12 minute read

The COVID-19 pandemic, for all of the hardship and loss it has heaped upon the US healthcare system, has initiated a period of unparalleled innovation as well.  A great deal of that innovation has been due to the courage and dedication of the physicians, nurses, and administrators on the front lines.  Convention centers have been made into hospitals.  Improvements in treatment have been spread among physicians by email and twitter, well ahead of their appearing in journals. 

Other parts of the healthcare system have had to innovate in order to take care of patients without bringing them to clinics or hospitals.  Telemedicine (or telehealth), the process of virtual face to face contact between a health professional and a patient, has gone from being the province of a few very early adopters to a general feature of care in the system as a whole.  Regulations about payment, licensing, and supervision have been changed or waived in order to make this crucial transformation possible. 

Telemedicine Acceptance

Anecdotal patterns reported by Massachusetts health systems tend to show that patients divide into two groups in their acceptance of telemedicine.  One group of patients are not comfortable with telemedicine. Another group likes telemedicine so much, they want to continue to be able to use it even when in person visits for non-urgent care become possible again.

Most of the group who do not want to participate in virtual face to face visits have devices that would support video connections, (95% of adults from households with incomes below $30,000 have cell phones and as incomes go up, the percentages go up toward 100%.). The challenge of making these patients comfortable with the “being seen” aspect of telemedicine will require a targeted effort at understanding their experience, addressing their concerns, and accommodating if they ultimately do now want to use it. While some may be concerned with the cost of the extra data or others may be unfamiliar with the technology, many people are sensitive about how they look and are hesitant to be “caught on camera.” 

There is a growing body of evidence that some patients experience their contact with their doctors in terms of difference of social status and asymmetries of power (1).  People may wish to avoid allowing professionals to see even a small area of their homes, because of their embarrassment or bitterness about the perceived difference between their economic situation and that of their health provider.  For some people, the revelation of the difference that they expect their video chat to show is just a part of their experience of medical care providers as intrusive rather than nurturing.  The questions that they are asked at their doctors’ offices, “Do you smoke?” “Do you wear a motorcycle helmet?”  “Tell me what kinds of foods you eat,” feel even more intrusive when the doctor can see into your home. 

Another group of patients likes telemedicine a great deal and wants to be able to get care using that medium in the future. These patients find the use of telemedicine convenient and empowering.  It saves driving, waiting in the waiting room with other people, waiting in the exam room, and then driving home after the visit.  The usual process of in-person visits can make the brief time with the doctor very charged.  Patients often report that by the time the doctor got to see them, they were so distracted, they forgot some of the questions that they had come to ask.  Waiting in their homes for their doctors to appear on their screens is a very different experience.  People can be more relaxed and less likely to forget their questions.  The experience of a differential in social status between physicians and their patients that is supported by all the trappings of an in-person visit is lessened by the parity of a virtual encounter, each in their own space. 

As telemedicine becomes better integrated into healthcare in general, it may also prove worthwhile to try to communicate to all patients the possible benefits of video interaction with their health professionals.  A website video can introduce not only instructions about using the telemedicine platform, but can give examples of how to interact with health professionals to get their needs met.  It can include a brief statement about the commitment of the practice to patient-centered care, to patients having a role in deciding their treatments. It can show patients how to arrange the lights in their room or the window to maximize or minimize the experience of eye contact.  The video can show patients how to access their medical information, their test results and their doctors, notes on each visit. Finally, the video can enfranchise patients to have lists of questions that can be sent in advance, and assure patients that their questions and their knowledge about themselves and their health are the most important information that their doctor wants in order to give them the results they are looking for.  It can give examples of ways that doctors and their team members can provide links to resources that have been less a part of face to face visits. 

Telemedicine Limitations

The medium in telemedicine conveys much less “information” in the form of body language and social cuing than in-person visits.  When there is less available information to take in, it can be harder for patients and professionals to maintain attention.  Words become more important, and body movements and facial expressions, less so.   Few people are used to continuously looking at their own image as they speak to another person.  For some people, this is aversive, while for others, it is rewarding.  The reduction of the other person to a picture that conveys less informational intensity can feel safer to some people, while to others, the view of them in their living setting feels invasive.

The loss of the fine details of facial expression and body language impacts commonly recommended patterns of interviewing.  When the professional is using the nods and the supportive vocalizations that are recommended for in-person interviewing, “un-huh, sure, I see,” most software platforms respond to the sounds by switching the designated speaker.  In this situation the patient is likely to feel they are being constantly interrupted.  In face to face meetings, most people consciously or unconsciously monitor the movements of the listening person to determine when they are preparing to begin talking.  This doesn’t work well in a telemedicine visit, again giving the patient the experience of being interrupted because they did not prepare for the professional to begin talking. Giving the patient uninterrupted time to tell their story, as well as offering summaries of what the health professional has heard can make clear that the professional is listening and help to mitigate the loss of visual information that goes with the medium.

