what diagnosis do they have. And from there, what treatment do they need? And I felt I was not going to be able to do that on video.
Krys Boyd [00:01:54] That question is obviously still of primary importance for people in the E.R.. I wonder, though, over time with experience, if you’ve added other questions to your list.
Helen Ouyang [00:02:05] Yeah. So if I can’t figure out what does this patient have in the emergency room, the next best question that I try to answer is, does this patient have anything life threatening or soon to be life threatening that I need to address, diagnosis and workup today.
Krys Boyd [00:02:22] What did it take for you when you were training to get used to the idea that everything in a hospital might be life or death? But the E.R. is is a totally different level of this. I mean, have you always been wired to sort of handle crises?
Helen Ouyang [00:02:36] I think on some level, yes. But you have to remember that the emergency room and the US health care system is also a safety net for everybody. So people might not be in there with life threatening situations, but they are there because they don’t have access to health care. Whether that be an insurance issue or they are unable to get an appointment or they just have nowhere else to turn. So we see all kinds of patients in the emergency room, not just those with life threatening issues.
Krys Boyd [00:03:04] Yeah. I was thinking as I was preparing for this interview, that I would ask you what a standard E.R. visit looks like. And then it occurred to me that people go to the emergency room with so many different kinds of symptoms. Like there’s no such thing as a standard visit, maybe.
Helen Ouyang [00:03:17] Yeah, that’s exactly right. And oftentimes, you know, what happens is people have something that’s been bothering them maybe for a few weeks, a few months, and then it really gets worse. Or they talk to somebody and they panic and they end up in the emergency room. So there’s really no standard visit.
Krys Boyd [00:03:36] Would you say that working as an emergency medicine specialist is generally very hands on in a way that some other medical specialties may not be?
Helen Ouyang [00:03:47] Yes, definitely. I mean, I think. Almost all the care we provide. An emergency room is very hands on. I do a lot of procedures. I examine the patients, so everything really is quite hands on in the emergency room. We give them medications, whether it’s by mouth or through a intravenous line. And all of that requires hands on care.
Krys Boyd [00:04:09] So these virtual visits, we’re going to be very different from the way you were accustomed to operating in the emergency department.
Helen Ouyang [00:04:16] Yes, extremely, extremely different, because first of all, the patients just call from home or their car or wherever they happen to be. They don’t have any vital signs. So when patients come into the emergency room, they’re triaged by a triage nurse and that person gets a few lines from the patients. Why are they here and gets vital signs on the patient. So their temperature, their heart rate, blood pressure to oxygen saturation. Maybe they get a fingerstick to check out what their glucose number is. We don’t have any of that information when the patient calls in.
Krys Boyd [00:04:50] So initially when you heard about doing more of these emergency room visits via some kind of telehealth platform, did you feel like you were going to be flying blind? Like you wouldn’t have even that baseline of information about people’s vital signs?
Helen Ouyang [00:05:07] Yes, exactly. So I was really, really hesitant to do that. In fact, a few groups of us had gone first to do them, and I declined to do it initially because I didn’t think I would be able to give them the care they needed. I was really, really nervous about doing this. Patients would be calling and without any vital signs, they self triage, so they could potentially be really sick having a heart attack even and be calling me on video. And I didn’t know if I would be able to handle any of that.
Krys Boyd [00:05:37] Self triage. That’s really interesting. I guess I had assumed that people would call in and maybe be, you know, told by some kind of professional like, you might qualify for a virtual visit, but this is just people thinking, I’m going to give this a shot rather than driving myself or taking myself to the E.R..
Helen Ouyang [00:05:51] Right. So these are people who maybe have a symptom and they Google it and they come across our virtual urgent care and they call in. It could be a wide range of symptoms and severity.
Krys Boyd [00:06:03] What was the set up for you as a doctor when you were assigned to a shift of virtual visits? Were you like in a little office somewhere? Just with a computer? How did that all look?
Helen Ouyang [00:06:14] We have the option of going into an emergency room or an office near the emergency room and using their computers or doing it at home. So if we weren’t able to get the technology to work on our end weather because our Wi-Fi was too slow or we couldn’t get our computers to connect correctly, then you would have to go in. Otherwise, I would be at home just like the patient.
Krys Boyd [00:06:37] And was the interface something like a zoom or a team’s call that we’re all familiar with?
Helen Ouyang [00:06:43] Yeah, initially when we started, it was another app and then we changed to Zoom, which most patients are familiar with. And now we have yet another version where it’s sort of embedded into the electronic record that they’re using to sign up with us. So it’s much more intuitive in one click now.
