It is very important to be cognizant of the patient’s setting. Are they at home? Or are they at work? Are they alone or could there be other people off-screen? I always ask about the level of privacy they have and if there is anything that could impact information exchange.
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 interviewingDr. Sanjiv Shah.
Dr. Sanjiv Shah is the Chief Medical Officer of MetroPlus Health Plan, New York City’s Health Plan. Dr. Shah completed his internal medicine residency at Mount Sinai Medical Center and is board certified in Infectious Diseases. He completed a MPH in Epidemiology at the Mailman School of Public Health of Columbia University. He also sees patients at Gotham Health Gouverneur situated in New York City’s Lower East Side.
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?
I was born in Tanzania, East Africa. My Dad practiced Family Medicine. We moved to England in the 1970s and I did my medical training at the University of Nottingham. I was interested in Infectious Diseases and, by chance, I met an American physician who was doing an externship in England who was instrumental in my moving to America, specifically NYC. I completed my ID training in the Bronx at a time when the HIV epidemic was at its peak. You understood very quickly how socioeconomic factors were inextricably woven into the fabric of the epidemic and it is very interesting that we see exactly the same thing today when it comes to COVID.
Can you share the most interesting story that happened to you since you began your career?
I was doing ID full-time in the Bronx and taking courses for my MPH degree at the same time. Juggling the two was proving difficult and I was looking for a part-time clinical opportunity. A colleague at NYS’ AIDS Institute told me about a part time job to work as a Medical Director at an HIV Special Needs Plan (SNP). I found out that NYS had initiated a demonstration project to create 3 HIV SNPs in NYC as people with HIV and Medicaid required extra care coordination to access care with HIV specialists and, most importantly, achieve adherence at the high levels necessary for HIV treatment to be successful. This part-time opportunity was at MetroPlus: That’s how I made an unexpected career change into managed care 17 years ago.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
A wonderful politician friend of mine from England was fond of telling me that “optimism is the fuel of progress and pessimism is the prison we lock ourselves in” and I must say it has been the best bit of advice I have ever received. He was also a great encourager and he did not shy from an uphill battle.
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?
During my residency at Mount Sinai Medical Center, we rotated through Elmhurst Hospital Center in Queens, NY. It was the best clinical experience of my life and solidified my decision to pursue training in Infectious Diseases. The Associate Medical Director at the time was Joe Masci. He ran morning report where residents presented the overnight admissions. He was a clinical maven but what was most influential was his understanding of the socioeconomic impact on health outcomes. He imbued me with this understanding. Joe is still at Elmhurst and is now helping NYC Health and Hospitals as it leads the fight against COVID in NYC.
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?
Aside from the ability to conduct a physical exam, a patient’s body language and demeanor are much easier to discern in-person. A great deal of clinical acumen stems from this direct observation. Also, I recall from the earlier days of the HIV epidemic, how important it was for patients to have a personal interaction to address the stigma and isolation patients living with HIV often faced. A hand-shake meant a lot for someone who felt ostracized by their community, families and, on occasion, others in the health care system.
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?
For me, the main issue is the technology. Many patients do not have ready access to the internet or easy access to devices that are necessary for a successful telehealth experience. The platforms can sometimes be difficult to negotiate due to HIPAA restrictions. Slow internet can lead to people talking over each other. Many times, the interaction goes from audiovisual to telephonic which further limits the personal interaction. Moreover, patients may have certain physical complaints that cannot be properly evaluated when they are not in the same space as the clinician.
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.)
-Prior to the first or second telehealth appointment, it is important to conduct a dry run to ensure that the actual visit goes smoothly.
-Prepare for the visit ahead of the visit if possible. Review the chart prior to the visit. It makes the visit flow, avoids awkward pauses and ensures that all of the important issues get addressed.
-During the visit, it is very helpful to have 2 screens so that you can engage the patient visually and have continuous access to the medical record.
-It is very important to be cognizant of the patient’s setting. Are they at home? Or are they at work? Are they alone or could there be other people off-screen? I always ask about the level of privacy they have and if there is anything that could impact information exchange.
-Post visit, it is very important that someone from the clinical team go over the next steps. For example: labs, referrals, medication changes or renewals. All of these things are important if the visit was in person but take on an added relevance if the patient is not in front of you.
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?
The no-show rate can be brought down to effectively zero. This is a great benefit, especially for people with chronic diseases. Telehealth also can eliminate traditional barriers to care such as transportation, childcare, weather, taking time off work, etc. Also, we have seen a significant uptick in telemental visits. Mental illness can greatly impact an individual’s ability to seek care and leave their home. Mental health care often requires frequent and regular appointments (often weekly or more) and telehealth can greatly facilitate successful engagement with a multidisciplinary team.
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?
Review of home monitoring devices, e.g., temperature, blood pressure, pulse oximetry, blood glucose, weight scales, can facilitate the discussion. Patients can show you all the medicines that they have in their homes. The camera set up is very important to show the clinician’s full face.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
The home visit was a bygone method to deliver care that also allowed the clinician to gain additional insight into their patients’ lived experience. A telehealth system that can mimic the home visit experience would be welcome. Also, a system that could overcome the limitation of not being able to do a physical exam. For example, a system that could allow measurement of vital signs and basic auscultation. Also in-home laboratory services can also enhance the telehealth experience.
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 think that something that could enhance 3-dimensionality could be helpful to normalize the provider-patient experience but I am not necessarily excited about artificial reality. The lived reality is what’s most important.
Is there a part of this future vision that concerns you? Can you explain?
Access comes with responsibility. HIPAA, confidentiality, patient autonomy are all important considerations. Also, there are potential legal ramifications if either party records the exchanges. We also do not want to leave behind people (providers and patients) who cannot adapt to the technology. They need constant encouragement and education but if they should not be penalized if they cannot master the technology.
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. 🙂
Along with increasing technology and improved care delivery systems, the importance of universal health care as a human right cannot be understated. COVID has taught us that no one should be left behind. My British politician friend gave this great analogy: “Our presence on this Earth is like being shipwrecked and sailing together in a lifeboat. You can either sell what food there is to the rich so they survive and then generate fights over it, or you can share it out. It isn’t just a moral decision but a practical one. There is no shortage of food in the world simply a shortage of money with which to buy it.”
How can our readers further follow your work online?
For more information about MetroPlusHealth plans, benefits, and services, visit www.metroplus.org and join the conversation at facebook.com/MetroPlusHealth/and twitter.com/@metroplushealth.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.