Donaghy E, Atherton H, Hammersley V Acceptability, benefits, and challenges of video consulting: a qualitative study in primary care. Br J Gen Pract. 2019; 69:e586-e594 https://doi.org/10.3399/bjgp19X704141
Shaw S Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study.Southampton (UK): NIHR Journals Library; 2018
Yeung A, Johnson DP, Trinh NH Feasibility and effectiveness of telepsychiatry services for Chinese immigrants in a nursing home. Telemed J E Health. 2009; 15:336-341 https://doi.org/10.1089/tmj.2008.0138
Wade V, Whittaker F, Hamlyn J. An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities. J Telemed Telecare. 2015; 21:490-493 https://doi.org/10.1177/1357633X15611771
Rocca MA, Kudryk VL, Pajak JC, Morris T. The evolution of a teledentistry system within the Department of Defense. Proc AMIA Symp. 1999; 921-924
Scuffham PA, Steed M. An economic evaluation of the Highlands and Islands teledentistry project. J Telemed Telecare. 2002; 8:165-77 https://doi.org/10.1177/1357633X0200800307
Berndt J, Leone P, King G. Using teledentistry to provide interceptive orthodontic services to disadvantaged children. Am J Orthod Dentofacial Orthop. 2008; 134:700-706 https://doi.org/10.1016/j.ajodo.2007.12.023
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Consultant Orthodontist, Clinical Lead in Orthodontics and Restorative Dentistry, Croydon University Hospital, 530 London Road, Thornton Heath CR7 7YE, UK
The principle of the video consultation is to provide safe, effective, evidence based care and advice that your patients require. This article guides dental clinicians in the use of video consultations by adapting their current communication skills and developing new ones. It covers guiding principles, selection of cases and patients, systematic preparation, communication, using technology, sharing information and importance of practice. The challenges of using video consultations and how to overcome these are discussed. Being able to use video consultations confidently and professionally is rewarding for the clinician and beneficial for the patient. Evolving communication skills to accomplish this will ultimately improve the quality of patient care and enhance personal job satisfaction.
CPD/Clinical Relevance: There is a need for dental professionals to develop and adapt their communication skills to using video consultations.
Article
Video consultations are increasing in the medical profession as a result of the COVID-19 pandemic. Chris Hopson, Chief Executive of NHS Providers recently reported that Trusts in England are carrying out 6000 online consultations a day compared to 200 before the crisis.1 Currently, in general medical practice, only two-thirds of appointments occur face to face.2
Video consultations have benefits for both patients and healthcare professionals. For patients, reducing travel, eliminating infection risk, increasing convenience and improving access to healthcare are advantageous.3,4,5 For healthcare professionals: strengthening networks between clinicians, encouraging patient self-care, cost-effectiveness and reducing the number of patients who fail to attend appointments are important.6 Clinicians and patients communicate by video in a similar way as during face-to-face consultations with high degrees of satisfaction.7,8 Crucially, video consultations have the advantage of the clinician obtaining ‘visual information and diagnostic clues coupled with the benefit of the therapeutic presence of the clinician’, which is absent in a telephone call.9
There are disadvantages as well for this form of communication: weaker patient–clinician relationship, dependence on technology (data connection, up-to-date devices), organizational challenges and reduced continuity of care.10 The advantages and disadvantages are summarized in Table 1.