Krys Boyd [00:07:02] Okay. So how quickly did your perspective on the potential value of these visits start to change?
Helen Ouyang [00:07:09] It took a while. I mean, it was up and down. Initially, I think when I first started, I was quite nervous. And then I would see a few patients, particularly Covid patients, and they were extremely grateful because they were feeling unwell and they didn’t want to leave the house, and they were also considering others and didn’t want to get on the subway or a taxicab and infect other people. So I was starting to see some good effects there, but I was still nervous about someone calling me with something that I wouldn’t be able to handle or people getting upset that I’m not able to treat what they need and have to send them to the emergency room anyway.
Krys Boyd [00:07:47] Yeah. How often did that happen?
Helen Ouyang [00:07:49] So that’s a good question. I think in our practice it’s maybe, I think around 10% across all our doctors. I find myself maybe 1 to 3 times during a shift that I have to send the patient into the emergency room. But as I started doing more and more of these shifts, I was able to address more and more issues as I got better at doing the physical exam through the video and learn how I can do things remotely that I didn’t think I would be able to do.
Krys Boyd [00:08:18] Yeah. Talk us through that. That process of learning to do a physical exam that you were trained to do in one very specific way using this technology. What were some of the things that you discovered would work?
Helen Ouyang [00:08:30] Yeah. So like the throat exam, a patient calls in with a sore throat. It’s. It’s pretty hard to see in the back of someone’s throat, even in an emergency room. You know, we have special lights. We have a tongue depressor. But I’ve got a pretty good depending on the patient’s anatomy, of course, of getting the best lighting I’ve learned. If they’re in the bathroom, it works really well. If they’re under a computer and they can use their phone as a flashlight, that works well, or if they have another person in the room who can shine their phone light, that helps me see into the back of their throat. I’ve learned how to position your head, telling them to not forward look up to get the best position. So that’s one thing I’ve learned. The abdominal exam, that’s something I normally would do in an emergency room. You know, I would palpate their abdomen and see where they have tenderness. But in some patients especially, they don’t look very sick. And I think it’s reasonable to do this. I’ll walk them through it so I’ll have them do it themselves and then I can deduct from their exam whether I think they need to go into the emergency room.
Krys Boyd [00:09:32] I would imagine this is really comforting for people who have some anxiety about seeing any doctor for any reason.
Helen Ouyang [00:09:39] Yeah, sometimes people just call us for advice because they don’t know where the next place to turn is. So they’re not looking to me necessarily to be there, end all, be all diagnosed, what they have treat it solve what they have, but they just want to know what kind of doctor should I go to next? Do I really need to go to a doctor or I’m traveling in a couple of days? Do you think I need to go see somebody before then? Things like that. So I just oftentimes help them navigate and talk through the risk benefits of a plan.
Krys Boyd [00:10:12] You note in the article something that we all know, which is that ERs can be chaotic places for people who are already feeling maybe sick and scared. The waiting room experience alone can be distressing. I mean, I recognize that when you’re on your shifts, you aren’t spending much time in the waiting room. But even in the best run hospitals, they are pretty miserable places.
Helen Ouyang [00:10:32] Yeah, definitely. The waiting room can be very, very distressing. Everybody is mixed up in there. You have no idea how long you’re going to wait. It’s extremely busy. You can see some people who are there that might be bleeding or coughing a lot, and that can be really scary. So definitely the waiting room can be very distressing for patients.
Krys Boyd [00:10:52] So skipping that is a win for patients who might do a virtual visit.
Helen Ouyang [00:10:56] That’s definitely a win. But I think even the lead up to that, I have had a lot of patients email me after this article came out that just being able to skip the subway ride or skip traffic, getting to the emergency room makes them arrive in like a much more peaceful state. Or even if they’re going to see their primary care doctor to not have to go through the transportation of getting there and making it on time. That is very helpful.
Krys Boyd [00:11:23] Yeah, that’s really interesting. I’m thinking about, you know, if you have something as serious but manageable as the flu, assuming that you are not in some high risk group, just running a high fever means you probably shouldn’t be behind the wheel of a car or trying to navigate a subway or whatever other public transit you might take.
Helen Ouyang [00:11:39] Yeah, that’s definitely true. I mean, I’ve had many, many patients call me from bed. They’re literally lying sideways and I can see how miserable they feel. They have something like the flu. It’ll get better, but they feel terrible in the meantime. So they don’t need to be going outside and feeling worse. If I can talk them through what they need. And oftentimes they’ll have a family member who can pick up prescriptions that I write. Or there’s also prescription delivery companies, so they can just get their full course of care without ever leaving your bedroom.
