Accept the fact that things may not go smoothly. — I think this is the most important thing to remember. Things may not go smoothly every time and that is okay. Often you need to think on your feet and adapt to technology issues as they arise. I used to get incredibly stressed when my headset or mic would suddenly drop out, or the internet connection would become terrible, but once you learn how to adapt to these issues that worry disappears.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewingBryce Dundon.
Bryce Dundon is a physiotherapist based out of Vancouver, B.C. Canada. He completed his Doctor of Physiotherapy degree at Bond University in Queensland, Australia. Over the past few years he has been working in a variety of settings including private practice, clinical Pilates, sport performance clinics, inpatient hospitals, and leading an occupational rehabilitation program.
When Covid-19 hit and clinic spaces shut down he shifted to a Telehealth model of practice and began his own Telehealth company, Flash Physiotherapy.
Outside of work he is a musician and avid gardener working with traditional outdoor gardens and indoor vegetable hydroponic systems.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
My path to becoming a physiotherapist was a bit of an unusual one compared to most. When I first went to university I completed a Bachelor of Arts, majoring in Anthropology. As I was nearing the end of my undergraduate degree, I had a long-boarding accident which resulted in a complex fracture of my leg. I had to undergo a couple surgeries on it over the next few years which lead me to attend quite a few different physiotherapists throughout my rehabilitation process. It was then that I started to become more interested in physiotherapy as a career option, but at that time I didn’t have the necessary education for it.
After graduating, I worked a variety of jobs ranging from a busboy in an upscale restaurant to working in commercial railway construction. After floating around different industries I finally decided to go back to school and focus on something that I had a passion for, physiotherapy. I re-entered the education system as an older student to complete the pre-requisites at a local college, and eventually applied for the Doctor of Physiotherapy program abroad.
My path was definitely not streamlined and some may say I wasted a few years floating from job to job, but honestly, I don’t think I would have done it any other way. I didn’t know it at the time but the experience of working in a variety of industries actually became quite useful when I was running an occupational rehabilitation program.
Can you share the most interesting story that happened to you since you began your career?
The most interesting story happened while I was a student on clinical placement in Queensland, Australia. The hospital I was working at was one of the largest in that part of Australia so you would get a lot of cases flown in from more remote parts of the country.This included prisoners who were injured while carrying out their sentences in the correction system. Often these prisoners would have 1 or 2 full time corrections officers with them at all times, and most were very respectful and compliant with care. However, there was one post-operative patient who stood out.
I was with two other students at the time, and we were doing our rounds among our usual patients on the ward when suddenly all hell broke loose. There were corrections officers, security officers and nurses running the halls and yelling out various commands as alerts were announced on the PA system. Being the newbies on the ward, we didn’t know what was happening. A few seconds later a man wearing a hospital gown, and a post-operative lower limb Aircast ran by as fast as possible and out the ward. We later found out that it was one of the prisoners that had attempted to escape from the hospital. This man had climbed up into the drop ceiling and managed to make it 2 wards away, which is roughly a 100 meters through the cramped ceiling space. After we spoke with one of the nurses, it turns out that he actually fell through the drop ceiling and onto a, luckily, empty patient bed. He was then apprehended out front of the hospital by the corrections officers as he was trying to get into a taxi.
That story is one that I will never forget.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
When I was first starting out after graduation, I had a very intense feeling of “impostor syndrome.” I felt like for whatever reason, everyone else had it all figured out, and I didn’t deserve to be there. I think partly due to my unconventional pathway to physiotherapy.
At this time I was doing locum coverage covering for a more experienced physiotherapist. This is usually incredibly daunting as a new practitioner because this previous clinician knew far more than I did at the time. I expressed to my colleague that I was feeling overwhelmed, and she said to me “sometimes people don’t care about what you know, they just want to know how much you care,” and it truly resonated with me. It helped me understand how empathy, and compassionate care is one of the most important aspects of treating patients. It also eased a lot of the anxiety I was feeling at the time because I truly did care about them.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
Without a doubt, I would not be where I am today without the help of my parents. I was very fortunate to have parents that always encouraged me to continue my education, but never forced it on me.
During my undergrad I was pretty lost, even though I was majoring in Anthropology it wasn’t really something that I wanted to do the rest of my life. I was trying to find my passion in school so I trialed everything from calculus and statistics, to print making, and audio music recording. In hindsight the print making and audio recording really helped give me a creative outlet during a time when I felt lost during my undergraduate degree. My parents may not have thought it was the best use of my time, but they didn’t force me to take a certain path.
