Your daughter injured her right arm playing in the backyard, your husband has stomach pain that seems to be getting worse and you have an annual physical scheduled for early next month.
In the past, decisions about whether to turn aches and pains into doctor visits were relatively straight-forward and staying up-to-date with preventive and follow-up appointments was part of a healthy lifestyle and routine care. But then came COVID-19 and with it, a new question: Is it safe to go to my doctor’s office, or is there another way to receive that care?
While all UCLA Health medical clinics and hospitals have rigorous infection prevention policies in place, video visits remain an enticing option for some patients. In fact, about 28% of primary and specialty care outpatient medical appointments have been conducted as video visits since mid-March, when coronavirus became a concern.
But while video visits offer patients a way to speak to their physician or another member of their medical team remotely, there are some cases when you really need to come in.
To take the mystery out of this process, we spoke to five UCLA Health physicians and one dietitian about what you can accomplish during a video visit, when you really need to come in — and how to know the difference.
Please note: Before you schedule a video or phone visit, check with your insurance provider to see if this appointment will be covered and what your copay might be. While most insurance providers are covering telemedicine visits, this could change.
PRIMARY CARE
Dr. Daniel Croymans, Internal Medicine, Westwood
Video visit OK:
- Follow-up appointments to cover medication management or chronic disease discussion
- Symptoms that suggest a COVID-19 infection (fever, body aches, cough); can order a diagnostic test after this appointment
- New patient intake, if high-risk for complications of COVID-19
In-person may be required:
- Urgent issue with or without concerning symptoms, such as shortness of breath
- Acute new symptoms (abdominal pain, low back pain, ear pain or hearing changes, hip pain, diarrhea)
- Shortness of breath or a cough that won’t go away, in which case a physician needs to listen to the patient’s lungs and check oxygen saturation. A chest x-ray may also be necessary.
- Annual physical or wellness exam
Daniel Croymans, MD, MBA, a primary care physician in Westwood, says a virtual appointment is best when the patient and provider already have an established relationship. “Video visits are an excellent option when the patient needs a general follow-up appointment, either for medication management or to discuss a chronic condition, such as diabetes,” he says.
But if a patient is having an urgent issue, such as shortness of breath when there is a history of heart failure, or is experiencing a new symptom, such as abdominal pain, an in-person visit is likely required.
In some cases, Dr. Croymans says, he’ll start with a video visit and have the patient or a family member assist with the remote clinical assessment, for instance, by pushing on a specific area of a distended abdomen or holding up the camera so that he can see where the patient may be experiencing tendinitis. But what starts as a video visit may be converted to a same day, in-person appointment, if necessary.
“A good rule is that if you have any new symptoms, you should reach out to your physician to ask what type of visit is best,” he says.
When it comes to establishing care with a new primary care physician, Dr. Croymans says he has handled some of these appointments remotely, specifically when the patient is older or high-risk for a severe course of disease if he or she contracts COVID-19.
PEDIATRICS
Dr. Susan Duan, Internal Medicine-Pediatrics, Santa Monica
Video visit OK:
- Chronic disease follow-up (asthma, acne, ADHD)
- Cold symptoms
- Symptoms possibly related to COVID-19 (fever, muscle aches, cough); can order a diagnostic test after this appointment
- Acute concerns that parents want to check before coming in (vomiting, rash, diarrhea)
- Questions about newborn behavior or childhood development (fussiness or colic, sleep training, toilet training)
In-person required:
- Newborn appointments
- Well-child exams
- Routine vaccinations
- Acute concerns that may require an intervention (possible broken bone, concussion, or a cut that may require stitches)
Susan Duan, MD, is a primary care physician board certified in internal medicine and pediatrics. She sees patients of all ages in Santa Monica, and says video visits are best for kids when she’s following up with parents about their child’s chronic medical condition.
“I can talk to the patient and their parents to see if a medication is working or if they’re experiencing side effects, and then make the necessary adjustments to their prescription,” she says. “I can also take time to answer any questions they might have.”
Answering questions via video is also great for first-time parents who want to discuss newborn behavior or childhood development, such as fussiness and colic, sleep training, starting solids or toilet training.
