Patient Care Bonci

Ten Ways Your Telehealth Backdrop Can Improve Patient Care

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My mother, who’s 89 years, thinks FaceTime involves a washcloth and some CoverGirl. So, she was understandably puzzled when I sat her in front of a computer for her first-ever telehealth visit.

“I don’t know if I’m going to like this. What’s this new doctor’s name?”

Fortunately, the physician was prompt, and he appeared on the screen smiling in a white lab coat with his name stitched above the breast pocket.

“Hello Connie. I’m Dr X. How are you feeling today?”

“Everything hurts.”

“I’m sorry to hear that, but I’m here to help…”

For the next hour, Dr X conducted a thorough and professional video exam. He was engaged and empathetic and summarized the key takeaways. So, I was surprised after the call ended when my mother said: “I don’t trust that guy.”

“Why not, Mom? He was great.”

“Did you notice the plant in his office?”

“Uh, yeah.”

“It was dying. Leaves turning brown. Do you want someone who can’t take care of a plant taking care of your mother?”

Now, I’m willing to bet that doctor had no idea his plant needed water, or that it was even in the room. But that one little detail kiboshed his entire effort to appear competent and win my mother’s trust.

It may seem unfair, but recent research suggests that your background during virtual visits is important. And it matters now more than ever: Telehealth has become a crucial part of modern healthcare provider services. Many patients now prefer telehealth, particularly for routine care, mental health care, minor illness, and chronic disease management. As always, projecting professionalism and building patient rapport are key. But in telehealth, like it or not, that also requires paying attention to what’s behind you.

“A background has measurable impact on patients’ telehealth experiences, which suggests a need for careful selection and design,” said Morgan Stosic, PhD, a social psychologist and researcher at the University of Maine.

Stosic authored a study, published in Telemedicine and e-Health in 2022, that found certain videoconferencing elements can help doctors convey more warmth (family photos) and competency (diplomas) and better connect with patients. Other elements, however, can distract patients (artwork, eg) and compromise the recall of clinical information.

Another study, conducted at Durham University in the United Kingdom and published in PLOS One in September, examined the impact of six different Zoom backgrounds on viewer perceptions of trust and competency. Backgrounds with books and (non-dying!) house plants engendered the most trust and competency, while backdrops with home-living spaces and novelty items encouraged the least.

“First impressions are formed instantly,” the Durham researchers wrote. “Within the first few seconds of meeting someone, we spontaneously draw inferences about their character traits.” Online, these inferences are influenced by the environment the person is in.

“Patients think they’re choosing the best doctor, but they really don’t have the tools and data to support that choice,” explained Ernesto Gutierrez, MD, a healthcare business coach in Spain whose online company (Practice Growth Formula) helps physicians present more effectively. “The only thing patients have is perceived expertise. So, a doctor needs to be thinking, ‘How do I engineer this perception with my telehealth patients?'”

To help you avoid the same fate as Dr X, Medscape Medical News spoke with practicing clinicians, telehealth trainers, researchers, and related experts. Here are their best tips for perfecting your webside manner.

1. Blurred, Virtual, or Real?

It’s tempting to take the easy way out and blur your background or choose a virtual one. But Erin Hulfish, MD, the director of telehealth education at the Renaissance School of Medicine at Stony Brook University, in NY, recommended against that.

“Those backgrounds can lead to a sense of mistrust,” she said. “Patients could think there’s somebody else in the room or wonder what is being hidden. They may worry about privacy and not speak honestly.”

She encourages her students to use real backgrounds that are clean and professional, “just like a patient would experience during a normal face-to-face appointment.” Avoid any messiness or disorganization. Having everything in its place subconsciously reassures patients that their care will be just as meticulous.

2. Books

Literacy is generally associated with intelligence and academic performance. So, having medical books on a shelf can make you appear smart and competent, as the Durham study found.

