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Internal Medicine Journal 44 (2014)
T E L E H E A LT H S E R I E S
Practical aspects of telehealth: doctor–patient relationship and communication S. Sabesan,1,2 D. Allen,3 P. Caldwell,4,5 P. K. Loh,6 R. Mozer,7 P. A. Komesaroff,8,9 P. Talman,10,11,12 M. Williams,13 N. Shaheen14 and O. Grabinski,15 on behalf of The Royal Australasian College of Physicians Telehealth Working Group 1 School of Medicine and Dentistry, James Cook University, 2Department of Medical Oncology, Townsville Cancer Centre, Townsville, 13Department of Child and Adolescent Health, Mackay Hospital, Mackay, Queensland, 3Quality Occupational Health, 14Aged Care Services, Royal North Shore Hospital, 15 Communications Unit, The Royal Australasian College of Physicians, 4Discipline of Paediatrics and Child Health, 5Centre for Kidney Research, The Children’s Hospital at Westmead Hospital, Sydney, 7Rehabilitation Medicine, Rankin Park Centre, Newcastle, New South Wales, 6Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, 8Faculty of Medicine, 9Monash Centre for the Study of Ethics in Medicine and Society and 12Department of Neurosciences, Monash University, Melbourne, 10Neurosciences Department, Geelong Hospital and 11Deakin Medical
School, Geelong, Victoria, Australia
Key words telehealth, video consultation communication skills, telemedicine, doctor–patient relationship.
Abstract The fourth in a series of articles about the practical aspects of telehealth, this paper provides advice and information for specialists to communicate effectively with patients during a telehealth video consultation.
Correspondence Odette Grabinski, Communications Unit, The Royal Australasian College of Physicians, Sydney, NSW 2000, Australia. Email: [email protected] Received 21 August 2013; accepted 28 October 2013. doi:10.1111/imj.12323
Introduction Doctor–patient communication during a medical consultation is an important part of any therapeutic relationship between a patient and their doctor. It is complex and affected by many factors including the personality and communication style of both the doctor and the patient, the physical environment and the level of education of the patient.1 Some studies on face-to-face consultations have reported a strong correlation between patient satisfaction and interview length and high levels of information received, whereas others found a correlation with affective behavior and in particular, the physical interaction.2 It is estimated that only 7% of emotional communication takes place verbally, whereas 22% is communicated by tone of voice and 55% by posture, gaze and eye contact.2 During a telehealth consultation, as the patient and the specialist are not in the same room, the dynamics observed in a video consultation can differ from a tradi© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
tional face-to-face consultation. Therefore, it is understandable that there will be ongoing concerns regarding the doctor–patient relationship and rapport for the delivery of clinical services through a video consultation. Table 1 summarises selected studies, albeit small, that examined various aspects of telehealth consultations. As the issue of doctor–patient communication in technology is a complex and evolving topic, future in-depth qualitative studies are needed to explore perceptions of the patient and the doctor. Many consultations are supported by rural-based doctors and nurses.6,8 This adds another dimension to the doctor–patient communication in that they can take the role of filling any perceived gaps in the communication between the specialist and patient. Video consultations also facilitate the presence of extended family members, which is an added advantage. These studies show that patients can experience effective doctor–patient communication through technology101
Sabesan et al.
Table 1 Selected literature for doctor-patient communication and building rapport for video consultations Authors
Setting
Results
Schmidt et al
Hospice patients
Sabesan et al,4 Mooi et al,5 and Doolittle and Spaulding6 Mair and Whitten7
Medical oncology networks; questionnaire-based surveys of indigenous and non-indigenous patients. Systematic review of studies on patient satisfaction from many fields of medicine
Varieties of facial expressions of emotions were observed. Expression of both positive and negative emotions were apparent. More than 80% in agreement on a Likert scale for closeness of the relationship with specialists, ability to ask questions and satisfaction with overall care. Good levels of patient satisfaction were noted in most studies. Note: the studies were limited by small sample sizes.
