Dr Dane Vishnubala kicks off the series exploring remote consultations with a one-on-one interview with Dr Roger Neighbour (OBE MA DSc FRCP FRACGP FRCGP).
Follow Arc Health: @archealthio
Follow Dr Dane Vishnubala: @DaneVishnubala
Follow Doctors.net.uk: @Doctors_net_uk
Explore more educational resources for remote consultations at archealth.io/education. Arc Health helps clinicians save time with remote consultations. Our technology is used in hundreds of NHS GP surgeries, care homes, hospitals and pharmacies. Find out more at archealth.io.
Dane: Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass. This is a podcast where we catch up with leading healthcare professionals to discuss tips and tricks for carrying out remote consultations, as well as bringing you key nuggets of information for your CPD. Now you can listen to us on Apple Podcasts, YouTube, Spotify, or wherever you get your podcasts from. So I hope you enjoy the episode.
So to kick us off, I’m joined by a man who needs no introduction. I’m delighted to have Dr Roger Neighbour join us today.
Dane: Hi Roger. So Roger, I’ll give you a good intro before we get started. Roger is a GP
Roger: Was, was. (laughter)
Dane: Was. A retired GP. Through Roger's career he's authored three fantastic books, which many of us will have seen or read, The Inner Consultation, The Inner Apprentice and The Inner Physician. And he's got a strong interest in psychological medicine, consultation skills and medical education. He's also an examiner for the MRCGP and has an OBE for services to medical education. So Roger, first of all, thanks for joining us.
Roger: It’s a pleasure.
Dane: So I guess it'll be interesting for a lot of us to hear about your career today and basically how you got here.
Roger: Thank you. Yes, indeed. It's funny when you look back on life, you can sometimes only in hindsight recognise what were the key moments. You don't always recognise them at the time. But I know one thing that was absolutely formative for me was on day one, as a medical student, I was lucky enough to go to King's College in Cambridge to do my preclinical. And on day one, very first day there, I was having a conversation with Kendall Dixon, who was the director of studies in medicine, who was just going through what's entailed. And he said okay, well in the first year you do anatomy and physiology and biochemistry. And the second year you do more anatomy and physiology and so forth.
And I didn't fancy biochemistry. Although, I did A-level chemistry and got a good grade at it. It wasn't a particular passion of mine and it all just seemed a bit of a drag. So I looked very closely at the small print in the regulations and it said that some medics had to do anatomy and physiology. But then it was a choice. It was you could do biochemistry or history and philosophy of science or experimental psychology. So I said to Kendall, actually, I dropped the experimental psychology and he said, no, no, that's for the natural science people. Medics do biochemistry. And I said simply it doesn't actually say that.
And we had a slight, not a contretemps exactly, but I fought my corner and he fought his for a moment. Then he capitulated and said well okay, do experimental psychology then. So alone out of the whole medical school intake that year, I did experimental psychology instead of biochemistry. And it was fantastic. Think it properly kept me sane because, I mean, I don't know your memory of doing anatomy and physiology was, but it's pretty soulless stuff, isn't it? Anatomy and physiology, rather. It's just a memory slog. With experimental psychology, it was fantastic. We ran the whole gamut from learning theory, running rats through mazes, to working with adolescents and doing psychoanalysis on a union model and everything in between. And it was fantastic. Really loved it. And so I went through the whole of my medical career, never having done any biochemistry. But having had a real interest in things like the logical right from that very early stage. And I don't think anybody's died because I don't know the Krebs cycle, but I certainly know that my career was largely shaped by having that kind of parallel line of thought to think slightly outside the conventional medical box and start getting interested in things psychological. So that was definitely a key moment and I didn't know. Part two, which is the MA part of the Cambridge degree in psychology. And that was brilliant. So that in hindsight was certainly a key moment. And after I finish whatever I do this year, next year, I plan to rule the universe. So when I do that, I'm gonna make, I'm going to cancel biochemistry for the medical curriculum and replace it with something psychological. I think will be much better off if we did that. So that was one key moment. The other thing that in hindsight, I didn't recognise it at the time. It was a key moment... rolling on a few years to when I was a trainee. I was lucky enough to get on what was then the Watford vocational training scheme at the ground floor. I was one of the first intakes. It was just this was the early seventies and vocational training was just getting off the ground. And I was one of the first intakes in Watford, which for my sins has been my hometown. Apologies to all football fans out there.
But my trainer, Peter Thompson, who was also the course organiser, had previously been on a course for trainers. It was run by one of the great lions of general practice called Paul Freeling, whose name I think is probably still remembered in many quarters as a real pioneer of thoughtful vocational training. And he had run a modular course for trainers, which my own trainer had been on.
