The concept of telemedicine has been part of our human experience since ancient history, and really parallels the advancement in communication over the centuries. The idea of being able to communicate medical information over a long distance has been necessary since the onset of the healing arts. The need to communicate birth or death notices, details of a plague outbreak, or the extent of battle injuries have been challenging doctors and inventors over the ages. Early versions of long-distance communication of medical information have been reported to include modalities such as smoke signals, drums, and even flag semaphores (those oddly marked flags people often wave on military vessels). The invention of the telegraph propelled civilization into a new age of electronic communication and arguably initiated the early renditions of modern telemedicine. The telegraph soon became the telephone and the use of the more reliable means of long-distance communication became immensely popular, especially in the military. Doctors and military personnel could now order supplies, communicate injury and casualty counts, and even perform doctor-to-doctor consultations over long distances.
A long list of pioneers forged the way for the development of telemedicine. Willem Einthoven, inventor of the electrocardiograph, started developing the idea of the use of the telephone for remote consultations in 1906. One of the first publicized modern ideas of “telemedicine” appeared in Hugo Gernsback’s April 1924 issue of Radio News Magazine . Despite the periodical being a radio-based magazine, it took a very advanced look into what health care could be if we used a television equipped with a microphone to facilitate communication between doctors and patients.
Traditionally, the first real-time audio-video telemedicine consult is often credited to the University of Nebraska in 1959 when doctors performed a neurological exam on a psychiatric patient. From there an interactive network between Logan International Airport and Massachusetts General Hospital in the 1960s developed into a true telemedicine network.
Telemedicine has been a dream in the minds of innovators for many years. As we just reviewed, there have been many trailblazers who have worked tirelessly to give us a vision of the future and how health care could evolve to serve an even greater good. As with all visionary ideas, after the honeymoon of thought is over, the reality of implementation sets in and a whole host of deterrents begin to emerge. The practical and widespread adaptation of telemedicine has been slowed over recent years due to appropriate concerns of privacy, regulation, ability, and acceptance. HIPPA has outlined clear guidelines for addressing privacy concerns for visits conducted via telemedicine means. Government regulation and health insurance reimbursement practices are an evolving topic, have but becoming more favorable as time passes. Acceptance was the “bogeyman” that often hid in the back of the minds of individuals who were new to telemedicine and were skeptical of their patient’s acceptance a virtual visit over a live-in-person visit. Well, the COVID-19 pandemic has basically revealed that such concerns, though valid, may be less of a barrier that we initially thought. In March of 2020, we as medical professions were faced with a “burning building” scenario of either closing down our offices due to governmental shutdown orders or finding other ways to care for our patients’ needs. In this “stay and burn” or “jump” scenario, many of us chose to jump. In this case, the leap of faith was to jump into this questionable space of telemedicine. Providers across the world seemingly overnight temporarily closed the doors to their traditional office-based practice of medicine and entered the virtual world of jacket, blouse/shirt and tie, sweatpants, and the onset of the virtual visit! Practitioners were not alone in this leap of faith. Local medical boards, governors, President Donald Trump, and insurance companies alike, to our surprise, immediately removed nearly all of the regulatory barriers to telehealth, and our ability to care for patients transitioned into the 21st century. We were all suddenly ushered into caring for a variety of medical conditions that we, just the week before, had thought could only be handled in person (because that is all we knew how to do). Doctors and patients were finally sitting in the classroom of life together and learned how to relate medically to one another in a virtual space. As the weeks went on, we learned that patients actually enjoyed the convenience of seeing their doctor from the comfort of their own home. Doctors realized the efficiency and convenience of virtual visits and that topics that were once thought impossible (i.e., the medical exam) were actually possible.
This book serves as a punctuation point in the history of telemedicine, specifically in the neurosciences. The voices you will hear in the book come from around the world and wish to articulate where we are “today” and to nod to where we may be in the future. This book and the following chapters are designed to express to you the reality of this changing component of the practice of medicine. We by no means intend to state that telemedicine is a defined field that has all the answers. By contrast, we acknowledge that clear guidelines, research, and data in the virtual practice of medicine re limited and ongoing. We acknowledge that many chapters and concepts are being articulated for the first time and may be imperfect. To that end, the authors involved in this project have agreed to revisit these topics 4–5 years from now and update you on any progress. So, with this background being laid, let’s turn the proverbial page on the in-person neurological evaluation and let’s start to understand the components of the virtual neurological evaluation of a patient.
The virtual visit
When preparing for your televisit, it is good to start with the end in mind. There has been a lot of experience with telemedicine now, and we are starting to see a few trends in the research about what makes a televisit successful. There is a growing number of research papers about patient perceptions of virtual visits and lessons learned from such interactions. One such article published by the Mayo Clinic recounts feedback from 49,000 patient comments over an 11-month period. Their overall findings suggested that the patients who were most satisfied with their visit appreciated the relationship that they established with their provider. The Mayo Clinic argued that the key elements to establishing a good virtual patient-doctor relationship from the perspective of patients was mainly focused on the communication skill of the provider and was less focused on the patient’s receipt of a prescription. The study supported the notion that a patient-doctor relationship can effectively be established through a video consultation when the provider focuses on patient-centered relationship building. This brings us back to the basic tenet of health care. The base word is “care” and that should be your focus. The ability to exhibit empathy, compassion, and attentiveness has been found to be a key element that makes a great doctor and will help you have a great virtual visit with your patients.
The key premise in setting yourself up for a successful virtual visit in the eyes of your patient is to start the visit with the right mindset. Yes, our goal is to make an accurate assessment of the patient’s medical concerns, decide on the need for appropriate diagnostic testing, make a diagnosis, and then prescribe appropriate treatment. That is the basic requirement of being a physician and the basic assumption of what your patient expects from you. That is equivalent to going to a fast food restaurant, ordering a hamburger, and receiving a burger, bun, tomato slice, and shred of lettuce. Yes, you have received a hamburger and that thing you received will fulfill your basic request for sustenance and possibly taste, but will you enjoy it? Probably not, when compared to another restaurant that uses toasted buns with sesame seeds, flame-broiled organic buffalo meat patties with a special rub seasoning, freshly harvested tomatoes, lettuce, pickles, and onions from a locally grown garden topped off with an in-house-made sauce. It’s as if this burger was made with you in mind, and I bet you will love it more! Both are burgers, both have the necessary components of providing you with a meal, but the one that you most enjoy has all the extras made just for you. It is the same with your televisit. When you approach your visit with the mindset of getting to know your patient, providing them with a structure for the virtual visit, listening to their story, and providing them with appropriate education and guidance, your efforts are more likely to be received in a much more positive light.
The basics of communication skills needed to perform an in-person medical examination have been taught in medical school for years. In 2001, the essential elements of physician–patient communication were examined in depth to provide guidance for medical schools and standards for professional practice. The culmination of such research was discussed in a 3-day conference in Kalamazoo, Michigan in May of 1999. The proceedings became known as the Kalamazoo Consensus Statement and were published by Gregory Makoul. This group identified seven essential elements of a good doctor-patient relationship, and these are outlined in Table 2.1 .