Telemedicine may have indeed come into its own during the COVID-19 pandemic; an overnight success 20 years in the making. But that doesn’t make every physician or other caregiver savvy enough to employ the technology and every patient accepting of it either.
Treating patients via telemedicine for physicians or other healthcare workers means learning a new skill set, according to an opinion piecetoday in the Annals of Internal Medicine.
The authors, Lynn Flint, MD and Ashwin Kotwal, MD, MS, both of the University of California-San Francisco, start with an anecdote about how upset a family became last year when a physician had the end-of-life talk to a 78-year-old patient via telemedicine. A granddaughter recorded the session on her cellphone and the clip went viral; an example of how cold and dehumanizing telemedicine can be.
As Flint and Kotwal put it: “Fast forward to now.” Because of COVID-19, physicians and patients live in a world of social distancing and the monitoring of time and supplies that must be judiciously distributed. Telemedicine’s everywhere. However, the adage said that medicine is as much an art as a science needs to be applied to telemedicine, as well.
Healthcare providers need to prepare for telemedicine consultations. They also need to make sure that the patients can use the technology, or at least can rely on someone who can help them. The healthcare worker should be in a private place and remove personal protective equipment.
“Finally, clinicians should start the actual conversation by checking in with themselves first—especially now with the distractions of the pandemic,” write Flint and Kotwal. “A deep breath brings one into the present to focus on the needs of the patient and family.”
Consider including a healthcare worker who regularly works with the patient. The authors suggest starting out with brief non-urgent telemedicine encounters; get the patients used to the process.
“Even for urgent conversations, a few minutes spent chatting about a patient’s interests or background can quickly build rapport,” write Flint and Kotwal. “To further build trust, clinicians should acknowledge that telecommunication is not optimal. If patients or family members express disappointment, clinicians can use ‘I wish’ statements (for example, ‘I wish I could be there in person to support you.’).”
When it comes to having the critical conversation, the physician should have an agenda and a goal in mind. Flint and Kotwal note that step-by-step frameworks for having these sorts of telemedicine conversations with COVID-19 patients have been disseminated. They’re out there.
“Asking permission at regular points in the conversation provides natural transitions, builds psychological safety, and allows patients and families some control,” write Flint and Kotwal. “For example, a clinician can ask, ‘May I tell you what I understand about how your father is doing today?’ Likewise, clinicians should regularly check for understanding, use summarizing statements, and orient back to patients when loved ones are also in the conversation.”
Telemedicine limits the ability to pick up nonverbal clues, like long pauses or when patients repeat questions. The clues may, of course, be more overt, like crying.
“Frequently pausing and asking, ‘Does that make sense?’ or ‘OK if I go on?’ may help persons feel included,” write Flint and Kotwal. “When using silence to respond to emotion, clinicians should physically indicate that they are present and listening by nodding.”
Flint and Kotwal conclude: “Effective serious illness communication through telephone or video can empower patients and align treatment options with their values while preserving warmth, meaning, and human connection. Patients and their loved ones are likely to be understanding, even appreciative, as clinicians provide guidance during these extraordinary times.”