Link to podcast: Telehealth & Texting
Welcome to DPC Pediatrician. We’re Dr. Phil Boucher and Dr. Marina Capella, two DPC pediatricians who are on a mission to share our love of direct primary care with you. Hey everyone, welcome back to DPC Pediatrician. Today we are going to talk about communications in the office when it comes to text messaging, telehealth, those sorts of things.
Because one of the favorite features of patients by far, and I think for a lot of physicians too, is that you don’t have to bring patients into the office for every little thing. And so we wanted to have a conversation a bit around what does that actually look like? How do we do it?
And how does it work for patients when it comes to the text messaging, the telehealth visits, those sorts of things. I’ll just start off by sharing our big picture of our practice. Like I tell people, Yes, I’m hilarious and have a sparkling personality, and that’s why a lot of parents join my practice.
But honestly, if you look at their favorite feature, it’s that they can text message us. And at the end of the day, especially in pediatrics, where most of the People that are having children at this point are pretty tech native. They hate making phone calls. They would rather text. They’re comfortable in their texting. We just embrace that.
And we say, yeah, you can call if you want, but frankly, most people like text messaging us. And if we look at our favorite features of the office text message is by far and away the best feature or favorite feature amongst our patients. And so we, We’ve gotten to the point where if we miss a call,
we just text them back and say, hey, sorry, I missed your call. What’s going on? And then they happily are like, here, let me just text it quick. Let me dictate a little voice message to tell you what’s going on with Louise or whoever it might be. Parents really like that.
And it quickly trains them to just text us. And so when they have issues, they simply text. And I don’t know what it’s like in your practice, Marina, if you can speak a little bit about how you approach that or any kind of big picture differences when it comes to your patients.
Yeah, I would say, like you, that’s something that I really looked forward to in this practice. Although I would say maybe in the very beginning, coming out of the fee-for-service world and the busy pediatric world, I was a little bit hesitant about it because, you know, we’re accustomed to having panels of a few thousand people and…
We’re accustomed to being burned out and thinking about the prospect of having parents being able to text us 24-7. For some people, that can seem overwhelming and there can be some trepidation around that. But in reality, when you’re starting out with a panel of zero, right, and you’re building your way up, In the beginning, it’s very easy.
As people start to get busier and they get to their goal numbers in terms of their panel size, I would say it can get a little trickier to manage the text messages, especially during busy seasons like the middle of winter, right? Like after Thanksgiving into January,
especially a lot of texts about fevers and coughs and vomiting and all that stuff. So for me, Once I actually learned what DPC was like and that the volume was much less than in the fee-for-service world, I thought this is fantastic because it creates a more personalized relationship.
And also I remember working in both general pediatrics and in urgent care. There were many visits that I thought this could have been a phone call. This could have been a text message. This didn’t require a full visit. And I felt bad for the families that had to take time off work or find a ride or…
just take time out of their busy day and drag along three other kids in order to come and ask about, Hey, my baby hasn’t pooped for three days. Is that normal? Or, or you’ve got to come in for that.
And then they poop in the waiting room and you’re like, perfect. 99213. Yeah.
Exactly. Or, or the bug bite. That’s just a mosquito bite that they’re worried about. Like that totally could have been a picture or even pink eye, a lot of pink eye and urgent care. I thought how much money and resources are being wasted because you know,
this could have been a photo and a few sentences back and forth in text message. So I really love that. I don’t necessarily have to arrange for visits and parents. They don’t have to drive all the way over here and figure out their schedule and they can just get some pink eye drops when they need them,
of course, or be reassured about eczema or a bug bite and things like that.
I was going to say, I think that that is one of the biggest things is there were so many times when I was in the fee for service practice where I was like, wow, I really wasted their time, my staff’s time checking them in for this super benign thing that one picture or, and three sentences would have,
I would have known exactly what it was and could have reassured them. I could have given them some advice. I could have told them here’s what to watch for. And then I could have checked in the next day and save them.
Yeah.
the trip across town, the waiting room, the other germs in the waiting room, the finding insurance cards, the stress and all those sorts of things with like literally two minutes of texting back and forth could have done that.
Yeah. Definitely. And I think a lot of fee-for-service practices and big hospital systems are embracing telehealth, right? In fact, I think they’re over-encouraging the use of telehealth in some ways. But in those large systems, it’s hard because when you utilize those telehealth services, you’re getting most of the time some advanced practice provider, right?
You’re not getting your physician that you trust, right? you’re getting someone else. I remember when I worked in urgent care, a teenager had ear pain and they had done a televisit and they had been prescribed antibiotics for an ear infection, even though of course you didn’t examine them. Right. And then they come back a week later,
they see me in urgent care and they’re like, my ear is still hurting. I took the course of antibiotics. And I look in there and there’s an earbud stuck way down there. I mean, that was completely inappropriate for him to take antibiotics for a week, right? For an earbud that got stuck.
Oh my gosh.
Yeah.
But there’s so many stories like that. Like I can think of similar stories like that too, where it was just totally, oh yeah, we can just do that over telehealth. Give us insurance information, wait for somebody. They’ll pop on, they’ll do the visit. Oh yeah, you need an antibiotic, that sort of thing.
