As Telehealth Use Increased, Physicians' Webside Manner Evolved

At the core of healthcare delivery is the provider-patient relationship. As telehealth grew in popularity over the past 18 months, providers had to establish and maintain this relationship virtually. Thus, physicians have had to adapt and strengthen their 'webside' manner — that is, bedside manner for the digital age.

Though telehealth usage is much lower than it was at the height of the COVID-19 pandemic, it is still growing. Use of the care modality rose by 2.3 percent from August to September, similar to a 2.4 percent increase from July to August, according to a recent FAIR Health report.

Not only that, but telehealth appears popular among seniors as well — a demographic that had many concerned as healthcare went virtual last year. A new federal report shows that telehealth usage by Medicare fee-for-service beneficiaries grew from approximately 840,000 virtual visits in 2019 to nearly 52.7 million in 2020, a 63-fold jump.

As health systems rapidly set up new telehealth programs or grew existing ones, it was up to physicians to ensure that the patient-provider relationship not only remained unaffected but also expanded to include new facets.

The benefits of connecting with patients via virtual visits

Access is undoubtedly the biggest boon conferred by telehealth on clinicians and patients alike. Instead of making appointments for in-person care and having to travel for doctor's visits, patients can just pull out their phones or computers.

"I sometimes have young people that call me from being on a bus or in a car, or I even had one young person that was at a convenience store and felt comfortable enough to do an entire physical with me from the store," said Anisha Abraham, MD, acting chief of adolescent medicine at Children's National Hospital in Washington, D.C., in a phone interview. "The beauty is we can catch them where they are — they don't miss appointments."

Another way in which telehealth deepens the provider-patient relationship is that it allows physicians a glimpse into the home lives of their patients.

For example, if a physician is discussing a sleep problem with a patient and they can see children darting in and out of the screen, they can get a sense of what might be aggravating the problem, said Ravi Nemivant, MD, a critical care and sleep medicine physician at Downers Grove, Illinois-based Duly Health and Care, in a phone interview.

Further, telehealth visits allow physicians to bypass some of the administrative tasks that take up time during in-person visits.

"You kind of go through this whole process of checking, reconciliation of records, taking vital signs, doing an examination and that takes up maybe like half of the time slot, but ultimately what people want is the discussion of what I think is going on with them and what's the plan going to be?" Nemivant said.

"The telehealth process enables us to kind of skip all of those things and really just get to the meat of the matter,” Nemivant added. “We still do some record reconciliation and stuff like that. We make sure that their medications are correct and check their social history and things like that, but it's much more efficient because that whole check-in process just isn't necessary."

Telehealth also makes connecting with patients harder

Perhaps the most challenging part of a telehealth visit is not being able to conduct a physical examination.

"We have lost the ability to actually touch our patients to examine them to really know what might be going on in that way," Children's National Hospital's Abraham said.  

For example, if a patient with a sore throat visits the doctor in person, the doctor can ask questions but also look into their throat and feel their neck, which provides a great deal of information. That’s not quite as easy via telehealth, however.

In addition, it's harder for physicians to pick up nonverbal cues — an especially challenging issue when bad news needs to be shared.

"When they're in person I think, we have a better sense of how they're reacting to things and whether or not they need additional support," Abraham said. "That's very different when you're doing a Zoom interview or a telehealth interview."

Seeing patients in their home environment, despite having its advantages, also creates barriers.

During an in-person conversation, clinicians can just focus on listening, understanding what they are being told and repeating it to patients so they can confirm they have understood correctly.

"On telehealth, it's a little harder, because you're in the middle of their normal lives," said Robert Dums, MD, co-medical director, VelocityCare, Carilion Clinic, in a phone interview. "And so, there's background noise, there's kids yelling, there's TVs going on. So, it's a little harder to reflect things back."

Then there is the dreaded issue of technology problems. Sometimes there are lags or the Wi-Fi connection isn't good, impeding the flow of the conversation, said Duly Health and Care's Nemivant.

"There's an energy associated with that connection that you can never replicate through telehealth," he added. "While telehealth has a role in healthcare, it's hard for us to ever see a future where that's the only way you deliver healthcare, but it can be a useful tool to engage with patients in timely fashion."

What providers have learned about conducting telehealth visits

The barriers discussed above have led providers to tweak their webside manner in a number of ways. One is ensuring they are asking all the right questions and listening carefully.

"I've gotten really used to it just becoming part and parcel of what I do — to say, "Hey, can you get your pulse? I'm going to time you for 30 seconds and keep a count. And what was it?" Carilion Clinic's Dums said. "[We] didn't really have to do that in-person."

Dums also uses his questions to develop a rapport with his patients by making them laugh. When he needs to check a patient's throat, he says, "Well, pretend like you're going to eat the camera so I can look in your throat."

"That usually works, because it makes them laugh a little bit and then they don't take it quite as seriously... I mean, I think if they can laugh a little bit, even if they're not feeling well, helps a lot," he said.

Children's National Hospital's Abraham echoed Dums, saying she also relies on more detailed questions to get the information that she needs.

"We do need to do a lot more due diligence in terms of how they're actually feeling," she said.

Being more observant of her patient's home environment has been another key learning for Abraham.

"I think it's very important for providers to be just aware of what their background is like," she said. "Is it distracting? How are they appearing on screen? Are they optimizing their own presentation of their image? And so I sometimes will ask, is everything going okay? And who's that person there? Is that mom and is that your brother? And are things all right? Because you sometimes can get clues as to whether…there might be additional challenges or barriers for them getting services or care."

It is evident that seeing patients via telehealth requires a different skill set — one that providers will continue to hone as telehealth becomes increasingly integrated into care delivery.