Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Dr. Cliff Coleman, who is an Associate Professor of Family Medicine at Oregon Health & Science University. He practices as a family medicine physician at a Federally Qualified Health Center.

Cliff’s clinical interests include treating medically complex individuals and underserved populations. He also is a national health literacy expert. Cliff’s ongoing research and teaching help lead the way toward health literacy competencies for all health professionals.

Communication about health is changing very rapidly these days. I was especially intrigued with Cliff’s recent paper that he authored, “Health Literacy and Clear Communication Best Practices for Telemedicine,” that was published in the Journal of Health Literacy Research and Practice. This is a topic we all need to learn more about.

Welcome to Health Literacy Out Loud, Cliff.

Dr. Cliff Coleman: Hi, Helen. Thanks for having me.

Helen Osborne: Let’s take it from the top. Also, I just want to let listeners know, you and I have known each other as health literacy colleagues for a long time, and we’ve seen the evolution of this field. Now you’re writing about telemedicine. Tell us all what you mean by that term telemedicine.

Dr. Cliff Coleman: This is a whole new era of communication for us brought on largely by necessity from the COVID-19 pandemic and need for isolating ourselves and reducing exposure.

Telemedicine has been around for quite a long time. The notion is that there are often times and places where we can deliver healthcare at a distance, either by telephone or two-way video. People have been doing this for a long time, but it’s really accelerated in terms of need and use over the last 10 months or so because of COVID.

Helen Osborne: It certainly has. This podcast will be out for a long time, but it’s so visceral. It’s happening so immediately. People are not going to the clinics for routine appointments.

You are a family physician, so you see people not on an emergency basis. Describe how you see patients and why telemedicine has become so important a modality these days.

Dr. Cliff Coleman: At our clinic, we see over 200 visits on a typical day. It is a very busy practice in a high-needs community. In the midst of the early months of the pandemic, we found that our patients were afraid to come see us. The public health messaging they’re getting is to avoid travel and avoid places where people are congregating. Clinics are particularly a fearful place.

But I think a bigger, longer-range issue is that going to the clinic is a hassle. To come have a 20-minute visit with me often may be a four-hour odyssey for many of my patients in terms of getting to the clinic early enough to make it to their appointment on time, using public transportation perhaps to travel, then waiting for me as I’m running late and then whatever else we need to do after I’m done with my short visit.

Things that might literally ruin a person’s day in terms of scheduling, it may be perfectly acceptable to avoid those now by trying to do a lot of this work by phone or two-way video.

Helen Osborne: Until COVID struck all of us and shut down a lot of routine care, you would have asked that person to come in and see you without question. You would not have said, “Instead of taking all the buses, why don’t we just talk by phone?” Is that correct?

Dr. Cliff Coleman: That’s right. The reality was that a lot of things have always been able to be done by phone. It’s been known for decades that many primary care practice visits don’t actually require seeing someone face-to-face in terms of the medicine, diagnosis or treatment.

But from a practical standpoint, we busy primary care providers had no way of getting reimbursed for that time. While we could have been sitting at our desk doing a lot of good healthcare by phone, it wasn’t viable for us because we didn’t have time in the day and there way no way to get reimbursed for that.

That was an actual source of frustration for years, which now we’ve quickly dispensed with.

Helen Osborne: Put this into context. Let’s say in February 2020, your patients were coming in to see you. Now mid-March, everything is shut down. All of a sudden, it’s telemedicine. What was that transition like from your perspective and from their perspective?

Dr. Cliff Coleman: To do the right thing, we all knew we needed to keep people from having to come in, especially for things that didn’t require a face-to-face visit.

Helen Osborne: Like what?

Dr. Cliff Coleman: Let’s say I’m talking about diabetes self-management. What we really needed was a half-an-hour discussion about why a person’s blood sugars are not being well controlled, but it doesn’t require physically touching the person necessarily.

We could have done it by phone in the past. But the way the healthcare system was designed, for us to get compensated for that time, the rules literally would say it had to be done in person.

There was no mechanism necessarily for us to get paid for that time. Even though we would have loved to be able to do it that way, we couldn’t make it financially viable.

