Virtual care and the doctor-patient relationship from the lens of a social scientist

Demand, interest, and investment in virtual care have increased exponentially since the COVID-19 pandemic. There exist immense opportunities to grow and develop virtual care, to improve the patient experience. However, unlike the retail or the hospitality industry, standards for engaging patients in the digital healthcare space should be different, and for good reasons. Health care, including virtual care, should aim for health equity, and at no time in history, the need to address health equity has been more critical. As virtual care expands, its goal should be to make healthcare accessible, equitable, and inclusive. The current article maps the patient journey and points out social determinant factors that can impact access to virtual care and impact the doctor-patient relationship. Using a social sciences lens to develop a healthcare delivery system and a digital infrastructure that is accessible and equitable is one step closer to achieving the goal of value-based care.

I am no doctor or medical provider. I am a social scientist who works in health, and I have spent many years understanding the social factors that impact population health. I am pro-technology, and I know technology can do wonders. But at the same time, it is essential to examine social factors that may impact the doctor-patient relationship, especially when technology becomes a gate-keeper of doctor-patient interaction. The focus of this article is patients because I believe that identifying and addressing patient barriers will lead to positive patient outcomes that will benefit every stakeholder- patient, provider, caregivers, and health plans.

So what is a doctor-patient relationship?

It means the relationship between a doctor and a patient. Hellin defines it as,

"To attend those who suffer, a physician must possess not only scientific knowledge and technical abilities but also an understanding of human nature. The patient is not just a group of symptoms, damaged organs, and altered emotions. The patient is a human being, at the same time, worried and hopeful, who is searching for relief, help, and trust. The importance of an intimate relationship between patient and physician can never be overstated because, in most cases, an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship".

The emphasis here is on the relationship between two individuals, who previously unknown come to a shared understanding of the physical and mental health symptoms. None of us can deny that we have had our share of a good and not so good doctor interaction. Ask yourself, what was it that made you decide you want to go back to the doctor? I bet the answer will be how comfortable she/he made you feel, heard your concerns patiently, provided an accurate diagnosis and a plan of action. Those of you who didn't feel the same way went for a second or third opinion. In other words, a good doctor-patient relationship is one that is based on clear communication and trust.

The doctor-patient relationship has been a topic of active inquiry since the time of Hippocrates. It has evolved over the ages. Michael Balint, in 1964, stated that illness is both a psychosocial and a biological phenomenon. He encouraged doctors to look past the physical signs and symptoms and focus on the "patient's unique psychological and social context, thereby allowing them to understand the 'real' reason for the consultation." Understanding a patient's biography is, therefore, critical to the understanding of the experience of the illness (Armstrong, 1979). This relationship is the cornerstone of patient-centered care. With COVID-19 and a push for ramping up virtual care/ telemedicine infrastructure, relationship building between a health provider and a patient has taken on a new meaning. There is much to know...

who is virtual care best suited for,' 'for what conditions/ diseases or disorders it is best suited for,' 'for what types of services it is best suited for,' 'whether it 'will bridge or widen inequities' and how effectively can virtual care assist in the 'digital translation of emotions and experiences?'

Such is the importance of the doctor-patient relationship that the very first chapter of the American Medical Association's Code of Medical Ethics is devoted to the Patient-Physician Relationship, and a specific chapter dedicated to the Ethical Practices of Telemedicine.

According to the code, physicians using telehealth service should

(a) Inform users about the limitations of the relationship and services provided.

(b) Advise site users about how to arrange for needed care when follow-up care is indicated.

(c) Encourage users who have primary care physicians to inform their primary physicians about the online health consultation, even if in-person care is not immediately needed.

Patient journey: mapping social factors that impact access to a virtual care platform

The following pictorial illustration shows a five-step patient's journey to seek telehealth/ virtual care consultation

Step 1 shows the conditions (new or existing) for which a patient may seek telehealth consultation. The point of entry could be a chronic illness (heart disease), an infectious disease, mental health condition, therapy, or medication. At this stage, an individual could be a new patient or a continuing patient. Help sought at this stage could range from getting a diagnosis to getting a preventive check-up, to a referral.

