Virtual Integrative Medicine: Pros and Cons and Optimizing Patients' Experience

Challenges and Benefits of Virtual Visits

A Medical Economics article pointed out that when the pandemic began, many health care facilities and practices immediately saw a significant drop in patient visits and as a result, income as well. ¹ Patients' fears of physically coming in to a doctor's office for a visit and changes in billing that allowed telemedicine visits both added to the increase in the virtual appointment, according to the article. When the pandemic was obvious, the article stated: “Practices with telehealth capabilities quickly ramped up their capacity, while others installed the technology needed to conduct remote visits. According to the Medical Economics^® 2020 Telehealth-EHR survey, more than 77% of doctors surveyed used telehealth for the first time because of COVID-19.” ¹ Despite clinicians' lack of experience, the article reported that telehealth became a lifeline for patients and that “patients and doctors alike embraced the technology and the convenience, and practices began to collect income again.” ¹

While telemedicine provided a solution, virtual visits have been difficult for many clinicians since, as mentioned above, so many doctors had never practiced this way previously. Clinicians have recognized both the benefits and the challenges. Brent A. Bauer, MD, FACP, Research Director, Integrative Medicine and Health, Mayo Clinic, Rochester, Minnesota, in an interview, also commented on the challenges and benefits of dealing with virtual visits. He stated: “I am sure my experience is not unique, but clearly there is a deep connection that often happens during Integrative Medicine consults with patients' and family members who are actually present in the room. Losing this was, of course, quite painful, but I believe there are some additional benefits from virtual visits that have somewhat helped compensate for this.”

On the benefits of virtual visits, Bauer reported: “On the clinician side, I have been reminded of my early days of clinical practice when home visits were still a routine part of patient care. I learned so much more about my patients when I was actually able to enter into their daily lives. This helped create a deeper connection and facilitated a more therapeutic bidirectional relationship. Now, through video visits, I am once again being reintroduced into my patients' homes, albeit with a limited view of what fits on the computer screen.” He continued: “These video visits have allowed me to see, for example, pictures of my patient's children or their wedding day that are displayed behind them on the camera. I have also seen glimpses into their family life, their pets and in many cases clues as to both the challenges and supports they have within their own environment. Noting these, I have been able to adapt my consultation and my recommendations in real-time as we incorporate those cues from their home environment. So while virtual visits have caused us to lose some degree of the intimacy that occurs in an in-person visit, they have also restored a small connection to my patients' daily lives in a way that cannot be achieved with only an in-person visit.”

Randy Horwitz, MD, PhD, FACP, Professor of Medicine, University of Arizona College of Medicine, Medical Director, Andrew Weil Center for Integrative Medicine at the University of Arizona, Tucson, Arizona, in an interview commented on some of the challenges of not meeting in person: “Although the verbal history is arguably the most important part of an ‘H&P,’ the lack of a thorough physical exam detracts from overall quality of care, in that confirmatory findings are tougher to appreciate, and there are more subtle challenges in virtual visits. Clearly something is lost when communicating through a computer. The intimacy of an in-person encounter allows a more focused exchange between a patient and a provider, encouraging sharing and openness.”

Dr. Horwitz added that virtual visits may make it more difficult to discern subtle cues from facial expressions or body language, and this has been reported elsewhere by clinicians as one of the challenges of telemedicine. He said, “Today's technology is good, but is still two-dimensional. Sometimes more can be gained by what is left unsaid, and inferred by aspects that are best appreciated in person.” Dr. Horwitz stated: “One of the most important aspects of an Integrative Medicine visit is giving the patient space—space to tell their history and thoughts. Inherent in this are moments of silence. Silence gives the patient permission and an opening to explore and discuss. It's sometimes more difficult to do this through video screens. The workaround is to be present with the patient throughout the visit, and to become as comfortable with electronic silence as we are in person.”

