Dr. Scott Cunneen of Cedars-Sinai Medical Center: “Give the patient one last chance for comments or questions”

Give the patient your undivided attention, just as you would in the office. Don’t be texting or looking at your electric bill during the appointment. Give the patient one last chance for comments or questions. (“Is there anything we’ve missed today? I want to make sure you have everything you need…”) One of the consequences of […]

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Give the patient your undivided attention, just as you would in the office. Don’t be texting or looking at your electric bill during the appointment. Give the patient one last chance for comments or questions. (“Is there anything we’ve missed today? I want to make sure you have everything you need…”)

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. Scott Cunneen.

Scott A. Cunneen, MD, FACS, is the Director of Metabolic and Bariatric Surgery at Cedars-Sinai Medical Center in Los Angeles. Dr. Cunneen holds a bachelor’s degree from the University of Notre Dame, a master’s degree in physiology from Georgetown University and a master’s degree in human nutrition from the Columbia University College of Physicians and Surgeons. He earned his medical degree from Georgetown University, where he was awarded membership in the medical honor society, Alpha Omega Alpha. A Fellow of the American Society of Metabolic & Bariatric Surgeons, Dr. Cunneen is often called upon to teach laparoscopic procedures throughout the country. Dr. Cunneen is the author of WEIGHTY ISSUES: Getting the Skinny on Weight Loss Surgery. He is also the author of 21 Things You Need to Know About Diabetes & Weight Loss Surgery, which was published by the American Diabetes Association.

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 always interested in medicine and helping people as a general surgeon, but I quickly learned that a lot of general surgery is not necessarily “happy” surgery. I already had a master’s degree in nutrition, so I was interested in wellness and healthy living. Having the opportunity to apply that knowledge surgically to a group of people who were in great need was indeed of interest to me. At the time, all bariatric surgery was “open surgery,” which was very uncomfortable for the patient and occasionally carried serious risks. As the procedures became less invasive, however, we became able to make a drastic change in how we could accomplish significant weight loss for people with a lot less impact on them physically. As the program developed, it became a pleasure going into work every day because our patients are generally happy about the transformation they’ve achieved. These are people who often find themselves backed into a corner with no options. They’ve tried every diet in the world and they’re losing that battle, so we can offer them a way out. They’re so appreciative and I find it personally satisfying to see people thrive following surgery.

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?

I think all of us in the field of bariatric surgery owe a big debt to people like Dr. Edward Mason and Dr. Henry Buchwald, two pioneers of what was then called “obesity surgery.” It was a lot more difficult for them in those days and they really spearheaded this monumental effort. There was a lot more negativity about these procedures back then. There was also a lot more discrimination against people who were morbidly obese, an attitude which was actually considered acceptable at the time.. Unfortunately, to a large extent, obesity is still considered to be a character flaw, a personal shortcoming versus a medical problem. These pioneers changed the future with a small group of surgeons — we’re talking dozens rather than the thousands who are practicing today — so I have to be appreciative of the pioneering efforts of these brave surgeons who put their careers at risk and have enabled us to safely do these surgeries today. Being physicians, many times our reputations really become who we are. Today, we stand on the shoulders of these giants.

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?

Well, there’s definitely better communication, it’s easier to read body language, and you pick up important cues when someone is in the room with you. The video makes it better than a telephone, but it’s not the same as being in the room. For the physical exam part, of course, we really need the patient in the room, plus the fact that people tend to trust you more than if you are on video, where they may not feel like they’ve actually met you or made that personal connection. So while virtual appointments are good for a general introduction or for follow-ups when they already know you, many people just need that extra in-person thing.

In my particular specialty, bariatric surgery, patients come into the office with some added baggage, if you’ll pardon the play on words. It’s not just that they are severely overweight when they first arrive, but they often carry with them a sense of embarrassment, shame and failure for losing what is often a battle of years, or even decades. The benefit of having a patient in front of us enables us to forge a relationship and a sense of trust that we are not only going to help them succeed in this battle, but we’re going along with them on this life-changing journey. Other benefits include the ability to spot problems –- both physical and emotional -– that they may have missed or that may not have been noticed by other physicians.

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?

The conversations we have with our patients are quite personal. Patients want to be assured that they have complete confidentiality as well as the undivided attention of the doctor. And, no matter how good the Zoom connection may be, that separation between doctor and patient can be quite disconcerting. We all agree, I think, that the virtual appointments have been safer and necessary, under the present circumstances, but at the end of the day, nothing beats actually being in the room.

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. Acknowledge the discomfort level — and share it. (“Boy, this IS weird, isn’t it? I’d much rather be with you, but you can help me out by letting me know if I’m missing anything you wanted to show me or talk about.”)
  2. Share documents via email. (“Here’s where you were at our last appointment. How’s your blood sugar level…is it improving?”)
  3. Work important behavioral questions into the conversation. (“So, are you drinking enough water like we talked about last time? And are you finally managing to get enough protein in your diet? That’s so important, you know.”)
  4. Make sure your support network is up to speed. (“I’m going to contact Dr. So-and-So. He may want to run a couple of tests to find out where that pain is coming from. His office will be in touch with you to set it up.”)
  5. Give the patient your undivided attention, just as you would in the office. Don’t be texting or looking at your electric bill during the appointment. Give the patient one last chance for comments or questions. (“Is there anything we’ve missed today? I want to make sure you have everything you need…”)

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? What tools have been most effective in helping to replicate the benefits of being together in the same space?

I would say Telehealth offers patients a more immediate response to a serious question or symptom they may be experiencing without waiting for the next available in-office appointment. It saves them the time and trouble of getting to the office, especially if they feel ill or are in pain. And, perhaps most importantly, patients get the undivided attention of the doctor without delays or interruptions often experienced in doctors’ offices.