But what about the loss of touch that the new medium brings?  I spoke with a urologist recently who was bemoaning the sudden preference among his patients for telemedicine visits over coming to the office.  He said that he had two patients already that day with testicular pain.  “I’m sorry, but I can’t evaluate testicular pain over a video chat.”  “Besides,” he went on, “the evidence for the importance of touch in medicine is very strong.  Your patient satisfaction numbers go way up if you just put your hand on the patient’s shoulder to offer some comfort, even if you don’t need to touch the patient for an exam.” 

Medical practices are working to have protocols for which complaints require in-person visits and which can be done virtually.  While some markers of a patient’s health (blood oxygen, pulse, temperature, blood pressure, blood sugar, and more seemingly every day) can be monitored at a distance through advances in technology, the role of physical touch in diagnosis and treatment will remain at the core of the healing arts. 

Touch and Medicine

Touch has been central to the physician-patient relationship for as long as there have been physicians.  Patients allow their doctors to touch them in places and in ways that they would allow to no one else.  The gentleness and the carefulness that doctors are trained to use in this touch is a bonding experience that supports healing.  If this trust is violated, if a doctor is unduly forceful or disrespectful, this can be a cause for grievance and even litigation.

Touch is so important that the word is used metaphorically to describe relationships.  We are said to be “touched” when someone else does something kind or when we recognize effort toward noble goals in others.  This equivalency in the use of “touch” is less metaphoric and more literal than we usually think.  Physical touch and interactional “touch” have similar impacts on the neuroendocrinology of the people involved.  Just as the doctor’s comforting touch releases the neuropeptide oxytocin in the brains of both participants, which increases social interest, improves recognition of others’ emotions (2) and increases trust between people (3), so compliments and the recognition of a person’s efforts and successes releases oxytocin and increases mutual trust (4) when used in a benevolent conversation.  Patients are “touched” figuratively and literally when another speaks kindly of them and their efforts. 

Trauma-Informed Care

The term “high-touch care” has been used to describe a team-based approach to patients with complex health needs and psychosocial difficulties who respond so much better when their healthcare team proactively reaches out to check on their condition, monitor their progress, help them solve problems, and show support (5).  It usually describes a team that includes a care manager who can actively help with the social determinants of health and a behavioral health clinician who is on the team or consulting to its members.  The patients served by the team often have a history of trauma as children as well as during adulthood.  For these patients, frequent contacts which include the expression of interest by their health team members correlate to their taking better care of their own health needs (6).  For these patients, the principles of Trauma-Informed Care (TIC) have been shown to lead to better engagement between the patient and medical professionals, better self-care, improved functioning, improvements in depression and anxiety, and ultimately less cost in overall healthcare services (7).  TIC might be defined as a way of offering the healing and bonding benefits of a doctor’s touch to patients for whom physical touch can be triggering of experiences of past abuse.  It offers a way to put into practice the discoveries about how people can be “touched” by ways of interacting that are not physical. 

TIC is not a treatment for trauma but a set of principles and approaches for adapting other sorts of care to make them more likely to be helpful to people whose lives have been affected by traumatic experiences. Five principles that are commonly used to guide TIC:

• Safety – requires understanding the patients’ experience of care and adjusting to make it a safe experience.
• Transparency and trustworthiness – patients have access to all information about their care
• Choice – meaningful choice in the direction and goals of care
• Collaboration and mutuality – shared decision making in pursuing goals
• Empowerment – interactions focus on patients’ strengths and successes as much as possible (8).

It is ironic that the principles of TIC could just as well have been written as a summary of the principles of patient-centered care articulated by the Institute of Medicine (IOM) in its “Crossing the Quality Chasm: A New Health System for the 21str Century” report in 2001 (9).  The report called for: care based on continuous healing relationships, customization of care based on patient needs and values, the patient as the source of control, shared knowledge and free flow of information, and the need for transparency.  At that time, the IOM was asserting that these principles should describe care for all patients.

These principles can be put into practice in telemedicine, offering an approach that can make the medium and the distance that are inevitable in telehealth into a way to deliver high-touch care.  The principle of transparency (10) is a core aspect of TIC and high-touch care.  Patients need to “unfettered access,” as the IOM put it (9) to all information about their conditions and their care.  This is more possible now than just a few years ago because of the growing implementation of “Open Notes,” an addition to the common patient portal that allows patients to see all of the notes written by their health professionals in addition to the current availability of their test results and their appointments.  Currently over 45 million patients have access to their online notes (11).  Patients who might be said to need TIC have been shown to respond particularly well to open notes, reporting that it improves their trust in their doctors, and it helps them understand their illnesses and treatment plans (12).  The same link that takes a patient to a telemedicine visit with their doctor and to their patient portal can take them to instructions on how to access the doctor’s notes.

When Open Notes is implemented, it is a good idea to have training for anyone who is going to be writing in the patient’s record in how they can use language in ways that are factual, clear to a lay person, and non-blaming to patients.  A good example of the need for non-blaming language is the word “obese” which is a clearly defined descriptive term in medical parlance and an insult in the language of most non-medical people.  Many patients take their medical record as a secret document about them that may be used by authorities in ways they can’t control.  It can be a relief to see the record when it has been written with the assumption that they will read it.  The record also provides an opportunity to “officially” notice efforts and achievements patients make on behalf of their own health.  As mentioned above, recognition of a person’s efforts and successes increases the output of oxytocin and builds trust (4).  It is a positive “touch” of the patient.

