Video consultations FAQs for clinicians

The Covid-19 pandemic limits face-to-face contact. Video consultations can be a useful
alternative and are appropriate for some patients, some of the time. These questions may
help you with the decision.

a) Is it likely to work for the patient?

i) Does the patient find it difficult to attend the appointment in person (for example,
travel costs, carer duties)? If so, they may be highly motivated to make the video
option work.
ii) Does the patient have access to the appropriate technology and, if necessary,
support? Even when the patient is not confident in using video technology, a carer
or relative may be able to set it up and get them started.
iii) Are you confident that the patient will have adequate privacy, and if not that they
are happy and comfortable with that? (It may be appropriate to ask them where they
plan to receive the video call and who might be in the room.)
iv) Does the patient or their carer have concerns about attending an appointment via
video? Reassure them that they are not being discharged from your clinic if they have
a video consultation. Some patients may be more willing to try a video consultation if
they know that they can choose to return to traditional consultations in the future.
v) Is the patient fluent in English? If they need a health advocate you may need to invite
both the patient and the advocate to the video call. They may prefer to use a family
member – will that be appropriate for the consultation?

b) Is it likely to work clinically?

i) Does the patient need to attend the appointment physically? Do you need to examine
them at that visit? If not, consider video follow up
ii) If a physical examination is needed, could the patient do this themselves or with
assistance from a carer? For example, do they have the equipment and skills to take
their own blood pressure or weight? Have they or their carer demonstrated this
to you?
iii) Will a remote assessment of the patient provide you with sufficient information
to support the key clinical decisions and actions that are likely to emerge? This is
a question of clinical judgement – there are no hard and fast rules. You may wish
to discuss particular case scenarios with colleagues who are experienced in video
consulting.
iv) Do you need to demonstrate a procedure or show the patient how to use a device?
And if so, will this be possible using a video connection? For some patients it may be
better to explain the procedure to the patient in clinic before attempting a first video
consultation.
v) Does the patient have to attend in person for blood tests, testing, et cetera?
If so, might the results be shared via a video appointment timed when the results
are available

c) Would the patient prefer a video consultation?

i) Research shows that where video consultations are an option, patients want to
have a choice of whether to consult in this way. Ideally, the decision to have a video
consultation should be shared between you and the patient, taking account of the
clinical needs of the consultation and the patient’s wishes.
ii) For first time patients, provide them with an information leaflet or a link to an
instruction video that explains what video consultations are and how they work.
Make sure that patients have adequate time to consider whether they want a face-toface
or video consultation.
iii) Make sure that the patients understand that the video consultation has to be
scheduled in the same way as a face-to-face consultation, and that they will not be
able to use video to talk to their clinicians outside their appointments.

As with any new technology, there’s a learning curve. Here are some ideas for how to
improve and build your confidence.

a) Do I need to familiarise myself with how a video consultation happens?

i) Get to know the technology that is used in your clinic. There are many different
platforms (for example Skype, Microsoft Teams, Zoom, Attend Anywhere. Your clinic
will probably use just one of these, and will have some instructions on how to set it up.
ii) If possible, shadow another clinician (with the patient’s consent of course) to see a
video consultation in action.
iii) Understand how the consultation is going to work from the patient’s perspective.
For example, the patient will probably have been sent a letter or email containing a
link and joining instructions. You will be more confident playing your own role if you
understand how the patient is going to connect with you.
iv) Be aware of governance requirements, for example, the processes for gaining and
recording patient consent

b) How do I test the setting and adjust the technology before the actual consultation?