But there are times when books can interfere with that perception, namely when:

  • There are so many it looks like you’re in a public library.
  • You’re the author, and you give the impression of trying to make a sale.
  • The titles are polarizing (Vladimir Putin: Life Coach), worrisome (This is Going to Hurt), or just plain weird (Knitting with Dog Hair).

3. Plants

Background greenery promoted feelings of competence and trustworthiness in the Durham study because of the “established human preference for natural environments,” said researchers. Flowers would probably have a similar effect, added Stosic, giving your professional space “a bit of life.”

photo of a "Do" graphic

However, avoid lots of plants or a big bouquet. These can be distracting. A single healthy floor plant or orchid will do.

4. Artwork

In general, artwork of all types is distracting and should be avoided. This is especially true for the Banksy you bought at auction: Kids’ drawings and, of course, any portraits or busts of you. There are exceptions, though:

  • In the Durham study, a small family photo engendered feelings of warmth toward doctors. It’s also another way to make a professional environment less antiseptic.
  • Framed diplomas, certificates of recognition, hospital affiliations, and even awards (sans league bowling trophies) “provide patients with a sense of assurance,” said Hulfish. You’re educated, you’re professional, and you’re recognized for it.

5. Doors

If there’s a door in your background, close it. You wouldn’t leave the door of an exam room open when you’re with a patient, and the same logic applies here.

“Closed doors convey privacy,” said Hulfish, “and that’s important to virtual patients.” She recommended locking the door or hanging a “Virtual Exam in Progress” sign outside to prevent interruptions.

6. Desks

By its very nature, telehealth separates you from your patients. Positioning yourself closer to the camera and looking at the lens rather than the screen for better eye contact help broach this divide, but making a connection is still the medium’s biggest challenge.

So, Stosic recommends never putting anything additional between you and your patients, such as a desk. Either stand or, if you’re sitting at one, pull the computer closer so it’s not obvious.

7. Novelty Items

Ironically, Stosic’s study found that the more viewers liked a doctor’s background, the less likely they were to remember clinical information.

Again, you don’t want to distract them. A few strategically placed elements that convey warmth and competency are fine, but patients don’t need to see your signed Michael Jordan basketball or the rainbow trout you caught in Patagonia. Their focus should stay on you.

8. Mobile Phone

Keep it out of the picture, said Stosic. Even if it’s in silent mode, patients don’t know that. Plus, you may be tempted to glance at texts or notifications.

Similarly, avoid doing nonemergency telehealth calls from your car, an airport, or anyplace that isn’t professional and where patients can tell they don’t have your full attention.

9. Pets

Although some doctors use pets to connect with patients, the experts Medscape Medical News spoke with said the risks outweigh the rewards.

photo of a "Don't" graphic

If the pet is in view, even if it’s dozing, the patient may pay less attention to you. Plus, there’s always the chance it’ll make noise and disrupt the call.

The only exception is using the pet to establish rapport with a new patient and then letting it out of the room before starting the visit.

10. Attire

What you’re wearing isn’t technically part of your background, but it is an important element of your presentation.

“A lot of doctors think it’s okay to conduct telehealth visits in a more casual and relaxed manner,” said Gutierrez. “But you have to look the part. If you don’t, you can spend the next hour being an amazing doctor, but [because first impressions are so important] your patients will have worse treatment adherence and less trust in you.”

Stosic’s research shows that patients are more comfortable when their doctors are in white lab coats. And although she hasn’t studied name tags specifically, she speculates they probably add to the sense of competency and professionalism. Plus, it helps new patients remember your name.

Other tips:

  • Avoid decorating your lab coat or name tag with smileys, baubles, or other distractions.
  • Simple earrings and rings are fine but save the fancy watches and other bling for the annual hospital gala. Not only is it distracting but it may rub some patients the wrong way.
  • Make sure your white coat is clean.
  • Forget the stethoscope around your neck; you won’t be using it.