When the pandemic struck, there was this rush to get waivers and change rules for an emergency basis for things that we all in primary care had been asking for, for years, and now suddenly had.

This ability to conduct perhaps a whole clinic day by phone or video, they wanted us to start doing them and we didn’t even have the necessary equipment available. We’ve outfitted our exam rooms now with landlines, which didn’t exist prior.

Then the other piece that happened was that many providers moved to work-from-home environments in order to decompress the clinic space so there were fewer people around.

That required a whole new set of equipment and complexities of “What does your home internet service look like and how reliable is it?” and things like that.

Helen Osborne: Right away, someone flipped that switch and you’re not ready for it. You deep down know it’s workable because you’ve been wanting to do this for a while. Now you’re doing it. Now we’re many months into this.

Put this into context about the benefits you see now as someone who’s been experienced with telemedicine, what are the drawbacks and what are your ongoing questions about it?

Dr. Cliff Coleman: It’s a mixed bag. There are definite benefits. From the patients’ perspective, I think not having to come in frequently for things like chronic disease management is a real positive.

Being able to have a visit from the comfort of your own home, as a patient, and not having to deal with transportation issues, perhaps not having to find care for a child or loved one you look after, not having to miss work, those are all huge benefits.

Helen Osborne: Huge.

Dr. Cliff Coleman: These visits probably help provide better access to populations who’ve historically had troubles with access to care. I’m hopeful that that benefit will be able to extend that particularly to our vulnerable populations, for whom access is a bigger issue, and we can help reduce some inequities in access.

Helen Osborne: Absolutely. I can hear those benefits. I feel them as a patient. I certainly have been the patient in some telemedicine appointments, too, as have people I know. There are many benefits.

From your perspective as a doctor, what’s the good side of this?

Dr. Cliff Coleman: For me, it’s actually been great. I feel like my work has been more efficient. I think perhaps about 25% to 30% of my visits are perfectly suited to a telemedicine format. It helps me be more efficient in that sense. I’ve found that my work has been a little bit easier in some ways.

Of course, there are certainly a lot of cases during the day where we’re talking on the phone or on video and I just can’t fully help the person because I can’t examine something that’s going on. But we’ve figured out ways to manage around those as well.

Helen Osborne: It sounds like there’s goodness on both sides. What about the downsides for patients, for you and for other clinicians?

Dr. Cliff Coleman: For someone who’s always concerned about patient communication and my ability to get the right information from a person and be able to then give the right information back to a person, I’m pretty concerned that there are some areas that we may not even fully understand or recognize at this point, but that may create more barriers to understanding. I worry that we may be even worsening some inequities or disparities if we’re not careful.

One example that I’ve noticed in my visits has been the lack of ability to read body language. It’s been a real problem for me on phone visits. Even on video visits, actually, it’s harder.

I was on a video visit yesterday with a person and we were really having a hard time reading each other. What ended up happening was we continuously were interrupting each other. We couldn’t read the cues of when the other person was finished speaking. It was awkward, almost to the point of frustrating.

I worry that actually we may have given up on trying in some instances when maybe better information could have been exchanged in a face-to-face encounter.

Helen Osborne: Cliff, I deal with that all the time on these podcasts. You and I are talking from opposite ends of the country. These interviews are almost always done by phone. I can’t read your cues either. I don’t see the guests visually while interviewing them. I’ve learned some ways around that interruption and talking and listening part. It doesn’t always go smoothly. Often, it does.

Are you coming up with an inkling of the best ways to do this, to do good turn-taking when you can’t see each other?

Dr. Cliff Coleman: I don’t have a solution for that. Part of the reason I wanted to write this paper that you mentioned was that I wanted to start these conversations and get input from the broader community of patients and healthcare professionals so we can at least start thinking about some of these issues while we try to figure out how to work through them or around them.

Some of the issues are going to be technological. Some phone services have a built-in delay that shuts sound off on the listening end until the system detects that the person has stopped talking. That builds in extra complexities.