Krys Boyd [00:12:13] How did you get over the concern that, like, okay, I think I can diagnose this person pretty confidently with the flu or Covid, and I think they’re probably going to be okay with these medications. But like, there has to always be that thought in the back of your mind. Like, what if there’s something I’m missing?
Helen Ouyang [00:12:31] Definitely. I think when I started, I was more conservative, so I would send more people to the emergency room and to urgent care. But since then, I have a pretty good gestalt of how they’re going to do. And we also can follow people up so I can schedule them another visit in a day or two, and they’ll see me if I happen to be working or one of my colleagues who can read my note and see what I was potentially concerned about. Or sometimes I can even call them and just say, Are you okay? How are you feeling now?
Krys Boyd [00:13:02] That has to be pretty remarkable. I don’t know how often you get to do that with regular E.R. patients. Follow up on the phone.
Helen Ouyang [00:13:09] Yeah. What’s actually interesting is that this past year, since we started our virtual urgent care program, we’ve been linking it with our emergency room. So our virtual urgent care is part of our hospitals, part of our emergency room. It’s the same staff. So we’ve created a program where patients can follow up from their E.R. visit with one of us on virtual urgent care. So say somebody comes in and they have a skin infection and we start antibiotics, and we’re worried that this might not be the right antibiotic or it could get worse. I can schedule an appointment with one of my colleagues for them to see them in a day or two, just to see that it’s getting better and they can look on the camera and if it looks worse, they can tell them. Now you have to go back to the emergency room and now you need to be admitted to the hospital or it looks really good. Continue what you’re doing.
Krys Boyd [00:13:58] Helen, you note in the piece that like, despite your desire as someone who cares about patients to focus on each patient or maybe on their families, it is not uncommon for you in a regular E.R. shift to be pulled away from one patient to deal with something or someone else. Talk about how that can happen, like the circumstances in which you might be with a patient and then be pulled away to deal with someone who has, I guess, a more significant, urgent problem.
Helen Ouyang [00:14:26] That just happens all the time. So I’ve been interrupted in every way you can imagine. I have been doing CPR on a patient, and another patient’s family member will come and try to ask me a question because they don’t know what’s going on. I will be speaking to a patient and a nurse will hand me an EKG to sign and look at. I have people who pull me away to see other patients that they think might be more sick. So in every way you can imagine, I’ve been interrupted an emergency room and my interaction with a patient has been interrupted.
Krys Boyd [00:15:01] I get cranky just writing a script when someone comes in and interrupts my flow. I mean, how much do you have to manage your emotions when this kind of thing happens?
Helen Ouyang [00:15:11] Yeah, it can definitely be frustrating, but it is honestly just part of E.R. care that I’m just so used to it at this point, but it can be frustrating.
Krys Boyd [00:15:22] So with virtual visits, are those distractions eliminated? Minimized?
Helen Ouyang [00:15:29] Yeah, there’s pretty much no distractions. And if there is a distraction, it’s a good one. So for us, the virtual urgent care visits, the patients make appointments, so they have a lot of time that they are logging on and seeing me and it’s just me and them on a camera. It’s extremely, extremely intimate. When I first started, I was a little taken aback by it because it’s just the two of you staring at each other. But it’s quiet, It’s calm. They have all of my attention. And if there is an interruption, then I know something’s going on. The patient’s life. So I’ve had new mothers call me and their newborn is crying. And I can see sometimes they feel frustrated. And that allows me to ask, are you getting enough help at home? Is everything going okay? Or I’ve had patients who call me from noisy shelters. I can hear other people in the background and I can, you know, double check that they’ll be able to get the prescription that I write for them.
Krys Boyd [00:16:29] I mean, that context has to be really, really helpful to you. People may or may not reveal a lot about their lives when they’re just in the E.R..
Helen Ouyang [00:16:40] Yeah, that’s correct. I think they feel safer in their home. And oftentimes there’s family members around. So, you know, an emergency room, a person might show up by themselves because a family member can’t come because they’re busy or maybe they’re immunocompromised or they can’t be also exposed. But on video, I can see people in the background. So I can ask the family member to come on if I need to, if I want to elicit their help or just get their opinion on how they think the patient’s been doing. So that’s really, really helpful. And I think it makes the patient feel safer and more comfortable.
Krys Boyd [00:17:15] How does that compare with the way in a traditional E.R. setting before you start ordering tests or as you start ordering tests? Like, what do you do to gain some context about a person’s health and their lives?