And so when in due course I became Peter's trainee. I don't know how he obviously sensed that I was interested in that sort of stuff. So as a trainee, I went on a course for trainers. And I was by far the youngest one, the baby of the group and people were very kind to me. But right at that very early age, I got interested not only in medical education, but in Paul Freeling's approach to things, which is very much group-based. It was heavily Bouldin orientated with a lot about the doctor-patient interaction. And that was certainly very formative and that in a way kind of focussed the interest I already had in things psychological and focussed it in perhaps slightly more on on the educational aspect of it and the doctor-patient relationship of it's an aspect of it which, you know, you can probably sense of being the focus of my non-clinical career ever since then.
So, very quickly, that third and formative moment was after I'd been trained for a number of years, I had a phone call from Bill Stiles, who was then the colleague, the RCGP secretary who said so would I consider becoming a college examiner?
And I, being young and arrogant, said, well, I'll give it some thought and I'll let you know. Deciding whether I would grace them with my presence without realising actually this was hotly competitive. It's quite an honour to be asked. Anyway, long story short, I did become a college examiner and that was fantastic.
Dane: Well, let's take some of that medical education components forward. I think that's quite a nice overview. And I think it's interesting that, you know, as you point out, there are quite a few key moments where things influence where you go next. But I know that recently, you've been doing a lot of video consultation education. But I think to probably get us started in what is probably one of the introductory podcasts here, what are the key differences in video consultation on face to face?
Roger: Yes, it's interesting because what COVID has done in medicine and in lots of other fields is it's accelerated the process of change that was already underway and it's slightly changed the emphasis, the emphasis within it.
So we're seeing that in all sorts of walks of life. But in particular in medicine and clearly, for all sorts of reasons, there was a over the last few years, there's been a gentle pressure to move away from the standard ten-minute face-to-face consultations being the default mode and very rapidly in the space of three months, that's completely shifted. And I think the thought behind your question as to where the differences lie, I'd like that not to be the too many differences between the two, because at the core of it, you're still in one way interacting with a person who thinks you can help with their problem. And ultimately, any kind of consultation now, whatever the medium, is a problem-solving exercise. The patient comes in with a problem and hopes to leave the encounter with a plan for dealing with it. And all that's ever thought, spoken and theorised about the consultation is really just a strategy for solving a problem. And the basic strategy doesn't change. You work out what the problem is, to the best of your ability, and then you use your professional experience to propose and negotiate a plan. And that's essentially shorn of their trappings of Face-To-Face consultation and a video consultation are just that. It's a problem-solving conversation.
Dane: And what about opportunities and challenges in going with that? Do you see any particular opportunities where it's really providing something new that is helpful to us?
Roger: It certainly is possible. It was born of necessity and it's the only possible way of coping with the isolation requirements at the moment. And I think that's fantastic. And although I'm from a generation that wasn't brought up to consult by video, it's clearly been a Godsend - a lifesaver in many ways to go from. Four months ago, 25 per cent of our consultations were being done remotely and actually rather more by phone and by video to now, 90 per cent roughly of encounters are remote now. And there's been that huge swing. I'd like to think 25 per cent was too low. The 90 per cent is too high. And I think, you know, when the heat dies down, we'll find some kind of central ground. So I think that there are, as you rightly say, there are both opportunities and challenges. Let's talk about where the opportunities are largely in terms of practicality.
From the doctor's point of view, it's been the only way, really, that you can actually deal with patients without putting either yourself or your staff or all the patients at the risk contact. That's inevitable. It's also in terms of accelerating a process that was already underway. I think we've known for a while, haven't we? That a large number of patients find a hassle of booking appointments mixed, travelling out with children or on public transport or taking a day off work just for an appointment. This is not an effective way of doing medicine. So I think there are all sorts of realistic ways, why face to face as being the gold standard or the default needs to soften. But there certainly are some challenges. Some of them are too technical. I guess we can talk about those first, but some of them are more conceptual and no less important for that, in the sense that for most GPs and certainly all of the younger generation, by which I mean anybody under about 50, who've grown up with access to video through their smartphones as being just part of ordinary life, I think the idea of medicating somebody by video is with a face time or whatever is not news at all.