Bonus Tip: Trust Your Gut

If all this seems like a lot, know that the idea is not to agonize over every background detail. It’s to be more thoughtful about the impression you aspire to create in the burgeoning field of telehealth.

This leads to Hulfish’s “most important” tip: Record yourself.

“That’s what we do with our med students,” Hulfish said. “Just as in any speaking course, we have them watch themselves on video. ‘How do I look? Is this the best camera angle, lighting, and background for me? What are my mannerisms?'”

“We are our own best critics.”

Friday Feedback: Fat but Fit Revisited

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A recent study in the Journal of the American College of Cardiology raised questions about the concept of “healthy” obesity and the idea that a patient can be “fit, but fat.”

MedpageToday contacted dietary and cardiology experts and a variety of healthcare professionals and asked:

How do you assess fitness in the obese patient or do you even attempt to make that assessment?

Should the conversation with the patient change based on the Fit-Fat data from this study?

The participants are:

Carl “Chip” Lavie, MD, FACC, medical director, cardiac rehabilitation, and prevention at the John Ochsner Heart and Vascular Institute in New Orleans

Leslie J. Bonci, MPH, RD, CSSD, LDN, director, sports nutrition at the University of Pittsburgh Medical Center Center for Sports Medicine in Pennsylvania

Jana Klauer, MD, a physician in private practice in New York City

Martin Binks, PhD, associate professor, nutritional sciences, behavioral medicine, and translational research lab at Texas Tech University in Lubbock

Bruce Y. Lee, MD, MBA, director, Global Obesity Prevention Center (GOPC) at Johns Hopkins University Bloomberg School of Public Health

Merle Myerson, MD, director, Center for Cardiovascular Disease Prevention at Mount Sinai Luke’s and Mount Sinai Roosevelt hospitals in New York City

Elizabeth Kitchin, PhD, RD, assistant professor, division of clinical nutrition and dietetics at the University of Alabama Birmingham School of Health Professions

Beyond BMI

Carl Lavie, MD: “In a perfect world, everyone would be lean, fit, and metabolically healthy (meaning good blood pressure, glucose, and lipids) throughout life, but the most important factor for long-term prognosis is fitness, which is much more important than fatness, for long-term risk. The major determinant of fitness is regular physical activity. The bottom line is that lean and fit and overweight/obese and fit stay healthy by maintaining high levels of physical activity. Therefore , a major decrement in health (and metabolic health) is due to decrements in physical activity and therefore fitness.”

Leslie Bonci, MPH: “The results of the study demonstrate that long term, being obese does have a negative impact on health. But that does not mean we need to focus on diets or extreme exercise. Instead, the emphasis is on gradual changes, educating patients on how to get healthier and finding the deal maker for that patient. The consequences of behavior should be to live long and live well, with strategies that are attainable, maintainable. and sustainable.”

Martin Binks, PhD: “It is always prudent to focus on increasing physical activity and fitness and also to ensure that our patients value this at least as much if not more than the number on the scale. In some cases, due to a wide range of factors noted above, weight loss is essential in combination with improved fitness, in other cases it may be more important to focus primarily on improved health overall with far less emphasis on the scale.”

Jana Klauer, MD: “While BMI is a quick assessment of body weight, the more important variable is percentage of body fat and how it is distributed. Body fat that is concentrated around the abdomen raises the risk for disease, independently of BMI. Measurement of waist size should be part of every physical exam; I am surprised by the number of physicians who do not measure this!”

Applications for Patient Care

Bonci: “We should address physical, nutritional, and emotional fitness. Ask your patients about energy levels, what they do to move, or how much of their time do they spend sitting, Do they tire more easily? Do they choose stairs or elevator, does walking make them winded or cause pain. Nutritionally ask about the number of meals consumed daily, as well as plate, food preferences, and beverage choices. Ask about emotional fitness — what is motivating them, what would they like to change and how can we be of help.”

