HOW TO DO IT Video consultations in ordinary and

Video consultations in ordinary andextraordinary times

Callum Duncan,1 Angus D Macleod 1,2

ABSTRACTTele-neurology is a neurological consultation ata distance, or not in person, using varioustechnologies to achieve connectivity, including thetelephone and the internet. The telephone isubiquitous and is a standard part of how wemanage patients. Video consulting has been usedfor a long time in some centres, particularly in thosewhere the geography means that patients have totravel long distances. Various technologies can beused, and with the development of various internet-based video-calling platforms, real-time videoconsulting has become much more accessible. Wehave provided a tele-neurology service in the NorthEast of Scotland since 2006 using videoconferencing with far-end camera control. Morerecently, we have complemented this using aninternet-based platform (NHS Near Me). Here weoutline the practicalities of video consulting in‘ordinary’ times and comment on its use in the‘extraordinary’ times of the coronavirus pandemic.

INTRODUCTIONTechnology is ever advancing, smart-phones are everywhere and the way peoplelive and interact has changed enormouslyrecently. This is particularly true of theyoung, but many older people are alsoembracing new technology. The use ofvideo calling using various platforms hasexploded during the current coronavirusdisease 2019 (COVID-19) pandemic andhas become a lifeline for many in the newnorm of social distancing and isolation.Video consultations are becoming

increasingly important for providing neu-rological services. Face-to-face in-personconsultations, allowing a comprehensiveneurological examination, will always bethe gold standard.1 However, video con-sultations can be effective, convenient anda timesaver for patients, particularly forthose who live far from a neurology centreor when a comprehensive examination isnot necessary.2–4

We provide neurological services toOrkney and Shetland from Aberdeen

Royal Infirmary in the North East ofScotland (figure 1). Travel to Aberdeenfor assessment requires a plane or over-night ferry journey, and some patientsfrom the outlying smaller islands mayrequire more than 1 day’s travelling time.We set up a tele-neurology service in 2006to the Balfour Hospital (Orkney) andGilbert Bain Hospital (Shetland) usingvideo conferencing with far-end cameracontrol, and in 2016 expanded this toinclude Dr Gray’s Hospital in Elgin(65 miles from Aberdeen). We undertakemost return appointments by telephoneand more recently by NHS Near Me, aninternet-based video consultation usingthe Attend Anywhere platform.This article focuses on the practicalities

of conducting video consultations in‘ordinary times’ and in the ‘extraordinarytimes’ of COVID-19.

VIDEO CONSULTATIONThere are two main ways to undertakea video consultation:1. Video conferencing with both near- and far-

end camera control (figure 2) gives a goodquality picture and allows a comprehensiveassessment including a directed neurologicalexamination. It requires far-end supportfrom either a trainee doctor or a trainednurse. A good quality video conferencingunit with a screen at either end are connectedby a dedicated integrated services digital net-work (ISDN) line to ensure good picturequality. Internet-based connections such asJabberTM using a near-end personal compu-ter and far-end video conferencing unit arepossible, but depend on internet bandwidthand ‘volume of traffic’; also, the picture qual-ity is not as good due to pixelation whenmoving the far-end camera.

2. An internet-based video-calling platformthat allows the patient to connect intoa virtual waiting room using their own com-puter, laptop, tablet or smartphone. Theclinician then connects into the patientfrom their clinic room or office computer(figure 3). This method is much more

1Neurology, Aberdeen RoyalInfirmary, Aberdeen, UK2Division of Applied HealthSciences, University of Aberdeen,Aberdeen, UK

Correspondence toCallum Duncan, Department ofNeurology, Aberdeen RoyalInfirmary, Foresterhill,Aberdeen AB25 2ZN, UK;[email protected]

Accepted 15 June 2020

© Author(s) (or theiremployer(s)) 2020. Nocommercial re-use. See rightsand permissions. Published byBMJ.

To cite: Duncan C, MacleodAD. Pract Neurol2020;20:396–403.

