When technological innovations do not reach consensus: the case of tele-consultation of andrological patients.

Since the end of February 2020, Italy has witnessed a complete upheaval in the organization of the national and regional health systems due to the pandemic caused by COV-SARS2 (COVID 19). An immediate consequence is a reconversion of clinical activities in all types of hospitals (public, private, and semi-private) leading to a significant delay of scheduled clinical and surgical procedures, including uro-oncological and andrological services [1, 2]. Even urological emergency services have suffered from the pandemic [3].

Under normal circumstances, most clinical andrological activities are regarded as elective procedures. However, during this specific crisis, andrological services have experienced an almost total suspension of activities. As a result, the Italian Association of Andrology (SIA) promoted a series of initiatives in support of the andrological sector [4]. Uro-andrologists in SIA recognized that a period of forced home-based quarantine might exacerbate the incidence and impact of andrological diseases, especially those related to the sexual sphere. Mental health issues are frequently associated with erectile dysfunction, especially depression and anxiety-related disorders, but transitory states of altered mood (i.e., dysfunctional-inducing states resulting from specific life stresses) also occur [5]. Therefore, clinicians should be aware of flare-ups of andrological disorders during the COVID-19 pandemic, especially among younger patients. In some Italian regions, the local governments forced hospitals to stop physical urological and andrological outpatient visits. In this situation, SIA decided to offer patients a tele-medical specialist services as an alternative to traditional face-to-face visits. The Urology Unit of the Santa Chiara Regional Hospital in Trento followed this practice, starting from 13 March 2020. An experienced uro-andrology staff member contacted patients by phone by and offered a tele-consultation as a replacement for the scheduled physical visit.

The tele-consultations were carried out by means of a case report form made available by the hospital, which provided standardized collection of the patient’s personal and clinical data and the reason for the referral. Details included actual symptoms and past and present medical history. At the end of the consultation, the physician submitted written instructions to the patient and, if required, a drug prescription through the same online platform. The following day the tele-consulted patients were contacted again by a different staff andro-urologist and were requested to answer a brief, dedicated fou-item questionnaire (4qPSQ) (Fig. 1) aimed at assessing the level of patient satisfaction with the consultation on the previous day.

Fig. 1

Detailed content of the patient satisfaction questionnaire.

The 4-questions patient satisfaction questionnaire (4qPSQ).

Briefly, analysis of the first 57 telephone consultations in our institution showed a low rate of patients who reported the tele-consultation to be reassuring [Question 1: 30 patients (52.6%) answered ‘Neutral’ and 8 (14%) answered ‘Disappointed’). Similarly, a low level of satisfaction with the service was reported [Question 2: 38 patients (66.6%) answered ‘Not/Somewhat’; Question 3: 35 patients (61.5%) answered VERY POOR/POOR/NEUTRAL). Finally, only 15 patients (26.3%) reported that they would recommend this type of service to another patient (Question 4: score 8–10). Table 1 contains generic patient’s characteristics at the time of the tele-medical assessment. Table 2 provides details of the answers to the questionnaire.

Table 1

Patient’s sociodemographic and anamnestic characteristics at the baseline.

No. of screened patients	61
No. of analyzed patients	57
Average age (mean ± SD)	51.9 ±1 8.4
BMI (mean ± SD)	26.5 (±4.1)
Educational level
Primary school	12 (21.1)
Secondary school	31 (54.4)
Post-secondary education	14 (24.5)
Smoking
Yes	23 (40.4)
No	34 (59.6)
Charlson Comorbidities Index
0–1	54 (94.8)
2 or more	3 (5.2)

Table 2

Satisfaction rate and 4qPSQ responses at the follow-up telephone consultation.

Overall response rate	57 (93.4)
Telephone consultation mean time (minutes) (±SD)	7 (±3.2)
4qPSQ
Q1. How do you feel after this telephone consultation?
Disappointed	8 (14.1)
Neutral	30 (52.6)
Reassured	11 (19.3)
Satisfied	8 (14.1)
Q2. How satisfied are you with this service?
Not	18 (31.6)
Somewhat	20 (35.1)
Very	19 (33.3)
Q3. How would you rate your overall experience with this telephone consultation?
Very poor	10 (17.6)
Poor	15 (26.3)
Neutral	10 (17.6)
Good	22 (38.5)
Outstanding	– (–)
Q4. How likely is it that you would recommend this service to a friend?
1	–
2	12 (21.1)
3	12 (21.1)
4	10 (17.5)
5	8 (14.1)
6	–
7	6 (10.5)
8	5 (8.7)
9	2 (3.5)
10	2 (3.5)

Based on these results, the hospital management together with the uro-andrologists decided to suspend the service of andrological tele-consultations and to schedule the patients for conventional outpatient hospital visits at the earliest convenience. The findings were unexpected since onco-urolological patients were satisfied with tele-consultation as an alternative to physical visits during the COVID pandemic [1, 6, 7]. However, because of the priorities dictated by the pandemic and the short period of time in which this approach has found application, there are limited data regarding its feasibility and the perception of the patients. Our findings suggest that an approach with telemedicine, although innovative and useful for its application, only partially satisfies patients presenting with sexual disorders.

This brief experience convinced us of the importance of an empathic and in-depth personal contact with the andrological patient who obviously wants to divulge his sexual health problems with another human being. A face-to-face consultation with exchange of verbal as well as non-verbal gestures seems to be an essential prerequisite for a satisfactory and effective andrological consultation, which cannot be substituted by tele-medical communication. Crucial factors in the assessment such as relationship factors including partner dissatisfaction, a poor sexual relationship, intimate details, and gauging of emotions with the partner during sexual intercourse are difficult to elicit and assess during the tele-consultation process. It is obvious that all these essential emotional aspects are greatly curtailed during a tele-consultancy and hence might explain the poor satisfaction with the tele-medical approach among andrological patients. Although our small study has provided interesting findings, the importance of the results are limited by a small sample size and the use of a questionnaire that was not designed for this specific purpose and has not been validated.