Creating Virtual Presence During a Pandemic.

This article describes ways in which telemedicine has reshaped the doctor-patient relationship, and how we may face the challenge of maintaining a clinician's presence in the virtual environment.

COVID-19 has accelerated clinicians foray into telemedicine. As a result, many clinicians are forced to create or adapt their style of practice while using a technologic medium less familiar to us prior to the pandemic. While the predominant discussion in the current COVID-19 era of medicine has focused on understanding how to use the technology and adhere to the new rules and regulations, what will ultimately matter to our patients and profession is the following: how can we maintain a healing presence in the virtual environment?

We often speak of “presence” as a core element for creating a caring connection between clinicians and patients. A clinician’s highest calling is to comfort others in their suffering, a fundamental contribution to our own sense of purpose and meaning in our work (1). While there is no standard definition, we identify presence as undistracted healing engagement between clinician and patient. Many aspects of modern medical practice have created challenges to presence: the endless clicks within the electronic health record, fast paced office hours with shortened appointment slots, onerous in-basket tasks, and the constant ringing of our cell phones. Despite these impediments, COVID-19 has required clinicians to maintain our therapeutic relationships with our patients more than ever. The challenge immediately upon us is to recreate presence in this virtual medium. Answering this call successfully will make a strong case for retaining telemedicine as an effective tool for patient engagement, and for commensurate payer reimbursement as such going forward.

In a 2019 study, Brown-Johnson et al (2), explored the ways clinicians “create connection, engage in interpersonal interaction and build trust with individuals across different circumstances and contexts.” They conducted and analyzed interviews with primary care physicians and nonmedical professionals to understand how they foster connection and trust, while customizing their approaches to develop presence. Three categories of behavior defined clinician presence: purposeful intention to connect, conscious navigation of time, and awareness of the physical environment.

In the first 2 categories, clinicians rely on our well substantiated skill sets of attentive listening and relational communication. Deploying these skills remains a priority in the virtual space; however, COVID-19 has infiltrated our collective conscience and our ability to purposefully connect and navigate time. All levels of our society have been impacted and many of us, we fear, will know at least one person who dies from this pandemic. These fears impact both clinicians and patients alike and requires an extra measure of effort to avoid distraction. Mindful practice, the use of techniques to help us focus on being in the moment, has become more critical than ever.

Keeping in mind the interdependence of these categories, it is the third one, the physical environment, where most of the unique telemedicine challenges lie. Classically, our physical environment has been defined by the spatial layout of the exam room, lighting, temperature, and positioning of the computer screen. In addition, there are all of the telling nonverbal cues exchanged between clinician and patient and, of course, the laying on of hands, which provides both comfort and important diagnostic information.

How can we overcome the limitations of telemedicine in order to create and maintain virtual presence? It begins with awareness, which then inspires adaptation. The easier lift is ensuring that phone connections are clear, and light, position, and backdrop are optimized for video viewing on both the clinician and patient end. The gravity of concerns brought up during the COVID-19 pandemic require an exceptional degree of focus. Although we may be on “mobile” devices, we should remind ourselves and our patients to situate in a quiet, private environment for consultation. The typical medical office can be rather sterile and impersonal. Video visits give us an advantage by allowing patients to find a comfortable space for their visit, perhaps even more suitable than our office. At the same time, we have the ability create a warm environment with simple adjustments to the light or background.

Where we lose some connection through touch and gesture, we must heighten our verbal interrelatedness through active listening, reflection, and use of empathic statements. COVID-19 related stress and anxiety may affect our patients’ attentiveness, so presenting information in smaller portions with frequent use of Teach-Back (3) may be even more essential than usual. Although we’ve lost the ability to calm patients with our hands, we have become more purposeful in the tempo of our speech and tone because those are the most receptive senses to patients in the virtual environment. In fact, the virtual practice may help patients focus on our voice and words. More than ever, they are not distracted by conversation in the hallways or the informational signs posted on the walls that can be distracting when we counsel face-to-face.

Our relationship with the electronic health record is also impacted by the telemedicine transition. Since its inception, screen time has been competing with direct patient interaction in the office or at the bedside. In a fateful ironic twist, the patient him or herself has become a screen, or just a voice. This will require us to verbalize more clearly when we have to refer to the record, as the patient cannot see it and may only perceive the clinician’s inattentiveness.

The current COVID-19 crisis implores us to find creative ways to achieve and preserve presence during virtual patient care. Our patients need us to master this skill set now more than ever. The ideas suggested herein are just a start and are intended to inspire dialogue and future study. Telemedicine has been catapulted to the forefront of outpatient care for now but will likely remain a significant modality going forward beyond the current pandemic. The way we deliver care in the years and decades after COVID-19 will assuredly look different than the time before it. So, the effort we make now will continue to serve us and our patients well and keep us connected well into the future.