396 Duncan C, Macleod AD. Pract Neurol 2020;20:396–403. doi:10.1136/practneurol-2020-002579

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accessible but lacks the far-end camera control availablewith video conferencing, and so physical examination ismuch more challenging.

Practicalities of undertaking a real-time video consultationusing video conferencing with near- and far-end controlUndertaking a video consultation using dedicatedvideo conferencing requires a near-end unit for theassessing clinician. We have this in our neurologylibrary (figure 2) and use a Cisco video conferencingunit and Phillips monitor. Using a drop-down menu,the near-end clinician dials into equivalent video con-ferencing equipment in a dedicated clinic room in theperipheral hospital.The responsibility of the far-end assistant includes

receiving the incoming call from the near-end clinician;bringing each patient into the room; retrieving infor-mation available only on local IT systems; facilitatinga directed neurological examination; assisting thepatient out of the clinic room; and arranging for teststo be done locally (bloods, etc).We ensure the patient isinformed in advance that they are coming to a videoconsultation. The near-end clinician, who also ensuresthe patient can hear and is comfortable, explains theprocess and informs them that the system is secure and

confidential. Technical support is available to us fromthe NHS Scotland National Video ConferencingService in real time.

Far-end clinical room set-upChairs are positioned to face the far-end video confer-encing unit (figure 2C and E) and the couch is angledtowards the video conferencing unit to enable remoteexamination under direction (figure 2B and D). Chairsmay need to bemoved aside to allow assessment of gait.The far-end camera is controlled by the near-endclinician.

Far-end assistant trainingWeuse amixture of internal medical trainees, advancednurse practitioners and specialist nurses as far-endassistants. All doctors at core level should be able toundertake a neurological examination under direction,but in practice, their confidence and skill varies con-siderably, which may affect the near-end clinician’sdiagnostic confidence. It is an excellent learning oppor-tunity for the trainee and promotes neurology to core-level doctors. Because the clinic is undertaken by thenear-end clinician, it does not count as a trainee clinicfor the purposes of UK neurology training, but theneurologist can facilitate a mini-clinical examinationor case-based discussion on the cases seen. Nursesrequire specific neurological examination trainingbefore assisting with the clinic, and involving one ortwo dedicated nurses can help to build and maintaintheir skills.

ConsultationThe initial consultation resembles a face-to-face con-sultation, except that examination is undertaken differ-ently (next section). It is important to look at thecamera and to speak clearly. To support discussion atthe end of the consultation, the share or presentationfunction (depending on the video conferencing model)allows the patient to see the near-end clinician’s com-puter screen to review scans, other results or relevantwebsites. As NHS Orkney and NHS Shetland corre-spondence, laboratory results and radiology are allavailable on the NHS Grampian electronic record, thefar-end assistant needs to access only limited informa-tion from local systems. In Scotland, all radiology isavailable on a national Picture and archiving commu-nication system, accessible from any health board.Once comfortable using the technology, it is possibleto have complex conversations with patients, includingbreaking bad news.

Neurological examination under direction (box 1)The amount of direction required depends on the far-end assistant’s experience and confidence. It is better tobe prescriptive and detailed about the required examina-tion unless the assistant is already experienced in

Figure 1 Tele-neurology services from Aberdeen. Image mod-ified from https://commons.wikimedia.org/wiki/File:Scotland,_administrative_divisions_-_Nmbrs_-_colored.svg under the CCBY-SA 3.0 licence.

Duncan C, Macleod AD. Pract Neurol 2020;20:396–403. doi:10.1136/practneurol-2020-002579 397

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Figure 2 Video consultation using video conferencing: (A) Near-end room set-up, (B) examination by trainee under direction, (C andD) far-end room set up, (E) patient being interviewed.

Figure 3 Video consultation using NHS Near Me on the Attend Anywhere platform.


