Clear is kind. Communicating to Patients clearly prior to an appointment on what to expect is paramount. Spell-out every detail to how the appointment is conducted, even if it seems obvious to assume. The best and most efficient approach to providing Remote Care is having a methodical protocol that is defined in-writing for the initial Telehealth appointment. KEY: A well-crafted and easy-to-read email outlining these details in bullet-points alleviates a tremendous bit of confusion for those unfamiliar with Remote Care.
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 interviewingTami Bronstein, Medical Herbalist-Physiologist.
Tami Bronstein, BSc Phyt (Hons), MNIMH, RH(AHG) is a University-qualified Medical Herbalist-Physiologist, nearing 30 years in-practice. She graduated University of Wales/College of Phytotherapy (Cardiff/London, U.K.), and Hofstra University, Exercise Physiology with Psychology (New York). Her Post-Graduate work-study alongside Medical Doctors (France) is a Specialty in NeuroEndocrinology, with support through Plant Medicine and Dietary Remediation.
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?
Certainly! It may be important to note that I have always been about 10 years ahead of mainstream awareness, so what may seem commonplace in Well Care now was met with a mixture of quizzical responses, and variable acceptance at each stage in my educational courses and professional journey.
My early work in the early 1990s began in the Health and Wellness realm, applying my first Bachelor of Science degree in Exercise Physiology with Psychology (Behavioral Modification) into the Corporate Wellness world. I served as an Independent Wellness Consultant and Instructor/Fitness Trainer for companies such as Johnson & Johnson, Bristol Myers Squibb, Sanofi Aventis, a variety of Commercial Fitness Centers, and in Private Practice for Individuals. I also taught as Adjunct Faculty in the Health and Wellness Department for a local Community College, for 6 years.
As part of the Personal Training program at a J&J Live For Life Wellness Center, we were required to provide a 5-minute hands-on bodywork treatment at the end of each training session — leading me to embark into further clinical training in manual therapeutics. I became qualified in Neuromuscular, Osteopathic, and Structural Integration/Joint Mobility modalities for Physical Pain and Rehabilitation in the mid-1990s.
Along this early stage of my work, I had a number of clients on multiple medications for everything from High Blood Pressure to Heart Disease, and Hormonal Imbalances to Mood Disorders, which influenced their bodies in a variety of ways. While my personal interest in Natural Healthcare was notable as early as my high school years — with my first book on Herbal Medicine — it was not available in formal clinical study back then. I knew I could help my clients with my knowledge in Nutrition and Herbal Medicine therapeutics — yet — I needed further clinical knowledge. In 1998, I found a University course of study overseas in England (UK) through the University of Wales/College of Phytotherapy — and once again — embarked on the next chapter of my professional journey. The course was a 5-year Bachelor of Science program, which meant obtaining TWO highly specialized University degrees in Adjuvant Health fields of study.
A few years after graduation, I furthered my Clinical background through a 3-year Fellowship overseas with Medical Doctors of France, specializing in a groundbreaking perspective within NeuroEndocrinology and the application of Plant Medicine for the rebalancing of Hormones, Cellular Metabolism, and Immune function.
Can you share the most interesting story that happened to you since you began your career?
My work remains infinitely interesting because each Individual who works with me has their own story, and unique Medical History to parse through in providing effective care. That said, one of the most interesting experiences I have had so far has been being called on-tour to provide Care for members of the Eagles Band while on the road — and through that experience — additional A-list musicians reaching out for significant support of critical health concerns in remaining able to perform around the world. Having grown up with my Dad who worked 30 years with a major Network Television Broadcasting company, I was no stranger to the world of Entertainment Production and the unique needs that accompany the life of a traveling Artist. It felt like being “at home” while on the road behind-the-scenes to provide Care.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Knowledge is Power.” — Schoolhouse Rock
Yes, I will acknowledge the profound impact that Public Television programming has had on shaping how I have evolved through life from my earliest of Wonder Years. Growing up, a fundamental belief instilled in me is that no one can take away our knowledge. There is no wasted time when we are empowering ourselves with expanding our minds through learning, and challenging the status quo. Beyond qualifying to have the skill and ability to effectively help people resolve or manage health-related issues, the process of learning strengthens the brain and the Neuroscience concept of “Neuroplasticity” in our overall functioning for a long productive life. In that light, I will admit here that my formal education quest is not finished — stay tuned on that!
