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In today’s COVID-19 Update, Marsha Redmon, an executive presence coach in Potomac, Maryland, offers practical tips for physicians engaging in telehealth, including how to make sure you make eye contact with patients and using the right equipment.
Learn more at the AMA COVID-19 resource center.
- Marsha Redmon, executive presence coach
Unger: Hello. This is the American Medical Association's COVID-19 Update. Today, we'll be discussing practical tips for physicians engaging in telehealth with Marsha Redmond, an executive presence coach in Potomac, Maryland. I'm Todd Unger, AMA's chief experience officer in Chicago. Marsha, why don't you start by telling us a little bit about who you are and what you do?
Redmon: Yes, thanks very much. So my background is that initially I was a broadcast television reporter, so I have an undergrad degree in broadcast journalism, and then I went to law school. I practiced law at Gibson, Dunn & Crutcher, I was a litigator and I found that it wasn't quite as fun as I thought it would be so I went back to TV news. And then about 20 years ago, I started working mostly with lawyers, but also with physicians and other professionals, teaching them how to communicate effectively in the course of their work. So now in the last year, almost a year, my focus has been completely around virtual communications for professionals.
Unger: That's really a big change in communication, of course. How are you finding that as a challenge, particularly with physicians?
Redmon: Yes, it is challenging. For many professionals, the trick is that we're not used to being on camera, and so understanding the need to translate the way we communicate and the need to connect one-on-one over the camera is the biggest challenge. So as we think of physicians in the course of their work, they're so used to doing in-person communication for the most part that it has been really a drastic sea change.
Unger: Yeah. So this is no longer just the fun part, for your social feeds or anything like this. This is an important part of doing your job well.
Redmon: Yes, absolutely. And really the number one issue that I see, and this holds true across the board for all professionals, but I feel it's even more important for physicians, and that is the need to be able to make eye contact on camera.
I'll say I've had two telehealth visits in the last nine months, both of them were amazing for many reasons, but in one instance, the physician really didn't make eye contact with me. I have to say, I work a lot with lawyers and I find for them too, it's just not natural to stare at the webcam, but that is what we have to do in order for our patient on the other end to feel like we're looking at them. So if I'm speaking to you and I'm looking over here, maybe because I have a laptop with a webcam, and then I have maybe a bigger screen over to the side, which is where I'm looking at charts or other information about the patient, they don't feel like I'm looking at them. It can be really very off-putting.
Unger: And that may not just be an in-person versus virtual syndrome because what you find, if you've been to in-person visits, is there's a lot of work as physicians have to chart through their EHRs, screen after screen, where they're not looking at you. And that's part of a big cause of physician burnout is that physicians are spending so much time behind the laptop and not necessarily face-to-face or even eye-to-eye with patients certainly as much as they'd want to.
Redmon: Yes, and that makes sense. So the takeaway here, I think, is to connect at the beginning. So at the beginning of the visit, as you would in person, you might shake their hand or really look at them and greet them is to do the same thing here, paying special attention to the eye contact so that at the very beginning, they connect with you, you connect with them and you establish that bond. And then later, when you're delivering important information, to connect again with the eye contact.
Unger: Well, let's talk a little bit about the underpinnings and infrastructure that you need to make virtual communication successful. You mentioned right up front that need to have eye-to eye-contact, is there anything that someone should do to facilitate that in terms of their equipment, to start with?
Redmon: Yes, for sure. So the other thing that makes it easier to make eye contact is to make sure that the webcam is in the right place. The only thing you need to remember is that your webcam should be at your eye level. And so if you want to test it, you can put your hands next to your own eyes and then move them out until you hit your webcam. I'd say about 80% of the time, what we end up doing is this because we have a laptop sitting on a desk and so the webcam is way too low, and so it's shooting up at you, which is not the look that we want. Basically, it's shooting up your nose. So, again, it doesn't feel like we're looking at the person or the patient on the other end. So it's important to get that webcam up to eye level, whether it's a laptop or an external webcam, to sit it on books or boxes or whatever it takes to get it to eye level. That can make a huge difference. So the webcam at eye level is the first step.
The next one is to be sure that the webcam has decent resolution. So if you look like you're in a room full of fog, or if it's very shaky, you might need to invest in an external webcam.
Unger: I don't know if the audience has noted, but I have upgraded by webcam, not super expensive to do, a lot of different models out there available on the market just clip right on top of your laptop. And I think it's probably tough because a physician is not just listening and making eye contact, they're taking notes and a lot of times they're typing those notes at the same time, so that's tough to do just logistically isn't it?