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neurological examination. Broad instructions, such as‘examine the cranial nerves’ will leave less experiencedassistants uncertain what to do. It is important that theexamining assistant does not obscure the view of elicitedsigns. The far-end camera can be moved up, down, leftand right, and zoomed in and out as required.It is not possible to assess fundi (a retinal photograph

taken by a local optician is a good substitute) or to seefasciculation (due to pixelation). Pupillary responsesand muscle tone (unless significantly increased) relyon interpretation by the far-end assistant. If reflexesare not seen, this may be due to lack of skill by theexamining assistant, although direction can help toimprove technique. The Montreal CognitiveAssessment (MoCA) Test Blind is the same as the stan-dardMoCAwith visual items removed and can be usedfor cognitive assessment.Box 1 outlines a standard examination. This requires

a mixture of direct instructions to the patient and direc-tion to the assistant. With adequate clear explanation, itis possible to assess strength in any muscle group;

collapsingweakness can be seen and it is possible to elicita Hoover’s sign. Parkinson’s disease and myastheniagravis are often best examined with the patient seated.They are usually straightforward to assess by video con-ferencing as the most findings are usually easy to see andinterpret visually. If the patient attends in a wheelchairand needs to have their gait assessed, the chair can bemoved to the back of the room and the patient assessedwalking towards the camera with support as necessary.The key to successful examination under direction is

to give clear instructions and to be adaptable. It isimportant to accept the limitations of the assistantand the technology. Rarely, we have to arrange an in-person review to perform a more-detailed examina-tion. This can be undertaken in either a visiting clinicor in the central hospital to coincide with arrangedinvestigations.

Practicalities of undertaking a real-time video consultationusing an internet-based platformThere are various platforms available for video calling:FaceTime, WhatsApp Messenger, Zoom, Skype,Microsoft Teams, Attend Anywhere, Cliniko, AccuRxand others. Some are set up primarily for social media,some for virtual meetings, and some for clinical use.Information technology (IT) security and encryptionare important when considering which medium touse, as patient-identifiable information will be shared,and some platforms may not be secure enough forclinical video consultations. Each organisation’s ITsecurity can advise on this, and usually a hospital willhave decided already which platform(s) can be used.We use NHS Near Me (using the Attend Anywhereplatform), as this is the package used in all ScottishHealth boards, and its benefits and challenges are com-mon to all platforms.The use of Attend Anywhere has increased exponen-

tially during the COVID-19 pandemic. In the weekbefore ‘lockdown’, there were 330 consultations perweek in Scotland. This increased to 10 770 consulta-tions per week over only 8 weeks (personal communi-cation, Hazel Archer, Access Program lead for ScottishGovernment) requiring significant upscaling of ITinfrastructure. Attend Anywhere is also available foruse in NHS England and NHS Wales, but other plat-forms are also used.With Attend Anywhere, patients connect into

a virtual clinic using their own computer, tablet orsmartphone. InNHSHighland, patients can also attenda staffed NHS Near Me clinic in a local communityhospital if they do not have suitable internet access or ifthey need other clinical support.

Patient experiencePatients are sent a website address to log into. This caneither be direct to their general practice or hospitaldepartment virtual clinic, or into a managed out-patient

Box 1 Standard examination under direction in a videoconsultation using far-end control and an assistant

► Ask the patient to stand and walk to the back of theroom (the camera may need to be panned up anda chair moved to give sufficient room). Next assesstandem walking.

► Ask the patient to sit on the couch facing the camera(figure 2B).

► Zoom in to assess pupillary responses includingassessment for a relative afferent pupillary defect. Theassistant may need to confirm the findings.

► Pan out slightly to assess eye movements by directinstruction to the patient (reminding them to keeptheir head still) or following the assistant’s fingerensuring it is not obscuring your view. The assistantmay need to confirm if nystagmus is present.

► The remaining cranial nerves can then be assessed asrequired. It is not possible to see tongue fasciculation.

► Pan out to examine bradykinesia, tone and power inthe upper limbs and then pan further out and down toexamine tone and power in the legs and undertakereflexes and plantar responses. It is not possible to seelimb fasciculation. We routinely assess shoulderabduction, wrist and finger extension, hip flexion, hipextension and plantar and dorsiflexion. Other musclegroups can be assessed giving clear instructions to theassistant.

► Sensation and coordination can be assessed with thecamera in the same position but the camera can bemoved to get a better view. Clear instructions shouldbe given. The patient can be seated on the side of thecouch to assess for a sensory level if needed.


