Telehealth Best Practices: Dr. Nell Smircina of PIQUE Health On How To Best Care For Your Patients When They Are Not Physically In Front Of You

Be above and beyond familiar with your platform, including Wifi and other technical aspects:
- There is nothing worse than fumbling with technology or not being able to talk your patient through how to turn their video on. Even when you have staff, things will come up on the call and you always want to be able to tell your patient how to troubleshoot on their end (sometimes their screen looks different than yours as the provider and you need to be aware of that). Have a back up plan for WiFi, like cellular or tablet data, in case something goes wrong.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Nell Smircina.

Dr. Nell Smircina is a practitioner and healthcare advocate, specializing in the integration of Acupuncture into the Standard of Care. She is the Founder of PIQUE Health, a concierge integrative medical practice in Beverly Hills, CA. In addition to her work with PIQUE, Dr. Nell teaches in various master’s and doctoral programs, serves as the President of CSOMA, California’s State Association for Acupuncture, as well as on the Advocacy Committee for the American Society of Acupuncturists, and actively coaches students and practitioners looking to have flourishing practices.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

I originally knew nothing about integrative medicine, let alone acupuncture, which has since become my life mission: bringing acupuncture into the standard of care. I originally went to school on the path of becoming a surgeon. As I got through pre-med, I realized I would have a very difficult time balancing all the things I wanted in life with that career choice. I had done internships in Physical Therapy since I was about 15 and thought that would be a better fit to allow for more schedule/family flexibility while also allowing me to operate my own business. However, as I started working in entry level physical therapy, I was extremely frustrated with the limited scope of practice and had so many unanswered questions about inconsistencies in patient results.

Fortunately, at the time I was also on my own health journey, needing solutions for chronic pain from previous gymnastics injuries. I ended up trying acupuncture out of desperation, and to my surprise it was the one thing that worked for me. As I learned more, I found out that acupuncture is only one modality within a complete system of medicine; and learning more about that system even brought me answers about why certain patients heal differently than others. It also was a way for me to help patients more comprehensively and expand my scope of practice.

I am a person who is slightly obsessed with being as qualified and effective as possible, so I set out to complete my masters and then doctorate (a designation only 1% of acupuncturists have) in California, which was known to have rigorous education for this medicine. Moving to California from the east coast, I went all in, wanting to learn the ins and outs of this industry. I managed the teaching clinic at my school while I was completing my doctorate, started consulting for various herbal and supplement companies, and then got into advocacy, serving as the President of the California state acupuncture association and on the Advocacy Committee for the National Association.

I set out to not only have a private practice, but a successful one, which would provide a high touch, elevated patient care experience and demonstrate tremendous value for acupuncture and integrative medicine. This last year with the pandemic has forced providers like me to really take a deep dive into analyzing how patient centric our practices have actually been, and how we can make them even more accessible to patients seeking care. Even with the advances in technology, the mindset shift and creativity levels had to kick in for me to determine how to deliver elevated care in a hybrid or virtual setting.

Can you share the most interesting story that happened to you since you began your career?

When I was just starting my practice in Los Angeles, I was working full time as the Clinic Manager at the master’s program teaching clinic I had been trained in as a student. I was also completing my doctorate and was seeing patients on a limited basis simply due to time constraints. I was offered an opportunity to meet with a Neurologist who ran an integrative medical suite in Beverly Hills, as he was looking for an acupuncturist. This opportunity was brought to me by one of the student interns at the clinic and I almost talked myself out of even going. I told myself unsubstantiated stories (I think we all are guilty of this time to time). I thought, “Oh, they probably want someone full time” or “I don’t really want to work for someone, and they are probably looking for an employee”. What stopped the story telling spiral was me refocusing on my why: bringing acupuncture into the standard of care. I realized the worst that could happen was that I’d meet some practitioners interested in integrative care and would have the opportunity to educate on the power of acupuncture as part of an integrative model. It was bigger than me.

