When a patient is sick enough to be referred for an in-person evaluation: Telehealth is limited in many ways and therefore should have a low threshold for in-person evaluation referrals. It would be helpful if the patient could somehow provide their temperature and blood pressure if possible.
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. Vicken Zeitjian
Dr Zeitjian was born and raised in Los Angeles, California. He completed his undergrad at UC San Diego and his medical degree at American University of the Caribbean School of Medicine. During his residency at Creighton University Valleywise Medical Center, Dr. Zeitjian discovered his passion for cardiovascular diseases. He is now in his second year of training in cardiovascular diseases at UT health San Antonio with plans to become an interventional cardiologist by 2023. When he is not at the hospital or seeing patients on Teladoc, Vicken enjoys playing the piano, tennis, and traveling back to L.A. to visit his family.
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?
Growing up in a very traditional Armenian household, my parents weren’t too thrilled to see me spending hours a day in front of a screen playing a computer game called Age of Empires. They were convinced I was throwing my future away. I would work tirelessly during the school day to finish every last assignment before I even got home to ensure I had optimized my gaming time. They weren’t too happy about that either. Little did they know the dexterity I would develop with my hand-eye coordination for interventional cardiology. In medical school, I was drawn to internal medicine because of the expertise it would require in the vast amount of clinical diseases, which then led me to discover my passion for cardiovascular diseases. The heart is the most important organ in our bodies and it’s what keeps us all going. I was just so fascinated at this extremely hard working organ. I’m now in my second year of fellowship specializing in cardiovascular disease and have been accepted into an interventional cardiology fellowship beginning next July. That’ll be my final fellowship before I move back to Los Angeles as an interventional cardiologist in 2023. It has been a long and very rewarding journey to say the least. Since the pandemic began last March, there has been a surge in demand for Telehealth providers. In my spare time when I’m not at the hospital, I take appointments on the Teladoc and Amwell platforms. I like it because it gives me the opportunity to practice my internal medicine knowledge and keep me sharp during fellowship. It can also get addicting after a while. My girlfriend jokes that Teladoc is my mistress. I have done over 8,000 virtual consults since March 2020.
Can you share the most interesting story that happened to you since you began your career?
In my third year of residency, on a flight back to Phoenix from Detroit, the passenger sitting next to me, a young man in his 30’s, began having a seizure. I was napping, and felt a thud on my left arm which woke me up. I quickly realized what was happening and started tapping on his shoulder, but he was unconscious. Fortunately, he had a pulse and I immediately called the flight attendant to see what medical supplies were available. He brought over a sealed backpack full of supplies and stated he had to call the on-ground physician on call for this flight as protocol. All the while I silently questioned what the doctor could possibly do from down there. Then the flight attendant asked me if he should tell the pilot to land the plane. The thought that I had the power to make that call was wild to me; fortunately that was not necessary. I laid him on the floor in the aisle with the help of a neighboring passenger, as others on the plane watched on intently. The man’s seizure stopped after a few minutes and he recovered from his post ictal state after about 15 minutes. His seizure stopped and I didn’t have to administer any benzodiazepines. I monitored his vitals through the flight, had him drink some juice in case this was provoked by hypoglycemia, and fortunately no other episodes occurred. After landing, I wheeled him out to the medical team waiting for us at the terminal.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Anything you do, do with love and passion”. I’ve learned that finding success and passion will not be evident at a superficial level. You have to believe it and manifest it. Delving deep and understanding the fundamentals of anything one does is important in knowing what you love. Whether it be choosing a career, loving someone, or even playing a computer game, give it your all and know that what’s meant for you will never miss you.
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 have a close friend who I met in undergrad named Armand Rostamian who has been a mentor to me since the very beginning. Our first encounter was on the basketball courts at UC San Diego. We were both quite competitive and as it turned out we were guarding each other throughout the game. To this day he thinks he “balled me up” during that game but that’s up for debate. Armand was a medical student at the time and his guidance and insight into the field inspired me to change my path from engineering to medicine and I will be forever grateful for that. I specifically remember a time we were out with friends when one someone from our group collapsed to the floor and began to turn pale. Armand quickly asked me to call 911 as he checked for a pulse and was getting ready to perform CPR. Seeing him act as quickly and efficiently as he did in an emergency situation was what inspired me to choose medicine. Fortunately our friend quickly regained consciousness. Armand is now a cardiologist practicing in Los Angeles.
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?
Seeing patients in person is such an important part of medicine and oftentimes the best way to treat them. There are countless advantages to in-person visits such as doing a physical exam, being able to perform diagnostic tests and really connecting with the patient face to face. Every patient is different, even if they have a similar medical problem, therefore each unique situation is best understood with an in-person visit. For example, diagnosing a rash can be difficult even with uploaded images compared to an in-person evaluation which entails seeing and feeling a rash.
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?