Advantages
Disadvantages
Patients
Clinicians
Reducing travel
Strengthens clinical networks
Weaker patient–clinician relationship
Eliminating infection risk
Encouraging patient self-care
Dependent on technology
Increased convenience
More cost effective
Organizational challenges
Improved access
Decreased non-attendance
Reduced continuity of care
Video consultations are not new in dentistry. They were first introduced in 1994 by the United States Army in the Total Dental Access Project.11 They have continued to be explored since the 1990s in a range of uses. These have included improving access to specialist advice for rural populations,12 supervision of interceptive orthodontic care13 or remote consultations with restorative dentistry hospital clinics.14 However, the current healthcare climate, combined with new technology and reliable, fast data connections, has allowed video consultations in dentistry to be a viable alternative to face-to-face consultations. They can be incorporated into the daily clinical practice in a range of settings (primary or secondary care) depending on the service and the population that provider serves. It can be used in the main areas of dental emergencies (pain, broken/loose teeth, trauma, orthodontic casualties and broken dentures/crowns/bridges), remote consultations/supervision of treatment with specialists and ongoing provision of care (eg orthodontic appliances, oral health instruction). Other advanced applications in oral medicine, oral and maxillofacial surgery, prosthodontics, periodontics and paediatric dentistry have also been described.15
This article aims to be a practical guide for all dental professionals to develop the essential skills in performing a confident, effective and proficient video consultation with patients.
Figure 1. Example of video consultation equipment including front facing light source and two computer screens.
The principles stay the same
Video consultations are only appropriate for use in certain circumstances and clinicians should always ensure that the same standards of care are given as they would do in face to face consultations.16 This means providing safe, effective, evidence-based care and advice that your patients require.
It is imperative to explain to patients the scope and limitations of the video consultation, and ensure that this is accepted. Verbal consent is obtained and clearly documented in the clinical notes. It is also helpful to indicate who is present at the video consultation with the patient and the clinician. Patients or clinicians do not routinely record video consultations, unless specified.
If this cannot be carried out or is at risk of being compromised, as may become evident during the video consultation, pause the discussion politely. Then explain to the patient that a face-to-face consultation is needed to assess them accurately.
Helpful, current and easily accessible guidance has been issued by the General Dental Council, General Medical Council and NHS England.17,18,19
Case selection
Carefully consider what type of consultation will work with both your patients and yourself. Remember the limitations of the video consultation, but also the enhanced diagnostic information you can acquire compared to a phone call. The visual reassurance of a clinician should also not be underestimated. Developing a protocol can assist with this case selection process.
This will involve careful triaging of patients and then communicating to the patient (via phone, letter or email) as to whether they would like to engage in a video consultation. If so, instructions can be sent to patients. These may be written by the practice or can be provided by the software provider.
Not every type of consultation will be suitable, but start off with simple appointments and work up to more challenging assessments as you grow more confident.
Patient selection
While video consultations can be used for patients who you have not previously met, they work best with patients with whom you are familiar and have a rapport. In dentistry, this is often the case as we sometimes see our patients on a regular basis and have an existing patient–clinician relationship. The video consultation helps facilitate that relationship.
Other factors to consider are whether the patient feels comfortable using this type of technology, whether communication with the patient has been difficult in the past or whether the patient has the mental capacity to have a consultation in this format.
Get yourself and the patient ready
When the video consultation is arranged, ensure that both you and the patient have tested the technology before the appointment. Prepare yourself as you would with a face-to-face consultation: read through the notes, check the radiographs and consider any useful information that you could give to the patient electronically during the conversation. I will then prepare web links to relevant advice beforehand that I can easily access and share during my discussion with the patient. When the consultation starts, reassure the patient by letting them know what to expect, as it's probably a new experience for them too. If the patient is happy to proceed, take verbal consent and document this in the notes.
Be yourself
The video consultation is another way of creating the patient–clinician relationship, so you don't have to behave differently. Act as you are as if the patient were with you in the surgery, using your normal pattern in a routine consultation and assessment.
As it's a new process, you may miss out the points that you would do naturally – introduce yourself, use clear, concise questions, confirming answers and understanding, summarizing the key issues and don't forget to say a definite goodbye to end the call. Do all these normal, routine things in your normal, routine manner.
Finally, while you may have had video calls with friends or family in a relaxed and social basis, do remember that the consultation is a professional situation, so your appearance, language and dress also need to reflect this.
