How personal connections manage to survive in the high tech of telehealth
New skills and techniques help forge emotional bonds during remote appointments
Right under our noses, the delicate relationship between patient and doctor—in fact, between healthcare users and providers of all kinds—has been undergoing a subtle but steady transformation during the COVID-19 pandemic.
At the heart of this shift is telehealth, in which the video screen and the telephone have become crucial links in the remote delivery of many types of care.
For numerous patients and clients, telehealth is nothing short of a godsend—a way of receiving prompt advice and support at home, in order to minimize in-person contact during the pandemic.
However, some healthcare providers have discovered that their time-honoured techniques for providing treatment, offering advice or even conducting simple conversations have had to be modified, especially when video is used.
The overall challenge remains unchanged: The provider must build a relationship of trust and even intimacy with the user. But how can something so personal be accomplished in such a high-tech environment?
Getting comfortable with screens
The answer can be found in the various facilities of CIUSSS West-Central Montreal, where professionals in health care and social services have been crafting solutions to meet the particular needs of their clientele.
As Kathleen McDonald, a midwife at the Côte-des-Neiges Birthing Centre, notes: “If you need to create a strong bond, what works in person may not work during a virtual appointment.”
For example, she explains, when video is used, a person’s natural tendency is to look at the screen. Nevertheless, the healthcare provider has to make a mental effort to keep glancing into the camera to give the impression of maintaining eye contact with the healthcare user.
“It may seem a bit bizarre,” she says, “but if you’re constantly looking at your own screen, the person at the other end might think you’re looking away from them.”
Ms. McDonald has also found that certain visual cues of in-person acknowledgement—like nodding or leaning forward to indicate interest—lose much of their impact online. The solution, she says, is to interject more verbal cues into the discussion, including simple sounds (“Umm-hmm”) and short phrases (“Wow”, “Thanks for sharing”).
As well, the professional needs to remember that her or his face dominates the user’s screen to an unnatural degree. So, to ensure she’s not misunderstood, Ms. McDonald has had to become much more aware of the true message she’s sending with her facial expressions.
“Those little things do matter,” she says. “Even if you just happen to be thinking hard for a moment, it might be perceived that you’re upset or not listening, because the client is so focused on your face.”
Opening up to therapy
The need for intimacy and openness between doctor and patient is especially important in treating mental illness, says Tung Tran, Director of the Mental Health and Addiction Program for CIUSSS West-Central Montreal.
That’s why psychiatrists and other therapists sometimes need to fight fire with fire—in other words, use the technology’s most useful features to overcome its drawbacks.
One effective technique, says Mr. Tran, is to ask patients to use the camera in their laptop or cellphone to transmit views of a room or two in their home. What matters is not necessarily what the camera reveals about the patient’s home, but the fact that the patient is willing to disclose something personal about how she or he lives.
“For patients, the act of opening a virtual door to us is what makes them more inclined open up emotionally later on,” Mr. Tran says.
A significant challenge of another sort occurs during group therapy. In an in-person setting, the two therapists who preside over the session usually maintain eye contact and send each other non-verbal cues, in order to decide what to do next.
However, says Mr. Tran, these ground rules are altered by the use of the video screen, which gives the therapists only a small, partial view of each other. To remedy this, they use pre-arranged phrases (for instance, “Should we do that now?”) that may sound innocuous to patients, but enable the professionals to signal their intentions to each other.
Simpler solutions are available, too. Dr. Soham Rej, a Geriatric Psychiatrist and Co‑Director of the Telehealth Intervention Program for Isolated Older Adults (TIP-OA), makes a point of physically moving more slowly than normal. As a result, even if the online connection is slow, the image on the patient’s screen to will not become blurry or jumbled.
Dr. Mark Karanofsky, Director of the Goldman Herzl Family Practice Centre at the JGH, often begins his telephone appointments simply by engaging in a bit of informal chit-chat with the patient to create an air of friendliness and warmth. Once the ice is broken, he’s prepared to switch to a video call, if the patient prefers.
However, there are times when the patient’s nerves are thoroughly frazzled when the appointment begins, says Filomena Novello, who coordinates Rehabilitation Services at the JGH and the Technical Aids Service Department at Lethbridge-Layton-Mackay.
This can be due to a patent’s lack of understanding of telehealth and a subsequent reluctance to participate in the sessions. For many who are less tech savvy, Ms. Novello says, there can also be fear that is associated with using new technology and the internet. Or frustration might stem from technical problems in establishing a telehealth connection.
The only recourse, she explains, is to be as clear, calm and patient as possible. It often helps to provide easy-to-understand guidelines before an appointment is scheduled, and to review these guidelines and any other concerns that the patient may have.
And, as in so many aspects of life, practice makes perfect. Continuing to use the new technology will improve the new telehealth skills of patient and healthcare professional alike.
Coping with technical details
Indeed, the technical details are so important to a successful telehealth session that providers have had to quickly upgrade their familiarity with the technology.
At Herzl, a short instructional manual was developed in spring 2020 and circulated widely, says Dr. Karanofsky. Included are tips on getting the patient to hold the necessary identification up to the camera, dealing with emergencies that arise in mid-session, and deciding whether the patient would be better served by an in-person appointment.
Dr. Karanofsky has also found that the low resolution of a video image does not permit him to properly examine many skin conditions. For this reason, he asks patients to photograph the problem area and send him a picture before the appointment, so that he can base his advice on a photo of superior quality.