i) Find out which room you are likely to be using. Ensure that there is adequate privacy
and check everything that will fall within the patient’s view. For example, if you will
be consulting from a back office, consider whether the patient could catch sight of
‘messy’ areas. If you share an office, make sure you won’t be disturbed. Adjust the
light so you can be seen clearly.
ii) If possible, make sure you have two screens (for example dual monitors, or a
computer and a tablet). This way, you will be able to consult the medical record on
one screen while consulting with the patient on the other. Using two screens has
the added benefit that the patient knows whether you are looking at them when
you are looking at the screen. If you have only one screen, you can still minimise the
consultation screen while you access records and test results, if this is applicable.
iii) Laptop and desktop speakers can sometimes create a feedback loop, causing audio
distortion for you or the patient. If possible, use a headset. This provides better
quality audio, while also cancelling out possible background noise that can cause
interruptions for you or the patient.
iv) Test the video call at the start: make sure that the audio and video are working well
and check if any automatic updates have been made to the software since you last
used it. All of this can disrupt the clinic if not checked before the start (this is similar
to making sure that the consulting room is suitable for the clinic at the start).
v) If you are using a webcam fastened to the top of the computer screen, make sure
it is attached to the centre of the computer. This way you will be looking directly at
the patient as much as possible, and the patient will recognize more easily that your
attention is directed at them.

Inform the others in your team (or at home if you are working remotely during the Covid-19
pandemic) that you will be conducting one or more video consultations (at least when you
first start), so people don’t enter the room during the consultation or allocate the room to
something else assuming you don’t have a patient booked.

Many aspects of video consultations are similar to traditional face-to-face ones, but the first
few seconds are very different because you need to make the technical connection. This can
be daunting, but once you’re ‘in’, things will become more familiar. Here are some tips:

a) How do I call the patient?

You need to do the virtual equivalent of calling your patient into the consulting room.
Depending on which platform is in use in your clinic, this will happen in one of two ways:
i) You may need to call the patient directly – for example by clicking on a hyperlink in
the electronic record.
ii) The virtual clinic may have a ‘virtual waiting room’. If so, you should see your patient’s
name there. Just click on it. If the patient’s name doesn’t appear, this probably means
they haven’t ‘arrived’ yet. Try again in a few minutes. Make sure you connect with
the correct person. There may be many people in a waiting area depending on the
software you use and some patients may have a similar name (like in a “real” waiting
room). Check the date of birth and other details before you click on their name and
start the consultation.

b) How do I start the call?

When you connect with the patient via video, you will probably find that the initial
discussion is all about the technology as you both confirm that everything is working well.
You’ll find yourself saying things like “can you hear me?” or “why can’t I see you”. If there’s
a technical problem (for example you cannot see or hear each other) try these suggestions:
i) Test if the patient can hear you by calling their attention (for example say “Hello” as
you might on the phone)
ii) Type a message to the patient using the text-based chat window of the consultation
software (or see if the patient has sent you a message).
iii) Contact the patient by telephone.

c) How do I start the consultation?

Once you have established the technical connection (you need to take and record consent
at the start of the first consultation), you need to shift out of ‘set-up’ talk and into your
more familiar consultation talk. Here are some ways you might do this:
i) If this is the patient’s first video consultation, it might be appropriate to try to put
them at ease by saying that from this point on, the video consultation is much like
a face-to-face consultation. You could ask the patient if they’ve got any questions
about how the video consultation is going to work.
ii) If someone has been helping the patient get set up, now is probably the time to
suggest that they might leave the room. As in a traditional face-to-face consultation,
it is the patient’s choice who sits in on their consultation. In a face-to-face
consultation, you can often use body language to convey to the relative that it’s time
for them to leave. In a video consultation, you may have to make this suggestion
explicit. Of course, if the patient wishes their relative to stay in the room, that’s fine.
iii) Once you’ve established a connection that is (as far as possible) private, you move the
conversation onto the clinical phase in the conventional way.

Research shows that once the technical aspects of set-up are completed, video consultations
tend to be remarkably similar to traditional face-to-face ones. This guidance doesn’t cover
the clinical aspects of consulting (which you’re probably very familiar with), but here are
some areas where things may go a bit differently.

a) How do I convey to the patient that I’m engaged and interested in them?

i) You do not need to look directly into the camera on your computer, tablet, or phone.
Looking at the screen is sufficient for the patient to know that you are engaged in the
consultation.
ii) Because webcams tend to provide only a limited view, the patient may not be able
to see when you are making notes or looking at medical records. It’s a good idea to
tell the patient when this is the case (for example “If I’ve gone quiet, it’s because I’m
writing”,) to reassure them that you are still engaged in the consultation.

b) How do we know whose turn it is to talk?