Interestingly, many patients prefer virtual visits and the convenience it provides and still feel connected to their clinicians, according to the Medical Economics article. ¹ In terms of benefits of virtual visits for the patient, Bauer commented: “Virtual visits have certainly benefited many patients who previously found coming in for a visit challenging due to physical limitations and/or socioeconomic constraints. Being able to offer these patients a convenient form of consultation in the comfort of their own home has been a blessing to many. Even many who normally would have gladly come into the clinic for an in-person visit have found the convenience of a home video visit to be tremendously beneficial.” Horwitz reported that fewer patients tend to cancel, and there are less “no show” appointments, probably owing to the convenience of meeting from home.

Optimizing the Virtual Visit

It is difficult to know what the future of virtual visits holds for the general population moving forward as there are legal, financial, and practice management issues that are complex and will need to be worked out. Many practices have also returned, for now, to the option of in-office visits and yet still provide virtual visits as well. Experts suggest that in some form or another, virtual medicine is here to stay.

In an article by Srinivasan et al., Stanford health care physicians were surveyed about their experience with virtual visits. ² The authors of the article reported that at the beginning of initiating virtual medicine, “Despite high provider and patient satisfaction, technical limitations and system readiness challenges hindered visit quality, and from the provider viewpoint, left some patients unprepared for virtual visits. Providers observed that patients with cognitive impairment, language barriers, or technology access concerns experienced disproportionate challenges. Providers struggled with platform connectivity, the provider-directed patient self-exam, and establishing an emotional connection with patients. Some medical assistants (MAs) felt unfulfilled, with less direct patient contact.” ² To address the challenges of visits for both clinicians and patients, the Stanford group created a virtual model for improved care. Among the innovative changes were meetings with MAs in what is called Virtual Rooming where patients prepare for their visits, followed by a Virtual Waiting room where further education was provided, and Virtual Checkout where MAs helped patients schedule further necessary care such as bloodwork. The program also addressed establishing patient rapport and encouraged clinicians to listen carefully, establish visit priorities with the patient, take in the patient's home environment to learn more about them, and look for facial cues and body language to connect with patients' emotions.

To that end, Dr. Bauer commented: “I am blessed to have a great support team that contacts each patient well ahead of their virtual visit, makes sure they have all of the technical glitches worked out, and also sends selected reading material and handouts to each patient before we meet so they have a foundational understanding of the goals of the consultation and some basic understanding of the Integrative Medicine approach to promoting health and well-being.”

Dr. Horwitz stated: “We have extended visits, and the lack of a physical exam component gives us even more time to get to know and understand the patient and their motivations. Much of this extra time has been spent discussing COVID—patients ask questions about the disease and ask for advice (prophylaxis or treatment). I, in turn, need to find out how they're coping, either with social distancing/isolation, making sure that they have food, electricity, housing, etc. After this, we are able to explore their medical issues. A patient's current status is often far more important than the chronic issues that bring them in.”

To optimize virtual visits, an American Medical Association article ³ offered six practices to help clinicians, which included understanding the basics of technology use and being seated in environments conducive for the patient to see the clinician clearly; helping patients utilize tools at home that can help the clinician monitor the patient such as a home blood pressure monitoring kit, a weight scale, etc.; clinicians dressing as if they are going into the office; having a “good web-side manner” and in-depth conversation is important, and the article concurred with Dr. Horwitz's comment that the majority of diagnoses can be made with the history alone; and finally, the article stated that having follow-up virtual visits after a patient has been hospitalized may help improve outcomes.

Conclusion

In a new world of medicine created by the pandemic, there will indeed continue to be challenges as well as innovative initiatives that can, in fact, help improve medical care in general. Telemedicine will likely become a part of clinical training and education, and there are continuing medical education courses and other resources available now for clinicians on learning more about conducting telehealth medicine. The most important point is to create systems that optimize the experience for both the clinician and the patient. Ultimately, most clinicians and also many patients put a high value on the benefits of meeting in person. Dr. Bauer commented: “Now that we are back to a more normal clinical practice where many of our visits have been restored to in-person interactions, I definitely have a greater appreciation for the value of that human connection that occurs when we are both present in the same room at the same time.”▪