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virtual clinic service where clinic staff greet patients.Access requires use of Chrome or Safari browsers onsmartphone, tablet or personal computer. If the patientis unsure about their technology or internet connection, itis helpful to note that if they can make FaceTime,WhatsApp, or Skype video calls, they can use Near Me.The log-in screen takes them through a series of checks(‘test my equipment’) to ensure connection speed,speaker, microphone and video are all sufficient for thevideo call. Patients should be encouraged to do this inadvance of their appointment day, or clinic staff can doa test call the day before to test that the technology isadequate. The clinic invite letter has a contact telephonenumber in case of technical difficulties and video confer-encing support can contact the patient at a convenienttime to work through any technical difficulties. Onceconnected, they see a picture of themselves while waitingin the virtual waiting room.The clinician then connects inand the appointment starts. There are several usefulvideos demonstrating this process on YouTube (searchNHS Near Me).

Clinician experienceConnecting to the patient is straightforward. Signinginto the login page takes the clinician straight to theappropriate virtual clinic page, which is set up for eachdepartment. The appropriate patient is selected fromthe list and (using the join call function) the clinician

connects into the patient in the virtual waiting area, andthe consultation starts. Connecting takes about 10 s. Ifusing your office computer it is important to gothrough the ‘test my equipment’ function to ensureyour microphone and speakers are active. A headsetwith microphone can be used if required. While it ispossible to undertake the video consultation usinga single screen, a double screen is preferable as thisenables the clinician to see the relevant information inthe electronic record at the same time as the patient(figure 3). Because it is not possible to rectify technicalissues in real time, it is important to have a back-upplan. If the patient has not connected in or there aresignificant issues with the connection quality, wequickly revert to the telephone.Like video conferencing, it is important to look at the

camera and to speak clearly, but again, with practice,the consultation unfolds in the usual manner (apartfrom examination). There is a messaging function ifthere are technical difficulties with the video orsound, and both the microphone and camera can beturned off by either clinician or patient. The ability toperform a neurological examination is limited as thereis no far-end camera control or assistant (see the‘Neurological examination’ section). Using the sharedscreen function, the material displayed on the compu-ter monitor can be reviewed with the patient (figure 4)and a second participant can be invited by email or text

Figure 4 Sharing second screen with PACS open on patient’s smartphone. PACS, picture and archiving communication system.


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to connect into the consultation. This allows a relativein another location to join the consultation or a jointconsultation with two clinicians in different locations(eg, a prepregnancy planning clinic).

Neurological examinationAs the patient connects from their home or workplace,there is much less control over examination comparedto a face-to-face or video conferencing consultation.The picture quality varies from excellent to poordepending on the patient’s internet and device. It mayalso pixelate when the patient moves, reducing thepicture quality during examination. Patients often posi-tion the device close to themselves, especially if usingtablets or smartphones, and the clinician may see onlytheir face (figure 4). They may also call in from a smallroom with inadequate floor space. To carry outa remote neurological examination ideally, patientsneed to be sitting in a chair at a table or desk and tohave sufficient space behind them to stand and walk.Alternatively, a relative can hold a phone, tablet orlaptop about 2 m away to facilitate examination.Examination is usually limited to what can be observed.Eye movements, facial strength, tongue movement,tremor, bradykinesia and usually gait can be assessedby giving the patient direct instructions. Crude assess-ment of limb strength is possible if there is a willingrelative to assist (figure 5). If the conditions are correctand the relative is confident, a fairly good quality

examination can sometimes be undertaken. Box 2details a suggested room set-up instruction.