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?
Due to the nature of my work in meeting interesting people from all parts of the world with notable experiences, creative minds, artists, innovators, and varied educational backgrounds, I would say that I am the sum total of many parts and influences, in combination with my own characteristics and abilities. That all said, I could not be in this moment speaking with you about my journey into the “unconventional” healthcare path without my Parents’ steadfast encouragement and belief in me — notably when the world didn’t seem to understand or accept my Modalities of Care readily. It is immensely challenging to offer services that few people know about or comprehend, let alone appreciate and seek. There have been many-a “critical mass” moment financially, when I didn’t know whether I would sink or swim — laden with school and operational debt — yet having their unwavering moral support in those darkest moments are the lighthouse that empowers my course to-date.
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?
The singular benefit of having someone in front of me is the less tangible aspect of “energy”. Through communication in-person, there are subtle and subconscious cues we communicate through our eyes and emotional responses. We can get a “sense” of a person and the sources of their concerns in conjunction with their verbal and facial expressions that adds something extra to the overall picture.
That said, this is a loaded question, because I have been providing Telehealth-style Care long before it had a clever name. When I first saw a Patient remotely, I simply identified it as Care By-Phone, as early as 2004 — right when I returned to the States from the United Kingdom, upon graduation. There has never been any downside to effectively caring for people at a distance. In fact, many people — including locals — prefer to connect that way, purely out of convenience.
Through providing Phone consultations for so many years, I have cultivated a means of gathering the less tangible factors through the types of questions I ask and taking more time to connect on a personal level.
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?
I will answer this to the best of my ability in the next question!
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?
Perhaps it is the nature of what I provide that is unique to my response here, but aside from requiring increased time per call to more deeply connect with a Patient than other types of healthcare, I have not had any challenges to my work being remote versus in-person, and the resulting efficacy of Patient response to Care.
Through the secure digital platforms now readily available, even the process of paperwork to gather basic health history details has been facilitated. Prior to digital platforms, the process/time to exchange basic forms and diagnostic documents would be the only real challenge when working with people at a distance. Sending and receiving hard copies by regular mail added delays to Patient start-up, and was enough resistance on work flow for notable inconvenience on both sides.
In fact, between the digital platforms and consolidating exclusively to a Telemedicine approach to Care, my practice has been even more efficient because I can book an entire day of consultations (from home, if need be or if I prefer) and schedule a full day of compounding Custom Herbal Medicines — uninterrupted by calls — next day. Locals have the option to pick-up from a contactless secure climate-controlled location outside my Clinic door or shipped direct when further afield/out of state. Believe it or not, most Patients opt for shipping — even locally in-state — as we are a society of busy people!
The only additional adjustment is to maintain working hours to support time zone variables. I keep a later daily shift of hours to accommodate the midwest and west coast.
If there are more urgent next-day needs, I can always dash to Clinic to prepare for those less common situations — but I would not consider that a challenge, as it is part of a Concierge-style practice to aim for expedient support. I encourage Patients to reach out as-needed by text, and I do my best to respond by the end of the business day or assuredly by next morning. If it requires connecting by phone for clarification or deeper discussion, I will work directly to schedule the call.
Planning ahead for Existing Patient Follow-up one week in-advance of finishing current preparation(s) allows flexibility to schedule calls, prepare and ship custom herbal medicines on-time to avoid lapses in dosing.
If I were to advise other Practitioners for issues with balancing proper care alongside scheduling needs, it is that having the Secure Text option has been a game-changer to ascertain precisely what is required by the Patient.
