by Alexa B. Kimball and Nick Morgan

Most of us wouldn’t turn to a stranger on an airplane and tell him or her about our aches and pains, our digestive issues, or our deepest fears about the future. And yet, every single day, patients see new doctors for the first time and share intimate details about their bodies and their worries with a person they may know by recommendation but have just met. It’s remarkable — and it’s a reminder of just how central trust is to the patient-physician relationship.

At baseline, most patients want to trust their doctors. The Covid-19 pandemic has forced physicians to shift rapidly to virtual medicine, by both phone and video, in a way that will indelibly change the way doctors interact with patients. The key question now is: How will we be able to establish the same level of trust with our patients if we cannot meet them face to face?

Four central elements create trust: competence, logic, empathy, and reliability. Moving patient consultations to the virtual realm changes each of these elements in important ways, making trust harder to establish.

Communicate competence.

This is generally easy for physicians to demonstrate given their significant knowledge. Nonetheless, the background and appearance of the physician will continue to matter, especially in a virtual setting. It’s harder to establish credibility if it’s not clear you intend to make eye contact and engage because your camera is askew or if your background appears informal or sloppy. Make sure your surroundings look clean and professional and look directly at the camera while speaking to create the impression you’re making eye contact. Bright lighting is particularly important since the eye takes in more light than a computer camera. What appears bright enough to you may look dim to the viewer.

Even if you’ve done your best to present yourself well over a video call, the technology itself works to undermine a physician’s credibility. There’s a disjunction on these calls between video and sound — the sound is delayed very slightly. With a strong internet connection, the delay is small enough to be imperceptible to the conscious mind, but our unconscious minds read it as hesitation. This apparent hesitation suggests to us that the person to whom we’re speaking is less competent than they actually are. Paradoxically, the best way to demonstrate competence is not by talking up your own experience; it’s listening empathetically. Focus intently on what patients are telling you about their symptoms and repeat key phrases to ensure you’re understanding: “It sounds like you’ve been having these headaches for over a month. Is that right?”

Demonstrate logic.

Patients want to know, perhaps not entirely realistically, that you remember them, know about them, and are thinking about their problem comprehensively and logically. This is actually easier to do in virtual visits than in-person ones. Since both patient and record are on the same computer screen, virtual visits offer an opportunity to look at a patient’s record stealthily while you seemingly are looking at them. But be forewarned: Even slight eye movements are noticeable in the close-up view afforded by webcams; your patients will be able to see when you are reading. Rather than take that risk, why not share the screen you see and talk through the patient’s records and data with them?

Convey empathy.

Doing this in a virtual patient visit can be more challenging than an in-person one. In the clinical setting, appropriate levels of light touch can be incredibly reassuring and have valid therapeutic impact. Given that physical contact is impossible in the virtual world, listening becomes even more important.

Conveying empathy during a telephone visit is especially difficult because there are no visual cues that someone is about to speak. Misunderstandings can easily arise when we can’t see one another. Imagine you were on an audio conference call and, when you asked a question, you were met with silence. You’d probably assume the worst: that you asked a stupid question or talked too long and everyone stopped listening. For patients, this negativity bias means that if they ask a question and you pause to think or even unmute yourself before speaking, they’ve had a few moments to assume the worst. And depending on the context of the consultation, the worst could be very bad indeed.

Use verbal cues like “mm-hmm” to indicate that you’re listening while giving patients plenty of time to finish their thoughts. Mirroring the patient’s language can be another way to convey empathy and build connection. Rather than using complex medical terms that might sound forbidding to the patient, use their terms when you are talking to him or her, which will reinforce their feeling of being heard.

Even on a video call, empathy can be more difficult to convey. Because we can see one another on a video call, we assume that it’s essentially just as good as speaking face to face. But there’s a world of information that we normally take in unconsciously during in-person conversations that simply isn’t there over video. We don’t have the evidence of all five senses to help us build an impression of the person with whom we’re talking. The sound waves of their voice are compressed as they’re being transmitted, affecting in subtle ways the way we perceive tone and intent. We are contending with that slight delay between picture and sound. And, on a very basic subconscious level, we can see a person in front of us but cannot locate them in space. This strain on our proprioception increases our stress levels — and, for many patients, visiting a doctor is already a stressful proposition.

All these barriers suggest that it is particularly crucial in a telehealth visit to consciously and to deliberately work to establish trust and convey empathy. Deliberately eliciting and validating the patient’s experience are important, proven aspects of trust building. These strategies are all the more necessary in a remote visit because they will work to counteract all the unique stresses and disconnects created by the technology of telehealth.

Make sure you’re not just checking off a list of symptoms and make space for your patients to speak about how their symptoms are affecting their day-to-day lives. While in person you could convey empathy with a sympathetic face and posture or maybe a small appropriate touch, in a virtual visit you should verbalize that empathy: “That must be stressful. Let’s work together to make sure you can get back to your normal routine.”

Unfortunately, you can blow it by blaming technology for inevitable glitches. Figuring out connectivity is definitely challenging, but that frustration needs to be channeled elsewhere in order to ensure that patients trust what they see. Appearing uncomfortable with the technology required for a telehealth visit will work to undermine a patient’s perception of your overall competence, and thus their trust. So test your tech thoroughly before meeting with patients and be ready to help patients troubleshoot glitches as needed.

Interestingly, video visits also give clinicians a different insight into patients’ living situations and surroundings. You can learn far more about patients by seeing them in their home than you could in the anonymous setting of a generic exam room. There may be important clues in their surroundings that can help generate better treatment plans. Telehealth also can facilitate family members’ involvement in care, although it’s also true that some patients may not be able to speak freely while in a constricted home setting.

Be reliable.

By reliability, we mean showing up when the patient needs you. Telehealth appears to enable convenient and ready accessibility, and yet physicians’ schedules may not be set up optimally to meet patients’ needs. Staying on time for visits is critical in signaling to patients you are there when they need you — that you are reliable.

Doctors should also be conscious of the barriers to access many patients may face when it comes to telehealth. Depending on the patient population you serve, some of your patients may not have strong enough internet connections to enable glitch-free video consultations. Others may not have private space in their homes where they can freely discuss all their symptoms and concerns. Part of appearing reliable is anticipating these obstacles and working with patients to overcome them. Be prepared to suggest a phone number to call in if video conferencing is not working. If technical problems still persist, get the names of relatives or nearby friends who could assist the patient.

Doctors always need to create trust with their patients, and all four key components of trust are harder to establish in a virtual setting. It’s tough enough for people to talk about their most intimate experiences and fears with a health care provider; adding the glitches and disconnects of technology makes opening up even harder.

We believe physicians should remember that telehealth is always going to be a compromise solution. It’s better than nothing. It may be more efficient in some ways. It may continue to be an important way to reach some patients who live in rural areas or otherwise have trouble accessing care in person. But for some patients and some providers, it will always be unsatisfying when compared to an in-person visit. That’s why it’s so crucial for physicians to put in the extra effort to connect with patients in virtual visits.

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