Helen Ouyang [00:17:29] Why take a history from them? And I do a physical exam. But as we’ve talked about, oftentimes that’s interrupted by other people. So sometimes I’ll start a history of a patient and I get most of the information and I’ll start some orders and then I have to see some other patients and I come back to them and gather more information. So it’s much more touch and go. In the video visit. We do everything all in one shot.
Krys Boyd [00:17:57] And you can see the background like how not tidy but how clean a person’s living surroundings are or what they might have access to economically that maybe is not always obvious to you just based on how someone comes in dressed.
Helen Ouyang [00:18:11] Right, Exactly. I get so much information from that, like the state of their apartment, the type of place they’re living in. If there’s family members around that, they’re on their own. So I get so much information.
Krys Boyd [00:18:27] You are accustomed to the frenzied nature of the Presumably there are things about the pace that work well enough for your temperament that you stayed on the job these years. Do you feel differently, though, after a day on a virtual visit shift as compared with a day caring for patients who are physically in the E.R.?
Helen Ouyang [00:18:46] Yeah, definitely. I think when I do these virtual visits, I get a chance to sort of connect more with the patient. So sometimes we’re dealing with issues that aren’t directly medical or something that I can’t really help with because they have seen their primary care doctor or many specialists before. But we just have a connection. And I realize that that’s what the patient needs to just be able to talk through their medical issue in that moment. You know, we’ve all had that where we had some minor symptom. It’s gotten a little bit worse. Then we read something or hear something. And then we sort of panic in that moment. Maybe you try to rush into an emergency room, and that would be frustrating because I wouldn’t be able to help them. And there’s other patients around that are more sick. But since I’ve had these connections on virtual urgent care, I think I’ve been a lot less frustrated in the emergency room or realized that even if I can’t give a patient a medical answer, just be able to talk to them often is enough.
Krys Boyd [00:19:46] You share a really interesting anecdote about a young woman who had, I guess, chronic gastrointestinal issues. And your first thought is, what am I going to do for her that her specialists and her primary care doctor can’t do? Talk a little bit about that encounter.
Helen Ouyang [00:20:04] Right, Exactly. I had a young lady, she was in her early 30s and she had a lot of gastrointestinal issues that her doctors were still sorting through. She had seen, obviously a primary care doctor. She’d seen two gastroenterologist. She had had a lot of testing already, Cat scans, colonoscopies, endoscopy, eyes. And they were sorting through what she had. I think they were getting closer to a diagnosis, but they didn’t know exactly. And she called me with some of the similar symptoms that she’s been having. So nothing dramatically different or new. And at first I was just really struck by like, why are you calling me? I’m a new person. I’m a, you know, a generalist. I’m not a specialist like your gastrointestinal doctor. I’m not going to be able to do anything. Plus, I really can’t, you know, give you any immediate tests. So why are you calling me? So we sort of just talked through her symptoms and I they didn’t sound new and she looked really good on the camera. So, you know, I reassured her. I said, I don’t think she had to go to the emergency room. Obviously follow up with her doctors meant nothing urgent. I needed to be done today and I thought she would respond like probably angry or frustrated, like why did I even waste time talking to you? But she was actually really, really relieved and grateful. And that encounter just really stuck with me.
Krys Boyd [00:21:28] Yeah. You write that you had to think about what she actually needed, and it sounds like what she needed was someone to explain what she’d been dealing with.
Helen Ouyang [00:21:38] Yeah. I mean, she’s been going through these symptoms. She has seen several different doctors. I’m sure they talked to her after each encounter, but maybe not, you know, with each other. So I sort of reviewed everything with her and, like, reminder her what the her tests showed and, like, remind her what her doctors were thinking based on the notes they have written. And I think that’s just what she really needed. I think deep down she knew she was okay. But I think just hearing it from a doctor and having to face, you know, across from her, talking to her and listening to everything was just really what she needed.
Krys Boyd [00:22:18] I don’t mean to minimize at all that experience when I say this. I have some friends in the medical profession and I have leaned on them here and there, you know, made a quick call. Do you think this needs to be taken to the E.R.? What might I do about this? Who might I call about that? And it’s comforting. It sounds in some ways like what you were able to do is is function for this woman as if she had a friend in the medical profession.
Helen Ouyang [00:22:41] Right. Exactly. I think that’s a lot of what we do on virtual urgent care. And I think, you know, a cynic could say, well, doesn’t that drive up health care costs? But I honestly think at least this patient, she would have gone to the emergency room, has not been able to speak with me.