Elizabeth Kitchin, PhD: “As a behaviorist and patient counselor, I look at patients more as individuals than as a population. If I have a patient who is overweight or obese, and that patient is physically active, eating an overall healthy eating pattern, and has most of his or her numbers in a fairly healthy range, I am going to encourage them to continue those healthy behaviors. However, I would probably make it clear that too much weight is risky – so avoiding weight gain over the years is really important.”

Bruce Lee, MD: “A given body mass index could have different consequences for different people, meaning what might be healthy for one person might be unhealthy for another. A patient is a very complex system, therefore, a single measure cannot assess a single system. Similarly, a single measure cannot determine a person’s health. Physicians use a combination of various measurements to gauge a patient’s health such as blood pressure, heart rate, exercise tolerance, ability to perform daily tasks, blood tests (e.g., blood sugar, cholesterol), urine tests, symptoms, and findings on a physical exam.”

Merits of the Study

Klauer: “The Whitehall 2 study is important because it followed both men and women over a long period of time – 20 years – measuring weight and charting their health conditions. By classifying obese individuals at the start of the study as ‘metabolically healthy’ (absence of cardiovascular disease or diabetes) or unhealthy, the study was able to assess the effect of extra weight on health. The sobering finding that 20 years of obesity resulted in 8 times the progression to metabolic illness than those who were not obese shows just how dangerous extra pounds can be. In fact, only 10% of obese healthy individuals were able to maintain their health for 20 years. In my own practice, all obese, or overweight, patients are informed of this study.”

Lee: “As the study shows, although many healthy obese individuals do progress to becoming unhealthy obese, just because a patient has a higher BMI does not mean he or she is destined for more health problems. Additionally, the study reminds us that it’s very important to follow how BMI and all health measures change for a patient over time. Are these measures stable or worsening over time? This reemphasizes the importance of patients establishing stable relationships with their healthcare providers so that all of the appropriate measures can be followed.”

Binks: “The popularly held notion of ‘healthy obesity’ is misleading. While it is true that people of every size can potentially be healthy; most current conversations on the topic focus only on cardio metabolic health and not the wide range of other negative potential consequences of excess weight (e.g. mobility, musculoskeletal health, heightened risk for certain cancers, sleep apnea, depression, and overall quality of life, to name just a few). Also, absence of disease is not necessarily ‘health’ so when considering if one is healthy we need to assess a wide range of medical and psychosocial factors influenced by weight.”

Limitations of the Study

Lavie: “A very major limitation of this study and the paper that they reference from Kramer and colleagues from the 2013 Annals of Internal Medicine is that neither of these studies were fit versus fat studies, as neither study addressed any information about cardiorespiratory fitness or aerobic exercise capacity, which is a critical predictor of prognosis. My colleagues, especially Dr. Steven Blair, and I have published numerous papers demonstrating that fitness is more important than fatness in predicting long-term risk, and a paper by Barry and colleagues with Dr. Blair last year in Progress in Cardiovascular Diseases analyzed 10 studies that basically demonstrated that those who were overweight or obese but fit had half the long-term mortality as did those who were lean and unfit and had similar survival compared with those who are lean and fit. Basically, these results demonstrate that if one is at least relatively fit, BMI really was not relevant — normal, overweight, or obese, at least mildly obese, all had a good prognosis. (These data, however, may not apply to severe or morbid obesity.)”

Myerson: “It would be interesting to know what other factors were associated with the participants who became unhealthy. For example, did the ones who remained healthy exercise? There are several limitations to the study. The authors only included obese patients and not those who were overweight (BMI 25-29), women made up only 25% of the study population, and other measures of ‘healthy’ and ‘unhealthy’ were not considered.”

Kitchin: “One of the things not well-spelled out in this publication was whether or not the participants were participating in healthy behaviors. It just said that they started out metabolically healthy but didn’t stay that way. A big question I have is: what if they are exercising?”