Having identified a need for consultation, a patient can choose an in-person or a virtual care/ telehealth visit (Step 2). If virtual care is selected (or for that matter, the only choice available, as is during COVID-19), one can do so via the following modes: chat, phone, video, or email.

Barriers to access a virtual care platform

Two specific types of barriers affect access to a virtual care platform.

1. Socio-demographic barriers: age, disability status, limited English proficiency, income, education, and level of urbanization
2. Accessibility of a technological device

Socio-demographic barriers

The most critical socio-demographic barrier to impact access to a virtual care platform is age.

Technology use drastically declines with age.

Three things are essential to keep in mind when expanding health technology, like virtual care, for older adults.

• Age is an essential determinant of the use of technology. In the US, technology use among older adults age 65+ is 73%, compared to 97% among adults between ages 30 and 49. Sixty-seven percent of older adults use the internet; fifty-nine percent have broadband at home, 42% use smartphones, and 32% use tablets, with only 12% dependence on a smartphone.

Although technology use among older adults in the USA is increasing, there is much heterogeneity in what constitutes an older adult and in their technology use patterns. For example, in 2019, only 17% of older adults aged 80 up owned a smartphone, compared to 59% of older adults aged 65-69.

• Older adults need help navigating new technology compared to younger adults. This trend is extremely concerning given that most older adults live alone or with their spouses, who are older adults themselves. For example,

76% to 86% older men and women between ages 65 and 84 live alone or only with their spouses, compared to 58% and 76% of older men and women aged 85 above

Any company developing virtual care or health care technology should ask themselves, who is going to help vulnerable older adults living at home (and not in nursing homes) connect to technology to seek virtual care?

• Age is an important determinant of the preferred communication medium. Older adults, especially those born before 1945, prefer face-to-face communication, over the phone or other electronic communication medium. Although Baby boomers, or those born between 1946 and 1964, use technology, they "still appreciate face-to-face meetings and telephone conversations, and although they do text, their digital channel of choice is email." Insights on patients' preferred communication medium will allow health plans to devise inventive engagement strategies to make virtual care appealing.

It is unfortunate that older adults who are more likely to have health needs are also most likely to be challenged technologically to access care.

Disability status is the second crucial socio-demographic factor that can impact access to a virtual care platform. Much like older adults, Americans with disabilities are significantly less like to use technological devices, compared to those without disabilities. They are less likely to own a computer, smartphone, or tablet, and are less likely to have broadband at home, compared to their same-aged peers. It is essential to realize that disability is an umbrella term that constitutes a range of physical, cognitive, and emotional conditions that ranges in severity. For example, a person with visual limitations or physical disability may have a very different experience when accessing a virtual care platform than a person with cognitive impairment. Therefore, as virtual care platforms get built and expanded, it is essential to prioritize core principles of access, inclusion, and equity.

It is more often than not that people with the most significant health concerns are the ones who are left behind in the digital innovation space. Health care is one area where we cannot afford to overlook inclusion and access. Health products built with a vision of access, equity, and inclusivity benefits all!

Other socio-demographic factors that may impact access to a virtual care platform are limited English proficiency, income, education, and level of urbanization. These social variables are important determinants of digital technology use, including smartphone ownership and internet/ wifi access.

It is essential to realize that social determinant to virtual care access do not work independently, but interact in complicated ways to create barriers that ultimately impact access to care.

Accessibility of a technological device

Accessibility of a technological device, such as smartphones, tablets, computers, etc. is the second barrier that can impact the use of the virtual care platform. Owning a smartphone does not guarantee using every functionality. It requires internet/ wifi access (especially for video consultation), and digital literacy, such as knowledge of applications that need to be downloaded, knowing how to sign-up, upgrading software, or remembering passwords. Research shows that in the USA, 67% of older adults use the internet on their phones. Although there exists no national data, it can be safely assumed that none have heard or used or have enough memory space left to download an application. This could be a significant barrier, especially when health plans require downloading apps for secure communication. Using virtual care also requires having a stable internet, especially for video consultations. If such is the challenge, do we ever expect older adults, who are significantly impacted by COVID-19 and who would benefit from fewer hospital visits, to use virtual care realistically? How do we expect people with disabilities or those with limited income with no access to smartphones or stable internet to be able to access virtual care? This stage can make or break the pathway to the first interaction with a health provider via a virtual care platform.

Step 3: Access to a provider

Having identified challenges to accessing the virtual care platform, the next is the doctor-patient interaction. According to the figure, it is only at Step 3 that a patient ultimately consults with a doctor. This is the relationship-building stage. At this stage, a provider using his/ her best skills of communication elicits information from the patient, and using the data, provides recommendations (Step 4).

Barriers to the doctor-patient relationship

Clear communication is an essential component of the doctor-patient and a key factor to reach step 4 successfully. What social factors could affect this relationship? I have identified the following two:

1.   Communication barriers that can arise due to a patient's inability to communicate, lack of established relationship with the provider, and language barrier

2.   Psychological and cultural barriers

Communication barriers

Effective communication is the key to a successful doctor-patient relationship. Disability, especially having challenges with communication, can be a significant deterrent to this relationship. It could be an adult with Autism or someone who is deaf or hard of hearing, or someone with poor eyesight. A study by Kaiser Permanente Northern California found those with ASD have higher rates of chronic disease compared to similarly aged peers. The researchers attributed higher rates of chronic illness to social and communication challenges that may limit the use of preventive care. Autism Speaks provides a list of communication tips for a successful doctor-patient interaction, "use simple, direct communication when talking to a child – or adult – who has Autism and supplement this with visual supports when needed. Many people on the spectrum are confused by idioms or turns of phrase that might have a different literal meaning." It is imperative for virtual care to investigate how these challenges impact the health-seeking experiences and health outcomes of people with disabilities.

Now for a second, let's empathize with a doctor. Observations and physical examinations are critical tools of diagnosis and management of chronic disease. I interviewed a physician a couple of days back on his experience with virtual care. While he had adapted to COVID-19 and moved to telehealth and video conferencing, he stated, "I am unable to observe their gait, their demeanor, their physical status. During video consultations, they are usually seated in one place. I am unable to see the person as a whole." Such is the burden on both a doctor and a patient.

Having an established relationship (that may vary with the type of condition) with a provider is critical to the success of a telehealth consultation. According to a physician I had interviewed, he prefers seeing existing patients via virtual care because of an ongoing relationship that can be maneuvered, instead of taking on new patients. An informal discussion with a few of my friends who had accessed virtual care in the past six months also voiced similar preferences. My friends mostly used virtual care for follow-up appointments with an existing provider or to receive referrals. It is therefore not surprising that a recent study by McKinsey (June 20202) found that 76% had scheduled a visit with their PCP in person, and another 79% had scheduled a visit with their specialist in person. Those who already had a telehealth appointment, 54% had a follow-up office-visit with a PCP (compared to 31% via telemedicine), and 63% scheduled a follow-up in-person consultation with a specialist (compared to 28% via telemedicine). This stands in stark contrast to scheduled visits with psychologists and psychiatrists -66% via telemedicine vs. 26% in person. I do not want to over-interpret the findings, but does it indicate that certain conditions require an in-person visit or that patients continue to prefer in-person visits over telehealth? Does an existing relationship with a care provider matter? These are important questions to examine.

The third important factor that could impact the doctor-patient relationship is 'limited English proficiency (LEP).' Language is an important determinant of successful communication, diagnosis, and treatment adherence. Currently, the US has over 25 million non-English speaking populations who are at higher risk not to receive preventive care and are less likely to be satisfied with their care. Patients with LEP have poor clinical outcomes, such as drug complications, and poor understanding of diagnoses, and at high risk of being misunderstood by their physicians. This is worse for patients with mental disorders (Flores, 2005). LEP patients are dependent on medical interpreters, who are in short supply. So how does telehealth impact the doctor-patient relationship in an LEP population? I recently interviewed a friend who provides interpretive services to low-income Latinos in the Mid-western State of USA. According to her, while telehealth has its obvious advantage of making health care accessible to those who live far-off from clinics or those who work hourly wages and may have to take time off, it has ramifications on the doctor-patient relationship and patient satisfaction. As a telehealth interpreter, she has no visibility of body language, especially when patients feel uneasy about sharing information or disagreeing with a doctor's decision. It significantly limits her ability to probe, which impacts what she can effectively ask and provide the necessary information to a physician to reach a correct diagnosis. The three-way conversation also gets affected due to technological barriers such as poor connectivity that lead to longer appointments and patient frustration.

Another factor that can impact a doctor-patient relationship is 'access to diagnostic tools at home.' How frequently have we heard providers ask for temperature, weight, or BP over the phone? What if a patient does not have an instrument to measure one? What if the device is flawed or is out of battery/ charge? The patient, of course, cannot give a response. More often than not, a patient is called for an office visit. We cannot assume that everyone will have access to essential diagnostic tools, such as a thermometer or a weighing machine at home. With COVID-19, I have had doctors ask me to take pictures and send them? What if I didn't know how to take a picture, how to upload one, or not have the physical capability (shaking hands) to take a picture? So at the end of the day, the question is, who is virtual care for?

Psychological and cultural barriers

The final set of barriers that could impact a doctor-patient relationship is cultural and psychological barriers. These barriers are unmeasurable but tend to play a vital role in symptom expression and adherence to treatment. Armstrong, 1979, stated that a patient's biography is critical to understanding the experience of the illness. These biographies include life-span experiences, cultural beliefs, mistrust in the medical system, the experience of historical and institutionalized racism, discrimination due to one's identity, race, ethnicity, and immigration status. The psychological barrier could be as simple as 'I don't like technology,' 'I cannot use virtual care,' 'telehealth is not as effective as a real conversation,' 'I don't know who has access to my data (privacy concerns) etc. etc.

The final step

Satisfaction with care (step 5) is the last phase of a patient's journey. In my opinion, satisfaction, although an important metric, shouldn't be the only one used to assess the performance of a virtual care platform. While virtual care has its benefits, such as improving access, reduction in wait times, reduction in missed appointment rates, the real questions the health systems should ask are:

• Who is virtual care for?
• Does the mode of care (phone, video, chat, email) make a difference in patient engagement and satisfaction?
• Does the condition type make a difference in experience?
• How are the experiences of people with disabilities, older adults, or LEP different from others?

..... and so on

To that end, research should focus on

1.   Mapping patient journey through careful sampling

2.   Conducting multi-stakeholder studies that involve both providers and patients to understand better on how virtual care may impact the doctor-patient relationship and come up with actionable insights

3. Rigorous user testing of the virtual platform with different groups of patients, with differing abilities

4. Re-thinking strategies to ensure the confidentiality of information shared between a patient and a provider. It is more often than not that older adults/ people with disabilities will seek help from other family members or a caregiver/ friend to help navigate virtual care. In such instances, how do providers ensure the confidentiality of the information shared?

5. Using a social sciences and health equity lens to understand the barriers and facilitators to virtual care access, utilization, and satisfaction

In conclusion, I believe that social scientists should be a part of any healthcare team to help ensure that a doctor-patient relationship is sustained via digital platforms. A successful doctor-patient relationship = good clinical outcomes and patient satisfaction, which benefits everyone- patient, doctor/ health providers, family, and health plans!

The author is solely responsible for the views expressed in this article.

Author: Subharati Ghosh, PhD