Krys Boyd [00:22:59] Yeah, which is going to be expensive, no matter how minimal her care is in the emergency department.
Helen Ouyang [00:23:05] Right. Exactly.
Krys Boyd [00:23:06] Do you know anything at all about what insurers are willing to pay for these virtual visits as compared with a standard emergency room visit?
Helen Ouyang [00:23:16] Yeah. So, you know, there’s so many different health plans, so every insurer does it a little bit differently. For those people who have sort of like a standard rate that they pay for an E.R. visit. We know that these virtual urgent care visits are less, but a big issue was whether Medicare was going to continue covering these visits. So there was a big spending bill and it would have extended Medicare coverage for virtual care, not just virtual urgent care, but all types of virtual care for two years. But that was recently struck down and they sort of did a compromise where it will be extended till March 31st. So after March 31st, we don’t know what will happen with these virtual care visits.
Krys Boyd [00:24:01] Do you think it’ll be a loss if they’re not compensated?
Helen Ouyang [00:24:05] Yeah, because I think patients really like them. So, you know, there’s been some studies done. So, you know, in 2020, almost half of Medicare patients had at least one virtual visit. And that’s way up from only 77% before the pandemic. So I think patients really like it. In another study, they found that almost 94% of patients who had had a virtual visit were willing to do another one. So patients like it and it’s more convenient for them.
Krys Boyd [00:24:41] There’s something about it that that reminds me of what it must have felt like in the days where physicians made house calls. We can’t go back to that for a whole variety of reasons. But the idea that you can remain in the comfort of your home if you don’t drive or can no longer drive or get yourself around easily, someone in a virtual sense at least will come to you.
Helen Ouyang [00:25:04] Right? Exactly. It does remind me of home visits, especially when I really see patients like lying down in their bed or surrounded by family members. I feel like I’m just right in their homes. And, you know, virtual care has been used in other ways. There’s been hospital at home programs where patients have been able to be hospitalized at home and the doctor can come in virtually. So they’ll have a video and the doctor will come in and then there will be EMS workers or visiting nurses who will be on site. So they sort of get this hybrid experience, but they’re literally being hospitalized right in their homes.
Krys Boyd [00:25:44] That seems like such a good idea. I mean, anyone who would rather be at home than in a hospital but still need some care would surely be up for this.
Helen Ouyang [00:25:54] Yeah, exactly. I mean, oftentimes we hospitalized people just because they need I.V. medications like antibiotics. And honestly, that is something that’s very easily done in the home.
Krys Boyd [00:26:09] Do you think, Helen, that rotating virtual visit duties among your staffers could be a hedge against burnout?
Helen Ouyang [00:26:17] I do think it can be. I know on the inpatient side. So for doctors who provide inpatient level hospital care that has protected them against burnout in some studies. I will say, though, we sort of have a rule where I work that only the more experienced doctors can do virtual urgent care, because on the face of it seems quite easy. Honestly, you have to have some experience with recognizing when a patient just doesn’t look right or they say something that’s a red flag symptom they have to go in. So we’ve been kind of limiting it to doctors who have been working for a few years in the emergency room.
Krys Boyd [00:26:57] I will push back and say to me, a layperson, it does not sound at all easy to do it in either context, but I get what you’re saying. Like it’s like a a certain number of hours of experience caused you to see things in a in a different way than when you were starting out.
Helen Ouyang [00:27:16] Yes, exactly.
Krys Boyd [00:27:19] Did you interact with patients in a different way or do you interact with patients in a different way when you’re dealing with them virtually?
Helen Ouyang [00:27:28] I think I’m more patient with them because I know I have this a lot of time with them. Like I said, they have appointments, so I know those time is their time. The other people waiting there, you know, appointment time hasn’t started yet. So this time is just say for this one patient and I’m not getting interrupted. So I think my interaction with them is much better that way.
Krys Boyd [00:27:55] You obviously don’t have access to all the high tech tests and tools you have in the E.R. Is there one or a couple that you have missed most in these situations?
Helen Ouyang [00:28:10] I think an otascope, which is the look inside the patient’s ear because I think that’s a. You know, some of them like your pain that a lot of patients have. And it’s like very simple and they generally aren’t very sick, but there’s just no way I can look deep inside their ear. So inevitably they end up having to go to in person urgent care or an E.R.
Krys Boyd [00:28:34] That’s really interesting. I was sure you would say, you know, the ability to know someone’s blood pressure or body temperature, but actually lots of people can do that at home. Right?