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?

Video conferencing has definitely been the most effective tool in a remote visit due to the fact that doctor and patient can actually see each other’s face. In the past, out-of-office visits were all done by telephone, and it’s much harder to communicate over the phone. Today, with high-definition video conferencing, it’s virtually like being in the same room, so you want to make sure both people have excellent video, otherwise the conferencing isn’t as effective. Our staff helps the patients with initial set-up and a little practice to make sure they can connect successfully and avoid the anxiety that often accompanies trying something new. That doesn’t mean they all totally get it, but at least they’re not going into it cold. And most people who have done it once are okay the second time around. Many people are not comfortable just talking on the phone with a doctor, especially if it’s the first consult. So having video without having to put up with glitches or pictures cutting in and out, that makes it more acceptable to all concerned.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

If an encrypted, HPPA-compliant platform could give you more biometric data, if it would integrate with some sort of sensor so that you could check the pulse, the heart rate, the rest of the vital signs easily, without having to ask the patient to try to give it to you — that would make it a better experience. Also, using cameras that are more easily aimed, or like the newer ones that can follow your movements, versus having to stay in frame — that would make it better too. Obviously, that kind of screening would make things much easier for both doctor and patient. So often, the first appointment consists of “Ok, what’s the problem?” and “We’re going to run some tests and have you come back and talk about the results.” So that initial encounter doesn’t always require a physical assessment.

The initial consult is very important and I think with good video conferencing, doctors can get a good idea of what’s going on. And for patients who would be taking off work, driving from a distance, or who may not be sure they’re really interested in the procedures our particular department has to offer, all those things could create a barrier, whereas if they could jump on a phone call or video chat for half an hour and get the lay of the land, that may be enough to convince them to take the next step. So with good quality audio and video plus an easy-to-use platform that is not intimidating, patients can often get what they need right from their cell phone, without all the hassle of actually being there. You don’t have to have a complicated computer set-up since most phones have great audio and video capability these days. I use a tablet with touch-screen, which works great. And then the doctor can order testing without the patient having to actually be there — we can just type in the order and send it to a lab of their choice. Sure, some people need the physical interaction in order to build trust with their doctor, but some people don’t. And for our post-op patients, who have already been through the surgical recovery and all the testing, they just need to check in for follow-ups. Believe me, a lot of them would rather have a 15-minute video chat than a multi-hour excursion to the doctor’s office the week after surgery.

Are there things you wish patients knew in order to make sure they are getting the best results though they are not actually in the office?

I hope they would treat these visits as real, as momentous as they would a visit in the office, and even though it’s easier to accomplish, they should pay attention just as much. If they have to drive a long distance to see the doctor in person, as opposed to hopping online for ten minutes during a break in their day, I hope they would treat those two events with the same importance, the same respect, so that they’re not distracted. Some people will schedule a virtual appointment for a particular time and then, especially on a work day, they won’t be ready and will ask to reschedule. They’re treating that appointment with less importance than they would an in-person visit. They need to pay attention, focus, listen carefully, and treat it as if it were “real.” If they don’t feel comfortable, I would hope they would express that, and if they need technical help connecting, they need to call in and request it.

Do you see this as the wave of the future? It’s necessary right now, but will it continue when there is no pandemic to limit our access?

Well, now that most insurance companies are covering these visits for the patients, yeah, I do see this use of virtual appointments being used more and more as time goes by because of the convenience for many people. There will always be times when you want to be there, but there are times when you don’t need to be there, so that will save people time, money and most importantly, the stress of just getting there, all for a quick visit that’s over before you know it. Having that option is definitely valuable. And as technology continues to improve, the experience will get better.

We should remember that for the last year, many people have had limited access to medical care, so it’s really what you do with what you’ve got. The good news is so many things that have been in the works have become a reality during a time when a lot of people were unable to get any treatment at all because they were afraid to go into a hospital or doctor’s office. So having the ability to do certain screenings and prescribe treatment through these tele-visits has been very valuable, especially in rural areas where people have to travel long distances to get medical attention and might not otherwise be able to get a doctor’s attention at all.

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?

It’s getting better with broadband, you can get to the content faster, there’s not as much failure — and that’s probably going to help align all the technical things you need to make it work. We’re past the early days of Facetime or Skype when it was all pretty iffy, videos would freeze, calls would drop, and now everybody Zooms! So I think this is here to stay.

We’re looking at the perfection and wide use of biosensors — well beyond the capabilities of our smart watches — that will enable us to check heart rate and blood pressure remotely. We can also look forward to acoustic sensors which will allow us to diagnose patients though auditory means by listening to their heart, lungs and even abdomen without actually being there.

We’ll be able to project drawings and diagrams with easy sharing ability, giving patients the ability to refer back to them after the appointment. We can look forward to the ability to record entire conversations which can be stored in chat applications and referred to at a later date.

So the future is sure to bring the ability for us to easily mimic anything we can do for the patient in person, short of an actual procedure.

Is there a part of this future vision that concerns you? Can you explain?

People really do feel more connected in person. We haven’t gotten past that. We don’t want to minimize the importance of the relationship — confidence, intimacy, and all of the other things that people bring to the interaction with their physician — in favor of technical advances. We don’t want to turn the experience into a visit with a robot or have the patient become intimidated by the technology rather than concentrating on the positive aspects of the experience.

You’re 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 it be?

I would strive to take away the discrimination that goes along with a person’s size and replace it with acceptance. I would seek to have obesity more widely recognized as a chronic disease so that we could get people to treat it as a disease rather than as a personal flaw.

This was very meaningful, thank you so much! We wish you continued success!

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