Allow me to explain:
Determining whether a “quick question” is truly something simply addressed by a text relay, or if it actually requires an appointment with chart at-hand is essential — so that a “5-minute quick question” call does not turn into a 30-minute conversation without having access to the Patient record. Patients embrace a Practitioner who is open to LISTEN and take TIME to educate them on their conditions and symptoms, but it is equally essential that the Practitioner sets boundaries that foment the preparation, focus, and attention required for proper care. It can become chaotic or disruptive to the practice without clear protocols or making calls “on the fly” when unable to access the Patient chart for more informed responses and ability to take notes for future reference.
In summary, it is ESSENTIAL to determine when something can be addressed with a brief answer by text, versus the requirement for a more dedicated conversation. Having the digital tools like Secure Text to ascertain between what is needed to provide adequate support but not have the day’s schedule de-railed by something general that only requires a simple text relay.
Lastly, since “verbal tone” cannot be conveyed by written word, sensitive topics are often best discussed on a phone call. Text can be used as a gateway to setting up that time to connect more personally, while giving the Patient a sense of “direct access” to their Practitioner. I typically err on the side of caution and schedule at least a small amount of time for a phone call prior to compounding, or at least engage in a brief relay by text to ensure herbal medicine formulations and Care are on-point with symptoms and aims.
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.)
Five Things You Need to Know from my experience:
- Thoroughly research the ever-growing options in EHR (Electronic Health Records) digital services that also provide HIPAA-secure Document Upload Portal and Text/Video features. I have been slow to relinquish the paper chart format of documentation as my primary method of record keeping, so I had begun my digital expansion with a Text-only service, unaware of the breadth of digital options available or the ideal need for an EHR to store all the data that was accumulating month after month. Thankfully, the Text service I implemented has evolved to incorporate more services since that time — including secure Video, Electronic Health History/Consent Forms, and Document Portal — but if you already implement an EHR service, do explore the ever-growing add-on Text/Video options that incorporate user-friendly and mobile device-optimized services that resonate for you. I use OhMD, and they have been extraordinarily accommodating with details of the E-Form built-out that I required, and ensuring they seamlessly integrate text data with the Practitioner’s EHR chart service. Patients can fill-out forms and sign right from their smartphones (or desktop, if preferred) — no more issues with “my printer isn’t working” glitches or delays of snail mail. Patients today want their health care fast and simplified, like everything else. Any added resistance to the flow in this process is often seen as “annoying” and people are gravitating to services that provide convenience.
- One of the primary concerns I had through the years with offering Video Calls via common third-party services was security. Do your research into the secure services available, and see if you can experience the video calls prior to committing to a particular service. Get a feel for them first. This will inform your decision based on your own devices, internet connection and speed to support glitch-free appointments when video is preferred. Once you sign-on to a service and begin populating it with Patient relay history and other data, the thought of transferring to another product seems daunting, if not impractical.
- Clear is kind. Communicating to Patients clearly prior to an appointment on what to expect is paramount. Spell-out every detail to how the appointment is conducted, even if it seems obvious to assume. The best and most efficient approach to providing Remote Care is having a methodical protocol that is defined in-writing for the initial Telehealth appointment. KEY: A well-crafted and easy-to-read email outlining these details in bullet-points alleviates a tremendous bit of confusion for those unfamiliar with Remote Care.
- While detailed emails are often overlooked, directing the Patient to check their emails for the document should be a requirement for seamless appointments. [Make a point to request of New Patients that they check email SPAM boxes, as redirected emails can be a frustrating recurrence and complicate the process.] Request that Patients mindfully review the email about: how the calls will take place, what to have prepared for the visit, ideal environment where they should situate themselves during the call, limited distractions/noise, adequate lighting (if scheduling a video call), privacy, fees, etc. Excessive ambient noise and being in situations that are not private will limit the depth and ease of exchanging critical information that may be more sensitive in-nature, additionally compromising ability to focus attention. [For example, a Patient who takes appointment call while driving with their children on-board/others in the car with them, or while doing grocery shopping, will impede discussions of intimate details and compromise ability to take notes.