After working in a multitude of different industries after graduation I eventually told my parents about returning back to school for physiotherapy. I remember my mom telling me that she was surprised that I even wanted to go back to school to work on my pre-requisites, let alone continue on to do a Doctor of Physiotherapy degree.
Nevertheless they were happy to support me with returning back to school to continue my education.For that I will always be thankful, and I truly know that I am lucky to always have my parents’ support.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Absolutely. First, I want to highlight that Physiotherapy is a broad discipline, so in this case I am referring to private practice physiotherapy. Traditionally speaking, Physiotherapy is a very “hands-on” profession. Many of the assessment techniques that we are taught require hands-on assessment. For example, when we are testing the integrity of a knee after a suspected ligament tear. This is something that absolutely requires having a person in front of you.
There is also the therapeutic effect of the human touch. When we place our hands on someone for clinical assessment there is a sense of trust, and connectedness that helps build a “therapeutic alliance.” The term is common in many forms of practice but in this case it refers to the working relationship between a patient and their physiotherapist.
With Physiotherapy being a very active profession in itself, it does require a lot of observation. We observe compensation patterns, gait patterns and general movement strategies to name a few. These things are much easier to assess when the person is in front of you. For example, if you are assessing someone’s knee range of motion, you can simply observe from one side, and switch sides to observe the other. It sounds very straightforward, but in Telehealth that can sometimes be a challenge.
In addition, there are also quite a few factors that go into the assessment of an injury that often start in the waiting room. When you witness the non-verbal cues, like body language, or facial expressions of someone in a non-formal environment you often get unique information. For example, when a patient with lower back pain goes from sitting to standing, you may notice facial grimacing, breath holding and an overall increased effort level for a relatively simple task for their age and fitness level. This information helps guide you on how much you can assess this person in one session without flaring their symptoms.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
There are definitely challenges that come with communication when the patient is not in the same space as you. One being technology itself which I will go in to in more detail below, but the other is connecting with someone in an emotional sense. As I touched on above, there are a lot of non-verbal cues that we may not have the opportunity to pick up on during a Telehealth session. For example, someone’s facial expressions, their body language or their breathing pattern to name a few. This can affect how we interpret the information being provided to us. Associated with this there is also the natural flow of a conversation with someone, that becomes more difficult when they are not physically present. This natural flow can often end up providing pertinent information on what motivates a person, and what they truly value, that may not come out in the standard subjective interview process.
As I touched on above, one of the biggest challenges is technology itself. It is a brilliant tool and I love it, but sometimes it can drive you insane. It could be issues with your own or your patient’s internet connection, it could be terrible audio quality or background noise, it could be interruptions from patient’s family members, you name it. These challenges can change the way you may normally practice in a traditional clinic.
Specifically, in regards to Physiotherapy there is a lot of physical assessment required in the profession. It requires a lot of movement on the patient’s end which can sometimes be difficult to capture accurately on the patient’s video device. There are obviously ways around this, but it can definitely be a challenge compared to a traditional clinic where you can simply just observe or move when you need to see other aspects of the task being performed.
I have also found that some patients just don’t like doing things through a screen. This could be due to how they learn movement tasks, with some people requiring more hands on cues than others. Alternatively, some just don’t like working through screens. While this may close the door for some patients, those who can adapt to interfacing via screen can gain convenient access to a particular Physio that they would be unable to see in a traditional clinic space.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)
1. Accept the fact that things may not go smoothly.
I think this is the most important thing to remember. Things may not go smoothly every time and that is okay. Often you need to think on your feet and adapt to technology issues as they arise. I used to get incredibly stressed when my headset or mic would suddenly drop out, or the internet connection would become terrible, but once you learn how to adapt to these issues that worry disappears.
2. Always have a back up plan, no matter how many times things go smoothly.
I often fall into this trap. When you have multiple successful sessions with good audio quality, good internet connections and good video, you can get complacent. And that’s when you get blind-sided.
My backup plan now includes having an alternate headset and mic, having my phone and the patient’s phone number in front of me in case of connection issues, and being ready and able to quickly tether my internet connection to my phone if the WiFi drops. If you have the capacity, a good quality Ethernet cable connected directly from your modem to your computer will prevent a lot of issues with your internet connection or WiFi dropping out. Redundancies will be your best friend.