For many patients, though, it is. And a disproportionate number of patients clearly are elderly. A disproportionate number of people are socially disadvantaged. So that's a fact. And I think we can't assume that they are as tech-savvy as the average GP. And so leaving aside the technical stuff, which we will return to if you like, in just a moment, there is I think a real potential there of the fact that it's being done by technology that for some people is still unfamiliar territory. There is a danger of widening the health inequality gap, which which is pretty bad in this country already. And I think there's a danger with moving to video that the tech-savvy and the, well, well-off and the sharp-elbowed get better access to care, whereas the people for whom those barriers get pushed even further down the accessibility ladder. So I think that that is a real thing we have to think through in the long run. Purely in terms of the technology, there's one thing which I hope will emerge from our discussion, particularly around the idea of video consulting is that most of the important stuff happens before you actually make the connection with the patient.
Dane: Yeah, yeah. That's, that's true, isn't it? And we talked about this before, so let's move on to that. But I think probably just say with the challenges that you point out about health inequalities and I think you're completely right and that and maybe it's something that we as a profession need to be aware of and be mindful of at all times to just make sure we are addressing that in some way or form as you we move through. OK. So let's move on to the setting for the video consultations because I think there's a lot around that.
Roger: Yes, indeed.
Dane: So in terms of setting up consultations, obviously it is a worry to a lot of people and particularly, I guess, to GPs and doctors who aren't used to video consultations. And there's lots of debates about, you know, what should the background look like? Where should I set, what technology should I use? And I think my first consultation was- I spent a lot of time preparing what I thought should be the look and feel. But actually, I hadn't really discussed that for and I'd be really interesting to hear your thoughts from what you think setting up video consultation should look like and what we should consider.
Roger: Yeah. Although it's obvious to say so. It's nonetheless true of other things that's lacking from video consultation is quite a high proportion of the nonverbal stuff. I mean, I haven't fringed in our conversation. I had no idea what you're doing with your hands. You can see mine when I get particularly agitated. But now you can't. And this is, of course, the non-verbal stuff. It is really very important, particularly when you're trying to make a quick rapport with somebody whom you might not know. So, you even just setting up the frame. I mean, even if I could go back here. You can see more of my body language.
Roger: But you feel like you've got to shout to reach me. Whereas if I'm like this, this is too much in your face and it's intimidating. So getting some sort of balance right is important.
And also the messages that are communicated by the background, I think are really very strong. If you're a patient, walking into a GP's consulting room if it was the very first time you'd ever done it if you'd never been in a consulting room before. Most of the time, you can tell your a guest and slightly unwelcome guest in somebody else's territory, in the sense that the occupant of the room is comfortable, well off sitting in the comfortable chair, whereas you've had to wait outside and knock on the door for permission to enter and you're shown to a chair that is clearly a low-status chair compared with the one that the doctor is sitting in. These messages, although they're not expressed verbally, they do impact on the quickness of the connection and so forth.
And so I said this is certainly true with how you come across. Have you noticed you and I are doing it now and most of the other of the journalists you see on TV, they've all got bookshelves?
Roger: Which to a patient - and many of our patients will not have bookshelves. Many of them will not have books in any great number. And there's a message communicated that your background there is actually rather nice because I can see you very clearly against a clear white background and the books are kind of there like, kind of - “don't forget I know stuff”.
In what you can see in my room, which is my study, is a tip. Well you can see over there my bookshelves are a mess, that's my in-tray. And I'm wearing a shirt that says I am not at work.
If you're patient tuning in to this, what have you got to go on at first glance? Other than this sort of information?
Roger: And I think it's something we will come back to. If it's possible, when you're consulting by video, if at least some of the time you can use the record option and just watch yourself later and think, how is this person coming across - forget it's you. How is this person coming across? Is this somebody I could open up to? Is this somebody who seems interested, you know, who's gotten a bit of a welcoming appearance, maybe an occasional smile or whatever? I think that kind of feedback is very valuable.
Just quickly, on some of the other technical stuff, I mean, don't get backlit. I mean, don't have a bit of a bright window behind you, that puts your face in shadow. I personally think that landscape format is better than portrait. It just seems more natural. It just seems, it feels more personal. One of the great things - and I think one of the things that can cause one of the big problems with video is actually to do just with the technicalities of the quality of connection.
Dane: Yeah, yeah.
Roger: I, I guess most of the time you're working from a surgery, you've probably got decent broadband and up-to-date stuff. If you've got work, if you're working from home, well that's a matter of your own choice. You're probably working for your own laptop with your own home broadband connection. Sometimes, I don't know what yours is like, but mine fluctuates a bit. It's pretty good most of the time, but not always. And certainly, your patients may well be working from laptops or poorer connections, not necessarily with a high-speed connection. And the net result of that is that with many of the video platforms, some are better than others. But with many of the video platforms, the net result of slightly dodgy connections is to introduce a jerkiness into the picture, which will sometimes freeze or you get a time lag where there's a distinct number of seconds, sometimes between one person speaking and the other person actually hearing them. Which is enormously disruptive if you're trying to have a conversation with some ebb and flow. And so that idea of a time lag has a really important impact on the consultation because first of all, you're just nodding at the moment but in real life, you probably are probably going, uhuh, mhmm, right, oh, yeah, yup, yup, yup. Those are the noises that when they're face to face and in real-time, you don't notice because they're just little murmurs of encouragement. But if they come half a second too late. They become interruptions. So what the patient hears is talking, talking, talk ....uhun.
