HealthManagement, Volume 20 - Issue 7, 2020

Communication in the Time of Corona - The Rise of the Virtual Clinic

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In this article, we discuss some aspects of note with regard to virtual clinics, including their proposed benefits and associated challenges. We end by providing some tips for healthcare providers who are beginning to incorporate virtual consultation into their practice.


Key Points

  •  COVID-19 crisis has heralded unprecedented change across healthcare systems globally.
  • This has led to the rapid integration of virtual clinics into clinical practice.
  • There are several differences between communicating with a patient in a face-to-face setting and over a telephone. It is important for physicians to bear these in mind when interacting with patients via telemedicine.
  • Virtual clinics may provide several advantages for healthcare systems, including easier access to specialised care for geographically or socially isolated populations.
  • Whatever the communication modality, healthcare providers should strive to maintain effective, patient centred communication and care throughout this pandemic.


Introduction

“The single biggest problem in communication is the illusion that it has taken place.”

George Bernard Shaw, Irish Playwright


The coronavirus pandemic has resulted in widespread changes to the way healthcare is delivered worldwide. Virtual clinics have long been mooted as a potential solution to a wide array of challenges associated with the delivery of care. This unprecedented global healthcare emergency has led to the rapid integration of virtual clinics into clinical practice.The precipitous nature of this change has resulted in unique challenges which may require innovative solutions in order to ensure the delivery of high quality, patient-centred care.


In this article, we discuss some aspects of note with regard to virtual clinics, including their proposed benefits and associated challenges. We end by providing some tips for healthcare providers who are beginning to incorporate virtual consultation into their practice. As highlighted by the quote at the beginning of this article, truly effective communication is a complex, multi-faceted process that is challenging to achieve in the real world setting. We feel that, as healthcare providers, it is critical that we all strive to maintain effective, patient-centred communication throughout these challenging times. Our hope is that this article will help our readers achieve this.


What is Telehealth?

We will begin by defining some of the terms related to virtual clinics. Telehealth is defined as the distribution of health-related services and information via electronic information and telecommunication strategies. This umbrella term can relate to a variety of different services, including education, monitoring, health promotion and real time interaction. Telemedicine is a related term that generally refers more specifically to the provision of clinical services and eHealth has also been used interchangeably with telehealth in the UK and Europe. As such, ‘virtual clinics’ would fall under the umbrella terms of both telehealth and telemedicine. A virtual clinic generally refers to a clinic where the patient does not need to go to the doctors office or waiting room. Instead, they can talk to and see their doctor via their telephone, smartphone, tablet or computer. Virtual consultations between doctors can also be performed in a similar manner. For example, the provision of a heart failure specialist’s advice to general practitioners via web based conferencing (Gallagher et al. 2017). There are undoubtedly a multitude of potential varieties of virtual clinic/consultation spanning the spectrum of medicine, from primary to tertiary care. The basic commonality is that they all seek to ensure that a patient can receive appropriate care, from the appropriate person at the appropriate time, using technology to achieve this goal.


The Rise of the Virtual Clinic

As Plato’s Republic stated; ‘our need will be the real creator.’ The current pandemic necessitated a seismic shift in service delivery and the widespread adaption of telemedi-cine. Healthcare providers were unable to bring patients in for face-to-face reviews and so innovative solutions were required. While this rapid change was undoubtedly impres-sive, it may mean that many healthcare providers struggle to keep pace. In the next sections, we discuss some aspects of note with regard to virtual consultation with the aim of helping healthcare providers to adjust to this new care paradigm. Where possible, we provide reference to existing literature. However, it is important to note that these manu-scripts come from a variety of settings and that what works in one setting will not necessarily work in another. Patient demographics, cultural and societal factors must all be taken into account at a local level in order to determine the optimal approach. Guidelines are also available with regard to telemedicine and telehealth and it is important that prac-titioners ensure that their local practice is aligned with best-practice guidelines within their own jurisdiction (American Telemedicine Association 2009).


Differences in Communication

There are several differences between communicating with a patient in a face-to-face setting and over a telephone. It is important for physicians to bear these in mind when interacting with patients via telemedicine. Previous studies have demonstrated that telephone interactions can result in a reduced perception of affiliative behaviours (Sadikaj and Moskowitz 2018). An affiliative behaviour is a social interaction that functions to reinforce social bonds with a group. One study reported that there tended to be a mismatch during phone conversations between an individual’s self-perception and how the other person in the conversation perceived them. This study was performed in cohabiting couples. As such it is likely that relative strangers (like a physician and their patient) would have even more difficulty interpreting each other’s behaviour. It is important that physicians bear this in mind and are cognisant that there may be a mismatch between how they are perceiving the clinical interaction and the patients’ perception.


Building rapport is an important part of any clinical interaction and this may be more challenging over the telephone. This may be particularly challenging if the doctor and patient have not met before. Specific research has been carried out with regard to building rapport in telemedicine, particularly focusing on psychological medicine (Glueck 2013). The physician-patient relationship has been found to have a small but significant effect on patient outcomes and correlates with improved patient satisfaction and well being (Kelley et al. 2014; Sheikh et al. 2019). Another study found that patients who were highly satisfied with telemedicine tended to comment on medical communication skills from their healthcare provider that demonstrated patient centred relationship building (Elliott et al. 2020).