I went to the meeting and it turned out to be an ideal situation. They were not looking for an employee- they were looking for an Acupuncturist who wanted to have their own practice in a medical suite. This was really my foot in the door to building a Beverly Hills practice. I started small and learned so much from others around me before moving into my own space. This was just a confirmation that you can’t go wrong by letting your “why” guide every decision you make.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I have so many! One that is currently playing over and over in my head during this time in my life is from Gary V: “Are you humble enough to let some of the plates drop”? We tell ourselves stories all the time about things we “have to do” or get married to ideas that may not be the best ideas. 2020 was a year that forced plates to crash for many, and I always like to take opportunities to be as intentional as possible. Don’t let things fall away by accident; take inventory and decide what needs to stay and what needs to go…and be brutally honest with yourself about it.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

Dr. Jack D’Angelo, who I’ve known in many capacities throughout my entire life. We are definitely cosmically connected even being a generation apart. We have extremely similar personalities; and his mentorship has been particularly impactful for me because he can give feedback almost from a mirror to the future because of how similar we are. He has built successful practices, worked himself into the ground, pushed himself (and those around him) along the way, and made such an impact on patients he has had in his care.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

Something as simple as a physical exam or being able to have physical touch is a huge benefit to in person care. As a practitioner, getting to use all of your senses for the patient’s benefit is part of that in person experience. From a diagnostic perspective, being able to see/feel changes in a patient’s body has always been an important tool in determining what is going on. And truthfully, going to the doctor can be so cold and clinical, but the human interaction takes that edge off if done properly.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

Things can get missed if the practitioner is not doing their part to dig a bit more with questioning and listening. If you’re in front of me, I may notice a bruise that was not mentioned, and then it turns out the patient bruises easily, which could lead to a vitamin deficiency diagnosis. Or examining an injury and feeling it’s hot to the touch or the skin is healing slower than anticipated on a surgically operated area. The biggest thing is not being able to notice something the patient does not bring up. Both patient and practitioner must be even more communicative than usual when you’re not in the same space.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)

1. Be above and beyond familiar with your platform, including Wifi and other technical aspects:
   - There is nothing worse than fumbling with technology or not being able to talk your patient through how to turn their video on. Even when you have staff, things will come up on the call and you always want to be able to tell your patient how to troubleshoot on their end (sometimes their screen looks different than yours as the provider and you need to be aware of that). Have a back up plan for WiFi, like cellular or tablet data, in case something goes wrong.
2. Be very clear about how the visit will go…manage expectations:
   - Telehealth is not the same as an in person visit, as much as we’d like it to be. Managing expectations for a virtual visit is even more important than an in person visit. Patients need information on how to get the most out of the visit. There are so many distractions in a doctor’s office, and so much human interaction, but when it is truly one on one in a Telehealth call, letting the patient know up front what that experience will be like adds meaningful value. And it means you as a provider will get more relevant information you need for the best care possible.
3. Do your part to review patient information before the visit and hold the patient accountable for having information completed before the visit:
   - It’s a patient centric experience, but that does not mean the patient has no ownership of the experience. You want patients to own their responsibility in their health and you’re there to guide them, so they need to be coached to start that ownership by being prepared for the appointment. Having my patients fill out everything possible in advance of a call so I can review it brings them more value during the visit. Don’t be hesitant about articulating the importance of that, especially for a virtual call when time is even more of the essence. Anything that can be reviewed before the time of call is important to allow for the unknowns that will come up.
4. Do as much of an observational exam as possible and let the patient be as comfortable as possible:
   - You still need to get as much information as possible, and the usual questions you would do during a patient intake are relevant, but take advantage of the patients being outside of the office. Allow the patient to be in their own environment, or at least ask if that’s their usual environment. Ask them what’s going on if they’ve just shut themselves in a small room and you can hear the chaos of kids in the background. Allow them to have a loved one on the call if they ask. You may learn something you would not have learned by observing them in this authentic way which would have never come up had the patient come to a visit in your office.
5. Have ready-made value adding resources for outside of your Telehealth session:
   - When I’m not physically seeing my patients as often as I normally would, having quick resources like books, electronic pamphlets and articles is key. Having an easy-to-use patient portal for communication and posting of resources makes the back and forth easier. Creating a Telehealth workflow for yourself and your staff can help with this process. An example would be patient books appt, gets reminder email, does visit, gets follow up review of visit, then receives information adding value to their experience such as a book recommendation on their particular issue or ailment, or articles on managing their specific condition. These ready-made resources are still an extension of you as a provider and the patient feels that as another touch point, even if you can’t physically be sitting with each other in the office.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Observing a patient in their natural environment can be a huge benefit, and for the patient not having to have the stress of navigating getting to the doctor’s office (especially in LA traffic) is really helpful and convenient. I was doing a Telehealth consult with a patient and his kids were in the background. He picked up a toddler a certain way a couple times during the call to get him to calm down; and come to find out that happens multiple times a day, every day, with that same arm he was complaining of shoulder pain and elbow pain. His thought was the pain was from tennis but didn’t understand why taking a break had not decreased the pain. It never would have occurred to him that it wasn’t the sport causing the issue, and I doubt my usual ask of “if there were other movements or activities that contribute to the pain” would have sparked that possibility in office. I so appreciated the opportunity to see a snippet of his life, which allowed me to better help him.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