If the patient is not in front of me, I am solely reliant on the patient’s history. I will often collect a very detailed history and will have to make my conclusions based on what the patient says. While this often works, it is mostly subjective and therefore objectivity and accurate assessment becomes difficult. For example, the diagnosis of strep tonsillitis is definitely made with diagnostic testing i.e. a rapid strep test or throat culture. These are not available on telemedicine, therefore getting an accurate history is important. It becomes problematic when patients are unable to see their tonsils, feel their lymph nodes, or measure their temperatures. It can get frustrating for both the patient and me when a conclusion cannot be reached simply due to a lack of information. Similarly, as a cardiology fellow, I am inclined to run an EKG on a patient and perform an echo with a bedside ultrasound when someone complains of chest pain, both of which I cannot do if I do virtually. So most of the time when a patient calls complaining of chest pain or any cardiac related symptoms I immediately refer them to the ER. Another frequent, and not often talked about, challenge is patients calling with a predetermined idea of what they “need” based on Doctor Google. When patients come in thinking they know what’s best based on their internet search it becomes difficult to refute their ideas, even when backing them with medical data and guidelines. Some patients even get upset claiming that Telemedicine is a waste of time.
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.)
Absolutely, let’s dive right into it. 5 things you need to know to best care for your patients when they are not in front of you are:
- Compassion: The nature of being a Telehealth provider is that you’re not these patients’ PCP, and they’re calling in and trusting you to take care of them from cities and even states away. Listen to them. Make them feel comfortable and heard. Try to build that connection with them that you would with your own regular patients.
- The patient’s history: Knowing what medical problems someone has or what kinds of diseases they’ve suffered from in the past will shed light on the problem at hand, especially when I don’t have access to their medical records. A lot of times, patients don’t even know or have access to their own medical history, making it extremely difficult to diagnose them
- Previous medications: knowing a patient’s medications reveals what medical problems are being treated. It is important to remember that all medications have side effects, and I have often seen that a medical concern may be directly related to the side effect of a specific medication.
- When antibiotics are appropriate to prescribe and when they are not, especially since patients frequently ask for antibiotics for “infections” which may or may not be present. Antibiotics have side effects and shouldn’t be taken unless necessary. Know your viral infections from your bacterial ones.
- When a patient is sick enough to be referred for an in-person evaluation: Telehealth is limited in many ways and therefore should have a low threshold for in-person evaluation referrals. It would be helpful if the patient could somehow provide their temperature and blood pressure if possible.
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?
Since the pandemic and quarantine began, Telehealth created a massive opportunity for patients to complete simple visits and tasks without risking infection in a Doctor’s office or hospital. Telehealth is great for simple prescription refills, bladder infections, or dermatological fungal infections. Or even for patients who have tested positive for Covid, scared and concerned about what to do next. Telehealth provides a platform for doctors to ease patients’ minds and treat their symptoms from the comfort of their homes when possible. I enjoy calls like these knowing I’ve made the patient’s life just a little bit easier, or made them feel a little more comfortable, even if all I could do is offer guidance and direction.
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?
The video feature on visits have been incredibly helpful since I can at least see the patient and make an assessment based on their appearance and history. Sometimes I’ll even ask them to perform certain maneuvers on themselves to act as a sort of “virtual physical exam”. In addition, patients are often able to show me their physical exam findings so I can help interpret them.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
In a perfect Telehealth world, I would love for patients to be able to transmit accurate vital signs and an EKG through a device or gadget that uploads that information straight to me. Vital signs will often identify who needs acute in person care and whose symptoms can be treated at home.
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?
Patient open-mindedness is important in coming up with a treatment plan. Oftentimes, when I ask patients how I can help them, they answer with “I’m calling for you to prescribe me an antibiotic” even when the symptoms they’ve listed scream viral infection. What they don’t understand is that I can’t give them anything without first assessing their situation and even then, if it’s not indicated, I can’t prescribe it simply because “that’s what always works for them” or it’s what their PCP always prescribes. Developing an accurate assessment and plan is important for best patient care. As a physician, I am interested in hearing about all the symptoms present in order to make an accurate diagnosis and initiate a treatment plan. I also wish patients would be more understanding of the fact that some things simply can’t be done over Teladoc like ordering lab work or prescribing narcotics and that we’ll do everything we can to provide you with the next steps for getting appropriate treatment.
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?
Telehealth applications that monitor markers of chronic diseases such as blood pressure, heart rate, and glucose are so exciting and important because they provide a way to objectively assess patients and provide the most accurate management options. There are several applications currently available and many more currently being developed.
Is there a part of this future vision that concerns you? Can you explain?
Sometimes I’m concerned that patients believe telehealth is a replacement for in person evaluations and annual checkups. I’ve received requests for “encounter to establish care” or “annual physical exams” which are not well addressed with telehealth visits. Patient’s often call asking for long term medication refills for medical conditions such as hypertension. While refilling meds for a month in difficult situations is possible, we cannot fill meds for the long term because there is no follow up available. Additionally, yearly physicals are important in finding certain diseases that are just not possible to do via Telehealth.
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. 🙂
Creating a central medical journal or database with medical references and guidelines, geared toward the general population, not medical professionals, would be extremely helpful in providing broad education to patients. Finding accurate information in this era has become extremely difficult due to the overwhelming amount of information available, some accurate and some not. Physicians often use UpToDate as a resource for diagnosis and management. I would like to see an equivalent resource available for the general population to easily use and have access to accurate information.
How can our readers further follow your work online?
My Linkedin is https://www.linkedin.com/in/vickenzeitjianmd/. I’d be happy to connect with and provide insight to anyone interested in a career in medicine or Telehealth.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.
Thank you for this awesome opportunity!