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In Part 1 of this series, I described the three hurdles that prevent us from implementing telemedicine: a roving definition of the VCPR, the “pain” we experience when starting something new, and the fear of failing to provide good care. In this vein, we must all acknowledge that telemedicine is a wonderful tool, but it does have limits and requires proper case selection for best results. Assuming you are assessing a chronic hip dysplasia lameness and not an unstable, polytrauma, hit-by-car case through the digital platform, let’s first address a few housekeeping items.
The Client’s Responsibility
For the telemedicine exam to be fruitful:
· The client must be in a well-lit, quiet room and pre-send any photos of lesions,videos of limping, etc.
· The patient must be present and adequately corralled to allow for close-up views of whatever you request.
· The cell phone volume must be on. (Hey, don’t judge. You’d be surprised.)
· The cell phone battery must have enough juice to last the duration of the visit.
· Fora more detailed, customizable checklist to send to clients prior to their telemedicine appointments, choose “Free Checklist” on the Hashwag home page.
The Veterinarian’s Responsibility
· Tell the client up front what the limits of telemedicine are and that the consult may result in an in-person exam.
· Decide if you wish to do a “complete” exam or a “brief” exam that focuses only on the presenting complaint. Charge accordingly. Within reasonable time constraints, I recommend performing as complete an exam as possible (obviously excluding palpation, auscultation, and otoscopy). It is what I do in person, no matter the chief complaint. It is what we should strive for electronically.
· Clearly communicate what you want close-ups of and whether the video is in focus.
· Laugh about the bloopers and foibles of your first few virtual visits. Make this a bonding time with your client.
A New Perspective On Old Rules Of Engagement
Now we get to delve more deeply into the mechanics of performing an optimal physical exam, whether in person or through a digital screen. But it’s not what you think. I’m not going to describe a head-to-toe canine/feline exam. I’m going to stick strictly to the head—our heads, to be exact. While this section has a decidedly more philosophical bent, I promise it will give you new insight into how to be the best practitioner you can be.
Years ago, during a mundane wellness visit, my colleague palpated a splenic hemangiomain a Golden Retriever, performed surgery the same day, and bought her patient years of happy, healthy life. I applauded her expert skill…and secretly wondered if I would have found that splenic mass. Or would I have missed it? Would I have seen only what I expected to see? Felt only what I expected to feel?
The term in psychology for this condition is WYSIATI (What You See Is All There Is), and it causes a cognitive blind spot that can affect the in-person and telemedicine exam alike.
How do we practice best medicine, no matter the patient’s location? We realize this blind spot is possible and actively defend against it.
I See Dead People
Daniel Kahneman, in his book Thinking, Fast and Slow,[i] proposes a cognitive framework for understanding the WYSIATI problem. He suggests our minds operate through two modes of thinking: System 1 and System 2. System 1 is in charge of snap decisions based on conspicuous data and typical outcomes. It helps us navigate the world quickly and efficiently—intuitively—and for the most part guides us well. System 1 helps peolpe read this sentnece withuot much diffcuilty.
But System 1 also leads the unsuspecting traveler into the Dread Land of Assumption without warning. When given little data, we nonetheless can form an expectation that feels absolutely right because it is in line with our experience—and yet be dead wrong.
The movie The Sixth Sense capitalizes on the System 1 assumption that Bruce Willis’s character (a psychologist who, after failing a patient in the past, is trying to help a boy haunted by ghosts now) is a reliable source of information. In one devastating camera frame, we suddenly realize he is not, and we wonder how we could have been so fooled.
System 1 is our default driver not only because it usually excels at navigating life, but because System 2, which employs slow, distrustful, and labor-intensive analytic thinking, is lazy. Only after being stunned by the movie’s plot twist does System 2 rouse itself to trace the clues. Tell me to multiply 10 X 35 in my head, and System 1 merrily spits out an effortless answer. But give me 746 x 13, and my System 2 gets grumpy real fast. I’m stuck at 3 x 6 = 18, and ugh, I just don’t want to go on.
Focus Has A Currency
The point is, System 2 requires focus. Guess what? When you pay attention, you do indeed have to pay. The focus required for Activity A depletes your ability to focus on Activity B, until you direct energy back into your mental bank account. As you get the hang of a new workflow and an unfamiliar digital interface for your first telemedicine appointments, your focus will be split.You will be at risk of seeing only what you expect to see in the animal on the screen.
Shun distractions, stop multitasking. Write “System 2” on your notepad. Furrow your brow if you have to. (Studies show that frowning actually improves concentration, much as smiling produces happiness). I don’t care what you do, just do something to allocate energy to System 2 and engage your analytical side. Hunt for unexpected clues, and you will practice good medicine.
Skimming The Radiograph
I once took chest radiographs of a coughing dog who occasionally yelped in pain, though I could never localize the source. I followed the radiology golden rule of looking everywhere but the lungs first, then squinted hard at the parenchyma. No bullae, no air bronchograms, no blunted pulmonary arteries. I mobilized all my attention and called this a moderate bronchointerstitial pattern…
System 2 started to slide back into its bog. System 1 was taking over again, telling the techs which room to return the dog to. But something—somewhere—didn’t look right. System 2 had paused to languidly point my attention back to the radiograph. I had rooms to see, drug doses to calculate, discharge instructions to write, but luckily I had enough mental energy and curiosity in my tank to pull System 2 back up and begin the search. Patient position, coned-down margins, cervical spine… 1-2-3-4-5-6-7-8. I counted again. Yep. Eight cervical vertebrae. System 2 found what was wrong with the radiograph—and the cause of dog’s intermittent pain. But only because I felt like paying attention.
This example is especially appropriate because I did not have my hands on the dog. I was using a digital tool to assess his health—and I found gold.
Remember the Why
We became veterinarians to help animals live better, healthier lives. Donning our Sherlock Holmes cap every time we walk into an exam room or open a virtual visit, we thrive on putting the puzzle pieces of science together to practice medicine. But boil our job down to its simplest form, and one thing becomes clear: we get paid to observe, analyze, and decide.
Sabotage can come swiftly and silently, until suddenly we no longer question and search, but assume and shortcut our way to clinical mistakes that can cost our patients quality of life. Whether your hands are on the animal or on the keyboard, be mindful, in every sense of the word, and elevate your game.
[i] Kahneman, Daniel. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011.