Dr. Tiffany M. Smith: “Recognize what you are not able to assess in a telehealth situation”

Recognize what you are not able to assess in a telehealth situation. It is important that you take the time and identify what you can no longer see as a result of having a telehealth appointment. We are all in different specialties and assess differently so you must identify what is important for you to […]

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Recognize what you are not able to assess in a telehealth situation. It is important that you take the time and identify what you can no longer see as a result of having a telehealth appointment. We are all in different specialties and assess differently so you must identify what is important for you to have a proper assessment. As I mentioned, you will not see patients bouncing their legs up and down under the table or fidgeting.

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. Tiffany M Smith DNP, APRN, PMHNP-BC

Dr. Tiffany M. Smith is a doctorally-prepared integrative and functional psychiatric nurse practitioner. She believes that everyone is unique, and there are no one-size-fits-all treatment plans. Dr. Smith’s mental healthcare approach addresses both the internal and external factors that affect your mental health and creates a holistic personalized treatment plan. Sign up for her 30 ways in 30 days DIY mental rescue toolkit here.

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 backstory begins with my husband. He is the reason I changed the way I practice psychiatry. My husband is a combat veteran and licensed military-trained nurse, and over the years, he developed increased pain which led to depression and anxiety, and it exacerbated his PTSD. He explored what our healthcare system had to offer and was frustrated with his results. Thus, he refused any further treatment from our healthcare system. I felt heavily responsible for finding a way to help manage his symptoms because our quality of life was declining. He was not able to stand for long periods due to fallen arches, heel spurs, osteoarthritis. He would isolate and thus spend less time with our children and me. We were no longer doing family activities, going grocery shopping, or having date nights. We worked together trying different modalities, but the one thing that made the most significant shift in his care was aromatherapy. Once I realized this was a favorable option for him, I went to school and became an aromatherapist to know how to use essential oils to support him. The essential oils helped him manage his pain where he could be more functional in his life. It assisted with better mood stability and better sleep. Next, I wanted to make lifestyle changes, so I got training in functional medicine and applied those principles to our lives, and he continued to improve. I was impressed with what I was able to achieve with my husband. Then I started to hear my clients’ challenges differently and how they could benefit from the approaches I applied to my husband. From that moment on, I transitioned my practice to be integrative and functional, which means that I accept other modalities as treatment components; I consider the internal and external environments a client has and its impact on their mental health; and I seek to treat the root cause of the client’s symptoms and not just cover up their symptoms.

Can you share the most interesting story that happened to you since you began your career?

I worked with a young man that lost one of his twin 5-month-old babies. He said he was in a deep, dark sunken place in his life and was very afraid of seeking mental health care. He thought medications would be forced on him, and he would be labeled and misunderstood. We worked through his grief and depression without any psychotropic medications. He stated he started seeing a little bit of light to hang on to until he was ready to take the next step in his care. When he felt strong with his mental state, he stated his mission was to advocate for mental healthcare among African-American men. His journey of deep grief and depression and fear of mental healthcare to his triumph and voice he found is an inspiration.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

There are so many life quotes that I could name, but the one that I find that can’t be said enough is “don’t sweat the small stuff” by Richard Carlson. I didn’t think very deeply about this quote until I heard the song “Like I’m Gonna Lose You” by Meghan Trainor featuring John Legend. That song impressed upon me that we don’t know what the future holds, and our loved ones could be taken from us anytime. So how we spend our time with them now means everything. I vowed not to sweat the small stuff. With my husband and my kids, I am more mindful of how I respond to situations and not argue or create tension over things that do not matter. My husband never expressed his thoughts around sweating the small stuff. Still, our actions aligned, and together without a conversation just began not being concerned about things that would concern us before and focused on living our lives together in love and harmony. It has been amazing!

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?

My husband is that guy. I don’t know how he does it because he keeps me genuine, honest, and true to my path. He has always been the one constant person in my life cheering me on. We go through so many changes in life and transitions in roles, and my husband has this way of keeping me grounded and focused on what I want and who I am. He does not impose his agenda or methods on me. His love and support are what allows me to go out in the world and share my gifts of love and support. I have never met anyone like him.

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?

Face-to-Face patient visits are very beneficial because you can see their full-body movements that can tell a lot about how they feel, such as tapping their toes or wringing their hands. Also, you can feel each other’s energy easier. In other words, you can read each other better and connect on a non-verbal vibe. Last, the client can assess the environment and feel safe about sharing their challenges in confidence.

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?

Assessing how a person feels when they are not in front of you can be challenging because you can’t see their full body language. This is very significant because they can have nervous tics in their lower body that can go unnoticed. Also, you may not see their nails, and they are a nail biter or their arms for possible cuts or injuries via telehealth. Therefore, the practitioner’s questions need to include what cannot automatically be seen as if they were face-to-face.

It can be challenging to create a rapport with a client via telehealth than face-to-face.

Last, I am dependent on technology such as the internet and software to work correctly. When people freeze or you can’t hear, it disrupts the flow of the conversation. These distractions can affect the patient’s disclosure of information.

