How to be a 3D OD in a 2D ocular telehealth world

There is a scene in the movie Vice when Vice President Dick Cheney, masterfully portrayed by actor Christian Bale, breaks through the “fourth wall” between performer and audience and addresses viewers directly.

Two-dimensional Dick Cheney seemingly pops out of the screen in all his looming, three-dimensional (3D) glory and plops right in the middle of the audience’s viewing room. When the scene concludes, there is no doubt in the viewer’s mind about who Cheney is, what he is all about, and where he is coming from.

It occurs to me that ODs employing telemedicine, especially live video conferencing, can learn a few lessons from stage and screen actors on how to “make it real,” increase the effectiveness of video calls, and have fun during ocular telehealth exams.

Essentially, ODs are performers during every patient encounter, whether we walk into an exam room in-person or our faces appear on a video monitor.

Obviously, we are not trying to act in the sense of “faking it,” but we are trying to project our absolute best selves. By exam’s end, there should be no doubt in our patients’ minds that we are cordial, competent, caring, and there to give them our undivided attention and complete care.

Given the inherent limits of virtual videoconferencing, we should work even harder in remote patient encounters to convey an “in-person” attitude.” A keen awareness of the images and sounds we project and the first impressions they create is foundational to successful ocular telehealth exams.

I have been using ocular telehealth for years both in my Veterans Affairs (VA) practice and my more recent work as an ocular telehealth OD with DigitalOptometrics. The following are a few lessons I have learned along the way that might be useful to other ODs:

1. Set the stage

Pay attention to your “costuming,” “props,” and “production set.”

What are you wearing? Well, hopefully at least khakis, Jake!

While many of us have opted to wear scrubs for in-person exams these days, upping our wardrobe game to include pre-pandemic professional attire (at least from the waist up!), including a white coat, has the potential to better convey the 3D, in-person effect we are trying to achieve in remote exams.

Do your “props” look professional, colorful, interesting, and pleasing? Ideally, you are not simply sitting in front of a blank, neutral-colored wall (or worse, that 1980s wood paneling you have been meaning to replace) with visible clutter or a shriveled potted plant in the background.

My degrees and licenses are clearly visible, but I also have books, pieces of old ophthalmic equipment and eyeglasses, as well as other curios and art to add color and interest to the “stage.” My wife and I experimented with different looks and analyzed still shots from my computer cam until we achieved the look we wanted (Figure 1).

Figure 1: Dr. Brown's home office

How about lighting? Remember, this is not one of those rubbernecking, Brady Bunch Zoom calls with workmates or relatives—patients’ attention is focused solely on you. If you are partially concealed in darkness and shadows like an anonymous informer on 60 Minutes, patients are going to be confused afterward about whether to get their prescription filled or call the authorities.

If your options are limited with your current lighting, check out some of the small, external lights that are readily available to attach to your computer to better illuminate your face and background on videoconferencing calls.

I purchased a small, rectangular one with adjustable illumination levels and use it in conjunction with adjustable desk lamps. My desk is also next to a window—with virtual exams, natural light is your friend.

Beware of “audience disruptions.” Patients will generally forgive a short interruption from a dog’s bark, a child’s scream or giggle, doorbell, or phone ding—but do not push your luck. Try to set up your “virtual lane” to minimize or eliminate such audio annoyances.

2. Get into character

The “opening scene” of a remote exam is key. It is important for ODs start strong and be fully “in character” right out of the gate.

A smile and upbeat greeting, upright or slightly forward-leaning posture, and relaxed, pleasant facial expressions can convey the same empathy, interest, and good intent as an in-person exam—only online, it may be necessary to turn it up a notch or two to get a similar effect.

In a busy clinic where an OD may be going room to room in rapid succession, it is necessary, after closing out one exam, to gather one’s self prior to entering the next exam lane.

It is no different when I practice in ocular telehealth mode except I may go from state-to-state instead! I cannot afford to dwell on the last exam. If I am not able to close out everything on the previous patient, I make a note or voice memo to return to that chart later.

Before connecting, I pause for a beat or two, take some deep breaths, center my mind “in the moment,” and, after reviewing the exam findings, start over in the role of “fresh and eager” OD who is totally focused on the patient in front of me.

By developing this type of “on-screen manner,” patients are more likely to feel your “presence” in the room, flat monitor notwithstanding.

3. Project all the way to the back row

Stage actors’ state-of-the art mics insure they are heard even in the back row, but they are still trained to project the voice, gaze, and essence of their character to the remotest seat in the house.

