Webside Manner: A Key to High-Quality Primary Care Telemedicine for All

Communication as a Key Dimension of Quality

Almost 2 decades ago, long before telemedicine tested provider/patient relationships with physical distance, the following concerns were expressed. “A three-thousand-year tradition, which bonded doctor with patient in a special affinity of trust, is being traded for a new type of relationship. Healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.” ¹ What, then, are the implications for the provider/patient relationship of compounding this threat to healing, caring, listening, and trust by adding physical distance to the process? Does physical distance ensure emotional distance as provider organizations ² increasingly embrace telemedicine?

Although implications for provider/patient relationships undoubtedly encompass many clinical domains, it also seems certain that implications vary with both the type of clinical problem being addressed and the status of preexisting provider/patient relationships. We focus here on primary care pediatrics, a domain in which we have gained extensive experience with both telemedicine ³ and traditional in-person care.

In considering the natural history of common childhood problems, ^4,5 it becomes apparent that the vast majority are self-limited. The profession of medicine has little to offer in reducing duration of these many illness episodes. Moreover, we often have little to offer toward reducing symptom severity besides recommending medications readily available without a prescription. Nevertheless, parents continue to bring their children to see us, and telephone triage guidelines endorsed by the American Academy of Pediatrics, ^6,7 widely used to support decisions about who should seek care, guide parents to contact us about many common clinical presentations. Why? One reasonable response is because serious illness sometimes presents in a similar manner to minor, self-limited illness, especially in very young children. Well-trained physicians are better positioned to evaluate the likelihood of serious illness than a parent.

But there must be further explanation. With the advent of vaccines that prevent the vast majority of serious bacterial illness (SBI), such as bacterial meningitis, septicemia, and joint infections, the likelihood of SBI is greatly reduced. Most parents may have only a vague awareness that such problems might occur.

To answer the question of why our care in addressing common childhood symptoms remains highly valued, then, we must look beyond the small probability that we will detect serious illness. We believe that society continues to look to the medical professional for service that: (1) maximizes the likelihood that the child will return to his or her preillness state, and (2) maximizes value. But for this assessment to remain valid, we must agree on our understanding of the concepts of value and cost.

In a recent commentary, Pandya expressed unease over a lack of consensus around the definition of value. ⁸ People commonly think of prices paid for goods or services as an accurate quantification of their value. But payment represents only one component of value. To understand the value of telemedicine in primary care, it is essential to use price, cost, and value as these words are formally defined in the fields of economics and epidemiology.

Values are “concepts used to explain how and why things matter. Values are involved wherever we distinguish between things good and bad, better or worse.” ⁹ They encompass “what we believe in, what we hold dear in the way we live.”

Cost “includes not only money, but also discomfort, pain, absenteeism, disability, and social stigma.” ⁷ Thus, in addition to demonstrated impact of telemedicine on utilization patterns, important effects on costs also include reduction in absence from school, childcare, and workplace.

Price represents the monetary quantity as goods or services are marketed and cost represents the monetary quantity actually paid. From the economist's perspective, neither price nor cost reflect the important construct of value. Value is synonymous for usefulness.

In contrast, cost is value monetized. Consequently, market forces are a major determinant of cost, and cost may or may not reflect value accurately. ^7,10,11 Market forces, for example, explain markedly greater payments for emergency department than office visits (roughly 10-fold in the Rochester, NY) for care of children with the same common problem (e.g., acute otitis media). Yet emergency department visits for nonemergency problems often consume much more of a family's time than an office visit. Accordingly, such high-priced emergency department visits are much less valuable than care provided conveniently yet priced much lower.

Thus, in addition to dollars spent, a broad range of illness-attributable burdens influence value. Value encompasses impact on the child's discomfort, time lost from school and work by the child and family members. No less important although rarely acknowledged, value is maximized by care that minimizes the anxiety of patients and family.

What Qualities Are Essential to Delivering Care Valued by Patients?

To fully understand the value of a care delivery innovation, impact on both physical and psychological morbidity must be considered. Impact on parental anxiety is thus an important part of our value proposition. Given the profound affection that parents feel toward their children, they want to know that: (1) their sick child will fully recover; (2) everything will be done both to reduce discomfort and to ensure that full recovery will occur as soon as possible; and (3) they are doing everything they can to ensure this outcome. Clearly, influences on parent decisions to seek care and parent assessment of the usefulness of that care extend beyond any direct impact that clinicians have on their child's health. In large measure, parents seek care because they are worried, and they want help in addressing the concerns that underlie their anxiety. The value of much of what we have to offer depends, fundamentally, on trust that is sufficient to reduce anxiety.

Accordingly, to answer our question of what attributes of our service are essential to value, we need to know how to address the full range of factors driving parents to seek care. ^*

One essential determinant is communication that delivers valid information and does so in a manner that promotes trust in its validity. Only then will anxiety be minimized and effectiveness maximized. Effectiveness encompasses a range of outcomes, all of which depend to some extent on trust. In addition to satisfaction and reduction in anxiety, trust enhances compliance with interventions recommended and increases the likelihood that parents will contact you, rather than seek care elsewhere, should concerns arise following an encounter.

The Basis for Trust

Accordingly, the question—wherein lies the basis for this trust?—is central to our value as clinicians and warrants careful consideration. Although both the status of medical professionals in society and prior experience with a particular provider surely contribute, interactions during a specific encounter likely a dominate provider influence on trust.

A fundamental issue, then, is how one builds and maintains trust in an interpersonal interaction. If one accepts the reasonable position that provider contribution to emotional change—reduction in anxiety in this instance—requires establishment of trust, it seems appropriate to look to the field of behavioral health care for guidance on qualities of communication that promote this change. Specifically, what attributes of interpersonal interaction, beyond information itself, might promote reduction in anxiety? What conveys the impression that a particular provider, when attempting to deliver reassurance, is trustworthy?