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. Recognize what you are not able to assess in a telehealth situation. It is important that you take the time and identify what you can no longer see as a result of having a telehealth appointment. We are all in different specialties and assess differently so you must identify what is important for you to have a proper assessment. As I mentioned, you will not see patients bouncing their legs up and down under the table or fidgeting.
  2. Ask them what you recognize you can’t assess. Are you a nailbiter? Raise your hands so I can see them in the camera. When was the last time you showered? You can’t smell a patient via telehealth. Has your weight changed recently? Do you harm yourself in any way. Show me your arms. Telehealth requires you to be more inquisitive to complete a full assessment.
  3. If possible, have someone in the office be a resource person that checks the client’s ability to log on and handle any technical difficulties before they see the provider because technical issues during the session cut into their visit time. I have had 15-minute follow-ups that took the entire time to try and troubleshoot what was going on, and then they had to be rescheduled. Or it may appear that they are a no-show, but they are having technical difficulties, and they could be charged a no-show fee when it was not their fault.
  4. Have backup options if there are technical problems. Maybe go to zoom, FaceTime, or telephonic if possible. Even if the technology is working fine, it does not mean it will last for the duration of the visit. Create a protocol to communicate and shift to a new platform if there are issues to stay efficient with your time.
  5. Stay calm. Have patience with yourself, with technology, and the patients. Most times, everything goes smooth, but be prepared if you have one of those days to stay in control and problem-solve the situation so you can care for your patients.

You can watch a video about these five ideas HERE.

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?

I get to see their environment. Seeing the client’s environment is valuable to understanding them. When my patients are experiencing mental health symptoms, I see it in their environment. Things may be messy, the room may be dark, and they may be unkempt. There are often other not-so-obvious things that can be caught. For example, a client saw me in his bedroom that had gray walls, gray linen, a small window, and no decorations on the wall or furniture. He was depressed. He primarily stays in his room and works from home in his room. Well, his room is depressing. So we discussed environmental changes that can aid in his mental well-being, and he followed through and made changes that also helped his mental health.

Patients are more comfortable and feel more in control of the situation when they are at home instead of going to an office. Telehealth breaks down some of the barriers to getting treatment. My patients share how they have extreme anxiety driving to the appointment, and some have panic attacks in the car before they come into the office. Telehealth removes many of these anxiety-provoking tasks because they do not have to make the same effort to get treatment. I believe that telehealth has reduced my no-show rate because of its ease. Clients appreciate not having to take off of work to have an appointment. They can be seen during their lunch break or in their car. This offers more access to care and keeps the client in their comfort zone, which leads to more disclosure of their challenges and a better treatment plan.

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 feel that essential tools that help the sessions feel more comfortable are not the latest and greatest technology. Because to most of the clients, telehealth is the latest and greatest without any bells and whistles. So having a client use a computer instead of a phone is helpful because it allows you to see more of them instead of just their head. Having headphones on provides comfort and security for both the provider and the patient because we both know that we are the only ones hearing both sides of the conversation. Talking slow and calm will allow a connection between the two participants because sometimes there are delays, and it will enable you both to process what you see and hear.

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

I would recommend the Facebook portal for all telehealth sessions. I like that the calls are encrypted. It moves with you and expands as others enter. It is hands-free, so I can see more of the client and their environment. Without the encumbrances of holding a device or being close to it, it will allow the client to be themselves more. I would be able to assess more natural behaviors as if we were in the office. You can also have more than one person on the portal, which can be suitable for a group meeting with people that may be in different places like a wife at home and her spouse at work.

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?

Yes, test the software before the meeting. Be early just in case there are any technical issues. Do a sound and camera check. Use a wired headset. Be in a good reception area. Have lighting in front of you and not behind you, and be sure you can see your face in the camera. Silence your phone and prevent any other distractions. Do not watch television or cook. Have someone watch the kids. You need to be in the present moment with the provider to get the best 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?

I like the virtual and augmented reality options available and coming down the pipeline for mental health. I think that clients will be able to see their improvements, and clinicians can better evaluate and treat them in these environments. Research supports the effectiveness of their use.

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

My biggest concern is the technology will not be available to everyone. In other words, will providers get reimbursed from insurance companies to offer this technology to their clients. If not, only the rich and famous would enjoy such treatment options because it will be a cash-based option for the provider to be compensated.

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. 🙂

I would start a movement called #Let’s heal together. We all have traumas, and they influence what we believe and how we act. Our insecurities and fears are projected as arrogance and hate. If we acknowledge that we all have our traumas that significantly impact how we behave and treat each other, we may be more kind to each other.

Most clients talk about a fear of being judged. People do not seek mental healthcare because of the stigma. Differences are not accepted in our culture. These beliefs and actions keep us divided, so we need a way to be on the same playing field and move together toward happiness and well-being.

How can our readers further follow your work online?

You can visit my website at www.DrTiffanyMSmith.com and follow me on Facebook: https://www.facebook.com/DrTiffanyMSmith; Instagram: https://www.instagram.com/dr.tiffanymsmith/; and Linkedin: https://www.linkedin.com/in/drtiffanymsmith/

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.

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