- Admittedly, I do find Video Calls can be more distracting than a simple Audio-only Phone Call. When we are too concerned with our appearance, lighting, positioning, video streaming glitches, or needing to look away from the camera to take notes can influence the efficacy of the appointment. I personally prefer Audio-only Phone Calls. They have now worked effectively for almost two decades in my practice, unless the Patient insists they prefer seeing my face on the first appointment. There are times I am working from home and unable to utilize the video feature, and I communicate this clearly if the Patient prefers we reschedule when video is an option. Set aside adequate — perhaps extra — time for calls, as it may be a bit more difficult to conclude appointments on-time if video glitches disrupted the call at any point or when there is no staff to prompt you that the next appointment is waiting.
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?
With Telehealth gaining traction alongside the digital tools that make it possible, I transitioned away from an appointment-based approach with per-call billing and moved to a Monthly Renewal Care Program that covers Unlimited Consultation care on a one-fee monthly basis. It can become far too complex when considering time for text relays, unanticipated calls for questions, updates on the latest testing or doctor visits, and other miscellaneous contact points for proper care. A flat monthly fee simplifies all of this, and encourages deeper connections. This is an opportunity to provide greater value, more effective results, and a feel-good takeaway.
Truth is, some months an individual will require more frequent contact with numerous simple questions that can be answered by combination of texts and calls, and other months only require connecting upon [herbal] medicine refills. I prefer to be accessible for questions that come up in daily life surrounding optimal dietary choices, subtle or new symptom observations, simple updates on progress, reviewing documents of the latest diagnostic testing, answering questions about information/products they have come across which may help or harm our goals, and such. No one wants to pay a full Follow-up Exam fee just to ask about the latest powdered health beverage that they just want to know if it would help or harm them, in consideration of their medical history, prescription pharmaceutical medication and herbal medication.
Telehealth is a brilliant modality to provide this type of Unlimited Consultation Care structure, riding the ebb and flow of need.
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?
Having a Secure Text platform has enabled me to be a go-to resource throughout the month for troubleshooting symptoms and issues that come up sooner than later, when best addressed. It is a modality where Patients can log updates and observations so they don’t have to keep cumbersome journals that they forget to use and save for review at our next call. Sometimes I can be of great service if they are seeing a new trend of symptoms, and we can troubleshoot before these symptoms become disruptive and all-consuming.
Telehealth generates a greater sense of being integral to an individual’s Well Care Team, facilitating more timely support. Its all about Practitioner access and not having to wait for the in-person visit to communicate useful information. In fact, the ability to log updates between calls can actually expedite Follow-ups!
As mentioned, I maintained paper charting and added a secure Text-only platform first. Over time, it became a primary method of communication, and the amount of information exchanged made it clear that I needed a digital charting platform to store the information.
Additionally, since so much information can accumulate within paper charts, certain key details to an individual’s medical history are critical to have noted where they can be readily seen every time the chart is opened. Electronic Health Records (EHR) services provide methods of highlighting key history details and medications in a Patient’s history that is essential to see every time I make contact with them to inform my recommendations in their best care. Digging through a paper chart can be extraordinarily inefficient and cause key details to be overlooked because they are so far back in the pages. It can be embarrassing and unprofessional to ask questions that have already been noted in-detail and at the core of their symptoms and aims for Care.
Digital services that combine Electronic Forms, Patient Charts, Scheduling/Appointment Confirmations, Document Portal for receiving diagnostic reports, and Text/Video all work together so that we can even record more personal details that help create deeper connections with our Patients. Having a voice on the other end of the call is just as effective as being in-person — with the exception of practices and conditions that require physical hands-on examination, culture, biopsy, scope, or scan.