Using technology
The video consultation is only as good as the technology and its specifications at both ends of the call. The author in another article has described the different available types of software and platforms.20 There are various pros and cons to each option. In the absence of a universally recommended platform, the choice will be based on each individual clinician's preference and circumstance. Regardless of the platform, the essential system requirements are generally: Google Chrome or Apple Safari web browser, a web camera (built in/USB), a microphone (built in/USB), speakers or headset and a reliable connection to the internet greater than 1–5 megabits/second. Encourage your patient to use the most suitable and high-specification device they have, to carry out the call. A good-quality camera with a strong WiFi signal (as opposed to 4G, if possible) will enhance the quality of the images and help significantly in assessing your patient. This also applies to the clinician's side as well. When the audio communication becomes unclear or broken, remember to use the ‘chat’ function to try to improve this. This is available on most platforms. However, if the video connection quality is poor or fails, pause the discussion and explain to the patient that you should both try to attempt to reconnect again. If this doesn't improve or fails again, switch to a phone call or organize a face-to-face consultation. Be sure to document any technical or communication difficulties in the notes.
Figure 2. A screenshot of a well lit and correctly positioned video consultation.
It is valuable for the clinician to use a noise-cancelling headset to allow clear, undisturbed speech and enable better hearing from the patient's call. To make the discussion and time more effective, use two computer screens or devices in the video consultations. This will allow you to keep communicating with the patient visually, while having easy access to notes, diagnostic tests and radiographs. Additionally, using a ‘self-portrait light’ with the computer or webcam will illuminate your face brightly making it clearer for the patient to see you.
Your set up
The consultation should be focused on the communication between you and your patient, so ensure that there are no distractions or barriers to this. You should check your set up and how you appear on camera before the consultation starts. You don't want to start making adjustments during your time with the patient.
Select a quiet room with privacy, and use a neutral and uncluttered background. Your patient doesn't want to be focusing on your family photos or the books on your shelf, rather than you. Advise your patient to do this as well. Personally, I use my surgery for my consultations with the dental chair in the background; this adds context and familiarity for the patient and the nature of the video link.
Check that the webcam is just above or at eye level and not looking up at you. This is usually a problem when using a laptop computer or tablet device. It will result in a distorted and elongated view of your face. Avoid this by elevating the device (with a stand or books) so that the camera is at the correct height. Decide on a landscape or portrait frame but remember that the patient should be able to see your hands clearly as gesticulations and hand mannerisms play an important role in communication. I personally prefer a landscape framing as this gives space and professional distance during the video consultation compared to a portrait frame that can enlarge your face and make you appear too close to the patient.
Lighting
The lighting is of paramount importance. Avoid having light sources (windows, or lamps) behind you as they cast shadows across your face. This will mean that the large component of non-verbal communication from your face is obscured.
Instead, try to be in front of a natural light source from the window to illuminate your face. If this is not possible, then try to lower the ambient light by closing blinds on windows or dimming the overhead lights. You can then supplement this with a ‘self-portrait light’ (or alternative lamp) attached directly to the webcam to provide a light source in front of your face.
Communication
The majority of communication consists of non-verbal expressions of the face21 and video can enhance this, but also, it may not have the same effect as in a face-to-face consultation. The verbal cues that contribute to flow and speed of a conversation may also be affected. This can be due to the quality of the video and audio connection, time lags and the unfamiliarity with this type of consultation. So the natural nods and shaking of the head or the instinctive ‘uh-huh’ and ‘ok’ may become lost or even a distraction. To counteract this problem, use plenty of eye contact, slow down and exaggerate your non-verbal and verbal cues, ensure that one person is speaking at a time and finally, if you need to interrupt the other person, use an obvious visual gesture like raising your hand. Good eye contact is established by looking at the screen and not into the webcam; this will strengthen your attentiveness and engagement with the patient.
Remember, you can switch to or use different modalities, if communication needs to be clearer or there are technical difficulties. The conversation can continue on the phone or images can be sent using secure patient–clinician apps such as Pic Safe or Hospify.20 These apps can be used as enhancements and adjuncts to the video consultation. The mere fact of starting with a video consultation and having visual contact would have built up some empathy in the relationship.