Redmon: Yes, for sure. For sure. I think that's one of the benefits of having, if you can have an external webcam that's up higher, and then you have your keyboard down lower. For many people now, and certainly we see it with the kids and the professors that are doing school all day, is people will actually get a webcam that's on a tripod or up at the right level and then end up using basically a little wireless keyboard, which is down on the desk, because none of us want to end up with carpal tunnel syndrome at the end of this. So separating those levels can be helpful.
Unger: See, I learned all these important lessons from my 20-year-old, my Instagram advisor here, on proper camera angles. But there's also one other, very key thing which you talk about is lighting, so let's talk a little bit about that.
Redmon: Yes, for sure. So again, if your webcam is not the greatest resolution, you can sometimes compensate by having better lighting.
Now, the reason this matters, and I think many of us may know this in the back of our minds, but I want to bring it out and spell it out, which is, again, for our patients to feel like we're looking right at them and we're connecting with them and that we form that immediate bond of trust or re-establish that bond of trust. They need to be able to read our expressions, and so that means they need to be able to see our faces clearly. So see our eye contact and read our face, that requires light, and so many of us don't have enough light or we have too much light.
So couple of easy hacks, one, is to simply use any kind of desk lamp and bounce it off of the wall in front of you. So that will soften the light so that it's not too bright and it will make the color of the light better as well. But you can bounce it off of the wall in front of you and then it shines on your face.
What a lot of other professionals do sometimes, if they have an external monitor that they've attached to their laptop, you can put that behind your laptop and elevate it and then just that white screen of the monitor will shine on your face over top of the webcam. So that can illuminate your face very nicely without having to go and get extra equipment. Of course, if you want to, you can always get a ring light on Amazon, which is a relatively small light that's powerful, and you can shine that right on your face.
One last thing I'll say about lighting, a big mistake many of us make is we have light behind us that's shining toward the camera. That's a big no-no. What that does is it causes the camera to think that that's what's important and then it makes your face very dark, and so your patient then cannot read your expression or see your face because suddenly now it's hard to see you.
Unger: Yeah. It's like having a conversation with someone facing the sun, it's just really hard to focus on that. Again, that's important in any kind of video or photography, and I definitely recommend the ring light is a great solution to that. Do you recommend also that people have a fixed setup so that they don't have to like scurry every time they want to have a video conversation?
Redmon: Yes, that makes it much easier because then you've handled all of the parameters. So you've dealt with your camera angle, you have your lighting setup. For example, what I see a lot of people do is at certain times of day there may be a window behind them or next to them, and so bright light shines in sometimes and then sometimes it doesn't. So that can be very disconcerting to show up all of a sudden, need to be on camera, need to do a video call, and suddenly the whole situation looks different but you're not sure why. For some people, they may have two locations in their house, both of which they've set up, depending on the needs of the family. But if each situation is rather nailed down, then they'll always know that they can show up and do what they need to do.
Unger: How do you feel about these virtual backdrops versus just showing what's behind you?
Redmon: I have a really strong opinion. A lot of people may disagree with me, but I find, in most cases, the virtual backgrounds are very distracting because they're not effective. If you move your arm forward or back, if you shift from side to side, parts of your body disappear. Your ears can disappear, your shoulder, your arm. I personally find that to be very distracting.
One thing that is helpful, and this is showing up on more platforms, sometimes you're able to do something called blur. What that does is it blurs your background, so it's not replacing it with an image which is much harder on your computer and doesn't work as well, but instead it blurs the background, which I find tends to work a little bit better. My preference is to try to simply make the background behind you a little bit less distracting.
Obviously mine is a little bit like a set because I do virtual workshops all day. But for all of us, the goal is really to declutter a little bit or simply to get more space between your back and whatever's behind you. So if I had a bookshelf with a lot of books behind me, if I were able to get an extra foot or a foot and a half between my back and the bookcase, it would help my patient to have their focus on me and not be sort of leaning in and trying to read the books on my shelf, which many of us have had that experience as we've been on camera, is whatever's behind us is a little more interesting than whatever we're doing. So that's a simple solution to managing your background.
Unger: I'm glad that you had the opinion that you did in terms of the virtual backgrounds. I agree with you 100%, they are very distracting to see that digital imagery every time someone moves. I tend to, when we talk to guests here, to keep it very simple in terms of the background. I'd rather have just a solid color wall than a lot going on in the background. And just for purposes of recording here, this is an actual wall sticker that, unfortunately for my daughter, I have applied to the wall in her bedroom. So she has AMA wallpaper. But the real thing does tend to work, and that's not just an outrageously expensive solution. If telehealth is going to be incorporated as a daily aspect of your practice that it makes sense to invest in something that's a fixed place and you can just sit down and look great, sound great and be able to do those things that you're talking about in terms of having quality eye contact and not a lot of distraction.