Since I am primarily reading the diagnostic/testing report documents, blood work, and working with verbal description of symptoms and medical history, my practice can function fully through Telehealth modality. This holds true for conventional practices for simple Follow-up appointments, when physical examination is not critical.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
At this moment, I have all the tools I need to provide direct access to help my Patients communicate with me, and to process their information. Perhaps having dictation service could be handy for note taking, however, I find that even voice-to-text on mobile phones are subject to mistakes, so manual entry will always require a bit of added time to ensure accuracy.
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?
The most important request I have of Patients is their comfort and confidence that the more detail they can recall and share with me about their medical history and symptom observations, the more precise we can tailor their Care. Our first appointment is quite long and heady as it is, requiring 60–90 minutes of time to comb through timelines and nuances in their health and medical background. Having the initial Electronic Documents include a general Health History form acts to cover some basics to expedite the initial work-up, but anything that supports recall is welcomed. The more complex the medical history, the longer our initial appointment can be, so allowing adequate time in the schedule is key to making Telehealth a seamless service. Adding a few minutes at the end of a phone exam while the discussion is fresh in-mind to enter information into the EHR will improve accuracy.
It is a challenge to remember everything at one sitting — whether in-person or virtual — so I aim to convey that as with any relationship, their support with me will deepen and improve over time as I get to know moredetails that may have been forgotten in that initial appointment. Conveying to Patients that Telehealth services are part of a journey together over time will alleviate the pressure to “get it right” on Day One. All I ask is that they try their best, and we will explore more together over time.
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?
For my particular type of practice, I don’t see the shared space in-person as required for my ability to provide the same sense of connection, understanding, evaluation, and support. Distance has not been an impediment, when I used to call it Care By-Phone or now, as Telehealth/Telemedicine.
Improvements in access to accurate at-home testing is exciting. Notably since the pandemic, Patients can experience long delays in getting in to see their doctors, so having more clinical information about the Patient at-hand for our appointments eliminates guesswork and eases Patients’ concerns or frustrations about delays in addressing imbalances sooner than later. We don’t always require new testing prior to getting started, but any past diagnostic reports can be helpful to reference over time with future testing to compare and contrast. If Augmented Reality technology can provide some remote diagnostic testing, that would be impressive!
Is there a part of this future vision that concerns you? Can you explain?
As with anything digital or automated, we must always consider security of the medical data collected with identifying information. In addition, errors in data transmission can lead to faulty diagnoses.
Further, computers are only as good as the information with which they are programmed. They are limited by the degree of human input.
Lastly, there are also non-tangible nuances to support of the human brain and body. We have the Emotional Body and Energetic Body that machines cannot anticipate at this time. Humans are complex creatures, subject to both “nature” and “nurture” influences. Equally, we are influenced by our mothers’ experiences while we developed en utero (if enduring stress, physical illness, or generally happy and calm), as well as our unique life experiences’ impact upon our psychological processes. All of these factors contribute to brain and body functions at-rest and in response to stress. How can an Augmented Reality technology learn and incorporate all of these influences, unless human interaction facilitates the information input? Its a loaded topic!
As a result, our health does not always fall into “if this, then that” computer processing. We can anticipate certain cause-and-effect processes, but what makes us human and what can resolve an imbalance cannot always be replicated or anticipated reliably by a computer.
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. 🙂
Since we touched upon technology, we can look to all we don’t yet know about the Human Brain. The movement we must continue to explore is not always “out there in space” but also “inner space”. Continued study to understand the Human Brain and influences of the energies within and around us will lead us to ways we can enhance and expand our functional abilities.
The Central Nervous System Hormones have direct communication loops with the body’s Endocrine Hormone orchestration, all of which sustains Cellular Metabolism — Life — itself. We know that Brain Function, Emotions, Environmental and Non-tangible Energies influence all hormones. Just as we have wireless communication and technology swirling around us constantly — keeping us connected — what more can our Brains do and how can we harness our own abilities to heal and do in our lifetimes? I sense we will see more evolve on this in the next 20 years and beyond, and I hope to be a part of these discoveries!
How can our readers further follow your work online?
With gratitude, Readers can learn more about my practice at: https://medherbalist.com
Social links therein!
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.