Well before the development of effective medications for anxiety and depression, behavioral health focused on the potential of interpersonal interaction to improve emotional state. Carl Rogers identified genuine warmth, accurate empathy, and unconditional positive regard as essential components of effective counseling. ¹² These qualities of interaction impart to another individual the sense that their emotions are fully understood and respected. With the patient/provider relationship thus established, patients and family are more likely to understand, to believe information on diagnosis and treatment, and to follow guidance offered. Words on a page, alone, which might be delivered through text message, cannot convey genuine concern and respect with nearly the power as words enhanced by intonation of voice, body language, and facial expression.

Impact of Trust on Utilization

As discussed above, trust has an impact on care-seeking behavior. It seems likely that capacity to impart trust through our telemedicine model contributed substantially to reduction in emergency department use after telemedicine access became available. In our experience, parents were sufficiently confident in care provided through telemedicine that they rarely sought in-person care following telemedicine visits. ¹³ Moreover, emergency department visits, overall, dropped substantially with telemedicine available in childcare and elementary schools (22% reduction ¹³ ) and in a center for children with special needs (50% reduction ¹⁴ ).

Threats to Trust

As previously noted, ¹⁵ the term telemedicine has been applied to a broad range of care models with different capacities for acquisition and exchange across distance of clinically relevant information. Several distinctly different commercial health service ventures are actively marketed under this label. Our concerns about models, including the capacity for real-time, face-to-face interaction but lacking tools for acquiring key diagnostic information have previously been expressed. ¹⁵

We are equally concerned about the quality of care available through models lacking capacity for real-time, face-to-face interaction. Given that the value of our care rests in large measure on our capacity for communication that reduces anxiety, models lacking this capacity represent a substantial threat both to quality of care and to the value and status of our profession.

The term bedside manner has long been used to describe “the way a doctor behaves toward people being treated to make them feel comfortable.” ¹⁶ Common use of this term reflects recognition this attribute's importance. Webside manner has emerged as a term to describe similar interactive behaviors, ¹⁷ analogous except that interaction occurs through videoconference. It is heartening that quality of communication in telemedicine has been recognized as no less important for telemedicine than it is for in-person care (however obvious this may appear, if you think about it), and use of the term webside manner may help in disseminating that understanding. Recognition of importance is but a first step, however, toward addressing effectiveness of communication in teaching, learning, performance evaluation, and quality assurance.

How Should We Address This Threat?

Your response might be that there is no need to; “market forces” will resolve the problem. Underlying this outlook might be an assumption that well-trained clinicians already fully understand that real-time videoconference interaction should be the default mode of communication for all telemedicine encounters. The fact that there are essentially no technical barriers to video interaction—given that most adult and many teens carry a smartphone with capacity for secure videoconferencing—suggests that video as default mode might be easy to implement. The continued national marketing of several commercial ventures lacking capacity for video interaction indicates that a more aggressive approach to address this threat is needed, however.

A more effective approach might be based on careful assessment of outcomes for telemedicine models with and without videoconference capacity. Our group and others have evaluated models, including this capacity, establishing high levels of effectiveness ^{13,14,18 –20} in addressing a broad range of problems that commonly present in pediatric primary care, as well as acceptability and satisfaction among providers, ²¹ patients, or their parents. ²² “Screen-to-screen” communication has been found to be similarly effective to in-person communication in one study, ²³ although relevance of this study to primary care might be questioned because of its focus on consultations on pelvic organ prolapse and use of simulated patients. Little or no consideration has been given to evaluation of models lacking videoconference capacity.

It would seem, then, that organizations responsible to society for establishing or enforcing professional standards lack the awareness of the importance of communication skills, or the authority or the will to address them. These organizations include medical schools, medical residency programs, specialty boards (e.g., the American Board of Pediatrics), and licensing bodies (e.g., New York State Board of Medicine). Relatively little research assessing physician communication skills and developing effective training to enhance and maintain these skills has been published. Large effects have been demonstrated, however, for programs that involved small group discussion or structured feedback on specific interview sessions. ^{24 –26} The technology required for real-time interactive telemedicine can also be used, of course, to record interactions. Such recordings would provide material for evaluation and feedback on communication skills, an opportunity that seems likely to have a powerful effect on enhancing quality of care. The vast majority of physicians have rarely, if ever, seen themselves in action.

The challenge to the medical profession introduced by telemedicine may also represent an opportunity for our profession to rededicate itself to interpersonal communication as one of its most essential skills. Recognition that communication skills training is essential reflects not only the importance of these skills, but also the fact that communication skills vary broadly among individuals. In common parlance, we acknowledge differences in such attributes as personality differences. Both innate attributes and life experience influence communication skills heavily. Development, evaluation, and dissemination of such initiatives seem warranted, not only to optimize quality of connected care, but also for enhancing quality of in-person care.

Widespread use of a broad range of telemedicine models already prevails. Given that fact, we must resort to judgment on choice among models while we await further results of well-designed studies of different models to guide our choice among them. A validated measure for patient perception of provider empathy is available for use in such studies. ²⁷ Sound hypotheses emerge from judgment based on expert opinion. In 1927, Francis Peabody wrote, “For the secret of the care of the patient is in caring for the patient.” ²⁸ In writing about qualities of communication that enhance emotional state of another individual, Carl Rogers identified genuine warmth, accurate empathy, and unconditional positive regard as essential components. ¹²

Literature also offers insight on human nature and might inform such judgment as well. Great literature delivers insight, and many believe these authors have. Shakespeare's Portia, in The Merchant of Venice, states,

Similarly, Louisa May Alcott notes in the final sentence of Little Men,