Helen Ouyang [00:28:43] Right. A lot of people do. They have their apple watches that they can show me at least like a very limited heart tracing, heartbeat tracing. A lot of people have pulse ox detectors now after the pandemic because they all got them during the pandemic. And a lot of people have blood pressure cuffs, as you said. So and even if they don’t have some of those things, I can, you know, walk them through it. I can get their heart rate by, you know, timing it out and asking them to count and doing the math. And just by interacting with them, I can sort of figure out, you know, is their blood pressure really low or concerning.
Krys Boyd [00:29:16] Aside from tests and equipment another thing you don’t have at your disposal is your sense of touch. And you mentioned, you know, walking through, you know, palpating a patient’s abdomen to sort of see how tender it is. But there are also these remarkable studies demonstrating the mere act of being touched in a caring way can be really good for a patient’s prognosis. Is that something you find yourself missing during these virtual visits?
Helen Ouyang [00:29:43] Yeah, I definitely missed out on both those levels. I mean, definitely if I examine the patient, I know exactly what I’m looking for. But yeah, they also missed out on sort of the healing touch. I think there’s reassurance there. I think, you know, just me getting out my stethoscope and listening to their lungs, that can provide a lot of comfort. So they do miss out on that. And that part is irreplaceable. And actually, that was one of the reasons why I was nervous about doing virtual urgent care. I just felt like all of these high tech inner tensions. You know, are they going to undermine the doctor patient relationship?
Krys Boyd [00:30:24] Helen, I can imagine finding a virtual visit much easier than a physical one, depending on the problem, for all the reasons we’ve already talked about. What about, though, for older folks or people who maybe have access to technology but aren’t all that comfortable engaging with it? Did you experience a lot of problems getting things to work so that everybody could see and hear one another as necessary?
Helen Ouyang [00:30:48] Yeah. I mean, I was surprised by the number of older folks who have called in successfully and seem to be able to use their video just fine. Although, of course, that’s like a select group. But yeah, I do think our older patients are potentially being left out. I’ve definitely had some call in with their family members or their family members do all of that and set it up for them and then they just put the patient in front of the video. But you’re absolutely right. I do think there’s a population that is harder to reach.
Krys Boyd [00:31:22] This also seems like something that could make it easier for people who don’t speak the same language as their caregivers. Like maybe there’s a little more time to set someone up with a translator using one of these platforms.
Helen Ouyang [00:31:34] Yeah, we have translator services, so we can just press a couple of buttons and a translator will come on. So that part’s been pretty smooth. And when that fails, I can use my phone. We have a way to dial into a translator there. I just put them on speaker and they translate.
Krys Boyd [00:31:54] Of course, there are going to be times when a particular test that is pretty standard in the E.R. doesn’t necessarily provide much useful information. I wonder if your experience providing virtual care made you think differently about the need to automatically administer certain tests?
Helen Ouyang [00:32:11] Yeah, I think everybody who comes into the emergency room ends up getting some bloodwork, possibly a chest X-ray or something like that, just because it’s there. And we don’t want patients to sort of. Often times if you don’t order anything at all, they walk away feeling pretty unsatisfied. Like, Why did I come here? Why did I wait for hours in the waiting room surrounded by other sick patients to just talk to you for ten, 15 minutes and go back home? So out of reflex, I think we oftentimes will just order it and it’s just sort of become routine. But on virtual urgent care, I have to really think twice about it. We do have access to tests, but the patient has to go and get it. And oftentimes it doesn’t result the same day. So I think very, very carefully if the patient really needs that test and I find myself ordering far less for the same symptoms that the patient could present to the emergency room in which I would have order tests.
Krys Boyd [00:33:07] Did you find patients did a pretty good job of self triaging or did you have people, you know, scheduling an emergency visit after slicing the tip of their finger off like something that presumably cannot be fixed with a DIY thing at home?
Helen Ouyang [00:33:21] I find that in general, patients are actually pretty good, and when they do call for a reason, like slicing their finger off, it’s like they’re pretty reasonable about it. They’re calling because they’re like, should I go to an E.R. or an urgent care and do I have to go like right now, or can I wait a few hours till my babysitter arrives? I’ve definitely had in the beginning some very, very sick patients call and so bed ridden. You know, they they sometimes could have, like, a tracheostomy, like a breathing tube connected to a ventilator. And I was shocked that families were calling in with patients that are that sick. But then I actually realize it’s because it’s so hard getting a patient like that to the hospital. And the family just really, really wants to talk to someone to make sure they absolutely have to go.