Also, you coach folks on presenting as professional and credible during their telehealth encounters, what else do you see typically or recommend?
Redmon: Yes. So another thing to manage is the noise, any background noise as well as your own audio. So to choose a place in your house where you have as much control over noise as possible.
The other thing I recommend if you do have a situation where there might be noise, whether it's street noise, or a pet, or a child, dogs that bark when the mailman comes, is to consider using a headset. So the headset that I'm wearing covers both of my ears, which is really helpful because I'm a person who's very easily distracted, and so while I'm talking, I don't want to be distracted by the noise in my environment. And then the microphone is a noise canceling microphone, and so that means even if there is a loud noise here at my house, my audience won't hear it. So that gives me a lot of comfort because like you, I am sitting here all day doing things like this and so I know I don't have to worry that much about the noise.
Unger: What about clothes? I know that, for instance, here, I don't wear a light gray jacket ever on the screen because I just will blend right into my background there. You don't ever want to be wearing green screen outfits either. Are there any things that you particularly recommend in terms of clothing?
Redmon: Yes, color is something to think about. So sadly, there are sometimes issues, especially if your webcam doesn't have a really great resolution, there are issues with wearing white. So I know doctors often wear white lab coats-
Unger: That is a problem.
Unger: That is a problem.
Redmon: So in many cases it's fine, but in some cases it's not. So the thing to do is check, see how you look. You can even take a screenshot of yourself while you're on camera in a telehealth situation, or have someone on the other end, maybe someone who works with you, take a little video or take a screenshot so you can see how it looks. I recognize, and I would normally say, wear the clothing that you would wear if you were meeting in the office, but white can be problematic.
Having said that, I would say that the other thing to avoid is large contrasts in color. So a black and white striped shirt, or black and white polka dots or something like that because there's so much contrast it can cause the camera to almost shake. So as far as colors go, that would be my recommendation. And then beyond that, to look professional but to dress in a way that makes sense given the context.
Unger: So you mentioned, of course, right up front, about eye contact. Are there any other visual cues that patients pick up on that you want to make sure to focus on during that conversation that keeps the personal connection active?
Redmon: Yes. So the eye contact piece, as you mentioned, is crucial, recognizing that the physician does need to take notes and do those things that she or he needs to do. But certainly at key moments, to stop doing the writing or the typing and really focus and connect with the patient, whether it's when you're delivering specific news or when you're delivering the key thing that this person needs to begin doing, or you need to make sure that they understand to be able to make the eye contact, maybe pause for a few moments so that you know you have their attention and to modulate the voice.
So one of the things that we find for all of us in these situations, and I know it's especially important for physicians, is to have that energy level that connects with the patient. So the first piece, of course, is the eye contact, but the other piece, the piece that really communicates energy and care is the voice. So when we're in person, much of that energy level and that sort of connection comes from the body, but in the virtual situation, it's much more about the voice. So all of you as physicians are good with your voice, I'm sure you all do a fair amount of work on the phone, and so the things that you do on the phone to connect are the same things you want to do with your voice in this telehealth situation. So a conversational tone, to have warmth in the voice, which often includes a variation in pitch, and to really have that care and connection that you really are communicating through the way you use your voice. And for a lot of us, smiling, breathing for a moment and really looking at the patient can help us to do that.
Unger: That's really important because, like we talked before this, you can really only see a very small portion of me so, so much is reliant on voice and just facial expression. That's the limited scope of what you would get on camera.
Moving on from the physical stuff, when we talk about the communication part, so some of that stuff can be pretty complex and complicated. What recommendations do you have for physicians to communicate particularly complex things virtually?
Redmon: Yes. And this is the same advice for all of us, it's challenging, the most important thing is to be clear yourself as the physician what are the key things you need to communicate. So as you think about this patient, as you think of the advice or the information you need to gather, and certainly at the end, the takeaways, "Here's what you need to do after this appointment," is to be very concise and very directive. Really to make bullets and almost to deliver it in a bulleted sense, and then to check in. Which in person, we can read their body language, we can see on their face, in person, if they're confused, or if they're not agreeing, or if they don't look like they're going to do it when they leave. In this context, it's harder to read. That's one of the reasons why it makes sense, if possible, to try to get the patient to move closer to the camera or to turn a light on, to do something so that you can see their face clearly, in addition to making sure that they can see your face clearly so you can read them.