Which to which the patients would say I'm sorry, what was that? And it's disruptive. So I think one of the messages is you have to build that into the way you talk in video and to do perhaps more of your encouragement with facial expression and gesture, than with the uhun uhun uhun that we're used to. And it takes a little while to get used to that. But when it goes wrong it's surprisingly disruptive.
Dane: Yeah. Okay. Yeah, no that's really interesting. So there are a couple of key points here. So there's the setting up of the frame. And I think you make an interesting point because at the moment you can't see my hands till I bring them up. So actually maybe for a consultation, having it just a tad further away to frame my hands easier would be-
Roger: I think, having your hands further away and also held a bit higher so that you don't have to plan too far away to get your hands in frame.
Dane: Yeah. Yeah. So that would be useful. You talked about the lighting and making sure it's not directly behind you so that the lighting is appropriate. And you know in a perfect world, we want the lighting coming from, from here in, don't we? So bookshelves and backgrounds, what are we trying to stimulate? It's an environment. What are we trying to say by it? I think it's really interesting.
Roger: If you're at home, and think you mentioned that you did some work from home, at home, you're probably in your 'home clothes'. From the patient's point of view, if it looks like they're consulting a doctor who's just come in from the garden or would be rather out shopping. It adds to the sense of I'm not welcome here. That I'm interrupting this guy's life. Not suggesting necessarily that you dress formally, but maybe at least from the waist up, you should dress like you normally would for work.
Dane: Yeah. And then don't stand up.
Roger: And then don't stand up. And practical things too like make sure your phone's off and you're not going to be interrupted. That kids know mummy or daddy is working.
Dane: Yeah. So they start setting up beforehand for quietness and at least a professional-ish looking attire. You talked about recording, which, just more for the viewers and listeners is that we do have a good medical-legal podcast around all of those elements in video consultations they can follow up on. But I think, like you said, you know, we all learnt, particularly for me in my training time, we learnt by watching our videos back. So I think that's just as useful to see on our video consultation. And then finally, you talked about the Wi-Fi strength. And interestingly, for me, my strength of Wi-Fi was so poor in the house that I actually just got a really long CAT cable. It plugs into my modem and plugs directly into my laptop to avoid that. But again, it depends on where your modem isn't it? As to whether that can work.
Roger: Just in kind of preparations. If a practice is introducing this very recently then it's something they've not done much in the past. Again, I think of it from the patient's point of view. How are they going to know? They will presumably try to contact the surgery their usual way, which is usually by phone. They will usually be answered by a receptionist. The receptionists need to know what they know all about it and know how it operates, how it works, how you make the connection, how you set up. So you need to make sure that the receptionist really knows. And also if your practice has a website, to make sure that the information about how to articulate what to expect and how to make the hook up, I think that there needs to be really, really nailed.
Dane: Yeah, that's really a good point, isn't it? Because it's about the unknown. It's another thing that the patient isn't used to. And if the receptionist isn't used to it either. So I think - I'm sure it was. I mean, might have been you at the RCGP when we had this conversation in the conference for it's around actually the receptionist being a patient and just trying out the process to make sure they understand it fully first, is always good stuff.
Roger: Or even yourself. There is no reason at all why you can't try to make an appointment with yourself and see how it goes.
Dane: And see what it feels like. Yeah.
OK. And so I guess moving on from that, I think you mentioned the kind of percentages and how high remote consultation has gone to; so obviously before COVID telephone and video consultations were very much a stepping stone, a lot of the time, to face-to-face consultation. But now given remote consultations are the norm, you know, clearly, we need to adjust our approach to consultations. And I know, obviously, based on your past books and models that importance around connecting, you know, how do we change that to emphasise connecting in a new way of consulting? Is there any tips or tricks that you have in mind for us?
