COVID-19 and physician-patient relationship: potential effects of 'masking', 'distancing' and 'others'.

Dear Editor,

As the world continues to battle coronavirus disease (COVID-19), restrictions and risk-minimization strategies have been put in place to prevent the spread of infection across health care settings, including general practice and primary care settings. As reported by the World Health Organisation (WHO), COVID-19 transmission can occur through two routes—respiratory droplets and physical contact (1). Therefore, WHO advises the use of face masks and physical distancing. The general practice settings at the very least will need to adhere to these precautions and adapt to the new normal. Here we are attempting to posit possible impacts of ‘masking’ and ‘distancing’ on the doctor–patient relationship.

The effect of ‘masking’

The emotional aspect of a doctor–patient relationship is largely guided by non-verbal communication. Both doctors and patients need to recognize and explore each other’s non-verbal cues (2). Non-verbal behaviour plays a significant role in the quality and satisfaction of this relationship, which in turn influences adherence and clinical outcomes (3). Wearing face masks would have a ‘masking effect’ on non-verbal communications expressed through facial expressions, subtle tonal inflections and voice modulation. In a randomized controlled trial from Hong Kong, doctors wearing face masks had a significant negative influence on patients’ perception of doctors’ empathy (4). Surprisingly, the effect was worse in an established doctor–patient relationship. The latter bears special significance in chronic disease care settings. What happens when both doctors and patients wear face masks (‘dual masking’)? Although there is no literature, possibly doctors’ perception of patients’ empathy too is likely to be affected. Perceived empathy is one of the key components of therapeutic relationships. During the COVID-19 pandemic, when ‘dual masking’ is a commonly encountered scenario, negative effects on mutual feelings of empathy, trust and overall doctor–patient relationship seem plausible.

The effects of ‘distancing’

The effects of physical distancing are another area of concern. First of all, COVID-19 is likely to affect the universal practice of greeting patients through a handshake. Handshake at the end of the consultation too could be a measure of patients’ satisfaction (5). Whether another form of greeting or regional greetings such as ‘Namaste’ or ‘Adaab’ would replace the ubiquitous handshake—remains to be seen. The acceptability of such regional greetings across different cultures is also a matter of debate. Second, the ideal distance between a physician and a patient during consultation is said to be between intimate and personal space, i.e. nearly 1 m (6). Although the desired consultation distance falls just within the recommendation by the WHO, keeping a greater distance is likely during clinical practice. The ‘distancing’ could differentially influence the feeling of comfort, privacy and intimacy. For example, during the pandemic, a distance of 2–3 m would be comfortable (or less anxiety provoking) for both doctors and patients but require the communication to be much louder which may in turn undermine privacy. Some non-verbal cues, such as ‘forward lean’, which have a positive effect in the doctor–patient relationship might also see a measurable decline (7).

Although widespread use of masks and practice of social distancing might lead to some concerns in day-to-day clinical practice, the authors do not intend to advocate, by any means, against use of these essential precautions.

Notwithstanding these limitations, masking and distancing could also have some beneficial effect on physician–patient relationships. Continuation of health care during the pandemic might lead to appreciation of health services and health care workers and inspire confidence in the health system. The use of precautionary measures by health care staff could also have a contagion effect and encourage patients to adhere to the appropriate preventive measures.

Is there an alternative to ‘masking?’

A face shield could be a potential alternative to masking (8). Face shields have many advantages over face masks in terms of better visibility of face and appreciation of non-verbal facial cues, greater coverage of area of face (including eyes and), preventing autoinoculation by inhibiting touching of face, easier to produce (easily available raw materials compared with masks and easier repurposing of existing manufacturing units) and possibility of reuse after sterilization. Thus, face shields may emerge as possible alternatives in the future, but the beneficial effect of using face shields on prevention of spread of COVID-19 requires further study.

Potential effects of other factors

Other factors, such as consultation length, which influences relationship and even patients’ outcome, might also be affected by the current pandemic (9). Fear and anxiety of contracting infection could affect the physician–patient relationship as well. How societal factors, such as violence against doctors during the pandemic (reported from India, Mexico), could influence the doctor–patient relationship is something to be watched for.

There is a need for qualitative research to understand and theorize the effects of COVID-19 precautionary measures on doctor–patient relationships. The research should be cross-cultural and across settings because a universal theory is unlikely to explain this complex phenomenon.

Conclusion

Are there any silver linings? The COVID-19 crisis could serve as a tipping point for remote consultation. Practice of telemedicine is purported to have a positive effect on the access and utilization of health care, without escalating the risk of infection. Telemedicine services could be delivered through audio calls (telephonic) or through Internet-enabled video consultations. Although video consultation seems to be the preferable method as it provides visual cues, important for therapeutic communications, it is limited by access to good-quality Internet connection and comfort level of the patient. Consultations through telephone, on the other hand, would be widely available, accessible, affordable and acceptable for patients. Nevertheless, the infrastructural and administrative challenge of the sudden need for massive expansion of telemedicine services and clinical challenge for the physicians and patients to adapt to this new modality appear to be important (10–12). These challenges would be far greater in the context of low- and middle-income settings.

In essence, the effect of COVID-19 outbreak on doctor–patient relationships is a clinical concern, which may have both negative and positive effects. An awareness of these effects might encourage clinicians and policy makers to pre-empt and think about strategies to deal with it.