Doctor–patient communication and relationship in telehealth

TELEHEALTH involves the provision of health care using technology such as videoconferencing and telephones. It has traditionally been used by clinicians to improve access to care for regional and rural communities and vulnerable populations. As part of measures to control the spread of coronavirus disease 2019 (COVID-19), telehealth has rapidly gained acceptance as a routine model for providing care at home, even for metropolitan patients. Professionals adopting this mode of communication include GPs, specialists and other health care providers. This model has proven useful for regular consultations and supervision of oral and intravenous therapies. Acknowledging some limitations, safe provision of care using telehealth is possible, but some elements still require face to face interaction.

The approach to telehealth is well established and many organisations have developed guidelines. Typically, a distant clinician provides a service to patients, and other health professionals, such as pharmacists, nurses and pathologists, provide support for documentation, prescribing, ordering of investigations and performing physical examinations. In most outreach settings, the patient is known to a small number of visiting clinicians.

However, the role of telehealth has been extended in the recent months due to the COVID-19 pandemic and doctors may have to alter their approaches to doctor–patient communication in telehealth by factoring in additional considerations as listed below:

1. Clinicians may have to rely on family members as support persons for the patient. Attending family members who don’t reside in the same house may need to consider physical distancing policies. Other members may be encouraged to join a consultation via videoconferencing.
2. Medication prescriptions and investigations may have to be organised by the providing clinicians themselves.
3. It is important to consider converting to telephone consultation if internet congestion interrupts video calls.
4. End-of-life discussions and breaking bad news – conversations that are usually undertaken face to face – may need to occur via telehealth. Current frameworks for end-of-life and breaking bad news discussion apply to telehealth, with attention to technical considerations.
5. Consultations may take place by specialists, GPs and junior medical officers who are not familiar with the patient. Confirmation of patient identity must occur.
6. Working from home and dialing into homes may require mechanisms for maintaining the privacy of both doctor and patients.

Doctor–patient communication in telehealth

Doctor–patient communication is an essential aspect of any therapeutic relationship between a patient and their doctor. It is influenced by many factors, including personality and communication style of both patient and doctor, the physical environment and patient education level. Only 7% of emotional communication occurs through the content of speech, whereas 22% depends on the tone of voice and 55% by posture, gaze and eye contact. In addition to technological considerations, the dynamics of doctor–patient communication and relationship may be different in a telehealth consultation. Although the parties are not in the same room, other clinicians and multiple family members may be present as support persons or facilitators. This approach allows families and other clinicians to adopt the role of addressing perceived gaps in communication.

Many studies have shown that patients can experience effective and satisfactory doctor–patient communication through technology-based consultations and that patients can establish a close relationship with clinicians regardless of ethnic and cultural backgrounds (here, here, here, here, here and here).

By synthesising the literature and guidelines and using personal experience of setting up and running telehealth models across a large geographic area for many years, we have identified the following advice to enable clinicians to offer a quality service via telehealth:

Mindset

Patients and their support people are struggling with both their current diagnosis and fear about the pandemic. Therefore, traditional frameworks for doctor–patient communication and relationship-building used in face to face interaction are still necessary for telehealth consultations, including aspects of compassion and empathy.

Technological aspects

Ensuring that audio and video qualities are acceptable and that you can hear and see each other clearly and that head and shoulders are in the middle of the screen and the camera is at eye level.

Maintaining privacy

Privacy considerations include ensuring that the health professional’s family members do not see patient-sensitive material. A secure computer in a closed environment is required.

Surroundings

A quiet location avoiding interruptions or noise at both patient’s and provider’s end is essential for an efficient telehealth consultation, especially for health professionals working from home. Some videoconferencing platforms allow blur or replacement of the background.

Confirming identity

Until now, most of the telehealth consultations were provided by clinicians well known to the patient. In the current situation, many doctors, including less experienced medical officers, who may not be familiar with the patient, need to provide consultations. The confirmation of the patient’s identity needs to take place before commencing.

Establishing rapport, relationship and trust

1. Introduce yourself to the patient and their family members, and establish eye contact by keeping the eyes at the level of the camera.
2. Spend some time initially discussing non-medical matters such as family, how they are coping with the current COVID-19 situation, fears and concerns.

Transfer of information

1. Speak slowly and use non-technical language.
2. Use visual aids to explain the situation. This may include online whiteboards, writing on paper and sharing of screens to show medical imaging and pathology where appropriate.
3. Summarise the consultation and check that they have understood the information. Where possible, consider sending a copy of the consultation summary to the patient as well as the GP.
4. Before completing the consultation, provide opportunities to the patient and family members for addressing current and future concerns by encouraging questions and offering contact details.
5. Highlight the importance of vaccinations, hygiene and physical distancing measures for the patient and family members.

Breaking bad news and communicating prognosis and end-of-life issues using telehealth

Traditionally, clinicians ensure end-of-life discussions and breaking bad news conversations are performed through face to face interactions. With physical distancing measures and the need to reduce unnecessary travel, this aspect of health care may now need to occur through telehealth. There are many frameworks available for breaking bad news and end-of-life discussions which are applicable in a telehealth setting.

One useful approach to discussing prognosis and end-of-life care is to use the acronym PREPARED.

Contents of the PREPARED framework are as follows:

• Prepare for the discussion;
• Relate to the person;
• Elicit patient and caregiver preferences;
• Provide information;
• Acknowledge emotions and concerns;
• Realistic hope;
• Encourage questions; and
• Document and D

It is essential to incorporate telehealth related matters into PREPARED to achieve high quality discussions. We believe an acronym – TELE-PREPARED – would be useful, as listed below:

• Technology is adequately set up for connectivity, audio and video;
• Extra time allowed for establishing rapport;
• Local support including family members and health professionals are available; and
• Establish eye contact using the correct camera placement, lighting and zoom to ensure emotions and facial expressions are visible.

After these complex conversations, a routine review conversation a few days after the discussion is beneficial to ensure there are no missed or new concerns.

There has been a rapid change over the preceding weeks and telehealth consultations will play an ongoing and significant role in the delivery of health care to both remote and local patient populations. Experience and learnings gained during this time are crucial to embed these enhanced services once the pandemic has passed.

Professor Sabe Sabesan is the Clinical Dean of the Townsville Regional Medical Training network. He is also the director of the Department of Medical Oncology at the Townsville Cancer Centre, Townsville University Hospital.

Danny Tucker is Associate Professor of Obstetrics and Gynaecology, and Director of Clinical Training at Townsville University Hospital and Health Services and College of Medicine and Dentistry, James Cook University.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.