Krys Boyd [00:34:10] It’s hard and it can be very expensive. Like if someone has to travel in an ambulance, even for a non-emergency situation, that’s very pricey.
Helen Ouyang [00:34:19] Right. So we’ve had some family members call in with older patients who they can’t get down the stairs for them to get anywhere an ambulance would have to come. So they call to see if it’s possible for me to treat them or if they actually have to go, if it’s reasonable to just wait a couple of days and see how the patient does.
Krys Boyd [00:34:40] Your piece also made me think how useful it would be if there were some centralized clearinghouse to just ask these urgent, but maybe not life threatening medical questions that you often address. I mean, some people have a really responsive primary care physician. Some people may be able to call their insurance company, but not everyone has access to this.
Helen Ouyang [00:35:01] I know that you’re absolutely right. I mean, I think there’s been some startups where you can have a physician sort of function as a I call it like a doc in a pocket or like a friend. And they can, you know, even accompany you to an emergency room or be on the phone so that when you get there, you can ask for sort of a second opinion right away. I know there’s been some companies have tried like nurse triage where you could call in and speak to a nurse. But I don’t know how successful they have been because I’ve definitely heard of some cases that have been mis triaged.
Krys Boyd [00:35:36] Do you think this could turn into a medical specialty all of its own?
Helen Ouyang [00:35:44] That’s a great question. I mean, we’re having our medical students and our resident state do rotate through virtual urgent care with us just to get a taste of it. I really think whether physicians like it or not, you know, this is the wave of the future because patients want it and it’s really getting to a point. They’re expecting it. So whether you really want to be doing these visits or you don’t want to be doing these visits, I think all of us have to get comfortable with doing them at some point.
Krys Boyd [00:36:14] What do you think we can learn from this new openness to virtual medical visits about developing more robust mobile health care delivery systems or things of that nature?
Helen Ouyang [00:36:27] Yeah. So, I mean, I think it’s just showing that there’s a need for this, that patients want it and that they will do it. So I think they do need to be developed more. I think the technology still needs to improve, especially in certain areas where there isn’t good wi fi or people might not be as tech savvy. I mean, I think all of that needs to be developed more, but we just have to do it really carefully and very thoughtfully because we don’t want to roll out anything where patients think that they’re getting, you know, exactly what they need from these tech services because, you know, we can’t do everything on these virtual platforms.
Krys Boyd [00:37:03] One thing that has always fascinated me about emergency medicine is that you might be there for a patient at a truly critical moment in their lives and you might or might not learn the ultimate outcome for that patient. Right. Is that something that you learn to just put out of your mind as a professional? Or are there patients whose lives after the E.R. you remain curious about?
Helen Ouyang [00:37:27] There’s definitely people I remain curious about and I follow them up. So I’ll save them and I’ll follow them up and see how they do in the hospital or see if they have future encounters that I can read about. So, yeah, they don’t necessarily just leave me because they leave the emergency room. And then there’s a lot of patients that I see repeatedly that I know quite well by now.
Krys Boyd [00:37:50] For the ones that you follow up on, is it their particular medical case and the curiosity of that that makes you want to know what happened or is it something about them as people or maybe a combination?
Helen Ouyang [00:38:03] Probably a combination. I mean, usually it’s their medical case, but sometimes I wonder, like, what the patient ended up deciding to do, like what decision they ended up making for somebody who wasn’t sure what they wanted or the family wasn’t sure what they wanted. So it could be all kinds of reasons that I follow them up. But sometimes I just like have a connection with the patient and then end up talking to them, like more than I would expect an emergency room. And I’m just curious if they ended up okay.
Krys Boyd [00:38:32] I’ve been thinking after reading your article as well, that there could be companies set up to do this or maybe some government agency. I mean, you don’t necessarily have to see people who are in your geographic area when you’re doing virtual visits. Do you?
Helen Ouyang [00:38:48] Right, Exactly. So for us, we have to be by where your licensed, and that is determined also by the patient’s location. So I’m just licensed in New York and New Jersey. So if a patient calls me from outside those areas, I can’t see them because I’m not licensed. But there are some startup companies who their doctors are licensed in all 50 states and they’ll see everybody. There’s also some companies where they’re providing care in rural areas. So some of these rural hospitals, they don’t have a doctor on site. So they will telehealth in to a doctor who might be in the capital of that state, who will walk them through what to do, including some pretty complex procedures.
Krys Boyd [00:39:34] So you said you think this is going to continue growing. What do you think are some best practices for physicians doing virtual visits?