Whether examining a patient crosstown, cross state, or cross country, it is vital for the patient to see and hear the doctor clearly. Today’s microphones and cameras are generally affordable and provide excellent sound and images, but if it has been a few years since you updated, make sure the quality of what you are projecting is up to contemporary standards.

You do not have to go full on Macbeth (“To see, or not to see?”), but make sure the patient hears you by speaking clearly and with volume. My preference for insuring both doctor and patient hear each other clearly is a wired (not Bluetooth) headset for a more consistent signal.

But you may ask, where do I look when I am talking to and listening to the patient? How do I make sure I give them enough eye contact?

Good questions, and I am still figuring those out myself.

I prefer an external camera mounted on top of my computer monitor and adjusted so that it is level with my eyes; not situated well below like with a laptop—which can give the impression of the doctor “looking down” on the patient. When I look into the camera, or just below it, in most cases, the patient will feel as if I am directly across from them, giving them eye contact.

However, unlike in-person conversation, it is harder to talk and look into the patient’s face at the same time to see how he is reacting. I try to position the window with the view of the patient just below the camera, if possible, so my eye movements that occur between talking and listening are minimized. Also, mounted devices functioning like teleprompters can align the view of the patient with the camera aperture. I have not tried these yet, but I am giving them consideration.

4. Know your audience

Remember: for many patients, your exam will be their first telemedicine encounter. They may hesitate to engage with a face on the screen and be unsure if this is a real conversation unless you “get into character” and “project” as described above. Most will catch on quickly, and soon the conversation will flow.

Some of the more humorous encounters I have had involved misunderstandings resulting from regional differences in accent and dialect! Be aware of those, adjust as needed, look for the humor in the situation, and everything will be fine.

Do not assume some patients are going to be more receptive than others, especially based on age. You goal is to provide good care and impress everyone, but remember if a patient is on your screen, she has, of her own volition, “bought a ticket to the show.” That signifies an openness to and curiosity about the telemedicine experience.

While millennials, as expected, generally rate telemedicine encounters highly, I have been surprised at the number of Baby Boomers and seniors who enthuse over the technology and respond positively to the experience. Across all age groups, post-exam satisfaction ratings are consistently high.

5. Know your limits

As good as a stage or screen performance may be, it is ultimately not real life.

Similarly, ocular telehealth exams are not intended to replace all aspects of an in-person exam. Many situations obviously still require techniques, technology, and procedures that can be performed only in-person.

However, various remote platforms, at this stage, are robust enough to address a wide variety of acute needs and conduct many types of follow-ups. Also, more advanced systems can capably provide a comprehensive exam that ensures an accurate prescription for glasses and contact lenses and a thorough screening to detect significant ocular disease that needs in-person evaluation.

Ocular telehealth’s no- and low-touch models have been a significant boon to ODs and their patients during the pandemic. This trend will, no doubt, accelerate as evidence of ocular telehealth’s accuracy and reliability continues to accrue. Peer-reviewed research is already beginning to demonstrate the high correlation between ocular telehealth and in-person encounters.^1-4

In 2020, ocular telehealth has emerged as a valuable adjunct to in-person eye exams and is becoming a more mainstream option and topic of serious conversation among ODs. Just like previous technological advancements, such as autorefraction and advanced diagnostic imaging, ocular telehealth is another valuable tool to supplement traditional and proven in-person methods.

Knowing the finer points of how to perform virtually will leave patients with a more 3D impression and no doubts regarding who you are, what you are all about, and where you are coming from.

References

1. Maa AY, Medert CM, Lu X, Janjua R, Howell AV, Hunt KJ, McCord S, Giangiacomo A, Lynch MG. Diagnostic Accuracy of Technology-based Eye Care Services: The Technology-based Eye Care Services Compare Trial Part I. Ophthalmology. 2020;127(1):38-44.

2. Maa AY, Medert CM, Lu X, Janjua R, Howell AV , Hunt KJ, Medert CM, Giangiacomo A, Lynch MG. The impact of OCT on diagnostic accuracy of the technology-based eye care services protocol: part II of the technology-based eye care services compare trial. Ophthalmology. 2020 Apr;127(4):544-549.

3. Faits L. Answering the call of teleoptometry. ICO Matters. Available at: https://www.icomatters.ico.edu/spring-2020-answering-the-call. Accessed 9/1/20.

4. Randhawa H, Morettin C, McLeod H, Wyles E, Sanghera N, Kattouf V, Chaglasian M, Messner L. The validity of spectacle prescriptions via tele-optometric comprehensive eye examinations; a pilot study. Invest Ophthalmol Vis Sci. June 2020;61(7):1604.