Summary: video consulting in ‘ordinary times’Table 1 compares the advantages and disadvantages offace-to-face, video and telephone consultations. Face-to-face in-person consultations will always be the goldstandard. However, video consultation is a useful alter-native that is straightforward to learn and, with experi-ence, user friendly. Consultations by video conferencingusing a dedicated ISDN line provide the most reliablepicture quality and allows a comprehensive neurologicalexamination. It is most useful where travel time is longand costs high. Trained neurologists can learn the tech-nique quickly and it has been shown to be safe andeffective.3 Patient experience is generally very positivewith reduced need to travel the biggest advantage cited(Callum Duncan appraisal patient survey).Video consulting using internet-based platforms is

more widely accessible and uses widely available tech-nology. However, the picture quality depends on thepatient’s internet connection and device, and neurolo-gical examination is more limited. Therefore, it is mostsuitable for return appointments, particularly wherea neurological examination is not required or wherethere are visible signs of interest. It has clear advantagesover telephone consultations and recent studies haveshown that it can be effective, easy to use and accepta-ble to both doctors and patients.4 5

Figure 5 Wife assisting with examination for fatigability ina patient with myasthenia gravis.

Box 2 Patient instructions before undertaking an inter-net-based video consultation

► Your upcoming neurology appointment is scheduled tobe undertaken by a video consultation. Instructions onhow to connect in using your computer, laptop, tabletor smartphone are enclosed. You need to havea reasonable internet connection, but if you can useFaceTime, WhatsApp, Skype or Zoom then you will beable to connect in. Please connect in to the website anduse the ‘test my equipment’ function in advance ofyour appointment to ensure your internet connection isadequate and that your microphone and speaker work.If there are issues please let us know by phoning thecontact number on your instruction sheet. We will beable to advise andmay be able to sort the issue for you.

► To make the most out of your appointment, it is best tosit at a table with the computer, tablet or smartphoneon the table in front of you. Sit back a bit from thedevice and if possible, you should have free floor spacebehind you so that the doctor can watch you walk.There should be enough room to move your chair backto see your arms and hands more easily. It is also usefulto have someone with you so that they can providea witness history and help with some simpleexamination.


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Video consulting in ‘extraordinary times’The social distancing restrictions during the COVID-19 pandemic have accelerated the need to incorporatevideo consulting into neurology outpatientconsultations.6 Social distancing is likely to remainthe norm for some time to come and video consultationwill be an important part of the ‘recovery’ period as wecome out of the pandemic.What is acceptable in ‘extra-ordinary’ times and ‘recovery’ is by necessity differentfrom ‘ordinary’ times. Video consulting by video con-ferencing with far-end control suffers from the samesocial distancing restrictions as face-to-face assessmentdue to the need to attend hospital outpatient clinics.During the current lockdown period, we have used

NHS Near Me to assess new and return patients to limitthe number of face-to-face assessments needed in thelockdown period. The exponential increase in the use ofNear Me across Scotland initially put considerable strainon the IT infrastructure, but an infrastructure upgrade hasresolved most of the issues. Because it provides onlylimited ability to undertake a suitable neurological exam-ination, it is most suitable for certain new appointmentswhere the neurological examination adds little to theconsultation, such as first seizures, epilepsy and headache.For other conditions, it can be used as a screening toolbefore either a soon or delayed face-to-face assessment to

allow a more comprehensive examination. It can be usedfor most return appointments and for explaining investi-gation results. If clinicians think detailed neurologicalexamination is essential, the patient still needs eithera face-to-face appointment or a video consultation withfar-end assistant.As lockdown restrictions are lifted, internet-based

video consultations could be incorporated into stan-dard clinic templates making it easier to incorporatesocial distancing measures in clinic waiting areas givingreduced footfall. Given the convenience of video con-sulting, including reducing the need to travel, patientswith chronic neurological conditions may want to con-tinue video consulting beyond the ‘recovery’ periodand it may become a standard part of neurology out-patient services.

CONCLUSIONVideo consulting is an efficient, effective and accepta-ble way to assess selected neurological patients. Duringlockdown and recovery, it is becoming an integral partof how we provide neurological services. When wereturn to ‘ordinary’ times, it has the potential for long-lasting changes to how we practise medicine, byimproving our patients’ experience of the managementof chronic neurological conditions.