3. The more prepared your patient is for their session, the better the outcome.
Preparation on the patient’s end is incredibly important. I give each of my patients a link that has information describing what a session looks like, and how they can best prepare. Examples include setting up in a quiet space, using headphones with mics, what exercise equipment to have nearby and how to set up their camera to maximize my ability to see how they are doing.
I always tell my patients ahead of time that things may not go smoothly, but we will figure it out and I can help walk them through it. I build in a 15-minute buffer between my sessions for some of my new patients, which, on a good day, allows me to finish my notes, but on a day with connection issues it allows me to troubleshoot with my patient to help them connect, without worrying about running late.
4. Building therapeutic alliance may require you to change how you practice.
I always strive to develop a strong therapeutic alliance with my patients. When performing a subjective interview a good clinician works to find what truly motivates the person in front of them, and discover what activities bring value into their life.
In a traditional clinic you can often gain a lot of information about a person informally through small talk. For example, while you are teaching someone an exercise for their rehabilitation plan, they may mention that they often go for walks with their kids in the forest. That may be an activity that they didn’t include in their subjective interview as “exercise” in their day because they are a high functioning athlete, yet it is an activity that is limited due to their injury and it brings them value and connection with the people they love.
These aspects become more challenging in Telehealth as there is less room for small talk due to the medium you’re working in. You may need to adapt your subjective interview skills, and find a better way to try to get these key pieces of information to identify these high value and motivating tasks.
5. Be available to your patients (if you can), even after your session.
You can increase the value of your Telehealth session by being available to your patients after their session is over. If my patient encounters an unforeseen barrier, having an open line of communication allows us to come up with a plan. It might be just a slight modification in their routine, or spending time addressing a concern. If it requires a re-assessment and complete overhaul of their treatment plan I usually request that we schedule a short follow-up session.
I never want my patients to stop moving toward their goal. If a short e-mail will help someone progress I am more than happy to provide one. Telehealth can make therapeutic alliance more difficult in some ways, but it can also help build and develop a long lasting relationship.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
Of course! I have been waiting for this one. The primary benefit of Telehealth is the ease of access. It has opened the door for people who would not be able to get into a brick-and-mortar clinic because of restraints like geographical barriers, work/life obligations, or physical impairments. For example, I have many new moms who want to get back into activity but they don’t have that option because of newborn child care. I also have patients who suffer from anxiety and don’t feel comfortable in a clinic. Telehealth allows them to get active again.
This ease of access also allows us to work as a “triage.” Often we can identify if an injury requires further intervention just through the subjective interview process and if something like medical imaging is required we can work through the patient’s Doctor to make the necessary referrals. Another advantage created by this ease of access is that we can begin addressing issues caused by an injury early on. Starting the recovery process as early as possible can help insure the injury does not become a long term problem.
Another benefit that I didn’t expect when I started treating people through Telehealth is the opportunity to observe them in their “natural” environment. Whether they are in their home or office you are seeing them in the same environment that they most likely will be performing their rehabilitation program in. You can see exactly what equipment/bench/chair/wall they are going to use, and if they don’t have something you can help them think of other options based on what is available. It also reduces the chance of giving someone an overly complicated exercise, that in reality they can’t perform at home. In a traditional clinic you may work on a skill with a patient but as soon as they get home in a different environment it’s easy for them to forget the nuances of the movement.
I’ve found that another benefit, which can be applied to a traditional clinic but is often neglected, is being accessible to patients after their sessions. A common issue in injury management and rehabilitation is that a 30-minute appointment twice a week is not going to make a big difference if they spend the other 167 hours of the week reinforcing bad habits. Being accessible to people builds a stronger relationship and helps create personal accountability which ultimately builds self-efficacy in managing their condition.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
I use a system called JaneApp, which integrates patient booking, billing and encrypted video conference. It is fully compliant with Canada’s Protection of Privacy Act. Another great feature of Jane App is that it integrates the digital exercise plan programming system, which makes charting far easier by automatically porting over your patient’s exercise plan into their charts.
Another more specific “tool” that is useful for patient education is the screen share function. For those who are not familiar, screen share is when you share what is on your computer screen with whomever you are connected with, so they can see on their screen what you are seeing on yours. For example, I can use an anatomical software on my computer to talk through and educate a patient on the relevant anatomy or structures of their injury. Alternatively, I use a lot of info-graphics and diagrams that I can talk through with patients to educate them on important concepts that are relevant to them.