Roger: I think it is. I guess that's really interesting because when the kind of conventional received wisdom about general practice. One of the things that the least my generation was very fond of labouring was, oh, in general practice, we know our patients. You know, when you've known this patient for 30 years, you'll do da da da da. And of course, A) that's not true for the doctors who haven't been in practice that long. And also, particularly with video consultations, you're probably seeing a greater proportion of patients who you haven't met in real life before, let alone by video. In a way that makes the conventional teaching work ought to be that that's really difficult. And yet, if you think to other people in your own life, other professions, that you might consult as an estate agent, solicitor or financial advisor, equally competent professionals who you haven't known for 30 years, you know, pretty much within seconds whether this is someone I can deal with or not. I don't think we've really got to the bottom yet of what it is about, about the initial few seconds of a consultation with a stranger that makes you feel either can or cannot feel at ease with this person or I either can or cannot trust them or accept them or work with them. And I don't think we've really got that. It's something I think to do with the non-verbals in the first few seconds of the encounter.
And if you're having a bad day at work with a face-to-face patient and you're frazzled. And the last patient's been demanding and the receptionist just phoned, with an extra visit and you're hassled and in comes the next patient who you think, oh, this can be quick one because it's just a blood pressure check. And the patient comes in and you're all typing up the notes from the previous one, and you're saying "roll the sleeve up, let's crack on". And then you look up and see that the patient is in tears for some other reason and you've completely misjudged it. That's, I mean, I exaggerate slightly, but we've all had consultations that begin a bit like that and they go from bad to worse. And you really can't blame the patient for. You know, for not, you can't blame the patient because it goes badly. The lesson I think you take from that is almost the best way I think you've got in a face to face or a video consultation, of getting it off to a good start in those first few seconds is to make sure that you really are paying attention to the patient and that they can see and hear that you are.
Dane: And we've all done that haven't we.
Roger: And that involves a degree of eye contact. At the moment, I'm watching the two of us on my screen. Much of what I'm looking at is at you. Whereas if I want to make eye contact with the patient, I need to look to the webcam. And now I'm making eye contact with the patients.
And the difference between this and this is quite noticeable. You can see it. The difference between this is eye contact with the patient. And this is not.
And so for things like that, I think just being very, very careful that you try to communicate interest and that's a facial expression thing. It's a gesture. It's a nod thing. It's a smile thing. It's the difference between sort of "Hi" and "how do you do?" There's no rights and wrong ways to go about it but I think because we each convey interest and concern in our own individual and idiosyncratic ways. And I think in terms of you say about making connections, which I think does help, which is perhaps more so in a video consultation than in a face to face one, most patients, when they see you face to face, don't know what the rules are. Yeah, they know there will be a little bit of chit chat. And then at some point, you'll probably say, anyway, what can I do for you? And then that's their cue to start. And that's the kind of choreography of the normal consultation face to face. I mean, on both sides know that's usually how it goes. Particularly with the patient for whom this might be a novelty, they don't know what rules are. And I think the only way for them to know what the rules are or the ground rules are, are for you to tell them if they don't know already.
So I think although it may sound slightly artificial, for a patient in their first video consultation, I think it's helpful. After you've done this: "Hello, I'm Dr Neighbour" or whatever your name is - to say something along the lines of you've probably not done this before but the way it goes is this. I'd like you, first of all, to start by telling me in as much detail as you can, what was the reason that you felt you wanted to talk to me today? And then I'll probably have some medical questions I need to go through with you, and then we'll see where that takes us and we'll discuss what we're going to do about the problem. In other words, to signpost. Also for the course of the consultation. I think that goes a long way towards setting it up. If that makes sense.
Dane: Yeah, definitely. So I think, you know, some of the key points you got across here is that signposting may possibly be even more important, given the fact that the patient here is not so aware of how consultation in this setting works. And you mentioned the overemphasis on gestures and things which I think are important, but also, the point you make is one we all do when we're rushed. We have a habit of sometimes someone I kind of vaguely know, a multitasker might still be finishing off something. And I'm trying to see if I can compound my time, which never really works, but seems a good idea at the time.
So, yeah, that kind of full attention is probably more critical, if anything, on the video, because other things get lost don't they?
Dane: Hi there, I hope you enjoyed episode one with Dr Roger Neighbour. Next time on Remote Consultation Masterclass, we’ll be discussing the importance of safety netting and when a video consultation is not appropriate. And this will be our second and final part of our podcast with Dr Roger Neighbour. So do join us for that, and do keep in touch with us for future podcasts by subscribing. And you can do this on Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from.
00:00 Episode introduction
00:46 Introduction to Roger Neighbour
01:35 How Roger’s career in experimental psychology began
09:02 Key differences in video consultation vs face-to-face
10:39 Opportunities and challenges with video consultations
14:18 Setting up for video consultations
17:03 Tips on improving video consultations
21:36 Solving connectivity (Wi-Fi) issues
23:12 Being alert and connecting with your patients remotely