I also recommend that you use what I teach, which are called signal phrases or signal words, to say things like "Here's the most important thing for you to remember after this appointment," pause, and then give them hopefully one short declarative sentence. Or, "There are two things you need to start doing once we finish this appointment," pause, "The first thing is," blah, blah, blah, pause. "The second thing is, you may want to write this down." Again, not in a way that's demeaning, but just to say... And you can even say, "This doctoring by video call is new and it may feel a little bit awkward, and so I'm going to be very clear and give you specific things to write down."
Unger: It's interesting because those are interesting adaptations, listening to you talk, some of those things obviously would be helpful in an in-person setting too, but you do have to adapt yourself to how people are interacting normally with computers, which even in communication, when I talk to folks that I work with, it's like you get one sentence in three bullet points is what I always tell them because people have moved on to the next screen by then. And it's funny to hear you basically saying simplify, bullet points, remind people, have them take notes. All those things are around them at this point, and they can do that rather easily.
Redmon: Yes. Yes, it is easier in that sense. Also, one thing that I would recommend, and I've seen this from my own experience with my father, is to say, "Are there others in your house that you'd like to join us on the appointment, only if they want to of course, but someone else who could write it down or having a second set of ears?" Since it is a virtual appointment, that's much more possible perhaps than if it were an in-person appointment. So maybe it's a teenager, maybe it's a grandchild or someone else who's in the house who can listen, who can take notes. That second set of ears can really make a difference, especially in those cases where it might be upsetting or new information. Sometimes the brain doesn't let information in if there's emotion involved.
Unger: I don't know, in terms of privacy rules what kind of complications are, but I guess you would have to ferret that out in advance, so to speak. I mean, it kind of gets to something that I want to ask you about for really difficult conversations, and physicians have a lot of those with their patients, is there anything additional to keep in mind?
Redmon: I would say there's even more need to be very clear and very concise and to have those phrases at the ready. Some people like to warn people and say, "I have some news that may be hard to hear, but we have a plan," pause, and then deliver the information. It may be in those cases, and I suspect a lot of physicians do this already, is if they know they're delivering tough news or complex news, they may suggest to the patient that they may want someone with them during the appointment as support and also as another set of ears. But certainly, again, as I mentioned a moment ago, and I've seen it in our own family, when the news is complex or it's scary or bad in a sense, it's often hard to hear and remember what you heard. So it's great to have another set of ears and certainly to have people around for support.
Unger: Well, one thing we didn't talk about earlier, and it's a real issue because we can't just assume that everybody's got high speed broadband connections, what do you do about connectivity? That could really throw a wrench into a video conversation.
Redmon: Yes, for sure. I would always recommend that the physicians make sure that they have a phone number. So in case the internet connection is problematic, in case the video call is dropped, to know in advance that this is the right number, that this is the number that this person can be reached on. Typically in most cases, of course, someone's mobile phone is different than their internet connection and so they would still be able to get through.
The other thing is, if they feel like doing it, the physician could try to troubleshoot a little bit and say, "You know what, why don't you close out the call and then log back in." Many times that will solve the problem. But having that backup phone number really makes a difference.
Unger: Well, last question here, we have talked to some educators about how they're starting to build training in about telehealth into their education and training programs, but for physicians that want to get more information on how to implement best practices in telehealth what are the first steps?
Redmon: Sure. So I would always say, and certainly with all the clients I work with, the first steps are to find out what are the questions? What are the challenges? So to really survey the audience, whether it's a group of hospitals, a group of doctors, find out what they're doing, find out where the challenges are. And then it always makes sense to do some sort of training, and of course it could be virtual, around best practices. Having surveyed their specific environment, then to be able to give specific best practices and even to do what I like to call checkups, oddly enough, to work individually or in small groups to work on the virtual persona and run through that checklist one by one. And to fix the lighting, fix the camera angle, the audio, all of those issues. It's a pretty quick process, but then each of the professionals knows it's been handled.
Unger: Do you do workshops on your site? Or how do you do this at scale?
Redmon: Yes, I do. So the easiest way to get in touch with me is to go to my website, which is my name, Marsha, marsha.com, and my easy email-
Unger: You have marsha.com?
Redmon: I do. Isn't that funny?
Unger: Wow. You must have been in early on that domain.
Redmon: Literally the first day I went on the internet, I bought my name.
Unger: Good for you. I wasn't that smart. Well, that's fantastic. There's a lot to learn, and physicians obviously have years and years of training, and I don't think they expected when they went into this that doing a great virtual call was something they'd have to add to their list. So this has been really fun, really interesting, really practical and helpful, so thank you so much for being on the COVID-19 Update with us today.
That's it for today's update. For more information on COVID-19, visit ama-assn.org/COVID-19. Have a good day.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA