Uro-oncology in the era of social distancing: the principles of patient-centered online consultations during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic poses significant challenges to healthcare facilities and as per social distancing measures, many consultations are now being carried out via means of telemedicine. As some urologists may not be skilled with remote consultations, there is a need for recommendations on patient-centered online medical counseling.
MATERIAL AND METHODS: We have identified eight areas of excellence and defined the principles based on our experience.
RESULTS: A professional setting should be provided, in which the privacy of the patient can be ensured. Accompanying persons should be encouraged into the consultation. Proper introduction could serve not only to verify the personality of the patient, but also to provide them with a sense of confidentiality. The interview should be held in a way to overcome the limitations of non-physical encounters, and pande-mic-specific issues should be taken into consideration. When arranging plans, the physician should judge accordingly in regards to what type of management is inevitable or safe, as well as available at this point; strict follow-up should be arranged. As home isolation may lead to unfavorable changes in lifestyle, this issue should be addressed too. The patient should be guided on how to self-educate. Concluding the visit should be aimed at proper evaluation of the patient's comprehension of the consultation.
CONCLUSIONS: It is vital to pursue consistency in providing care to patients. While online counseling may seem challenging, if one adheres to the principles of patient-centered practice, telemedicine may become a valuable tool in maintaining the best-quality care amid the ongoing pandemic. Copyright by Polish Urological Association.

INTRODUCTION

As the total count of confirmed coronavirus disease 2019 (COVID-19) cases is still rising worldwide, given the highly contagious character of the pathogen, the paramount instrument for prevention of further disease spread is the maximum limitation of interpersonal physical contact. This social distancing, apart from the need for providing care to COVID-19 patients, is another significant challenge for healthcare facilities, which now are not only postponing elective cases in order to secure access to ventilator-level care [1], but also cancelling appointments in medical offices in attempt to pursue social distancing measures. These preventive procedures are of particular importance in the elderly and in cancer patients, as this population is at increased risk of serious complications due to COVID-19 [2]. Thus, given the high priority of medical care in oncology, the emerging role of uro-oncology practitioners is to overcome the limitations of social distancing with telemedicine – a healthcare modality of established safety, efficacy and convenience [3, 4, 5]. The authors of this text are aware that a substantial population of urologists does not feel experienced with telemedicine. Thus, we propose some basic principles of patient-centered online consultations, in order to help provide and maintain the best-quality outpatient care to patients with urologic malignancies.

MATERIAL AND METHODS

Based on our experience in regards to online or telephone counseling we managed to identify eight areas of excellence. Within each area we defined principles which we found vital to maintaining proper remote patient care.

RESULTS

Setting. Much of the set-up measures depend on the tool used for communication, which can be either videoconference or a telephone call. These platforms will likely vary by geographic location. While videoconference best allows the consultation to resemble a physical encounter and include the role of non-verbal communication, a telephone conversation may be most suitable in patients not familiar with modern technologies (e.g. some of the elderly or rural population). As a general rule, the aim of the set-up is to provide a professional setting that both enables adequate communication and ensures patient privacy. This is important as many urologic conditions and symptoms are of great intimacy.

An ideal setting for the counseling physician can be achieved, among other things, with proper attire, adequate lighting and framing, professional visual background, protection from background noise or voices, as well as limiting external or personal distractions that could make the physician seem unfocused on the patient. The use of telecommunication instead of physical contact must not deprive the encounter of its professional character.

Accompanying persons. Counseling issues that relate to cancer may cause significant anxiety to the patient. Moreover, given the advanced age of many uro-oncology patients, they may also present some degree of cognitive impairment or distress. In these circumstances, it may be desirable that the patient is permitted, or even encouraged, if they wish so, to be accompanied by a close person during the online consultation to provide emotional support, improve the effectiveness of communication and help in decision making. Unfortunately, the degree of the accompanying person’s participation in the encounter will be greatly dependent on the capability of the tool used for communication. This is especially an issue with telephone consultations, and the role of the physician is to guide the conversation in a way that allows the accompanying person to participate, for example by asking the patient to pass the phone to the partner or to turn on the speaker function.

Visit introduction. The significant role of introduction at the start of an online consultation is to ensure the patient is fully aware that they are speaking to an actual physician and that the encounter is a true outpatient visit. Such an introduction provides the patient with a sense of privacy, which is essential for conducting a reliable interview. This can be further achieved by an explicit reassurance of the confidentiality of the encounter. At the introduction, it is also vital to ascertain the personal data and identity of the patient, as the non-physical character of the consultation may pose a risk of error (this is especially an issue in case of telephone encounters). Also, the physician needs to be fully introduced unless the patient knew his doctor beforehand. Additionally, it may be reasonable for the physician to confirm the patient’s consent to use an online visit in lieu of regular clinic visit.

Interview. While the routine principles of a medical interview apply to a non-physical encounter as well, there are some special issues that should be taken into consideration when performing an online consultation. Firstly, depending on the communication tool and the features of the medical records software used, some data such as a laboratory tests or imaging results may not be provided online. In such cases, extra time and as much effort as possible should be put into fully collecting this data verbally from the patient, without omitting data that could seem irrelevant and paying special attention to the units used on lab reports. Secondly, social distancing and thus perceived isolation may be a risk factor in developing or exacerbating a preexisting depression or anxiety disorder [6], which is a special concern in the population of uro-oncology patients. Both cancer patients [7] and elderly individuals [8] demonstrate high rates of depression and anxiety disorders, thus every interview in the era of COVID-2019 pandemic should be aimed to screen the patient for possible mental health issues, so that they could be timely referred to a psychiatrist. Thirdly, the inability to perform a physical examination is a major limitation of an online consultation. However, this may be overcome by guiding the patient on self-examination, either by verbal instructions or by asking the patient to reproduce maneuvers presented in the videoconference. While some parts of the examination, especially digital rectal examination, may not be feasible, others, like costovertebral angle tenderness or testicular examination may be easily performed by the patient. Fourthly, as we are living in a pandemic status, it is reasonable to also screen for COVID-19 symptoms. Fifthly, depending on the perceived quality of communication, in order to mitigate the risk of misunderstanding, it would be reasonable for the physician to paraphrase the collected data and to ask the patient to confirm its correctness.

Arranging plans. In general, the best treatment options offered to the patient as part of an online consultation will not differ from what would have been established during a physical encounter. However, the availability of many diagnostic and treatment modalities is going to be substantially limited as a result of the ongoing COVID-19 pandemic. Firstly, if considering surgical management as a treatment option, proper triaging should be implemented, for example by the model recently proposed by Stensland et al. [1]. The reasons for postponing treatment should be enunciated to the patient, not only by highlighting the unavailability of ventilator-level care, but also by explaining possible COVID-19 risks whereby reassuring the patient that not scheduling surgery during an ongoing pandemic is the safest option. Secondly, in some patients a physical encounter may appear to be inevitable in order to establish an important diagnosis or maintain proper follow-up. A good example are patients requiring cystoscopy. The authors of this article suggest that while in patients with confirmed low-risk (pTa LG) bladder cancer the follow-up cystoscopy, other than the first one after bladder tumor resection, may be safely postponed for a period of a few months, as even active-surveillance has been reported to be safe in those patients [9, 10] and thus delaying a recurrence diagnosis may not actually pose danger, in patients with high risk or unknown risk (primary) disease performing a cystoscopy, if possible to maintain adequate safety standards, is a must. In patients with a suspicion of a primary bladder tumor, an abdominal ultrasound may be considered in place of a cystoscopy, as its sensitivity has been reported to be very high [11]. Thirdly, as the availability of particular management modalities may be currently limited, the urologist must ascertain that the recommended diagnostic and treatment plan is feasible, for example by postponing currently unavailable imaging testing and substituting it with more accessible work-up. In addition, the patient must be reassured that even despite major limitations, the offered plan not only does not leave them without help, but still provides the best care currently available. Vice versa, if presence in a healthcare facility is inevitable, reassure the patient that proper safety measures will be applied, and the arranged intervention is beneficial for their health. Fourthly, early follow-up should be scheduled. Short time intervals between online consultations should be scheduled to not only reassure the patient about the consistency of care, but also to minimize any harmful effects of any incorrect data interpretation, which may be an unlikely, but still are a possible limitation of an online consultation. Arranging a short call a week or two after the consultation is a reasonable way to eliminate the risk of misinterpretation and to ascertain the patient’s compliance, which is especially important in patients who express doubts or anxiety, or in patients with advanced or high-risk disease.

Lifestyle intervention. Social distancing, as well as the fear of leaving home may lead to decreased levels of physical activity. Limited access to groceries may have a substantial impact on dietary habits. Reduced direct social support and lack of distracting activities may impede a planned or ongoing smoking cessation attempt or even pose a risk of a relapse. This is why lifestyle intervention should become a routine part of every online consultation in the era of the COVID-19 pandemic, especially in the population of uro-oncology patients, who are particularly prone to negative effects of smoking and increased cardiovascular risk (e.g. patients on androgen deprivation therapy). A brief smoking intervention, e.g. five A’s [12] should be performed. The patient should also be encouraged to involve themselves in physical activity. The development of indoor activity guidelines for elderly or comorbid patients should become an urgent priority for healthcare organizations. Another important point when considering lifestyle intervention is screening for possible alcohol abuse, as social distancing or home isolation might be a substantial risk factor.

Self-education and support. While people spend more time at home and limit their professional and social activity, the additional spare time gained could be utilized for self-education. Providing the patient with educational materials could not only act as a valuable supplement to the consultation, but also could help the patient to become familiar with their condition and available management options, as well as prepare them for asking questions during the next visit. Materials available at: https://patients.uroweb.org could be used for this purpose. Moreover, in order to make up for limited social activity, the patient should be guided to familiarize themselves with the activity of patient organizations. The list of several global or European patient organizations is provided in Table 1. We encourage physicians to become familiar with their national, regional or local patient organizations as well.

Table 1

Examples of uro-oncology patient organizations

Organization	Website address
European Association of Urology Patient Information	https://patients.uroweb.org/
Europa Uomo – The Voice of Men with Prostate Cancer in Europe	https://www.europa-uomo.org/
International Kidney Cancer Coalition – IKCC	https://ikcc.org/
World Bladder Cancer Patient Coalition – WBCPC	http://worldbladdercancer.org
European Cancer Patient Coalition – ECPC	https://ecpc.org/
Bladder Cancer Advocacy Network – BCAN	https://bcan.org/

Concluding the visit. To what extent the information provided to the patient is going to be understood is greatly dependent on the features of the online system used for counseling. However, regardless of the expected degree of misunderstanding, the physician must evaluate whether the patient correctly comprehends the arrangements. This can be achieved for example by asking the patient to repeat or paraphrase the recommendations. If possible, a summary of the consultation or the recommendations should be provided on-line to the patient, as well as appropriate contact details, should the patient have any doubts or late questions.

DISCUSSION

The ongoing COVID-19 pandemic has entirely disrupted the consistency of our communication with patients. Limited access to health services and social distancing are raising unprecedented significant challenges to the whole healthcare system. Telemedicine is a previously underestimated, but now promising tool which may at least partially help in overcoming these new difficulties. When adhering to several important principles of online counseling, telemedicine has an opportunity to become a safe and efficient tool in establishing and maintaining proper care in the challenging population of patients with urologic malignancies. We are aware that this population comprises a heterogeneous group of patients, and while some appointments are simple follow-up visits that can be easily and safely managed online, other patients, especially some new patients or patients presenting with complications may require a physical encounter anyway, but still we believe that online consultations, if performed properly, may play a great role during the ongoing pandemic.

While the current impact of social distancing on medical counseling is undoubtedly negative, this challenge, if successfully overcome now, may introduce valuable opportunities for the future. When the dust of the ongoing crisis settles and we become more experienced with the principles of telemedicine, we will have to reflect on the true priorities of our practice. How strict of a follow-up is actually necessary in uro-oncologic patients? Are we doing too many unnecessary in-person follow-up consultations? To what extent can the follow-up visits be replaced by phone calls or video conversations, in order to safely ease the burden in our offices and to provide the patients with more convenience? These, among many other questions, will need to be addressed after we successfully manage to overcome the difficulties of the current situation.

In the meantime, we should aim our effort at continuing to provide care to our patients and at keeping them and their family physicians aware that our offices, despite having limited patient access, are still functional, and at least for the purpose of urgent matters they can be easily accessed by means of online or telephone communication. Not providing a patient with any kind of diagnostic process or leaving them without necessary treatment may lead to seeing more advanced cancer cases once the COVID-19 peak has passed. While being protected from COVID-19 with social distancing, patients may become at risk of having lost their window for cure and dying because of delayed diagnosis. Therefore, we would like to stress, that increasing access to telemedicine, education of physicians and adapting guidelines should be an urgent priority for governments, as well as health and professional medical organizations.

CONCLUSIONS

Based on our experience, we have presented instructions on how to maintain the best standards of patient-centered care when counseling uro-oncology patients via means of telemedicine. The summary of recommendations is provided in Table 2. Bearing in mind that it is vital to pursue consistency in providing care to the patients, we believe that our guide could serve as a practical aid in maintaining best-quality care amid the ongoing pandemic. If we successfully manage to overcome the difficulties of the current situation and establish the role of telemedicine in providing care to our patients, we may be able to turn this challenge of inexperience into a promising opportunity for the future.

Table 2

Summary of recommendations in regards to maintaining standards of patient-centered medicine during online consultations

Make sure the setting is professional, safe and resembles a genuine consultation

Enable the accompanying person to participate in the encounter

Verify the identity of the patient, introduce yourself and reassure about confidentiality

If not provided online, carefully collect data regarding tests and imaging

Do not hesitate to ask the patient to perform physical examination maneuvers

Evaluate for depression and anxiety disorders

Use proper triaging when scheduling treatment

Do not order unavailable management plans

Reassure that despite limitations the patient will still benefit from the offered management plan

Schedule an early follow-up

Perform a lifestyle intervention

Provide the patient with educational materials (EAU Patient Information)

Encourage the patient to familiarize with patient organizations

Make sure the patient understands what has been arranged

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.