3
based consultations and that the patients can establish closer relationships with specialists. Patients from a range of ethnic and cultural backgrounds have been able to build effective rapport with specialists through telehealth. It is the view of The Royal Australasian College of Physicians Telehealth Working Group that communication should be based on the needs of individual patients and their families rather than be prejudiced by ethnic backgrounds. Practical tips for improving the quality of the doctor– patient communication for telehealth: • Before starting the consultation, check that the audio and video components are both working and ensure that your image is in the middle of the screen and zoomed in so that you are clearly visible at the patient end. • Introduce and greet parties at both specialist and patient ends of the consultation. • Explain that whatever is covered in a traditional faceto-face consultation will be covered in the video consultation and that the level of service will be the same. • If you have a webcam positioned at the top of your monitor/laptop, position the image of the patient end as close to the webcam as possible so that it appears you are making eye contact with the patient. • Spend some time discussing family, home and other social matters to build rapport (as you would in face-toface consultations). • Maintain eye contact with the patient by effectively using the camera and zoom in and out to pick up any non-verbal cues. • Effective transfer of information: the use of visual aids such as imaging studies and/or drawing on white boards can support verbal explanations. • Summarise the consultation and check that the patient has understood the information. • If the consultation involves the discussion of sensitive information, encourage family members and/or health professionals to participate in the video consultation at the patient end. • Before completing the consultation, suggest opportunities for addressing future concerns by offering the 102
contact details for local healthcare providers and other specialists.
Case 1: breaking bad news A 56-year-old patient presents to a rural hospital with increasing dyspnoea because of extensive pulmonary metastasis secondary to colon cancer. She was too sick to transfer to a tertiary centre and was therefore seen urgently (within 24 h) by medical oncologists through telehealth. At the request of the treating team, many family members attended the video consultation. The consultation included discussions about the patient’s diagnosis, prognosis and future management and what the patient could expect from therapy. After ensuring that the family and patient had no further questions, the patient was able to be treated without leaving her home town and within 48 h of participating in the telehealth consultation. FOLFOX with bevacizumab was started, and after two cycles, the patient’s dyspnoea and quality of life improved.
Discussion The patient’s initial diagnosis was determined by local internal physicians in close liaison with medical oncologists. On referral, it was obvious that the patient had an incurable and potentially rapidly fatal disease, hence the request for many family members to participate in the telehealth video consultation. By showing the scan on the screen, it was easy to explain to the patient and her family members why the cancer was incurable. The patient had the support of her family, a local nurse and doctors in the comfort of her home environment. This made it easier for all parties to accept and cope with the bad news. The patient had an excellent response to her first-line therapy and established a productive and close relationship with her local and remote healthcare teams. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
RACP telehealth
Commentary It is possible to conduct an initial consultation and discuss the patient’s prognosis through telehealth while establishing excellent rapport. The use of visual aids like CT images and the presence of local health professionals and family members make it easier for specialists to break bad news and for the patients to cope with the news.
Case 2: dealing with angry patients
between the patient and her healthcare team may have made the situation more manageable.
Commentary This case demonstrates that, similar to face-to-face consultations, communication barriers can occur during telehealth consultations. Therefore, most communication skills that are applicable to face-to-face consultations can be applied to telehealth consultations as well.
Practical tips
A 60-year-old woman had been seeing a regional endocrinology team through telehealth. Her diabetes was out of control because of family circumstances. When her issues were explored during a video consultation she became defensive and angry. After giving her a few minutes to gather herself, she was able to continue with her consultation. A social worker was asked to join the telehealth video consultation to discuss solutions for the patient’s family issues.
1 Screens can be barriers to effective doctor–patient relationships, therefore connecting with the patient on the screen at human level rather than an image on the screen is important for an effective therapeutic relationship. 2 Most communication techniques used in face-to-face consultations are applicable to video consultations. 3 It is useful to have a mental framework/checklist to ensure every consultation is consistent and successful.
