Virtual visits, masks, social distancing complicate patient/oncologist connections
As COVID-19 safety precautions and understanding of the virus continue to improve, many cancer centers across the U.S. have been reopening their doors to more patients.
“The landscape has definitely changed; although we’re all still dealing with a lot of uncertainty, we seem to have found a steady state in terms of our ability to care for patients with adequate infection control,” Kiri A. Cook, MD, assistant professor and director of clinical research in the department of radiation medicine at Oregon Health & Science University, said in an interview with Healio. “With respect to social connection, though, patients and providers are both still struggling.”
For patients with cancer who have not resumed office visits due to vulnerabilities, location or preference, the struggle to have clear, emotionally connected interactions with providers via telehealth continues.
“Our clinic staff knows how to do it better now — they work very hard to prepare patients for telehealth visits in their previsit calls, and patients are getting better at it, too,” Hanna K. Sanoff, MD, MPH, associate professor of medicine at The University of North Carolina at Chapel Hill’s Lineberger Comprehensive Cancer Center, told Healio. “At the end of the day, though, I live in a state with a lot of rural people without good cell service or WiFi access. I have done multiple consults informing patients of bad news recently. I had to tell somebody they were dying over a phone call. So, unfortunately, we are still struggling in this regard.”
A lack of connectedness
Although telehealth has been a valuable means of providing patient care during the pandemic, it often cannot foster the sense of connectedness and trust that an in-person visit offers.
“A big part of what’s fun about being an oncologist is building connections with people. I doubt many people would do the job if it were only about giving chemotherapy. You do it because you care about the people and their families,” said Sanoff, who wrote an article published in JAMA Oncology titled, “Managing grief, loss and connection in oncology — What COVID-19 has taken.” “So, when you can’t interact with them face-to-face and really feel a connection, it’s hard — especially when you haven’t met the patient in person.”
Sanoff said patients often struggle with the transition to a new oncologist under the best of circumstances and may experience feelings of abandonment. These feelings may be intensified when the first interaction with the new clinician occurs virtually.
“The feeling of trust is so important to patients with cancer,” she said. “To not only have a change in oncologist, but to only meet that oncologist through a virtual visit is very hard for these patients.”
By contrast, Sanoff said she has been able to meet some of her former telehealth patients in person and get to know them better than she could on a virtual platform.
“I saw someone in person who I had only ever met through video visits, and she was so different than I thought she was,” she said. “She was so fun and vibrant, and none of that came across on the video.”
Cook, who along with Jenna M. Kahn, MD, wrote a viewpoint in JAMA Oncology on making connections in the era of COVID-19-related social distancing, emphasized that the rapid implementation of telehealth in response to the pandemic has brought about improvements in care delivery that she hopes will be ongoing.
“Telehealth can be a valuable tool for involving patients’ families in discussions when visitor restrictions are in place, or when family members are otherwise unable to come in person to appointments,” she said.
Sanoff said rather than causing emotional distress, virtual visits in some cases have allowed patients to go on with their lives without unnecessary inconvenience.
“Virtual care has turned out to be really helpful for my patients who live quite far away,” she said. “I don’t see them entirely virtually, but if they’re on an oral chemotherapy and all that is needed is a checkup and labs, it’s a way to avoid having them drive 3 hours to Chapel Hill when they can have their labs done two blocks away.”
Even for patients who are seen in person, the physical distance, lack of discernible facial expressions beneath masks and dearth of physical contact may lead to feelings of emotional detachment and confusion.
According to Cook, facial cues may be misconstrued during important conversations while masks are worn.
“The relationships that we form with our patients are really important in making them feel secure in our care,” she said. “It just feels harder to build that same connection when we aren’t able to see each other’s facial expressions. I think when we interact with masks on, there’s a higher risk [for] misunderstanding, especially in complicated conversations about things like treatment and prognosis.”
Cook added that the inability to provide physical comfort can cause patients to feel more alone when coping with distress related to cancer.
“It’s harder to provide comfort and support in difficult times when you can’t put a hand on their shoulder or give a hug,” Cook said.
Care for the terminally ill
Restrictions due to COVID-19 have also disrupted the care and connection provided to terminally ill patients. Sanoff noted that social distancing requirements, travel restrictions and the closing of establishments have interfered with these patients’ ability to achieve their “bucket lists.”
When a patient is actively dying in a health care facility, providers are often faced with difficult decisions about visits from friends and family, Sanoff said.
“We’re in a situation where we’re trying to figure out who to let in the door to say goodbye,” Sanoff said. “Where do you cross the line in terms of when the risk would be acceptable? Even if someone may have been exposed, you might feel inclined to let them come in. It’s really so stressful for families.”
Barriers to training
The physical distance of virtual visits also has made it difficult to provide an effective learning environment to trainees, Sanoff said. In this sense, new clinicians may not be learning the more “soft skills” of oncology care.
“Normally, one of the ways you learn how to convey difficult news and have compassion as an oncologist is to watch the senior oncologists do it well, or do it badly,” she said. “Now, our trainees are distant and we’re trying to figure out how to get them in on a three-party line, or sometimes the attending calls after the resident has seen the patient and circles back with them, but it’s not a shared visit. I think this has been a major learning impediment to all of medicine, but I think it’s especially pronounced in cancer care because of the humanistic factor.”
Sanoff said most video platforms are now capable of bringing in a third party, but she added that this has not replicated the experience of watching a skilled oncologist at work.
“It’s not the same experience for the patients, either; it’s definitely awkward,” she said. “I think it will be OK, but it’s definitely added a new layer of complexity to medical training.”
Bridging the distance
Although there may be no single solution to this complex issue, Cook said there are small ways in which oncologists can remind patients that the patient/physician relationship is still intact.
“When we don’t see patients in person as frequently due to social distancing requirements, it’s easy for them to feel as though we aren’t working on their treatment plan,” she said. “Frequent reassurances to the contrary, even if by phone or through the electronic medical record, go a long way in making patients feel that they are actively being cared for.”
She added that taking extra time during visits to address the patient’s concerns, both related and unrelated to cancer, can help restore the human element of compassion.
“Although it’s hard to convey how much we care when our faces are covered and we have to be distant, welcoming body language and an open line of communication can help patients feel more at ease.”
In terms of delivering bad news regarding a patient’s prognosis, Sanoff acknowledged that doing so virtually goes directly against what most oncologists were taught in medical school.
“We’re taught not to give bad news over the phone, but I try to remember a few things,” she said. “One is to just honestly spell out the fact that this is incredibly awkward and not the ideal way to convey this information. I also try to give the patient some cues that they would normally get from body language. I might say, ‘I’ve got some bad news to share,’ and then give them time to readjust, make sure they’re sitting down and emotionally ready to receive the news.”
Cook said for more routine patient follow-up appointments, she generally gives patients the option of being seen virtually or in person.
“The vast majority are choosing in person,” she said. “Most of us understand the effectiveness of social distancing and masks and will continue to observe these practices until experts tell us it’s no longer necessary. Having said that, it will be so valuable when we can finally use our faces to communicate with patients again.”
- Cook KA and Kahn JM. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2020.2725.
- Sanoff H. JAMA Oncol. 2020; doi:10.1001/jamaoncol.2020.2839.
For more information:
Kiri A. Cook, MD, can be reached at 3161 SW Pavilion Loop, Multnomah Pavilion, 2nd Floor, Portland, OR 97239; email: email@example.com.
Hanna K. Sanoff, MD, MPH, can be reached at 101 Manning Drive, Chapel Hill, NC 27514; email: firstname.lastname@example.org.