As I touched on above I have a digital library of exercises that I use to create individualized exercise plans. During a session I may perform and demonstrate the exercise with the patient, and make sure they are capable of performing the necessary tasks. Then, we will screen share the digital library version of the exercise to illustrate what it would look like on the rehabilitation plan that is given to them. These plans include written and verbal instructions with video demonstrations. Many of these digital exercises are great, however the nuances of the exercises may be different, or we may be using the exercise to focus on a different aspect of the movement, so talking through it is incredibly beneficial.
People learn things in different ways, some learn more from actually performing the task, some are better at auditory learning through verbal instructions and some are better at visual cues. Through technology I can use a combined approach so they have access to the type of learning that works best for them.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
For my profession specifically being able to see patients through multiple video angles, like a Google street view of zoom, would be an amazing feature. For example, if someone is performing a lunge I could see 360 degrees around their body to observe the depth of their movement, and if there are any compensation patterns. If motion capture could then analyze joint angles and limb positions to create empirical data, like measuring the hip flexion in a squat between left and right sides, that would be even better.
I know that some of these things exist, but they are not fully integrated into the patient software available, and not many patients would have the means to purchase the necessary equipment. However, with the changes in cell phone technology and the speed that phone cameras are advancing, that technology may be available in the near future.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
Communication is key in the Telehealth format. Being honest about what is working and what is not working with your physiotherapist is far more helpful than trying to tell us what you think we want to hear. Communicate challenges to your treatment plan, even if it’s “hey, I didn’t have time” or “listen, I found it really boring” these are legitimate barriers to your progression. If we can identify these and address them early on, we can keep you going on the right path far more efficiently.
Another thing that people often don’t realize is that they have all the tools required to recover from their injury within them. They may not know what to do, they may not have the knowledge required to understand their condition or have specific fears regarding their injury but all of these aspects can be addressed. This is particularly important in chronic pain patients where education and the gradual progression of exercise is one of the most important aspects of their recovery.
There are, of course, certain circumstances where this isn’t the case, but a good Telehealth physiotherapist would identify this early on and make the necessary referrals.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
I have to admit that I am a pretty big nerd when it comes to technology, and I would be lying if I didn’t say that it all excites me. I think augmented reality could be an incredibly useful tool, but I also recognize that could open up barriers to people that aren’t tech savvy. I would love for a shared virtual space where my patients and I could work together to simulate a traditional clinic setting. A space where I could demonstrate movements through motion capture and my patients could “walk around” the virtual space to observe what they need to do and I could “walk around” them to observe what they are doing.
That being said I believe that things don’t need to be too complicated. Particularly now when social media and advertising often tout these secret exercises, supplements and devices, that are the magical key that someone is missing to recover from their injury. When in reality, things can be simple, straightforward, and effective when properly planned and managed. On the other hand, as people become more accustomed to technology like augmented reality, and it is no longer a barrier, it could unlock a multitude of options for people and help connect us in a virtual space.
Is there a part of this future vision that concerns you? Can you explain?
Like in many other professions, the role automation might play in Physiotherapy is a bit concerning. In an attempt to reduce labor costs, technologies such as artificial intelligence (AI) may start to work its way into our space. But I don’t think the need for skilled clinicians would ever be eliminated and I would always advocate strongly against it, but it is an aspect I think is important to be prepared address.
We also are not able to predict what technology will come in the future and the effects it will have. If we look at technology like social media, it has created a world of self-proclaimed “gurus” that have no proper credentials in the field but have acquired massive followings. Misinformation is easy to get especially when people are self-diagnosing and looking for treatments that they think would be nice, rather than treatments based on informed decisions lead by strong evidenced-based medicine.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
The movement I would like to inspire would literally be to get people moving. Exercise is such an important aspect of a well-lived life, yet many people struggle with either finding meaningful engagement, or finding what is right for them. Everyone faces challenges finding the time to be active in their day, but even small regular bouts of exercise can add up to significant changes. You do not need to change all aspects of your life at once, in fact taking small steps toward being active will make more consistent changes long term. Things do not need to be complicated to be effective, simply pick a starting point that interests you and build from there. If you are particularly lost, or have a condition that requires assistance seek guidance from a licensed medical provider.
How can our readers further follow your work online?
The platform I spend most of my time developing content for is my Instagram which you can find linked below. I try to provide free, pertinent content and education based around fitness, exercise and rehabilitation. I also have a website which I am expanding with regular blog posts.
I am still new to the whole social media world, and I try to do everything myself from the web development to social media marketing to content creation. I love connecting with people and enjoy providing information and insights that they can use in real life.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.