Having a confidential environment so the patient and provider can give their full attention to one another. It’s important to eliminate distractions. I’ve seen patients who had people in their household coming in and out of the room they’re taking their appointment. And that can break up any rapport the patient is having with the psychiatrist.
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 interviewing Dr. Thomas R. Milam, MD.
Dr. Milam is a Board-Certified Psychiatrist practicing out of Roanoke, VA. Dr. Milam received his undergraduate degree from WVU in Anthropology, graduating summa cum laude, and received his MD from the University of Virginia. His residency training in psychiatry took place at Duke and UVA. Dr. Milam has served in a leadership role throughout his 20-year psychiatric career and spearheaded the telepsychiatry initiative at his previous hospital. Currently, Dr. Milam serves as Chief Medical Officer at Iris Telehealth and an Associate Professor at Virginia Tech’s Carilion School of Medicine and Research Institute.
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’ve been a psychiatrist for over 20 years and have been doing telehealth for about 10 years. I’ve really enjoyed working on expanding opportunities to increase access to care in underserved communities. I’ve done that work as part of the academic community through my affiliation with the Virginia Tech Carilion School of Medicine and Research Institute and as the Chief Medical Officer at Iris Telehealth.
Can you share the most interesting story that happened to you since you began your career?
In 2009, my family moved to New Zealand for a year, and I worked as a psychiatrist there. No one warned me that when you’re meeting with a Maori patient in New Zealand, they often greet you by touching their forehead to your forehead and their nose to your nose, and you’re supposed to hold it there for a few seconds as a sign of vulnerability. I was really taken by surprise when my first Maori patient greeted me that way, but it’s an absolutely beautiful and meaningful cultural custom that I’m glad I got to experience.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
Our family motto is “it is what it is.” We’ve adapted that over the years to accepting things as they are and trying to let go of making things always be just as you want them to be. Whether it’s your house, your yard, your kids, or your job, there’s a lot of peace in accepting everything you’re given and moving forward.
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, there was a child psychiatrist who struggled with Parkinson’s disease. He was fairly young, and he was a great teacher and a great psychiatrist. He had shared his troubles with me, and we developed a friendship. The whole time he was struggling with Parkinson’s. At the time I knew him, my family was going through a challenging time. I went to him for counsel, and he told me he thought I was depressed. I remember telling him that I was a psychiatrist and I would know if I was depressed or not. But he said that, in his professional opinion, that was what I was experiencing. And, he was right. He was really the first person who taught me that, even as physicians, we can have our own problems and experience our own mental and physical health issues. Learning that we as psychiatrists are also vulnerable at that formative stage of my career was really valuable and helpful to me, and it makes me a better psychiatrist.
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?
Traditionally in psychiatry, you’re trained to observe patients from the very moment you see them — from seeing their demeanor in the neighborhood to observing how they respond when you call their name, to how family members interact with them, how they walk and dress. Those can all be important components that help providers understand a patient — particularly if you’re seeing them for the first time. And they can all be easier to discern in person. There are also some facial expressions that come across better in person rather than on video. That being said, there is so much that you can do now on telehealth — particularly for telepsychiatry.
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?
It’s always important to make sure the patient and the doctor are in a confidential space, so you can make sure the patient is comfortable proceeding with certain conversations. Sometimes people can feel embarrassed or watched, which can make them a little shyer — particularly if it’s their first time talking on a screen. It can take some time to warm up to it, and it’s important to have good providers who put patients at ease.
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.)
- Having a confidential environment so the patient and provider can give their full attention to one another. It’s important to eliminate distractions. I’ve seen patients who had people in their household coming in and out of the room they’re taking their appointment. And that can break up any rapport the patient is having with the psychiatrist.
- Make sure patients are comfortable with the technology they have to use. Clinics should work with patients or clients before they see the provider to make sure they understand how to log into the room and can download any software they need. Those steps will help ensure the patients are comfortable using it before they talk to their provider. Ideally, it would be good for them to have time to practice ahead of time.
- It’s always important for patients to know they’re in charge during the video visit. They need to give consent to see the provider through a telehealth connection and know everything there is to know about the encounter. If any part of the visit is going to be recorded or photographed, patients or their parent or guardian will need to consent to that beforehand. Remember, one of the most important things you can do as a telehealth provider is effectively put your patient at ease.
- The provider at the first visit should acknowledge that telehealth is different from seeing people in person. They should spend the first few minutes with the patient talking to them about what their experience is with telehealth. Make space to talk about this new kind of encounter and any fears or concerns a patient might have. Telehealth is a technology change, and it came on rapidly after COVID, but there is some hope that it can help increase access to care. I think patients will understand that — and it’s already proven to decrease no-show rates.