Helen Ouyang [00:39:44] Well, I think definitely number one is the recognition that not everything can be done virtually. I think, you know, people can get pretty comfortable in their homes and just want to take care of everything virtually. And there was just some conditions that we just can’t do that and probably will never be able to do to do that. I think definitely some flexibility with the patient and working with them. I think when I do virtual visits and I see their home environment and I see the resources they have, you know, I’m much more likely to make a decision with them that works for them, is convenient for them. Whereas an emergency room, it’s kind of like, well, this is what the evidence says, so we should be doing this.
Krys Boyd [00:40:26] Are there things, Helen, that you learned doing these virtual visits that you have brought back with you to the physical E.R. when you’re doing shifts there?
Helen Ouyang [00:40:36] Yeah, I think definitely just going back to the whole idea of what does this patient really need? I think in the emergency room, I can be in a very quote unquote medical mindset. So what does this person medically need? Like, what is their diagnosis or do they have anything a life threatening? Now, after doing these virtual visits, I’m much more, I think, flexible about why is the patient here? Are they just needing some clarification on their diagnosis? Are they just unable to reach their doctor and just sort of panic about the symptoms? They just need to talk to someone or they’re lonely. So I’ve become, I think, just much more understanding of why a person might show up in the emergency room, even though it might not be for a, quote unquote, medical emergency.
Krys Boyd [00:41:25] I am a great fan of Dr. Google. When I or someone in my family is experiencing symptoms, I wonder what you think about that, the sense that a lot of us have that we can figure our medical challenges out for ourselves and then take ourselves to some health care provider.
Helen Ouyang [00:41:42] I mean, it’s funny because when I first became a doctor, Dr. Google would annoy me because, you know, obviously the patient will Google something and they’ll come into emergency room and they will think they have the most ridiculous diagnosis. But now I actually am much more forgiving and I don’t mind it at all. Patients Google and I like it when they tell me because then I know what they’re worried about. And that allows me insight into what they need and what we need to do during the visit. So it’s actually helpful for me to learn that they Google something, they read something and what their concerns are.
Krys Boyd [00:42:20] Can these kinds of virtual visits work for people experiencing mental health crises when emotionally? The idea of being in an may be a dealbreaker?
Helen Ouyang [00:42:32] Yeah, it’s been interesting when people call in those mental health crises. Well, first of all, as just as you said, going to the emergency room is not very calming. So a lot of times people will have a mental health issue and it’s much easier for them to speak by video. But with that said, when they do have an emergency, you know, it’s not the same as somebody who has, say, abdominal pain that needs to go to an emergency room. And if I tell them to go, they’ll go. Oftentimes, these patients could be resistant to going. And then we have to find another way to get them to seek emergency care. So that could be reaching out to a family member. But that could also be calling 911, which I’ve done before.
Krys Boyd [00:43:16] If we are offered this option as patients, Helen, what are some things we should think about when deciding whether to try a virtual visit first or go directly to the E.R.?
Helen Ouyang [00:43:30] You know I think anybody with chest pain with stroke symptoms, anybody who’s having trouble breathing, they should go to the emergency room. I think a lot of people can benefit from calling virtual urgent care if they’re not sure, because I can talk them through it and help them figure out if they need to go. I think patients also need to be flexible and understand that just because they call into virtual urgent care doesn’t mean I can definitely solve their issue. So to have that flexibility available that they still might end up in the E.R. But what I can’t do because our virtual urgent care is tied into the E.R., is I can help their experience in the E.R. be a lot more smooth and a lot easier so I can put in a referral so I let my colleagues know that they’re coming. I can message a colleague and tell them what I’m worried about. I can look and see the patient volume at each of our emergency rooms and see which one might be a shorter wait. So I can do things that can make their E.R. care more smooth.
Krys Boyd [00:44:39] Dr. Helen Ouyang is an emergency room physician and associate professor at Columbia University and a contributing writer for The New York Times magazine. Her essay in The New York Times was titled “How Virtual Appointments Taught Me to Be a Better Doctor.” Helen, this has been so interesting. Thanks for making time for the conversation.
Helen Ouyang [00:44:57] Thank you for having me.
Krys Boyd [00:44:58] Think is distributed by PRX, the public radio exchange. You can find us on Facebook and Instagram and anywhere you like to get podcasts, you can find us by searching for KERA Think. If you would like to learn about upcoming shows or staff bios or sign up for our newsletter, that’s at our website think.kera.org. Again, I’m Krys Boyd. Thanks for listening. Have a great day.
