As the covid-19 pandemic makes its mark on society there are many implications for people living with long-term or life-limiting conditions. The advent of social distancing and the need for protection against the virus has heralded significant changes in how people interact with the healthcare system.
The main change for patients is the move away from face-to-face appointments to remote consultations using online platforms or the telephone. The arrival of covid-19 has massively accelerated the slow trend towards virtual care. However, while there is an emerging evidence base of research and guidance to support health professionals making this change, there appears much less evidence and guidance for patients and families communicating in this way. This issue emerged in a recent BMJ tweetchat about the “collateral effects of covid-19” in healthcare.
As members of the BMJ’s Patient Advisory Panel, as well as people living with an immune-deficiency (CG), and recently recovered from cancer (SC), this move to virtual appointments has presented challenges in terms of the quality of the experience and outcomes. As online or phone consultations are going to become the norm for the foreseeable future, ensuring that clinicians and patients maximise the potential benefits of these interactions is crucially important. Here we highlight some of the issues that arise in planning and delivering virtual healthcare appointments, while also offering tips for consideration by clinicians.
The virtual clinic appointment starts with scheduling and timing. For both authors this has been a little fraught. Firstly, scheduling an appointment requires clear contact information, processes, and expectation management. Where GPs have rapidly switched to virtual appointments, contact information is not always easy to find. Patients may be told that they need to email their GP with appointment requests but the email address of the surgery can be hard to find. If you are on the receiving end of an online clinic system, there may be problems such as a lack of clarity about appointment times, (“be by the phone for an hour either side”) or the receipt of appointment text messages with no information on its purpose, or who you will be speaking to. Phone calls may also come from “unknown numbers” with no way to ring back if the call is missed or dropped.
Once the appointment has been secured, without careful consideration there is a chance that virtual processes can replicate the worst elements of in-person appointments. By telephone, patients are unable to read the body language of the doctor. Are they tired or feeling frustrated? Is this to do with you, or the current crisis? A poor virtual experience can be unsettling. A difficult consultation can be made even more so if you have not met your clinician “in real life” before. New referrals can be fraught for patients at the best of times but “meeting” a doctor for the first time over the phone or video is even more difficult, particularly where strict adherence to privacy rules can lead to stilted conversations (i.e. starting a new consultation by asking patients to state your full name, date of birth, etc. without any preamble). Clarity is also helpful, for example, outlining how long appointments may take, if there are tools going to be used (diagnostic, shared decision making) and reasons for their use.
The way in which appointments are followed up and what patients can expect should be clearly laid out, keeping in mind that as the pandemic evolves, options may change too. A GP appointment for a minor issue might reasonably take a “wait and see” approach, where the patient is advised to ring back after a set period (e.g. four weeks). For monitoring of long-term health conditions or cancer, it would be useful for clinicians to lay out their current plans for how appointments may be held in the near future. For example, will all appointments continue to be virtual, or are there plans to shift to in-person appointments in so-called “cold hubs”? How will tests be carried out, and results be provided?
Many consultation guides suggest patients should find a private, quiet, well-lit room with good internet access. For those who are isolating with partners, parents, siblings or children, this may be difficult. Having access to the internet may also be difficult for those on low incomes or older people who do not routinely use technology. Consultations with the elderly, or people who do not have English as a first language, might be problematic without support from others. In these contexts clinicians and patients both need to be flexible, considering what the “least worst option” may be.
Finally, we believe there is a real need to take the time to discuss how people are coping with the crisis physically and mentally. Lockdown and isolation are having wide-ranging impacts on mental health and it is important that clinicians explore how their patients are affected, whether this is the primary reason for the appointment or not.
Difficulties in privacy and internet access aside, our general impression is that in many cases a video consultation is preferable to telephone. It allows clinicians and patients to see one another, for patients to show areas of concern to their doctors, and for doctors to assist patients in self-exams. Where patients and doctors have a pre-existing relationship, video calls allow for relationships to be reinforced. For new consultations, video supports the building of a trusting relationship and allows patients to feel more comfortable discussing personal issues, something which is particularly important given the power dynamics in patient-doctor relationships. Regardless of the medium, clear advice on what the appointment will look like and how it will be followed up is important.
Tips for video and telephone consultations:
- Be clear about how long an appointment is likely to take, who it is with, and what will be discussed.
- Take time to acknowledge the pandemic and how appointments have changed. Ask how patients have been affected by lockdown and isolation.
- Not everyone will be able to access a quiet, well-lit space with a good internet connection. Consider what the minimum for an effective consultation might be.
- Be clear about next steps for treatment and management, particularly in the current context.
- Discuss potential impacts, if any, on delays to treatment, scans or other clinical appointments.
Competing interests: None declared.
Competing interests: None declared