In this current environment, Dr. Duan says, she is happy to start with a video visit if a parent has concerns about a new symptom they’re seeing in their child, such as vomiting, diarrhea or a rash. “It’s very helpful get a visual of the child if it’s a sick visit,” she says, “even if I’m only seeing them on a screen.”
In some cases, she says, she will convert a video visit to an in-person appointment and have the parent bring the child to the office if she sees any red flags, such as extreme tiredness or listlessness or signs of dehydration.
Dr. Duan says she strongly recommends parents bring in their children for all well-child appointments, specifically when they are under age 2. This is especially important for appointments where there is a scheduled vaccination. “We do not want parents to delay or defer their child’s shots,” Dr. Duan says, noting that the Los Angeles County Department of Public Health recommends that immunizing the youngest children remain a top priority during the COVID-19 pandemic.
CARDIOLOGY
Dr. Ravi Dave, Interventional Cardiology, Santa Monica, Downtown Los Angeles, Thousand Oaks
Video visit OK:
- Medication management for high blood pressure (assuming the patient has a blood pressure monitor that’s been tested to deliver accurate readings)
- Review of test results
- Discussion about lifestyle modifications and related referrals (exercise, diet, stress management, sleep)
In-person required:
- New patient intake, including patients with high blood pressure
- Any cardiology appointment that requires a physical exam
Emergency action required:
- Chest pain or chest pressure
- Any other signs of a heart attack
Ravi Dave, MD, director of interventional cardiology at UCLA Health and a professor of medicine at the David Geffen School of Medicine at UCLA, says there are a few components of a standard cardiology visit that cannot be replicated in a video visit or telephone encounter. The first, he says, is taking the patient’s vitals.
“If a patient has a blood pressure machine at home, we can ask them to get some numbers and share that with us before their appointment,” Dr. Dave says, “but I prefer to collect this information in an in-person visit.”
A second routine part of a cardiology appointment is an electrocardiogram, or EKG, a non-invasive test that records the electrical signals in a patient’s heart to monitor heart health and diagnose many common heart problems.
And of course, a physical exam is required to listen to a patient’s heart and lungs, and to check for swelling – all of which can signal a new problem, such as a heart murmur, or provide valuable information about how well a chronic condition, such as congestive heart failure, is being managed. “No cardiology appointment is complete without this physical exam,” Dr. Dave says.
In addition to these in-person exams, Dr. Dave stresses that anyone who is exhibiting symptoms of a heart attack, such as tightness, pressure or pain in the chest back or arms, needs to call 911 or go to the hospital immediately. “Delaying this emergency care because of coronavirus concerns has led to many bad outcomes,” he says.
DIGESTIVE DISEASES
Dr. Kevin Ghassemi, Gastroenterology, Westwood
Video visit OK:
- Most new and follow-up general gastroenterology appointments
- Medication management and refills
- Consultations related to a procedure or imaging study (can order and schedule the procedure after the telemedicine appointment)
- Appointments with out-of-state patients who want a second opinion
In-person required:
- Bleeding from the rectum
- A lump or mass in the anus or rectum region
- A noticeable lump or palpable mass when the patient presses on the abdomen
- Preventive or diagnostic procedure, such as a colonoscopy or endoscopy
- CT scan or other imaging study
Kevin Ghassemi, MD, a general gastroenterologist and clinical chief of the digestive diseases practices in Westwood and Beverly Hills, agreed with other physicians that video visits are best conducted with a patient he already knows, to follow up on a chronic condition. But, he noted that digestive diseases appointments are different from other specialties.
“In gastroenterology, a lot of the physical exam is with the eyes,” he says. “Because I can still see how the patient appears, and can examine what their skin looks like and even look inside their mouth in a remote exam, video visits are often a good starting point.”
In a video visit, patients can describe any bloating or abdominal distention and then show their abdomen on the screen, he says. They can also point to an area where they’re experiencing pain, and with the physician’s guidance, press on specific areas of their abdomen and describe what it feels like.
“While there are some limitations,” Dr. Ghassemi says, “a lot can be accomplished in this sort of appointment.”
