Having rapidly adopted virtual consultations for a lot of clinics and with social distancing measures likely to be in place for the foreseeable future, we need to consider how these new approaches impact on the way we collaborate in patient-clinician partnerships. In order to ensure we are providing high quality person-centred care, we need to give ourselves every chance of forming strong teams between patients, health professionals and their wider support networks.
We may think that because phone conversations lack the visual cues of our facial expressions and posture, video conferencing is a blessing. It certainly brings some advantages and has previously been shown to improve self-management[i]. But is it altogether better? As we have been putting together packages to support healthcare in phase 2 of its COVID response, restarting systems and moving forward, I have been seeking out the evidence of how person-centred care can be provided in the ‘new normal’. Here I reflect on some of the challenges that video calls might create for us to have truly collaborative conversations and invite you to feedback your own questions and insights.
How does it feel? What is the immediate impact on us as people (and by people I mean both patient and clinician)?
Video calls are tiring, stressful and make us anxious ([ii],[iii]). It is hard work following a conversation when there are fewer visual cues to follow, the pictures sometimes freezes and the connection intermittently drops out. We’re more aware of ourselves as we can see our mirror image on screen and if it’s a group meeting we’re constantly looking at a sea of faces. The tiring nature of video calls may not be an issue for those patients who have just odd virtual appointments, although it will likely impact their decision making. But what about those patients who have multi-morbidities and may end up ‘attending’ multiple virtual clinics a week? What about the professionals who are running virtual clinics and trying to fit 10 half hour clinics into a day? Or even worse the GPs trying to see patients every ten minutes? There is a risk that we don’t factor this into how we schedule our time, because there is no travel to account for or rooms to book. But fatigue reduces quality, and because skills of person-centred care like shared decision making and motivational interviewing require deliberate and conscious effort, they are likely to be the first things to be lost.
Does it increase health inequalities?
One of the benefits of person-centred care is its impact on increasing health literacy and reducing inequalities[iv]. How do video calls play into this? On the plus side, lockdown has made a lot of people far more familiar with video calls than they were just a few weeks ago. What was once largely just the domain of business and long distance relationships has blossomed into a go-to meeting place, so it shouldn’t be too daunting a prospect. And for people who cannot easily travel, it is easier to access. Digital solutions generally can increase participation and literacy levels too[v]. However, anecdotally, it has been reported that clinicians need to spend more time with disadvantaged patients to help them prepare for video calls[vi] and not everyone will have access to a web-enabled device or can afford the data to make a video call. Those who are hard of hearing or need translators or advocacy might have trouble accessing the support they need. We must continue to be mindful of accessibility and equality as we move to more widespread virtual appointments.
What impact does it have on the way we make decisions?
Since a big part of person-centred care is about supporting patients to make decisions in collaboration with healthcare professionals, I was curious about how virtual appointments might affect this. One unknown for me is the impact on authority gradients. If the perceived power difference between the healthcare professional and their patient is big, it can stifle collaboration as patients are afraid to speak up or question decisions and recommendations. Does video conferencing increase or decrease that perceived difference? I have several speculations, but I am yet to find any answer from research so I hope this is picked up by researchers in the future.
There are positives for collaborative conversations from video calls – patients seem to talk more than in face to face appointments[i] for example. However, because it is tiring, people seem to unconsciously rely on easier or quicker processes for making decisions; like being swayed by how likeable the person is rather than the strength of their arguments[vii]. Not only might it be harder to understand people, but we have less trust in them too[viii], although arguably that might encourage people to push for more explicit explanations of why certain treatments are recommended or to question decisions made. If call quality drops, or speech is delayed, we may (mistakenly) attribute that fault to the person themselves, not the technology – perceiving them as less attentive, extraverted or conscientious[ix]. The development of the Patient Activation Measure (PAM) was in recognition that there was a need for an effective way to evaluate the complex interactions of patients’ knowledge, skills, beliefs and behaviours[x], so it follows that anything hindering our ability to make accurate judgements about patients may hinder our ability to provide truly individualised care too.
What can we do to mitigate against these challenges?
There are toolkits like this that give great practical advice on setting up and conducting video call appointments, including ascertaining whether video is the most appropriate technology to use. But they don’t seem to address the factors I’ve outlined above, only the technical aspects of a call. So to keep yourself truly person-centred I suggest;
[i] https://www.jmir.org/2018/4/e150/pdf
[ii] https://www.yourpsychologist.net.au/experiencing-video-call-fatigue-here-are-ways-to-manage-it
[iii] https://theconversation.com/finding-endless-video-calls-exhausting-youre-not-alone-137936
[iv] Durand M-A, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F. (2014) Do Interventions Designed to Support Shared Decision-Making Reduce Health Inequalities? A Systematic Review and Meta-Analysis. PLoS ONE 9(4): e94670. doi:10.1371/journal.pone.0094670
[v] https://www.goodthingsfoundation.org/sites/default/files/research-publications/improving_digital_health_skills_report.pdf
[vi] http://www.pulsetoday.co.uk/views/dr-shaba-nabi/the-human-connection/20040168.article
[vii] https://pubsonline.informs.org/doi/abs/10.1287/mnsc.1080.0879
[viii] https://academic.oup.com/jrs/article-abstract/19/4/433/1510170
[ix] https://www.sciencedirect.com/science/article/abs/pii/S1071581914000287
[x] https://patientengagementhit.com/news/what-is-the-patient-activation-measure-in-patient-centered-care
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