Research in general practice has suggested that telephone consultations may result in less problem disclosure than face to face meetings (Hewitt et al. 2010). The authors suggested this may be because telephone consultations tend to be mono-topical. It may also be due to difficulty in picking up non-verbal cues, reduced attention to patient concerns or unconscious limitation of opportunities for patients to disclose problems. However, the researchers in this study did not find that doctors limited disclosure in telephone consultations and overall found that there was little difference in communicative practices between face to face and telephone communications. Video consultation may allow for greater visual feedback and facilitate rapport building but there is limited research to support this at present (Hammersley et al. 2019).


Potential Benefits

Many benefits exist of the telephone interview. This mode of communication can provide easier access to specialised care particularly for geographically or socially isolated populations (Opdenakker 2006). Remote communication can facilitate care for those who have difficulties attending in person. This may include a variety of groups, such as parents looking after small children, shift workers, marginalised groups or those with physical disabilities. For example, it has been shown to successfully engage, retain and cure patients with hepatitis C from marginalised rural communities in Canada (Lepage et al. 2020). The reduced financial and time cost compared to a face to face interview may support a shift in the delivery of care to the community setting. This can provide greater integration of high quality care outside the hospital setting. In the long term, this may be more sustainable, may better meet the needs of the community and may result in improved networks of communication between primary, secondary and tertiary services.


The nature of the consultation can dictate whether telephone interview is useful. Routine follow up appointments where verbal responses provide sufficient information for the consultation are most suited to virtual clinic/consultation (Mann and Stewart 2000). For other consultations, particularly where additional information is required (patient atti-tudes, behaviours or clinical examination), the telephone interview may be less useful. Importantly, the interviewer may have less control over the phone to create the optimal atmosphere for appropriate medical consultation (Gergen et al. 1973). While visual feedback is absent, many social cues still exist on the phone (voice pitch and tone, speech volume, speech patterns). This provides telephone consultation with some potential advantages over some forms of computer mediated communication such as email and chat boxes. Learning how best to use each form of virtual consultation may take time and require an initial ‘trial and error’ approach with patient and healthcare provider feedback. If this feedback results in tailoring of the service, it may prove very useful with regard to optimising service delivery. This requires a culture that encompasses values like continuous reflection and iterative improvement.


Patient feedback is very important in order to develop a service as it is inevitable that there will be a degree of personal, regional and departmental variability with regard to patient attitudes toward telemedicine. One size does not fit all and while some patients may be enthusiastic about virtual consultations, others may prefer to continue with face-to-face consultations if possible. It is important that healthcare practitioners take this into account and strive to respect each individual’s autonomy as much as is possible and permissible. For example, it may be thought that elderly patients who may be less au-fait with technology may not have the same attitudes toward telemedicine as teenagers who have grown up with smartphones. However, it is important not to stereotype as some studies have shown similarly positive attitudes to telemedicine in elderly and younger patients (Greenwald et al. 2018; Kaambwa et al. 2017).


Patient Perspectives on Telemedicine

This mention of patient feedback brings us to an important question in telemedicine: what do patients think about virtual consultation? Thankfully, there has been some research in this field. However as a relatively new area of scientific enquiry, this is somewhat limited. In addition, there is substantial variability with respect to the delivery of telemedicine. For some patients, the ability to discuss personal issues over the telephone can provide greater comfort and ease. Some personal issues may be so sensitive that participants may be reluctant to discuss face to face with an interviewer. This may lend additional privacy and anonymity for those with stigmatised medical conditions or those suffering from phobias of doctors and hospitals, termed “iatrophobia” and “nosocomephobia” respectively. Visual anonymity can result in greater “self-disclosure” where more intimate personal information is revealed and this has been shown to result in greater positivity about the consultation (Gergen et al. 1973; Archer 1980). It has been suggested that an important aspect of delivering telephone care is ensuring that the patients’ knowledge and understanding of the intervention is addressed (Rushton et al. 2020). This should include explaining to the patient how the consultation will work at a practical level, the rationale behind it and the aims that are trying to be achieved.


Tips for Doctors Performing Telemedicine

Finally, we present some tips for doctors performing telemedicine for the first time. There is no panacea to ensure that a virtual clinic appointment will go well but these tips are intended to represent a common sense starting point for healthcare providers dipping their toes into the water.


1. Make sure both you and the patient are on the same page

It is important to clarify the patient’s perception of the consultation. Ask for their feedback on the consultation and encourage them to engage in the process on an equal footing with their healthcare provider. Check that the patient was happy with their virtual consultation and ask if there was anything that could be improved.


2. Take time to build rapport

Recognise that rapport may be more difficult to establish via telemedicine and invest time in this. Do not rush through the consultation but instead try to take time and maintain the normal rhythm of the patient-physician interaction. Phone consultations can have a tendency to be more mono-topical and problem-focused and it is important to try to maintain a holistic approach.


