In this series, AMS Healthcare addresses the challenges facing healthcare today – particularly in light of the COVID-19 pandemic. The AMS Community promotes compassionate care, development of the leadership needed to realize the promise of technology and the understanding of how our medical history influences the future of our healthcare. A new piece will be posted every Friday on Healthy Debate.
As a specialist physician in practice for 15 years, I value the ability to maintain strong relationships with my patients. I strive to deliver compassionate care no matter the circumstances. That is why I was frustrated and doubtful about providing care when the COVID-19 pandemic and the restrictions that came with it forced a switch to the most convenient form of virtual care, the telephone visit.
In addition to the anxiety related to the pandemic, I quickly noticed an internal dissatisfaction and uneasiness after a day of telephone visits. This mode of delivery seemed less than ideal to me and appeared to interfere with my ability to provide quality care. The explanation that I came up with was that I missed the face-to-face interaction with patients and the inability to have a patient in front of me during the assessment was, frankly, throwing me off.
I complained that I could not see my patients’ facial expressions or body language. I could not see how they moved their hands or how they got up from a chair. As an observant clinician, I needed this nuanced information to make decisions. I had worked for years to develop a style that used aspects of this face-to-face interaction as tools to build relationships with my patients, gather extra information for clinical judgment and let patients know that I cared about them.
The techniques that I had developed to demonstrate compassion – sitting across from patients at eye level, concentrating on body language or facial expression, and taking in their dress, movements or the way they kept their hands – were no longer available to me. Every patient encounter that I had by telephone felt incomplete, like something was missing. What once was rewarding and satisfying now had become disappointing.
And then I came to realize something. The in-person meeting had become of tremendous value to me, the physician, because I had become used to the convenience it afforded me. The difficulty I was having was internal. The problem was me.
I had come to value physician-centred care that involves having patients travel distances, wait long hours in one waiting room and then in another room for an encounter that may last only a few minutes, perhaps only to hear that they are doing fine.
If a physical examination is not needed, then this is a huge burden to the patient. Taking time off work, finding transportation and parking, dealing with the stress of being in another city, finding childcare, the requirements to fulfill the needs of physician-centred care can be significant. All so a patient can make the 15-minute appointment in the specialist’s clinic.
I now understand that telemedicine is one of the most patient-centred ways to provide care and one of the most compassionate things that medicine can offer. I became aware of this, I believe, when call after call, I would hear the palpable ease with which my patients spoke to me from their own environments. And the security that when the call ended, there would be no long trip home. Sometimes I would hear classical music playing in the background or pet dogs barking for attention. These were signs of contentment to me.
Once it became clear that the discomfort was a physician-centred problem, I became mindful of ways to show compassion over the phone and ways to stay present in my patients’ stories even without sitting directly across from them in an examining room. I became aware of the benefits of listening closely and intently and the value of concentrating on patients’ tones of voice as much as their words. I discovered how easy it is to pause and wait for a sentence to finish naturally without interrupting. I would catch myself when I was nodding and stopped this habitual gesture as it is not visible and therefore offers no reassurance to the patient. I reminded myself to speak out loud, which I hope resulted in some reassurance.
Instead of worrying about misunderstandings or that telemedicine was not working for me, I began making sure that my own spoken language is clear and unambiguous.
Part of the reluctance to embrace telemedicine is that it has been presumptively considered a lesser option for delivering care. But is it seen as a lesser option because it is in fact inferior or because it does not align with preferences of the physician?
Having now offered care this way for several months, it’s clear to me that telemedicine is not inferior but a method of making patient-centred care accessible with minimal disruption to comfort and well-being.
While adjusting to the pandemic restrictions, I found ways to be more patient-centred. Where I had thought I would not be able to provide compassion to my patients during the pandemic, the opposite has come true. I just needed to see it and embrace it.
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Dr.Joneja ; Congratulations for your honest and insightful article.I will incorporate your
principals of providing quality,pt.-centred care into my practice, effective immediately.
I wish you continuing success in your medical career and that in these days of Covid-19, that you and yours Stay Safe.Be Well.Randall Hurst MD, Windsor, Ontario.
Well written and great reflection. Yes, we can change our mental models (with difficulties), and the first step is awareness which you describe so beautifully. What other mental models do we need to tackle in Medicine?
Thank you!
John(y) Van Aerde, MD, PhD
Exec Medical Director
Canadian Society of Physician Leaders
I understand the benefits of remote “care” in certain disastrous situations. However, there are many concerns I have with this issue. #1 – nothing replaces face-to-face in person communication (with eye contact, empathy, focus). I work in a hospital and I see how “busy” or rather distracted residents and doctors are; texting on their phones non-stop, will look down and lose eye contact, curt; my own doctor often looks over at something on the computer when talking to me, or gets distracted by pagers / phone calls. I don’t trust a doctor to engage for 10-15min online and actually focus on my needs (likely they will be emailing, looking something up, distracted). Also remember that your doctor will still charge the government for $$ for your “care” online, despite this care being of lower quality. Lastly, one of the hallmarks of patient exam is the observation of the patient – do they look healthy, tired, pale, frail? how is their mood? what if your condition requires hands on or eyes on exam (e.g. skin issue?) – Do you think these signs and symptoms would be easy to gather over a brief grainy video?
#2 – certain professions should not be encouraged to continue with “online” treatments, such as those which require hands-on assessment and therapies (e.g. physical therapy, chiropractic, ND), otherwise you are just becoming an expensive “trainer” providing exercises / advice verbally, and I really feel this will tarnish the reputation of these professions in the long term. I have noticed these professions are still charging standard fees in person fees for these online discussions.
At the end of the day, nothing replaces in person contact. There is extensive research on how technologies and social media have detrimentally impacted our social norms, communication, and empathy – especially in children and teens. Let us accept this idea as a temporary solution to this health problem or as an adjunct in specific situations (e.g. individuals living remotely) and move back to the
This is interesting to read and as a caregiver I very much would like tele care to work. My mother and father both have difficulty hearing- especially over the phone. Do you think that they are exceptions and that in such cases care must always / continue to be in person? Thank you.
Mala… this is a brilliant piece of self-reflection, and dead-on. I went through this same reflection myself and came to the same conclusion you did. There are some aspects of what we do that require an in-person visit, and I never want to underestimate the therapeutic effect of the the “laying on of hands” that creates a relationship of trust over time (even just a handshake upon entering the same room, or a reassuring hand on shoulder upon leaving, letting a person know that you are there for them is so powerful). But there is a balance between that and meeting other needs like patient choice, convenience, time loss in the day, stress reduction, the benefits of a virtual “house call” and more in a video visit or telephone exchange. We are all learning this in real-time.
I say this again and again… virtual care is, simply, care. It behooves us to provide the right service for the right problem for the right patient at the right time… which also builds amazing amounts of trust.
I applaud your writing. More, please!!
Darren Larsen, MD, CCFP, MPLc
Chief Medical Officer, OntarioMD
Lecturer, DFCM and IHPME, University of Toronto.
Agreed, Darren. “Virtual care is, simply, care.” Absolutely, it is CARE. I wish, at the beginning of times we would not have called it ‘virtual’ as it is REAL care. Virtual is supposed to refer to the technology, and unfortunately it now stands next to the word care. ‘Online care’ might have been more accurate terminology. Semantics, off course, and the fact remains, it is indeed REAL CARE.
Johny
Thanks for a thoughtful piece on how you have transformed virtual care to both patient centred, helpful clinically and satisfying personally. Assume video would add more nuance to the virtual visit if/when available.
Brilliant!