There are going to be some technological solutions to some of these things. I would assume that if we can move more people away from phone visits and into high-quality video visits where the connectivity is solid, there aren’t delays in the visual and the sound and they’re well synchronized so that the system isn’t cutting in and out, expanding that kind of access will probably help.

But there will probably be some interesting solutions that we haven’t even imagined as the necessity for this is driven by more and more people using these technologies.

Helen Osborne: As a user of this, as a patient of this, my sense is that telemedicine visits are here to stay. I hear so many people talk about, “I got to see this doctor I never would have seen. My family member got in on the consult, too. We scheduled it. I didn’t have to go anywhere.” I have a feeling that the essence of this will stay in some way. Do you think that, or do you think once things open up we’re just back to the way it was?

Dr. Cliff Coleman: I certainly hope that we won’t go backward from this point and that we can actually expand these services. They seem to make good sense certainly from a provider’s standpoint, my standpoint. I think they make good sense from many patients’ standpoints.

I believe they’re going to make great sense from the payers’ standpoints, the insurers, for example. I think they’ll start to see some value in this as well.

Although I don’t believe anybody has looked at the economics of providing telemedicine services. I’m not familiar with that literature. I’m sure it’s actually been looked at.

I think, like many things in healthcare, the money is going to drive the innovation. If it financially makes sense for the payers, then I believe it’ll be here to stay. I certainly hope it will.

Helen Osborne: Satisfaction, effectiveness, efficiency, those are all drivers there.

Cliff, you’re so savvy on all the ways to communicate. I wonder if we can talk through a visit. I know you’re also humble saying, “There’s so much we have yet to figure out.” But I bet there are tips you’ve learned about communication along the way.

Can we take it from the beginning? When you start off a new appointment with a patient, how do you set the expectations? And how long are your phone appointments? Just 20 minutes or something?

Dr. Cliff Coleman: Yes, my appointments are 20 minutes. I realize a lot of primary care providers don’t have that. It may sound like a luxury to many.

It’s a different world when you call someone, especially if it’s not someone who I know or recognize their voice. First, I have to make sure I’ve got the right person.

Our payers are requiring us to identify people. By law, they have to be in the same state that we’re in. They want us to know what the person’s location is and some things like that.

There are some upfront questions about, “Where are you right now? Are you at home? Are you at work?” I’m working in Oregon, so I’m asking people, “Are you in Oregon, or are you across the river in Washington?” and, “Tell me your date of birth,” to make sure I can identify the person.

Usually, that’s all done for us in a face-to-face visit by a medical assistant who’s brought the person back to the room.

Helen Osborne: Now it’s you, right?

Dr. Cliff Coleman: Yes. I’m learning to do those things.

Helen Osborne: What about the content of what you’re going to talk about?

Dr. Cliff Coleman: The content is actually not that different for me face-to-face as it is now with this new telemedicine. I really am very interested in making sure I have a clear agenda for their time.

A typical family medicine patient comes to us with four or more issues that they want to have addressed during their visit.

Helen Osborne: Oh, really?

Dr. Cliff Coleman: In a 20-minute office visit, that can be extremely challenging, so it’s important to really know what’s important to patients up front.

Old studies show that the first thing that a person mentions is almost never their biggest concern.

People will call and make an appointment, and my schedulers will write down the appointment is to talk about back pain, for example. I’ll call them for our appointment time and I’ll say, “It says on my schedule here we’re going to talk about back pain today. Is that right?” They’ll say, “No, what I really want to talk about is X, Y and Z.”

Even more troubling is when they say, “Yes, it’s my back pain,” and then we spend 15 minutes talking about back pain, and at the end, they say, “By the way, I’m really concerned about this other thing.” That’s what we have called doorknob questions and things that come up at the end.

I spend a lot of time establishing agendas up front. For me, that means getting the full list of things that the person may want to talk about today, and then helping them prioritize them so that we get to their most important issues and concerns first. Then we make a plan if we don’t have time for the others.

I spend as much time as it takes to do that. Otherwise, I’ve found that visits will run way past their allotted time and we may not get to the thing that the patients are most concerned about. That’s bad for patient satisfaction, and it’s certainly bad for provider’s satisfaction as well.