The technical details can be somewhat tougher in physiotherapy, which involves verbal education as well as physical activity—more than in, say, a mental health session. Therefore, a suitable spot must be found in the patient’s home, where the camera can clearly capture the patient’s movements.
Maria Ambrosio, Outpatient Clinical Coordinator in the JGH Physiotherapy Department, advises patients to use a large, roomy space whenever possible, so that the laptop or cellphone can be safely and easily repositioned from table to floor to chair, if necessary.
If the patient agrees to the presence of a relative or friend at the session, says Ms. Ambrosio, that person can help move the camera and provide assistance, in case the patient experiences problems with mobility or in understanding the physiotherapist’s instructions.
Building trust also means that patients, especially vulnerable seniors, need to be confident that no one is out to scam them, says Dr. Syeda Bukhari, Director of the TIP-OA program.
To calm these fears, a day before the appointment, a JGH staffer calls the client from a familiar number. The client is reassured that when the phone rings the next day at a specific time, the caller will be a legitimate TIP-OA volunteer, even if the number is unfamiliar.
Dr. Soham Rej adds that TIP-OA has launched a digital literacy program to familiarize more seniors with using the internet and video platforms like Teams and Zoom.
Privacy and confidentiality
Of key importance to users of all ages is the trust that is generated when privacy and confidentiality are properly maintained. Intimacy can exist only if patients and clients have no qualms about discussing sensitive problems, even under unconventional circumstances.
This allows telehealth to work to its full potential. For example, Gabrielle Chartier, a Nurse Navigator in the Head and Neck Oncology section of the Segal Cancer Centre, says telehealth has made it possible for a patient to participate in a three-way video meeting with his or her own oncologist, plus a physician who has been brought in for a second opinion.
Previously, Ms. Chartier explains, it was uncommon for the patient to be present when two specialists met. Now, however, with the use of a secure connection, “the patient feels fully involved and is confident that everything is being done openly. Being patient-centred is how we build trust.”
A variety of safeguards are mandatory, says Maria Ambrosio, including the patient’s consent to participate in a virtual session and the use of a platform that has ironclad privacy protection.
As well, she says, the physiotherapist must conduct the session in a private room or in a space where curtains can be drawn. Thus, if the patient is asked to display any part of his or her body, it won’t be seen by anyone who passes by the physiotherapist’s work area.
Similarly, Ms. Ambrosio adds, the physiotherapist must wear headphones or earbuds, so that a passerby can’t hear any of the patient’s responses or comments. Furthermore, says Physiotherapist Mojdeh Hedjazi, the professional must disclose his or her own location or address, and must ask the patient to provide an emergency telephone number.
Looking to the future
To some extent, a number of these procedures and techniques may fall by the wayside, as the pandemic eases and in-person appointments again become routine.
However, there is wide acknowledgement—far beyond CIUSSS West-Central Montreal—that telehealth will continue to be used in numerous situations where a remote appointment can improve the speed, efficiency and convenience of care.
This means that professionals in a wide range of fields will have to be trained to work smoothly within telehealth. Actually, in many instances, this form of education is already well under way.
Dr. Mélanie Mondou, Associate Dean for Undergraduate Medical Education at McGill University, says medical students at all levels have been receiving instruction in telehealth since last year, using an online module created by the Department of Family Medicine.
The Collège des médecins du Québec (Quebec College of Physicians) also published a guide on clinical supervsion and telehealth , which was shared with all teachers. This is in addition to their training in general communication skills, which is a standard part of the curriculum.
Once the pandemic is no longer an active threat, Dr. Mondou says, the telehealth segment will be re‑examined and possibly modified, in the same way that many aspects of the medical curriculum are regularly reviewed. However, she adds, since telehealth is likely here to stay, there will be a need for ongoing education in that aspect of care.
According to Dr. Michelle Elizov, Associate Dean of Faculty Development, a series of workshops on telehealth was organized last summer by the university’s Faculty Development Office.
Each workshop—focusing on the basics of telehealth, how to supervise trainees in providing virtual care, and how to teach with Zoom—was offered three times in both languages, resulting in strong participation and positive feedback.
Caroline Storr, an Associate Professor in the School of Occupational and Physical Therapy at McGill, says the first group of occupational therapy students (whose clinical training Prof. Storr oversees) received training in telehealth last summer—a practice that is continuing with the current cohort of students.
As well, Prof. Storr notes, broader steps are being taken by McGill as a whole to centralize research into the use and effectiveness of telehealth in various fields.
Adriana Venturini, a physiotherapist and Assistant Professor in McGill’s School of Occupational and Physical Therapy, says physiotherapy students were already given some exposure to telehealth before 2020, but the arrival of the pandemic accelerated the need for immediate training.
Preparation for the use of telehealth in clinical practice is now a formal element of training in physiotherapy, she adds.
“It’s one thing for me as a trained and experienced psychiatrist to adapt to these new forms of technology,” explains Dr. Soham Rej, “but if you’re just starting out, it can be quite difficult. That’s why I’ve been giving a lot of coaching to the students I see clinically.”
“Training is something that students will definitely need from now on,” agrees Dr. Mark Karanofsky. “That expertise has already become crucial in enabling us to build and maintain strong bonds with patients and clients.”