Trauma-Informed Care calls for “empowering” interactions (13), meaning noticing and working from descriptions of what patients do right and what their strengths are in relation to their health.  This provides a way of using language in the telemedicine visit that touches both the person receiving and the person offering the empowering communication.  It is a small change in language, akin to the small changed is documentation, that builds trust and thereby can be expected to increase the effectiveness of the telemedicine interaction.  When a patient’s successes or good efforts are part of the medical conversation, it can lead to credible attributions about their commitment to their health, even if they have not been as successful as they or their doctor would like.  Attributions, when they are credible, can be “activating” (14) to patients, increasing their likelihood of further actions in service of self-care.  These attributions are the generalizations that grow from the descriptions of efforts and successes. They have been shown to influence how people understand themselves and to influence the actions they are willing to take based on that understanding (15).  An empowering observation and an activating attribution can constitute an engaging touch from a distance without being complicated to construct or out of place in a telemedicine visit.  “I notice in your record that you quit smoking a couple of years ago (empowerment).  I get the sense that you are determined to take actions to improve your health when you can (attribution).  What is the next step you are considering taking to improve your health? (activation).”  Empowering observations and activating attributions are part of “high-touch” care. 

Finally, the shared decision making called for in both Trauma-Informed Care and by the IOM in the Quality Chasm report (“the patient should be the source of control in their care”), require that the planning of care be a “mutual” process (16).  Shared decision making and mutual discussion of the patient’s health goals are approaches with substantial literatures (17).  The parity that can be part of the telemedicine and the immediate access to a set of resources available through links can make the mutual construction of a treatment plan easier over this medium than in person.  Adding new members of the health team to do different aspects of an ongoing empowering conversation with the patient in the same visit can make for a smooth passing of the relationship with the patient among health team members, (physician to behavioral health clinician, physician to care manager, and so forth). 

Summary

In-person visits will always be required for some kinds of diagnostic touch and for numerous sorts of treatments.  The bonding that can be part of in-person visits will not be fully replaced for health professionals or for their patients by telemedicine visits. There are some advantages to virtual contacts, however.  It is easier to provide patients with information resources and videos that explain routines of practice in their care by simply offering links.  If patients can be helped to manage their end of a video meeting for their comfort, there can be greater parity between doctors and patients that is a feature of the medium, and that supports mutuality in designing care.  To offer patient-centered care through telemedicine, many of the processes that have been described in face to face patient visits remain useful.  In addition, a more assertive outreach, using language that is empowering and activating for the patient, makes possible virtual “high-touch” care, greatly mitigating the loss of physical touch that is part of the almost universal implementation of telemedicine.

References

1. Blount A, When the doctor-patient divide is a chasm. Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 77-91.
2. Ellington D-M, Wessberg J, Chelnokova O, et al., In touch with your emotions:  Oxytocin and touch change social impressions while other’s facial expressions can alter touch.  Psychoneuroendrocrinology, 2014, 39, 11-20.
3. Kosfeld M, Heinrichs M, Zak PJ, Fischbacher U, Fehr E,  Oxytocin increases trust in humans. Nature, 2005, 6, 673-676.
4. Zuk P J,  The neuroscience of trust, Harvard Business Review, 2017, 3, https://www.emcleaders.com/wp-content/uploads/2017/03/hbr-neuroscience-of-trust.pdf
5. Dorr DA, Wilcox A, Jones S, Burns L, Donnelly SM, Brunker C,  Care management dosage. J Gen Intern Med. 2007, 22, 736–41.
6. Bodenheimer T, Berry-Millett R. Care management of patient with complex health care needs. Robert Wood Johnson Foundation. 2009. https://www.rwjf.org/en/library/research/2009/12/ care-management-of-patients-with-complex-health-care-needs.html
7. Long P, Abrams M, Milstein A, Anderson G, Lewis Apton K, Lund Dahlberg M, Whicher D, editors. Effective care for high-need patients: opportunities for improving outcomes, value, and health. Washington, DC: National Academy of Medicine; 2017.
8. Harris M, Fallot R, editors. Using trauma theory to design service systems. San Francisco: Jossey-Bass; 2001.
9. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
10. Blount A, “T” is for transparent.  In Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 108-130.
11. https://www.opennotes.org/
12. Gerard M, Chimowitz H, Fossa A, Bourgeois F, Fernandez L, Bell S, The importance of visit notes on patient portals for engaging less educated or nonwhite patients: survey study. J Med Internet Res., 2008, 20, e191
13. Blount A,  “E” is for empowering.  In Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 131-146.
14. Blount A, “A” is for activating.  In Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 147-162.
15. Rosenthal R,  Interpersonal expectancy effects: a 30-year perspective. Curr Dir Psychol Sci., 1994, 3, 176–9.
16. Blount A, “M” is for mutual.  In Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 163-184.
17. Blount, A,  Getting from “delivering care to patients” to “partnership with patients.”  In Patient-Centered Primary Care: Getting from Good to Great, 2019, Springer, New York, 33-49.