The COVID-19 pandemic has upended health care, with telemedicine emerging as a strategy to reduce risk exposures for patients and clinicians. Originating from the Greek root tēle-, tēl-, tēle meaning “far off, afar, at or to a distance,” telemedicine encompasses virtual clinical services. Video visits, in particular, can be effective for many types of clinical care and offer convenience and savings for patients. As care shifts to this virtual modality, however, there is a risk of jeopardizing the meaningful human interaction that is critical to clinical care and impactful to patients and clinicians alike.

The communication challenges of telemedicine, further compounded by COVID-19 related stress, call for strategies to help clinicians forge meaningful interactions with patients during virtual visits. The Presence 5, published earlier this year in JAMA, comprises evidence-based guidelines to foster humanism and connection in clinical care. Reconceptualizing this framework for video visits offers several strategies aligned with the Presence 5 practices: prepare with intention, listen intently and completely, agree on what matters most, connect with the patient’s story, and explore emotional cues. Prioritizing explicit humanistic practices can help clinicians foster meaningful virtual connections with patients amidst this challenging pandemic and in the future as telemedicine becomes more widely integrated into clinical care.

Prepare with intention

“It is much more important to know what sort of patient has a disease than what sort of a disease a patient has.”
– William Osler

Physical and psychological preparation before a virtual visit creates a foundation for a high-quality interaction and a more productive visit. During this time of crisis, clinicians may be juggling high volumes of back-to-back video appointments with greater family needs and/or working from home. Refreshing between visits through a personalized ritual such as standing up or taking a few deep breaths can help a clinician recharge and focus their attention. A brief chart review of the patient’s social history before initiating a visit can increase familiarization with key psychosocial information about a patient and their history and life circumstances. Prior to the appointment, it is also important to check audiovisual equipment and ensure a quiet environment to facilitate a smooth, mindful visit. Other tips include reducing technology distractions by disabling picture-in-picture functions that show the clinician’s own image.

Listen intently and completely

“It is the province of knowledge to speak. And it is the privilege of wisdom to listen.”
– Oliver Wendell Holmes

Attentive listening offers an opportunity to set a tone of respect and establish rapport for the virtual interaction. Several non-verbal strategies can foster humanism across digital divides, including sitting up straight and leaning forward to show interest, nodding to signal listening, optimizing eye contact by periodically looking directly at the web camera, and staying seated within the camera frame. Let the patient tell their story; if the technology generates lag time, wait three seconds before responding to avoid rushing the patient. The rapid transition to new technologies and new modes of interaction amidst a pandemic is challenging for everyone; when technical frustrations arise, professional acknowledgment and troubleshooting will help build a patient’s trust in telemedicine as a means of care.

Agree on what matters most

“If you want to go fast, go alone. If you want to go far, go together.”
– African Proverb

Early in the conversation, providers should describe the flow of a virtual visit and set a shared agenda that incorporates a patient’s goals and priorities. Use open-ended questions and reinforce the plan by asking for patient teach-back and explaining the available venues for further interaction with the health care system. This can offer reassurance that patients’ priorities and hesitations with virtual care are addressed as they stay at home during mandated physical distancing.

Connect with the patient’s story

“We must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph.”
– Elie Wiesel

In many ways, a video visit is an invitation into a patient’s home, offering a clinician the opportunity to view family members, pets, and belongings important to the identity of the person in their care. Clinicians should ask individuals who are present to introduce themselves and consider privacy concerns, asking if patients are comfortable discussing their health concerns with others in the room. These interactions can highlight valuable information about the patient’s sources of emotional and tangible support for health-related issues. Clinicians should be attentive to certain risks posed by physical distancing and stay-at-home directives; video visits can be used to assess a patient for concerns that may increase in times of crisis, such as housing instability, food and medication insecurity, substance use, and intimate partner violence (the latter of which should be addressed cautiously, acknowledging privacy concerns as above).

Explore emotional cues

“People will forget what you did, but people will never forget how you made them feel.”
– Maya Angelou

Despite the distance imposed by technology, clinicians can tune into emotional cues that manifest through facial expressions, body language, and changes in verbal tone and volume. While it is not possible to offer a tissue or a comforting hand on the shoulder over video, eye contact and verbal acknowledgement of emotions (e.g., “I can see this is hard for you” or “As I listen to you, it sounds like you are worried”) can be an effective substitute within the scope of virtual care and should be used frequently to ensure that patients feel heard and that their emotions are validated. Clinicians can also use their own body language, for example, putting a hand over their heart, to convey emotion.

The uncertainty and stress posed by COVID-19 will continue to generate unrelenting demands on the healthcare workforce, yet humanism is more important than ever. Even though virtual care precludes the physical contact that is central to the practice of medicine, specific strategies can help clinicians foster meaningful connections with patients during video-based encounters. Integrating humanistic principles into telemedicine will help clinicians, and patients better endure this challenging time, safely from a distance, yet together.

The authors would like to acknowledge Mariko Kanda Kelly, Ted Andrew Miclau, Gisselle De Leon, and Raquel Garcia.

Megha Shankar is an internal medicine physician. Meredith Fischer is a social science research coordinator. Cati Brown-Johnson is a research scientist. Nadia Safaeinili is a social science researcher. Marie Haverfield is a social science researcher. Jonathan Shaw is a family physician. Sonoo Israni is an entrepreneur. Abraham Verghese is an internal medicine physician. Donna Zulman is an internal medicine physician.

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