Sometimes it can be hard to tell whose turn it is to talk during a video consultation.
This is usually due to delays in the connection. When this happens:
i) Stop talking, acknowledge the problem with the patient, work out whose turn it is,
and then continue.
ii) Making the problem explicit, and flagging it as technical (for example “The Skype cut
out briefly!”) will help to reassure the patient that they haven’t spoken out of turn.

c) What happens if there’s technical interference?

Video consultations can suffer from technical interference, for example due to a busy
network or problems with latency. This can result in garbled talk, or blurry or frozen faces
on the screen.
i) Having a good connection and equipment helps, but otherwise there may not be
much you can do to change this. Be aware that some video consultations may turn out
to be less fluent than a face-to-face or telephone consultation.
ii) You may need to repeat things or ask for clarification more often. If there’s been a
technical glitch, a good way to resume the consultation is to repeat the last thing you
heard (or said).
iii) It may help to make the technical problem explicit and give the patient some signals
that you’re shifting from clinical talk to technical talk and back again – for example:
“What you said just now was a bit garbled” and (after you’ve fixed the problem),
“I can hear you now. What were you saying about your tablets?”
iv) If you are exchanging safety-critical information with the patient (for example about
medications or dosages), especially when there are technical problems, it’s a good
idea to ask them to repeat the information, to confirm you both have it correctly.
You will most likely write to them about any change in medication anyway.

Conventional thinking is that physical examinations are impossible via video link, but
research shows that it is sometimes possible to undertake a limited physical examination,
perhaps with the aid of the patient, carer or other third party. Here are some tips:

a) How should I prepare for doing a physical examination?

Whilst not all physical examinations can be predicted, some can. If you are planning to
do some aspect of a physical examination, inform the patient in advance and provide
instructions on what they will need to do. For example:
i) Take particular care to ensure that the room is well-lit and the patient is not in
shadow.
ii) Make sure any equipment is in working order and that the batteries work.
iii) Ask the patient to use indirect light if you need to examine something on their body.
If they shine a light directly on the skin, this may make it hard to see anything, as a
result of overexposure.

b) How shall I respond if a patient suggests a physical examination?

Be open to the patient suggesting that they would like you to do some kind of physical
examination, and discuss in advance whether it is feasible in a video consultation that they
perform the examination. As you know, physical measures such as taking the pulse have
symbolic significance and may be linked to patients’ expectations. You may both need to
be creative to work out if and how the desired examination can be achieved in the virtual
environment.

c) How can I help a patient to do their own examination?

When the patient is doing an examination (for example taking their own blood pressure or
checking their ankles for swelling):
i) Don’t rush them. Remember that the patient is probably not a medical expert, so it is
likely to take them longer to do the examination than you would take yourself.
ii) When you explain a procedure, make use of video to show as well as tell them what to
do. Demonstrate the procedure on your own body and (if relevant) us a duplicate of
any equipment, so that you can say things like “Hold it like this”.
iii) Whilst the patient may be very knowledgeable about their own condition, they
may not know the medical terms that you use. Try to provide descriptions using
everyday language (for example call it “the blood pressure machine” not “the
spyhygmomanometer”). Alternatively, refer to the equipment by its function or what
it looks like (for example “the little oxygen clip”). Better still, listen for the word your
patient uses and use the same word.

d) How can I make use of a carer or other third party?