Helen Osborne: That’s really important that you spend so much time on the agenda.

You talked about how you’re still trying to figure out about when to talk, when to listen, that turn-taking part. Are there any topics you find particularly troublesome to talk about with people? Is there anything harder over the phone than it might be in person?

Dr. Cliff Coleman: That’s interesting. I hadn’t thought about it that way. In healthcare there are always topics that are either more awkward, more difficult to bring up or harder to ask questions about.

I haven’t noticed any difference between doing those things over the phone or doing them in person.

I do think that it’s a lot easier to express empathy and non-judgmental attitudes by the body language that we use. I think I probably, and perhaps a lot of other providers, use that to help show that they’re open to discussing things that might otherwise be hard to talk about. Just leaning forward, having good eye contact and the look on your face, a non-judgmental look, I think that probably goes a long way.

I don’t know what we’re going to do about that if we’re transitioning to more and more telemedicine visits.

Helen Osborne: That’s really interesting. How do you show empathy just through your voice, your tone of voice, your pausing or your follow-up statement? It’s intriguing. I look forward to your research on that one. We’re building up your agenda of things you need to study some more.

Because we need to conclude our conversation here, how do you go about concluding your conversation with patients in a very respectful, meaningful way to put a closure to your 20-minute appointment?

Dr. Cliff Coleman: Exactly. I do it really the same way I would do it in a face-to-face visit. When we’ve hit everything on the agenda, I’ll go back and say, “Let me summarize the key points here.” We’ll go through a quick summarization of that.

Then I want to make sure that if the person has any questions they want to ask, I give them the opportunity to ask for clarification. We use the phrase “What questions do you have?” at that point.

Then if the opportunity is right and the need is there, using something like a teach-back to confirm that I’ve done a good job communicating a plan or information is certainly the same over the phone as it is in person.

Helen Osborne: Where you might say, “How do you explain this to somebody else?” or something?

Dr. Cliff Coleman: I might say, “Since I’m not there with you, I want to just make sure I’ve done a good job explaining things. Can you tell me what the plan is in your own words?”

The same is true when we’re using interpreters. If we’ve got a three-way call and I’ve got an interpreter on the line, I want to use those same closing techniques with my interpreter. Since I don’t have other ways of checking that I’ve been clear, using teach-back and those methods are even more important in those situations.

Helen Osborne: Cliff, you’re wonderful.

I want to summarize this and make sure I’ve got this all right. We talked about what telemedicine is and the fact it kind of came out of the blue. It’s here now. It’s the way many people are practicing. We’re all trying to figure this out.

I gather from you there’s a lot of optimism about it, a lot that’s good. There are some questions to still be figured out.

It sounds like you’re really building into practice some of those good communication strategies. And using some of those health literacy communication strategies to make the most out of your 20-minute phone appointment with patients.

For people to learn more, I recommend they go to your paper. We’ll have that on your Health Literacy Out Loud website. I think there are a growing number of resources about how to do telemedicine, and we’ll include a few on your Health Literacy Out Loud website.

From my perspective, I think we’re moving along this conversation. What questions do you have?

Dr. Cliff Coleman: I hope that we’ll have some broader conversations in this area and that people will share their experiences. I know that the experiences that I’m having here in this one clinic in this one corner of the country are not going to be representative of what else is going on out there.

I’m looking forward to hearing how people find creative ways to make this kind of communication even better than maybe it could be in person and figuring out ways to get around the obstacles.

Helen Osborne: Cliff, I agree with you. I applaud you. Thank you for taking a big stride in this type of conversation and way of communicating. And thank you for being a guest on Health Literacy Out Loud.

Dr. Cliff Coleman: Thank you very much for having me, Helen. It’s been a pleasure.

Helen Osborne: As we just heard from Dr. Cliff Coleman, it’s important to communicate about health even over the telephone and video and all the new ways we’re doing telemedicine. But communicating about health is not always easy.

For help clearly communicating your health message, take a look at my book Health Literacy from A to Z. You might be especially interested in Chapter 24 that’s about listening and speaking.

Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out every few weeks. You can get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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