3. Encourage disclosure of problems

Encourage patients to disclose issues or problems. Give them time to disclose issues during the consultation and an opportunity at the end to bring up any other concerns. Recognise that subtle cues and nuances may be missed over the phone and so try to explicitly give patients an opportunity to disclose.


4. Explain follow up plans

Ensure the patient is aware of plans for further follow up, if any. Explain when they can expect to be seen again, any investigations you intend to organise and if the patient is required to do anything. For instance, do they need to make an appointment with the secretary or will the secretary contact them? If a further clinic appointment is required, clarify if this will be in person or another virtual appointment. Enquire with the patient as to whether or not they have a preference for in person or virtual appointments in the future.


5. Listen!

Finally, as William Osler said; ‘Listen to your patient, they are telling you the diagnosis.’ If we can bear this adage in mind when performing telemedicine, it is likely that the rest of the consultation will fall into place.


We wish all of our colleagues the best of luck as they strive to continue to provide high quality healthcare during this pandemic.


Conclusion

The rise of virtual clinics during the coronavirus pandemic has changed our delivery of care. While these clinics have some drawbacks, it is clear that for the foreseeable future they will be an integral part of how we manage patients.


We believe that it is our responsibility as healthcare providers to ensure that we provide care for our patients in a manner that they are comfortable with and that respects their individual identity and cultural beliefs. It is important that we prioritise this approach in regard to virtual clinics.


Healthcare organisations should consider providing dedicated training to staff in telemedicine to promote good clinical practice and optimise service delivery.


Conflict of Interest

None. 



References:

American Telemedicine Association Evidence-Based Practice for Telemental Health. (2009) Available from americantelemed.org/files/public/standards EvidenceBasedTele-mentalHealth_WithCover.pdf


Archer RL (1980). Self-disclosure. In Daniel M. Wegner & Robin R. Vallacher (Eds.), The self in social psychology, 183-204. Oxford University Press: London.


British Journal of General Practice, 69 (686): e595-e604. doi: 10.3399/bjgp19X704573


Gallagher J, James S, Keane C et al. (2017) Heart Failure Virtual Consultation: bridging the gap of heart failure care in the community - A mixed-methods evaluation. ESC Heart Fail, 4(3):252-258. doi:10.1002/ehf2.12163


Gergen KJ, Gergen, MM, Barton WH. (1973) Deviance in the dark. In Psychology Today, 7, 129-130.


Glueck D. (2013). Establishing Therapeutic Rapport in Telemental Health. 10.1016/B978-0-12-416048-4.00003-8


Greenwald P, Stern ME, Clark S, Sharma R (2018) Older adults and technology: in tele-health, they may not be who you think they are. Int J Emerg Med, 11(1):2. doi:10.1186/s12245-017-0162-7


Hammersley V et al. (2019) Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care


Hewitt H, Gafaranga J, McKinstry B (2010) Comparison of face-to-face and telephone consultations in primary care: qualitative analysis. Br J Gen Pract, 60(574):e201-e212. doi:10.3399/bjgp10X501831


Kaambwa B, Ratcliffe J, Shulver W et al. (2017) Investigating the preferences of older people for telehealth as a new model of health care service delivery: A discrete choice experiment. J Telemed Telecare, 23(2):301-313. doi:10.1177/1357633X16637725


Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H (2014) The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials [published correction appears in PLoS One, 9(6):e101191]


Lepage C et al. (2020). Telemedicine successfully engages marginalized rural hepatitis C patients in curative care. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada, e20190025. 10.3138/jammi-2019-0025.


Mann, C, Stewart F (2000). Internet communication and qualitative research. London: Sage.


Opdenakker R (2006) Advantages and disadvantages of four interview techniques in qualitative research. InForum qualitative sozialforschung/forum: Qualitative social re-search, 7(4).


Rushton K, Ardern K, Hopkin E et al. (2020) ‘I didn’t know what to expect’: Exploring pa-tient perspectives to identify targets for change to improve telephone-delivered psycho-logical interventions. BMC Psychiatry, 20(1):156. doi:10.1186/s12888-020-02564-6


Sadikaj G, Moskowitz DS (2018 I hear but I don’t see you: Interacting over phone re-duces the accuracy of perceiving affiliation in the other. Computers in Human Behavior, 89, 140–147. doi:10.1016/j.chb.2018.08.004 For full references, please email [email protected] or visit https://iii.hm/14of


Sheikh M, Qayyum R, Panda M (2019) Relationship of Physicians’ Rapport with Patients’ Satisfaction and Psychological Well-being During Hospitalization. Cureus, 11(6): e4991. doi:10.7759/cureus.4991


Tania Elliott, Ian Tong, Arwen Sheridan, Beth A. Lown (2020) Beyond Convenience: Pa-tients’ Perceptions of Physician Interactional Skills and Compassion via Telemedicine, Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 4(3): 305-314. doi.org/10.1016/j.mayocpiqo.2020.04.009.





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