Yeah.
Yeah, for sure.
But it’s that discontinuity in relationships, I think, that we see in other systems. And here you have a provider or maybe a provider and a team, right? That actually, I shouldn’t say provider, I should say physician, right? That knows the patients that can easily skim through their chart or the text messages and
give appropriate care right instead of some random person in the system that is giving them advice and and then the pcp probably never even finds out about it unless there’s a problem right yeah so i love i love the text messaging and the parents i think like you said it’s one of the greatest features in their minds
because it’s peace of mind that text messaging really represents peace of mind for parents that if something happens i can text my physician, my pediatrician, and ask a quick question and figure out if it’s something that I should be worried about or not, and get a response within a reasonable amount of time.
Now, sometimes I will say that as I’ve gotten busy, I don’t always get around to them. Sometimes I have patients back to back for a couple of hours. And then during my lunch break, I get to respond to them. And parents know that I’ve told them, if it’s something really urgent, call.
If it’s something that can wait a few hours or an hour or two, then text is okay. How do you deal with that, with the urgency of messages in your practice, Phil?
So the big things that we do to facilitate that, because we have a good-sized panel and get a lot of text messages every week, a couple of things is we try and set the precedent of, yes, we will respond, but we’re not instantaneous. And even if it could be an instantaneous response, if it’s non-urgent,
I’m gonna set aside time to go through our text messages and just kind of set, here’s how it works. And the vast, vast, vast majority of the time, parents are grateful that they got back and expected a response within a few hours they weren’t expecting or needing an immediate response and if their kid has a
laceration they’re going to call and then i’m going to say can you just text me some pictures and i’ll be watching for that to come in But if it’s a fever, if they have a rash or a runny nose or all the other questions that they have, they know they’ll get a response.
They’ve given it the peace of mind of, okay, I put this out there. It’s not responded to yet, but I know that they will get back to me. And having that layer of trust is all that they need to feel like, okay, I got that message out there.
And so I think you’re absolutely right that it really provides that peace of mind that I have access and I don’t have to like claw for every little bit of attention and advice and suggestions. Or like, I think one of the things that keeps a lot of parents from reaching out to their
regular pediatrician is they know they’re going to get the runaround. They know they’re going to get the voicemails. It’s going to take three days. It’s going to require a visit for something that’s straightforward or some parenting advice or something along those lines. So then they just turn to the internet or their Facebook support groups or friends
or family or those sorts of things because it takes them on. So instead, they’re able to just reach out. They know that it’s out there in the ether that will get back to them. I can’t even think of the last time where somebody was like, hey, are you guys there? Because we get back within a few hours.
from a like scheduling workflow perspective our office is open from 8 to 4 30 and so we expect then that during those hours they’ll get a reply within a couple of hours when we first arrive we spend about we have 30 minutes blocked off to just
tidy up spruce make sure that things are getting put you know filed away that questions are getting responded to in an appropriate time period so that it’s not seven in the morning and people are texting and expecting a response right then. We just have the kind of standing of, okay, it’s eight o’clock.
We’re going to sit down at our computers. We’re going to work through Spruce, see what’s up, see who needs to get plugged in, where, and those sorts of things and give ourselves time to drink some coffee and to work our way through Spruce.
And then at 830, we meet and we huddle as a team to look through the schedule for the day. That is for another discussion. But then After closure, 4.30 comes, we close up for the day. Right away, they start getting a text message reply if they reach out of, hey, our office is closed,
but we can still help. You can book an appointment for tomorrow. If this is a non-urgent question and you just want to get us back, get it If you’re okay with waiting until tomorrow to get a reply, we’ve got your message. We’ll get back to you in the morning.
If it’s something that’s super urgent, here’s what to do or here’s how to do that. Or if you just want to book your appointment for tomorrow, click this button. So immediately they start being notified and that boundary has been set that, okay, I’m not going to get an instant reply. The office is closed.
There’s still these options of things that I can do. Now, I do keep an eye on spruce into the mid evening, at least. Usually it takes about seven seconds to know if this is an urgent sort of thing that I need to reply to or to help them with, or if this can wait till the morning.
If it’s their eczema, I just leave it in this inbox, wait till the morning. If it’s a random parenting question about potty training, wait till morning. If the kid has a fever and they’re not sure what to do, I’ll usually, you know, I know the patients well enough that I know how old their kid is.
I know that they were in yesterday. I know that they’re a newborn, whatever it might be. And then I can just really quickly give some specific advice without getting into the weeds of things. And that’s typically how I approach spruce. I will say that sometimes I look in the morning before eight o’clock just to see
what’s on the radar for the day. And not sometimes I always look before eight o’clock in the morning, but just to kind of, again, triage in my mind of, are there any acute things that are going to need to come in first thing in the morning or is all this stuff,
things that can wait and we can filter through it over the course of the morning.
Yeah, that makes sense. I will say there, there’s a little bit of psychology, of course, to this whole world of texting that sometimes parents text me, Hey, you know, my kid has a fever or is vomiting. And my mind kind of jumps to the assumption that that means they want to be seen right away.