Lastly, be aware of cognitive bias. This can emerge from seeing the patient in a different context from that of your surgery or clinic. This may have a subconscious impact on your decision-making process.22 Strategies to counteract the bias include using less instinctive thinking, using checklists and actively considering all the alternatives.
Sharing information
Sharing relevant, accurate sources of information with the patient before, during and after the consultation will help you to deliver a high-quality video consultation that will be clinically useful and informative for the patient.
Before
As the patient is waiting to start the consultation, you can provide information (even with a web link) that will prepare them for the consultation. I ask my patients to look at a video of how to retract their mouth so that they are ready to do this if I ask them to during our meeting.
During
If you're discussing a particular condition, medication or giving advice, then try to visually share the name of that syndrome, product or a web link that leads to more knowledge. I keep open a number of web browser tabs with sites that will be helpful for the patient and then I can quickly cut and paste them into the ‘chat’ or ‘message’ function during our conversation. Use the screen-sharing function to display photographs, images or radiographs to convey information effectively.
After
As the patient leaves the consultation, you can automatically direct them to websites as their ‘exit page’ that will assist them further, and reinforce the information that they have received. In my specialty, they may be led to the patient information area of the British Orthodontic Society website. Considering that up to 80% of information is forgotten immediately after any consultation,23 these are useful reminders to the discussion.
Confirm patient understanding and ending the consultation
There can be technical and subjective delays in both visual and audio communication during the consultation. Therefore, it is essential to clarify key points during the discussion, and confirm that the patient has understood them. Make sure there is ample time for the patient to answer this, in case of any interruptions in the connection. This can also be supplemented by an invitation to ask questions verbally or by using the ‘chat’ or ‘message’ function.
At the end of the meeting, summarize again the vital facts and what the management plan is. It's important to remind the patient of the limitations of the remote consultation and explain there may be a further need for a face-to-face meeting or a follow-up video consultation.
Finally, when drawing to a close, make sure there is an affirmative, definite and friendly goodbye to reassure the patient that the consultation has not ended abruptly or unexpectedly due to a technical difficulty.
After each consultation, ensure that the clinical notes document the discussions accurately with special reference to the video element. It's good practice to reflect on each encounter to see how it can be improved or what worked well as you develop your video consultation technique.
Figure 3. Using the chat function to share information (weblinks or complicated names) and keeping additional web browser tabs open with relevant advice.
Practice
Video consultations may be a new experience for you, and like any new technical procedure, it's important to practise.24 This will help significantly in preparing your set up and adapting your communication skills. Part of this can be done by yourself, but use your team to help you. Try being the patient, and vice versa, so you get valuable experience on both sides of the screen. Practising will identify the vulnerabilities and weakness of the process so these can be anticipated and rectified during a real consultation.
Practice is crucial when incorporating this into multi-professional video consultations. This type of consultation is both rewarding and valuable for clinicians and patients, but is more technically demanding and more complex in the area of communication.
Table 2 provides a summary checklist for how to prepare and conduct a video consultation.
Confirm patient's identity (name, birth date and address)
Explain the limitations of the video consultations
Confirm and document verbal consent to video consultation
Note other individuals present at the consultation
Keep account of the discussion and record in clinical notes
Log the information (weblinks/websites) shared with the patient
Summarize the management plan and and confirm understanding
Note any technical difficulties or any problems with communication
END THE VIDEO CONSULTATION
Video consultations are becoming more established and will become an integral part of the growing fabric of communication in healthcare, including dentistry.25 It is a fulfilling and refreshing experience that can increase the quality of your patient care. Therefore, adapting and developing our communication skills to this new modality is necessary.
The abilities that have been discussed will probably feel obvious, common sense and natural. However, the challenge is putting them all together and using a new, technical form of communication, to produce a seamless, concise, safe and professional consultation for you and your patient.