Table 1 Comparison of advantages and disadvantages of face-to-face, video and telephone consultations

Face-to-face consultationFormal video conferencing withfar-end camera control

Internet-based video callplatform Telephone consultations

Advantages Disadvantages Advantages Disadvantages Advantages Disadvantages Advantages Disadvantages

Best qualityverbal andnon-verbalcommunication

Inconvenience ofattending,particularly forpatients in remoteareas

Patients needonly to travel tolocal hospital

Patients still musttravel to peripheralhospital

No travelrequired

Requiresappropriate deviceand good internetconnection

No travelrequired

Cannot pick upon non-verbalclues

No technologyrequired forpatients

May not besuitable duringinfectious diseaseepidemic/pandemic

Full control of far-end camera andassistant forexamination

Requires expensiveequipment and ITsupport

Suitabledevices arewidelyavailable

More limitedexaminationpossible

Onlytechnologyrequired istelephoneconnection

No examinationis possible(other than ofspeech)

Gold standardexamination

Mostexamination ispossible

Not allexamination ispossible

Can shareimagingwithpatients

Some platforms donot havenecessaryencryption

Cannot shareimaging withpatients

Can shareimaging withpatients

Gives neurologyexperience totrainee doctors/specialist nurses

Variable quality ofexaminingassistant

Easy toincluderelatives indiscussion

Technical issuesmore common;real-time ITsupport notavailable

Difficult toinclude relativesin discussion

Can shareimaging withpatients

Initially slowerthan face-to-face,but almost asquick with practiceRarely technicalissues, but real-time IT supportavailable

IT, information technology.


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FURTHER READINGLarner AJ. Teleneurology: an overview of current sta-tus. Pract Neurol 2011;11:283–288.

Acknowledgements We thank the patients and medical traineefor their permission to use their photographs.

Contributors CD conceived the manuscript, wrote the first draftand approved the final version. AM contributed to the content,reviewed and revised the article.

Funding The authors have not declared a specific grant for thisresearch from any funding agency in the public, commercial ornot-for-profit sectors.

Competing interests None declared.

Patient consent Obtained.

Ethical approval information Not required.

Provenance and peer review Commissioned. Externally peerreviewed by Ralph Gregory, Poole, UK.

Map disclaimer The depiction of boundaries on the map(s) in thisarticle does not imply the expression of any opinion whatsoeveron the part of BMJ (or any member of its group) concerning thelegal status of any country, territory, jurisdiction or area or of itsauthorities. The map(s) are provided without any warranty ofany kind, either express or implied.

ORCID iDAngus D Macleod http://orcid.org/0000-0002-6284-4239

REFERENCES1 Chua R, Craig J, Wootton R, et al. Randomised controlled trial

of telemedicine for new neurological outpatient referrals.J Neurol Neurosurg Psychiatry 2001;71:63–6.

2 Larner AJ. Teleneurology: an overview of current status. PractNeurol 2011;11:283–8.

3 Duncan C, Dorrian C, Crowley P, et al. Safety and effectivenessof telemedicine for neurology outpatients. Scott Med J2010;55:3–5.

4 Shaw S, Wherton J, Vijayaraghavan S, et al. Advantages and lim-itations of virtual online consultations in a NHS acute trust: theVOCALmixed-methods study.Health services anddelivery research,no. 6.21. Southampton, UK: NIHR Journals Library, 2018.

5 Donaghy E, Atherton H, Hammersley V, et al. Acceptability,benefits, and challenges of video consulting: a qualitative studyin primary care. Br J Gen Pract 2019;69:e586–e594.

6 Nitkunan A, Paviour D, Nitkunan T, COVID-19: switching toremote neurology outpatient consultations. Pract Neurol. 2020;20:21618

Key points

► With practice, undertaking a video consultation isstraightforward, and is often more convenient for thepatient.

► Video consulting using a far-end assistant allows theclinician to undertake a relatively comprehensiveneurological examination.

► Neurological examination using an internet-basedvideo consultation is more limited, but pertinentaspects of the examination can usually be done.

► The extraordinary times presented by COVID-19 offeran opportunity to reconsider how neurologicalservices are provided; increased use of videoconsulting in the management of chronic conditionshas the potential to improve patient experience.


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HOW TO DO IT Video consultations in ordinary and