Conclusion Discussion In this case, a technique that is used for face-to-face consultations was adopted to manage the situation for the telehealth video consultation. By being patient and giving her time to cool down, the video consultation was successfully completed. Unlike a face-to-face consultation where only the general practitioner or specialist sits with the patient and their family, nurses and other allied health professionals were able to provide comfort to the patient as well. In this case, the existing relationship
References 1 Onor ML, Misan S. The clinical interview and the doctor-patient relationship in telemedicine. Telemed J E Health 2005; 11: 102–5. 2 Williams S, Weinman J, Dale J. Doctor-patient communication and patient satisfaction: a review. Fam Pract 1998; 15: 480–92. 3 Schmidt KL, Gentry A, Monin J, Coutney KL. Demonstration of facial
Effective doctor-patient communication is an essential component of a telehealth consultation. Sound communication and rapport between the doctor, patient and support staff can facilitate a satisfactory and positive experience for the patient and their family members. By applying some of the communication techniques used during face to face consultations, video consultations can provide a highly effective and convenient means of healthcare delivery for patients living in rural and remote areas, Indigenous communities and aged care facilities.
communication of emotion through telehospice videophone contact. Telemed J E Health 2011; 17: 399–400. 4 Sabesan S, Simcox K, Marr I. Medical oncology clinics via videoconferencing: an acceptable tele health model for rural patients and health workers. Intern Med J 2012; 42: 780–5. 5 Mooi JK, Whop LJ, Valery PC, Sabesan SS. Teleoncology for Indigenous patients: The responses of patients and health workers. Aust J Rural Health 2012; 20: 265–9.
© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
6 Doolittle GC, Spaulding A. Providing access to oncology care for rural patients via telemedicine. J Oncol Pract 2006; 2: 228–30. 7 Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000; 320: 1517–20. 8 Sabesan S, Larkins S, Evans R, Varma S, Andrews A, Beuttner P et al. Telemedicine for rural cancer in North Queensland: bringing cancer care home. Aust J Rural Health 2012; 20: 259–64.
103
Internal Medicine Journal 44 (2014)
T E L E H E A LT H S E R I E S
Practical aspects of telehealth: doctor–patient relationship and communication S. Sabesan,1,2 D. Allen,3 P. Caldwell,4,5 P. K. Loh,6 R. Mozer,7 P. A. Komesaroff,8,9 P. Talman,10,11,12 M. Williams,13 N. Shaheen14 and O. Grabinski,15 on behalf of The Royal Australasian College of Physicians Telehealth Working Group 1 School of Medicine and Dentistry, James Cook University, 2Department of Medical Oncology, Townsville Cancer Centre, Townsville, 13Department of Child and Adolescent Health, Mackay Hospital, Mackay, Queensland, 3Quality Occupational Health, 14Aged Care Services, Royal North Shore Hospital, 15 Communications Unit, The Royal Australasian College of Physicians, 4Discipline of Paediatrics and Child Health, 5Centre for Kidney Research, The Children’s Hospital at Westmead Hospital, Sydney, 7Rehabilitation Medicine, Rankin Park Centre, Newcastle, New South Wales, 6Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, 8Faculty of Medicine, 9Monash Centre for the Study of Ethics in Medicine and Society and 12Department of Neurosciences, Monash University, Melbourne, 10Neurosciences Department, Geelong Hospital and 11Deakin Medical
School, Geelong, Victoria, Australia
Key words telehealth, video consultation communication skills, telemedicine, doctor–patient relationship.
Abstract The fourth in a series of articles about the practical aspects of telehealth, this paper provides advice and information for specialists to communicate effectively with patients during a telehealth video consultation.
