Effect of telemedicine via videoconference on provider fatigue and empathy: Implications for the Quadruple Aim

Abstract

Telemedicine via videoconferencing rapidly deployed during the COVID-19 pandemic reduces contact and opportunity for virus transmission, with Quadruple Aim benefits of improved population health and associated cost avoidance of COVID-related illness. Patient experience of telemedicine has generally been positive, but widespread use of videoconferencing outside of healthcare has brought growing recognition of associated mental fatigue. Experience in telepsychiatry shows attending to non-verbal communication and maintaining empathic rapport requires increased mental effort, making provider experience more sensitive to cumulative fatigue effects. Since empathy and therapeutic alliance are foundational to all physician-patient relationships, these telepsychiatry findings have implications for telehealth generally. Health leaders and providers planning for sustainable incorporation of videoconferencing into ongoing healthcare delivery should consider the potential for unintended negative effects on provider experience and burnout.

Introduction

Public health orders to shelter-in-place and other restrictions associated with the COVID-19 global pandemic led to rapid uptake of Videoconferencing (VC) technology as a means for individuals to stay connected to one another, both in work and in private life. Healthcare has been no exception, with virtual care options being deployed to reduce the burden of COVID-19 and preserve valuable equipment and supplies.¹ Widespread experience with VC has led to the recognition that it entails its own set of cognitive demands and stressors, with discussion of “Zoom fatigue” and its mitigation entering our public discourse.² Drawing on the literature in telepsychiatry, this paper considers the potential for VC in general clinical use to be associated with unintended effects on participant experience, and hence impact on the Quadruple Aim of healthcare: improving population health, enhancing patient experience, reducing costs, and improving work life of healthcare providers.³

Telemedicine via VC has been in use for decades, with early telemedicine services typically addressing remote/rural service delivery.⁴ In the ensuing years as technology improved and with VC becoming more prevalent in non-clinical contexts, there was slow growth in interest in provision of virtual care⁵ but barriers to adoption remained. With the arrival of the global pandemic, however, health leaders worked quickly to remove organizational, regulatory, and funding barriers.⁶ In 2021, the College of Physicians & Surgeons of British Columbia updated its practice standard for telemedicine and virtual care⁷ to state explicitly, “Virtual care is a core component of medical care.” Telepsychiatry can be considered as prototypical of medical care delivered via VC. Psychiatrists are rarely expected to examine patients with physical touch, making mental health services uniquely suited for transformation to VC delivery during the pandemic.⁸ It is not surprising then to have seen our use of VC rapidly scale to become the prime mode of outpatient psychiatry service delivery.^9,10 Knowledge gained from study of telepsychiatry may be transferrable to other clinical practice settings such as cancer care, chronic disease management, longitudinal primary care, and others.

Viewed within the framework of the Quadruple Aim,³ it is self-evident that using virtual care solutions such as telepsychiatry (and telemedicine in general) via VC will improve the health of the population during a pandemic as it eliminates the potential for pathogen transmission in the clinic among patients, staff, and providers. It follows that reduced transmission of disease will result in avoidance of significant costs associated with pandemic illness. Evidence favours telepsychiatry over in-person care for cost.¹¹ Telepsychiatry is generally considered comparable in effectiveness to in-person care, reassuring us that there should be no expectation of sacrificing mental health outcomes by using VC to achieve communicable disease control objectives. To realize these outcomes, however, patients must be able to access and utilize the requisite broadband-connected equipment. There is recognition that limited access to technology or hesitancy with its use may impact the delivery of equitable healthcare service to vulnerable and disadvantaged populations. This “digital divide” could be widened with our pivot to using VC in the pandemic but is also an opportunity to address these gaps structurally while the issues are top of mind in public discourse.¹² Fortunately, there is evidence that when those with severe mental illness (ie, psychosis) have access to technology, their uptake of telepsychiatry is comparable to that for mental health consumers as a whole.¹³ Thus, telepsychiatry offers a lower-cost means of sustaining current mental healthcare delivery (albeit with a caveat about some vulnerable populations), while achieving important pandemic-related population health outcomes and cost avoidance.

Reviews of telepsychiatry¹⁴ and telepsychology¹⁵ have found VC to generally be associated with high levels of patient and client satisfaction. The pre-COVID literature on provider experience of telepsychiatry consistently showed that satisfaction with VC as a modality for consultation and psychotherapy has been lower for providers than for patients.¹⁶ This finding has held up in the context of pandemic care as well,¹³ with surveyed psychiatrists expressing a strong preference to return to in-person consultation. It may be speculated that the dissatisfaction with telehealth may be a generational effect with younger “digital natives” being more likely to feel comfortable adopting VC technology, but recent data on newly trained physicians showed that only 12% felt prepared to deliver virtual care.¹⁷

What challenges us when using VC?