- After steps 1–4, go back to business as usual and conduct your visits just as you would in person. Providers shouldn’t let the technology throw them off from getting the information they need. After you get consent and intro people to telehealth, just dive right in.
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?
One of the most significant benefits of telehealth is being able to connect excellent providers with great backgrounds and experiences to clinics — and clinic locations — who would otherwise have a hard time recruiting someone of really high caliber. There are lots of small towns with significant needs, and recruitment can be challenging. But telehealth takes away the barrier of geography. At Iris Telehealth, our providers see patients in all kinds of communities and circumstances. And it’s effective in patient homes, clinics, emergency rooms, and inpatient psychiatric facilities. There are a lot of opportunities to improve access to people. Studies show that most medical appointments take two hours total to drive there and back and have their appointment — that’s a real barrier for a lot of people. Often, people can’t take off work, or they may live too far away, or they may not have access to a car. And telehealth helps take down those barriers for people. Where I live in Virginia is fairly rural, and it’s not uncommon for people to drive three hours for a psychiatry appointment. That’s when I started setting up a program to train psychiatry residents on how to connect with these outlying clinics by working virtually through local family medicine offices. Patients are very grateful for that, and they’re much more at ease in their family doctor’s office than they would be in a psychiatrist’s office that may be far away or unfamiliar to them.
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?
In my honest opinion, CMS and the DEA made significant adjustments in prescribing abilities and reimbursements for telehealth, without which millions of people would not have been able to get care. But, because they were proactive at the start of the pandemic and changed some of the tools behind reimbursement and coding and online prescribing, that enabled telehealth to expand quickly and effectively. My biggest fear was people running out of their medications because they couldn’t connect to their provider. I was proud of the U.S. department of health and human services and its ability to quickly make some of those changes, and I hope many of them stay around.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
The perfect telehealth feature for me would be an app built into people’s phones to connect quickly and easily with their providers through some kind of portal. Those are beginning to emerge. In psychiatry, we’ve always wanted to be able to keep people well between appointments, which can be challenging. If they could use a portal to communicate with providers before things became crises, that would be extremely valuable in the future. Then we could focus more on preventative healthcare, rather than waiting for it to be a crisis and have the patient end up in the emergency room — which is a situation that happens all too often now.
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?
I always patients them to know that even though I may be in a different state or part of the country, that doesn’t mean I care about them any less. I want patients to know that they really can get truly high-quality care through telehealth. I want patients to be excited about telehealth and the opportunities it provides. It’s more efficient, and it’s easier. Telehealth is a truly positive, sustainable thing — not just a fad. But at the end of the day, patients should do what they’re most comfortable with. No matter what, patients should always be in charge, and they should always be driving their own care.
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?
Ahead of any VR or AR innovations, I think the simple technology of apps or portals that enable patients to have prearranged video visits or secure texting with their providers to help them stay well is an opportunity that excites me. However, there is an opportunity for VR to make an impact in this space. This Christmas, I got my family an Oculus VR set, and — while I got a bit carsick trying to use it — I got a firsthand experience of how this technology could work to support patients. I think it could be especially valuable for patients who are trying to work through traumas or feat. I remember I worked for two years with someone who had previously lived in an area that didn’t have any snakes or lizards moved to an area that had a lot of lizards running around. That patient was uncomfortable with that environment, and she refused to come out of her home. At the time, I helped her work through her fear with medicines, therapy, and desensitization. But when I began doing some virtual reality, I realized that programs like that help people diminish their fears through safe exposure. That work can be very meaningful — and I hope it becomes more available in the future.
Is there a part of this future vision that concerns you? Can you explain?
I always think one of the most important things is protecting patient confidentiality and ensuring they always feel safe and open with their provider. But I do have concerns about people offering cheaper versions of telehealth platforms that can be easily hacked. My biggest fear would be patient appointments showing up on YouTube or elsewhere in the future.
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. 🙂
If there were a way to ensure that every patient could have access to a phone or device with an app on it that could connect you to your provider in a confidential that would be incredible. That work could create opportunities for patients to access different levels of providers, whether it’s psychiatrists and case managers. And that’s very doable. In the future, I hope people create things that are patient-centric.
How can our readers further follow your work online?
Readers can follow or connect with me on LinkedIn (https://www.linkedin.com/in/tom-milam/) and through the Iris Telehealth website (https://iristelehealth.com/), where we post a lot of great information about telepsychiatry, and where I regularly publish blog articles.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.