Correspondence Odette Grabinski, Communications Unit, The Royal Australasian College of Physicians, Sydney, NSW 2000, Australia. Email: [email protected] Received 21 August 2013; accepted 28 October 2013. doi:10.1111/imj.12323
Introduction Doctor–patient communication during a medical consultation is an important part of any therapeutic relationship between a patient and their doctor. It is complex and affected by many factors including the personality and communication style of both the doctor and the patient, the physical environment and the level of education of the patient.1 Some studies on face-to-face consultations have reported a strong correlation between patient satisfaction and interview length and high levels of information received, whereas others found a correlation with affective behavior and in particular, the physical interaction.2 It is estimated that only 7% of emotional communication takes place verbally, whereas 22% is communicated by tone of voice and 55% by posture, gaze and eye contact.2 During a telehealth consultation, as the patient and the specialist are not in the same room, the dynamics observed in a video consultation can differ from a tradi© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
tional face-to-face consultation. Therefore, it is understandable that there will be ongoing concerns regarding the doctor–patient relationship and rapport for the delivery of clinical services through a video consultation. Table 1 summarises selected studies, albeit small, that examined various aspects of telehealth consultations. As the issue of doctor–patient communication in technology is a complex and evolving topic, future in-depth qualitative studies are needed to explore perceptions of the patient and the doctor. Many consultations are supported by rural-based doctors and nurses.6,8 This adds another dimension to the doctor–patient communication in that they can take the role of filling any perceived gaps in the communication between the specialist and patient. Video consultations also facilitate the presence of extended family members, which is an added advantage. These studies show that patients can experience effective doctor–patient communication through technology101
Sabesan et al.
Table 1 Selected literature for doctor-patient communication and building rapport for video consultations Authors
Setting
Results
Schmidt et al
Hospice patients
Sabesan et al,4 Mooi et al,5 and Doolittle and Spaulding6 Mair and Whitten7
Medical oncology networks; questionnaire-based surveys of indigenous and non-indigenous patients. Systematic review of studies on patient satisfaction from many fields of medicine
Varieties of facial expressions of emotions were observed. Expression of both positive and negative emotions were apparent. More than 80% in agreement on a Likert scale for closeness of the relationship with specialists, ability to ask questions and satisfaction with overall care. Good levels of patient satisfaction were noted in most studies. Note: the studies were limited by small sample sizes.
3
based consultations and that the patients can establish closer relationships with specialists. Patients from a range of ethnic and cultural backgrounds have been able to build effective rapport with specialists through telehealth. It is the view of The Royal Australasian College of Physicians Telehealth Working Group that communication should be based on the needs of individual patients and their families rather than be prejudiced by ethnic backgrounds. Practical tips for improving the quality of the doctor– patient communication for telehealth: • Before starting the consultation, check that the audio and video components are both working and ensure that your image is in the middle of the screen and zoomed in so that you are clearly visible at the patient end. • Introduce and greet parties at both specialist and patient ends of the consultation. • Explain that whatever is covered in a traditional faceto-face consultation will be covered in the video consultation and that the level of service will be the same. • If you have a webcam positioned at the top of your monitor/laptop, position the image of the patient end as close to the webcam as possible so that it appears you are making eye contact with the patient. • Spend some time discussing family, home and other social matters to build rapport (as you would in face-toface consultations). • Maintain eye contact with the patient by effectively using the camera and zoom in and out to pick up any non-verbal cues. • Effective transfer of information: the use of visual aids such as imaging studies and/or drawing on white boards can support verbal explanations. • Summarise the consultation and check that the patient has understood the information. • If the consultation involves the discussion of sensitive information, encourage family members and/or health professionals to participate in the video consultation at the patient end. • Before completing the consultation, suggest opportunities for addressing future concerns by offering the 102
contact details for local healthcare providers and other specialists.
Case 1: breaking bad news A 56-year-old patient presents to a rural hospital with increasing dyspnoea because of extensive pulmonary metastasis secondary to colon cancer. She was too sick to transfer to a tertiary centre and was therefore seen urgently (within 24 h) by medical oncologists through telehealth. At the request of the treating team, many family members attended the video consultation. The consultation included discussions about the patient’s diagnosis, prognosis and future management and what the patient could expect from therapy. After ensuring that the family and patient had no further questions, the patient was able to be treated without leaving her home town and within 48 h of participating in the telehealth consultation. FOLFOX with bevacizumab was started, and after two cycles, the patient’s dyspnoea and quality of life improved.