The most effective for myself and my patients have been those that integrate well with practice management or electronic health record software, as well as being available on a computer, tablet or phone. Patients are often already familiar with their patient portal, or the format of the emails/information they receive. Making this transition as easy as possible is key. I love that my patient still gets the same confirmation email and then reminder email, but it has a simple link to the HIPPA compliant video platform. They don’t have to do anything extra to access it; and it’s simple even for patients who are not super tech savvy.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

It would integrate with any device and look the same or similar regardless of it being on a computer, tablet or phone. It would look identical between Mac and PC. It would allow for certain stats like blood pressure, pulse or temperature to be done without additional contraptions. It would integrate seamlessly with practice management software to make documentation/HIPPA compliance simple.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

I would tell patients to also be well prepared for the call so their time is best utilized. Make sure all technology is tested and that WiFi is working well, fill out all paperwork as thoroughly as possible, check all emails from the doctor’s office, make notes before getting on the call to prioritize and organize thoughts, and be ready at the designated time.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

Some of these new healthcare apps are interesting and make a more integrative approach more accessible to patients, which I love seeing. I am seeing more of a focus on underlying conditions and a shift to virtual and preventative care. It is great to see people able to get their supplementation or medications sent to them in an easy-to-use fashion.

Is there a part of this future vision that concerns you? Can you explain?

Of course. Accessibility is wonderful, but not if we’re sacrificing the personalized approach of healthcare. Human interaction has always been a part of this process, and while some of that can be provided in a Telehealth setting, some things may fall through the cracks. This is particularly possible as more apps are doing things through algorithms and not through an actual person overseeing care. Doctors go through a ton of training to be able to provide diagnosis and care, and while the accessibility and affordability can be intriguing for a “one size fits all” approach, we could end up missing something that an actual person would have picked up on.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

Having acupuncture in the standard of care! An example to demonstrate the need for this that I deal with all the time and am shocked by: a patient has a surgery and is left to just rest and take pain medication, and told in a few weeks they can do physical therapy. How is it possible we don’t have more proactive measures than that? Well we do, they just aren’t in the standard of care.

Acupuncture is an intervention that can be done immediately (I start treatments the day after surgery) and can drastically reduce pain and inflammation, while expediting healing and reducing scar tissue and the effects of anesthesia. The best part of this would be patients having something proactive to do in their own healing, rather than feeling helpless. The body wants to heal…sometimes it just needs a little nudge in the right direction. We are doing patients a disservice by not giving them all the available options for their care.

How can our readers further follow your work online?

I regularly write articles and appear on various podcasts, so google may be your friend here, but my practice website is piquebh.com and my most active social is LinkedIn: Dr. Nell Smircina.

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.

Thank you for having me and I hope this brought value to your readers looking to have an elevated Telehealth experience.