An exception is when the patient has bleeding from the rectum, or feels a lump or mass that may be a tumor in or near the anus or rectum, or in the abdomen. In these cases, Dr. Ghassemi says, a patient needs to come into the office.
Another exception, of course, is when a patient needs a preventive or diagnostic gastrointestinal procedure, such as a colonoscopy or endoscopy, or an imaging study, such as a CT scan.
“Patients have been fearful of coming to the hospital or the clinic, and this has led to medical appointments being delayed,” he says. “Video visits allow us to continue to care for our patients without delays that could have long-term detrimental effects.”
NEPHROLOGY
Anjay Rastogi, MD, PhD, Nephrology, Westwood and Century City
Video visit OK:
- Review of lab results
- Patient education or discussion of lifestyle changes
- Medication management
- Quarterly follow-up appointments for chronic disease management when the patient is otherwise stable
- Follow-up appointments for severely ill patients with multiple health conditions who are seeing multiple physicians (as long as one of their physicians is regularly seeing them for a physical examination)
- Follow-up appointments for patients who typically have to travel from far away
- Appointments for out-of-state patients who want a second opinion (check with insurance coverage and state policies)
In-person required:
- New patients who require an intake exam
- Acutely ill or unstable patients with abdominal pain or a new symptom
Anjay Rastogi, MD, PhD, the clinical chief of nephrology and director of UCLA Health’s Core Kidney Program, says that while nothing beats an in-person visit, telemedicine has a lot to offer and should be utilized when the patient is interested.
For patients with a chronic condition, such as high blood pressure or chronic kidney disease, in which they need to see a nephrologist every three months, he says every other appointment can be conducted as a video visit as long as they are stable.
“I have these patients have their lab tests done about a week in advance of their appointment and send me their results,” he says. “Then we can discuss their results remotely, and still have a productive appointment.”
Other patients who benefit from a video visit are those with a kidney condition plus other medical conditions who are seeing multiple specialists. As long as this patient regularly receives a physical exam from their primary care physician or another member of their health care team, the other specialists can receive any necessary updates and conduct their visits remotely. The same is true for patients who travel from far away.
“For those patients, the frustrations of traffic and parking can sometimes impact our appointment,” Dr. Rastogi says. “If we have a lot of talking to do, sometimes patients are more engaged and attentive from their home, where they can relax. Having a patient’s undivided attention is a true benefit that sometimes makes learning easier.”
However, he notes, patients who need a physical exam must come in. This includes any patient who is unstable or acutely ill and then develop any new symptom.
“If a patient isn’t sure if they need to come in, they can schedule a telemedicine appointment to start,” he says. “I’ll have them walk me through their symptoms and triage the situation remotely. I can assess the situation and let them know if they need to come in.”
New patients, unless they live far away and just need a second opinion, also need an in-person visit. “If a patient wants to continue seeing me, I will insist that they come into the office for the first few appointments,” he says.
DIETITIAN
Nancee Jaffe, digestive diseases dietitian, Westwood
Video visit OK:
- All dietitian appointments can be handled as video visits
Nancee Jaffe, MS, RDN, chief dietitian in the UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, says her work hasn’t changed all that much amid the pandemic. “I’ve been doing telemedicine for several years,” Jaffe says.
This works well when helping patients manage their digestive issues, such as gas, bloating and constipation, through diet, Jaffe says. If a patient is telling her about something he or she ate that could have contributed to symptoms, she can have them grab that food and hold the ingredient list up to the screen for her to review. “If we were in the office, they would have to remember to email that information later.”
Patients also are less likely to cancel appointments or show up late for a video visit, and more likely to be relaxed and comfortable.
Though her approach to visits hasn’t changed much since the start of the pandemic, Jaffe says some of her strategies have. She’s more focused on helping patients get the groceries and supplements they need in this current environment, she says, in which patients are making fewer grocery store trips and specialty products might not be on the shelves.
“I take the time to look up brands on Instacart and other grocery delivery apps, and email patients information on how to get the gluten-free food and other specialty products they need,” Jaffe says. “I won’t give advice that isn’t practical in this environment.”