Discussion The patient’s initial diagnosis was determined by local internal physicians in close liaison with medical oncologists. On referral, it was obvious that the patient had an incurable and potentially rapidly fatal disease, hence the request for many family members to participate in the telehealth video consultation. By showing the scan on the screen, it was easy to explain to the patient and her family members why the cancer was incurable. The patient had the support of her family, a local nurse and doctors in the comfort of her home environment. This made it easier for all parties to accept and cope with the bad news. The patient had an excellent response to her first-line therapy and established a productive and close relationship with her local and remote healthcare teams. © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
RACP telehealth
Commentary It is possible to conduct an initial consultation and discuss the patient’s prognosis through telehealth while establishing excellent rapport. The use of visual aids like CT images and the presence of local health professionals and family members make it easier for specialists to break bad news and for the patients to cope with the news.
Case 2: dealing with angry patients
between the patient and her healthcare team may have made the situation more manageable.
Commentary This case demonstrates that, similar to face-to-face consultations, communication barriers can occur during telehealth consultations. Therefore, most communication skills that are applicable to face-to-face consultations can be applied to telehealth consultations as well.
Practical tips
A 60-year-old woman had been seeing a regional endocrinology team through telehealth. Her diabetes was out of control because of family circumstances. When her issues were explored during a video consultation she became defensive and angry. After giving her a few minutes to gather herself, she was able to continue with her consultation. A social worker was asked to join the telehealth video consultation to discuss solutions for the patient’s family issues.
1 Screens can be barriers to effective doctor–patient relationships, therefore connecting with the patient on the screen at human level rather than an image on the screen is important for an effective therapeutic relationship. 2 Most communication techniques used in face-to-face consultations are applicable to video consultations. 3 It is useful to have a mental framework/checklist to ensure every consultation is consistent and successful.
Conclusion Discussion In this case, a technique that is used for face-to-face consultations was adopted to manage the situation for the telehealth video consultation. By being patient and giving her time to cool down, the video consultation was successfully completed. Unlike a face-to-face consultation where only the general practitioner or specialist sits with the patient and their family, nurses and other allied health professionals were able to provide comfort to the patient as well. In this case, the existing relationship
References 1 Onor ML, Misan S. The clinical interview and the doctor-patient relationship in telemedicine. Telemed J E Health 2005; 11: 102–5. 2 Williams S, Weinman J, Dale J. Doctor-patient communication and patient satisfaction: a review. Fam Pract 1998; 15: 480–92. 3 Schmidt KL, Gentry A, Monin J, Coutney KL. Demonstration of facial
Effective doctor-patient communication is an essential component of a telehealth consultation. Sound communication and rapport between the doctor, patient and support staff can facilitate a satisfactory and positive experience for the patient and their family members. By applying some of the communication techniques used during face to face consultations, video consultations can provide a highly effective and convenient means of healthcare delivery for patients living in rural and remote areas, Indigenous communities and aged care facilities.
communication of emotion through telehospice videophone contact. Telemed J E Health 2011; 17: 399–400. 4 Sabesan S, Simcox K, Marr I. Medical oncology clinics via videoconferencing: an acceptable tele health model for rural patients and health workers. Intern Med J 2012; 42: 780–5. 5 Mooi JK, Whop LJ, Valery PC, Sabesan SS. Teleoncology for Indigenous patients: The responses of patients and health workers. Aust J Rural Health 2012; 20: 265–9.
© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians
6 Doolittle GC, Spaulding A. Providing access to oncology care for rural patients via telemedicine. J Oncol Pract 2006; 2: 228–30. 7 Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. BMJ 2000; 320: 1517–20. 8 Sabesan S, Larkins S, Evans R, Varma S, Andrews A, Beuttner P et al. Telemedicine for rural cancer in North Queensland: bringing cancer care home. Aust J Rural Health 2012; 20: 259–64.
103