And sometimes it’s my day off or, and I take days off during the middle of the week. So I’m not Monday through Friday. My schedule is very dynamic and And so sometimes I’m not running errands or I, you know, I’m trying to just take the day off and focus on other work that I have that’s not clinical.
So sometimes I see those messages and I think, oh, no, I’m going to have to like interrupt my whole day and go to the office to see them. And then once I actually start texting back and forth with the parent, they’re totally fine being seen the next day.
And just getting some reassurance and having some questions answered about what they can do from home. And often they don’t want to drag their kid to the clinic unless it’s really necessary. So I’ve had to remind myself, hey, don’t jump to the conclusion that this parent is begging you to see them right now. Once in a while,
that’s going to be the case with a really anxious parent in the beginning as you develop that relationship. But most of the time, parents are completely fine. And sometimes it’s way less urgent than you thought it was. They’re like, oh, well, we’re not going to be available till Friday. And it’s Tuesday.
And they’re like, we’re okay coming in on Friday. Right. So yeah, I’d say to just kind of like assuage people’s fears, like don’t jump to those conclusions yourself that parents are going to want instantaneous service. There’s really so much that can be done.
with just a couple of text messages or a three-minute phone call to answer some of those questions. Sometimes over text, I get kind of tired if it’s a more complex issue. And then so I say, hey, can I give you a call? And talking over the phone is much faster than having to navigate text messages
back and forth, especially if I’m out running errands or something.
Yeah, perfect time to just like, hey, I can’t text right now, but can I just call you quick? Let’s just talk through this. And I think… Like it feels like there’s this unnecessary urgency of DPC. You should be able to get in the next 45 minutes to be seen for your kid’s stuffy
nose and 101 fever that just started 17 minutes ago. Parents don’t want that anyways. They just want to know that you’re going to be there. exactly the level that they need when they need it and it’s like yeah you’re seven month old has a fever there’s a lot of viruses going around do this this and this
today and then let’s check in in the morning and see how things are going okay they still have a fever how are they eating how are they breathing all those sort of things do you want let’s put something on the books for friday just so things don’t
get too far and then we can see how it goes and that’s the parents are super happy with that when you when they know that they can trust that they’re going to be able to get in that they’re going to get the support they need when they actually need
it rather than like i have to you know leave baseball or the pool to go deal with
the stuff he knows yeah now briefly before we finish up what about video visits phil do you ever do video visits because most people who think of telehealth don’t necessarily think of the texting part but they think about the video visits do you incorporate that in your practice
I thought I would a lot more when I opened. Like I thought there would be a lot more because I was coming from fee-for-service where if you want to do something that’s not a visit and it was in the COVID era, then it’s going to be a video visit because honestly,
that’s what insurance required in order to bill for a visit was like, you know, synchronous audio visual. I found a lot less that parents actually want to do that. And they mostly want to text or we’ll do a video or a audio voice messages back and forth or a phone call.
And I can’t say that I often do actual like video visits because one, like the kid has never, available or in prime form to do a video visit. And two, usually like still pictures actually work better or just a video of their breathing or something along those lines actually works better than like, okay,
take your phone over to the kid and get them to do this or the other thing. Like I can get a pretty good sense of a creepy cough from about seven seconds of coughing video or audio that’s recorded and sent to me rather than trying to get on a zoom
and get them to cough and those sorts of things. So I don’t use it a lot. I will do like parenting consultations, especially if they’re not local or if they just want to talk through something without having to drive across town or if the parents are both at work.
Then I’ll do either just a phone call or a video visit if they really want to be on camera. I don’t particularly like being on Zoom. It makes me feel like I have to hold myself in a certain position and sit up all straight. And it’s a little bit fatiguing to sit like that.
So I usually say, I know what you guys look like. Do you want to just talk on the phone? and avoid video visits when I can. But that’s kind of been my evolution since starting is I don’t do a lot of telehealth forward visits outside of like Zoom sort of visits where it’s asynchronous video back and forth.
What about you? How do you incorporate that into your practice?
I would say similarly, I thought that I would do more, but the once in a while I do like if a family lives farther away or if it’s a behavioral health issue and we’re doing more. like talk therapy, some of the hypnosis stuff that I do.
But I think a lot of the times people really love the setting and the clinic and they prefer coming in. I think that their child is better able to focus than if they’re sitting in front of a computer screen. So yeah, I don’t use it as much,
but it’s nice to know that it’s there whenever I need it and I can incorporate in whatever way is appropriate to my patients and my practice.
Totally. Yep. It’s just nice to have a bunch of different tools. Sometimes the, the leaf blower or the chainsaw aren’t used as much for a season, but it’s nice to know that you have them when you do need them and that you have a bunch of different options. that for one,
keep you from having to have patients come into the office and you have to go into the office if you’re out and about, if you’re doing something else, just to know that you have that flexibility of meeting patients where they are and what they need and in relation to what your availability is, both.
physically and temporally and all the different yeah absolutely yeah well that’s what we have to say about telehealth and texting hopefully that clarifies some questions that you may have had about this in your own practice or your own soon-to-be practice thanks everyone for listening take care guys