Think carefully about how you will make use of a carer or other third party. Remember, this
is not their consultation but they may be key to getting the examination done. Here are
some tips:
i) If the examination is likely to involve moving the webcam to visualise a part of
the body other than the face and chest, another person may be needed to do this
repositioning. It may be appropriate to ask the carer to leave the room once this part
of the examination is complete.
ii) Even when someone else is available to help, patients may want to do as much as
possible themselves. Make sure you give them ample opportunity. If you think the
patient requires assistance, ask them if they want to have the carer help them out.

e) Shall I provide feedback for the patient?

Provide feedback on how much of the examination you can see and how clearly.
i) The patient and/or carer may have difficulty showing you what they are doing. You
can help by explaining how they can best use their technology (for example if they
have a tablet, use the camera on the back) and by telling them what you can see.
ii) The view may be too bright, making it hard to see the patient. If this is the case, ask
the patient if they can avoid having a light shine directly on them and use natural light
(for example from a window). Webcams are very sensitive to overexposure.

The final moments of a video consultation are usually very different from a face-to-face
one. In the latter, you would probably stand up, shake hands and accompany the patient to
the door. In a video consultation, you need to find other ways of achieving closure. Here are
some ideas:

a) How do I indicate that the call is ending?

i) Once the main reason(s) for the consultation have been addressed, you can ask the
conventional questions that indicate that the consultation is coming to an end (for
example “is there anything else you want to ask?”).
i) It may or may not be appropriate to ask the carer or third party if they have anything
to add. Indeed, it may be appropriate to suggest that the carer may leave the room at
this point to give the patient the opportunity for some confidential time with you.

b) Shall I summarise the consultation?

To reduce the chance that something is missed as a result of technical interference, it is
useful to summarise the main points of the consultation before ending the call.

c) How do I end the call?

i) To close the clinical phase of the consultation, follow your standard approach. For
example, you might say something like “When shall we book the next appointment?”.
ii) After you’ve achieved clinical closure, you can close the consultation by providing
conventional greetings (for example ‘okay, bye’) or waving, and then turning off the
video.
iii) Remember to complete your record-keeping in the usual way and (at the end of the
virtual clinic) switch off the technology.
iv) Arrange follow-on actions such as letters, blood test forms, referrals and make
records accordingly. Sometimes, your own input to these follow-ons may be greater
than it would normally be in a face-to-face clinic. For example, you may need to pass
some administrative actions to a clerk because the patient was not physically present
to queue at the reception desk.

If you’ve got this far, you have probably conducted one video consultation.
Congratulations! This short section is about reflecting on your experience and considering
how to take it forward.

a) What key points can I learn from in relation to the patient?

i) After your first video consultation together, you and your patient may decide to do
the next consultation face-to-face or via video. Revisit the advice given in the first
section of this guidance – you now have a lot more information to help you decide if
video is the right choice for this patient.
ii) Take note of the patient’s views. Just because you felt the consultation went fine by
video doesn’t mean the patient found it fine. Make sure you convey to them that
(subject to clinical appropriateness) it is their choice whether to continue this way.
iii) If the consultation could have gone better with a third party present, suggest this to
the patient – they may be able to arrange for a relative to be with them next time.
iv) Keep the dialogue open. In some cases, it works for some appointments (for example
annual reviews) to be done face-to-face, some interim ones by video, and additional
face-to-face appointments on an as-needed basis.

b) What key points can I learn from in relation to my own video consulting skills?

i) As with any technology, you will get better and more confident over time.
ii) Talk with other clinicians about the clinical and technical challenges you’ve
encountered in video consultations. You will learn lots by sharing these stories.
iii) You might want to reflect on, and write up, your experience for your annual appraisal.

c) How can I continuously improve the video consultation service in my department and organisation?

i) Your team may wish to formalise the sharing of stories about video consultations
that went well (and badly).
ii) Capture evaluation data. Make sure that patients are able to provide feedback
after their consultation in which they can share their experiences.
iii) Any video consultation that led to harm or a ‘near-miss’ needs to be treated as
a significant event; follow the agreed procedure that is in place for such events.
Where appropriate, notify the technical provider of the (anonymised) issue.