Empathy in the context of VC

Providers report that it is more difficult to establish comparable levels of empathy in virtual care settings.^15,18 Empathy is foundational to the physician-patient relationship and is positively associated with patient health outcomes.¹⁹

Empathy is conveyed with verbal and non-verbal behaviours.²⁰ Facial expressions, eye contact, body position, and vocal tone contribute to convey empathy non-verbally,²¹ as does the responsive modulation of these attributes in time.²² Much has been written on the importance of eye contact to provide information, regulate interaction, express intimacy, exercise social control, and facilitate service and task goals.²³ Reciprocal gaze is considered a particularly intimate mode of interpersonal encounter,²⁴ and high eye contact is related to patients’ perceptions of empathy, therapeutic alliance, and treatment credibility.²⁵ Faces with direct eye contact are processed more intensely by the brain.²⁶ Non-verbal cues are perceived quickly and preconsciously,²⁷ modulating concurrent cognitive processes as well as those immediately following.²⁸

Given what we know of the critical role of non-verbal communication in empathy formation, it is important to consider how technical aspects of VC may contribute to the ease or difficulty with which participants perceive non-verbal cues, and thus impact the effort required by providers to realize sufficient empathy in virtual patient interactions. Telemedicine via VC entails synchronous audio and video channels between participants making it sensitive to the disruptive effect of time delay (signal lag). Delays in the VC medium can make the interaction feel that it has less immediacy and responsiveness, weakening the empathic connection²⁹ and increasing cognitive load.³⁰ Silence has important meaning in communication, and it becomes more difficult to interpret when the participants must gauge whether silence reflects the actual interpersonal interaction or arises from technical difficulties with the connection. Video image resolution differentially affects recognition of negative emotions.³¹ This is not solely a function of camera and screen resolution: Pixellation, or loss of video resolution due to fluctuation in connection bandwidth, can transiently affect the VC session and create circumstances where non-verbal cues get missed or misinterpreted.³² Camera viewing angle (perspective) of face/head position³³ and of body position³⁴ impacts our ability to recognize others’ emotions. Video framing and field of view are also important for appreciation and interpretation of body language,³⁵ but even with optimal video framing certain semiotics of the patient encounter are still lost, such as the handshake and the way the patient enters and leaves the office.³⁶ Human perception of eye contact is very sensitive to small deviations in gaze, manifesting in VC as a parallax paradox: When looking at the other VC participant’s eyes on the screen I am not looking directly at the camera, and thus to them I do not appear as if I am making eye contact; when I look at the camera it will appear as though I am making eye contact when I am not looking at the other’s face at all. This apparent gaze discrepancy impacts patient perceptions of their providers³⁷ and is mitigated by bringing the camera angle within 5° of where the participant’s eyes are displayed.³⁸

It has been suggested that VC and other technology-mediated interactions are incapable in principle of producing the same experience of empathy as is felt in an in-person encounter.^39,40 However, this notion of intrinsic difference between the empathy experienced virtually versus in-person has been challenged.⁴¹ The level of perceptual richness in VC communication determines the verisimilitude of the participants’ representations to one another and appears to be the critical factor determining whether the necessary and sufficient conditions are met for empathic communication to be possible.³²

Susceptibility to distraction

Well-implemented VC technology aspires to be transparent to the participants, such that each literally looks through the screen to see the other, rather than looking at the screen and being conscious of it as an intervening object.⁴¹ A characteristic feature of contemporary VC platforms is the presentation of a self-view, where the participants see their own video image alongside that of the other. In addition to being a distraction,³⁰ there is evidence that the increased awareness of one’s own visual presentation increases inhibition and self-critical thought⁴² with conscious self-evaluation leading to increased defensiveness, diminished spontaneity, and greater attendance to social image.⁴³ Controlled self-presentations require effort and can be draining, even if the intent is to convey an accurate impression.⁴⁴ Lozano and colleagues⁴⁵ recommend that patient self-view be switched off in VC as its use “…may lead to disruption in communication, exacerbate distress, or make the sharing of intense emotions more difficult”. However, they deemed self-view to be helpful when enabled for the provider as an additional tool to guide therapeutic communication, although this benefit needs to be weighed against the potential for provider distraction.

What is the effect of VC on fatigue in the clinical context?

The net effect of VC on providers’ cognitive load is such that telepsychiatry in clinical practice has been estimated to require 15-20% more clinician activity and attentiveness than in-person care.⁴⁶ Those estimates pre-date the onset of the COVID-19 pandemic, and so may be cumulative with the general Zoom fatigue that providers are also accruing during virtual rounds, meetings, teaching sessions, and personal VC calls. When we consider that the transition to telepsychiatry during COVID-19 has been reported to be associated with an overall increase in visits of 26.2% (due to a net increase in the volume of appointments scheduled plus a reduction in no-show rates),¹³ the risk of provider fatigue, stress, and burnout is compounded. There are multiple contributory causes for compassion fatigue and provider burnout, including workload,⁴⁷ and physicians are at higher risk for burnout than other workers.⁴⁸ Stresses associated with higher burnout have a direct and immediate effect on physician empathy, which can be measured to vary across a single shift.⁴⁹ The experience of authentic, humanistic interaction with patients (and with colleagues) enhances physician well-being,⁵⁰ and failing to connect meaningfully with patients has been shown to contribute to burnout.⁵¹ Taken together, these findings raise the possibility that our wholesale pandemic adoption of telemedicine may risk establishing a positive feedback loop that threatens the Quadruple Aim: Provider empathy is less easily established in VC leading to more cognitive work of care. This raises associated fatigue, which is then compounded by the observed increase in service volume. Diminished experience of felt empathy and meaningful connection to the patient reduces physician well-being and is less able to have a balancing effect against the experience of burnout. As stress and burnout grow, empathy becomes ever more difficult to manifest creating a vicious cycle. Unchecked, this can eventually undermine patient outcomes and satisfaction which have been shown to be positively correlated with provider empathy.^19,52

Sustainably incorporating VC into clinical practice

Medicine (including psychiatry) has responded to the pandemic imperative to embrace virtual care, realizing the immediate patient outcome benefits of reduced exposure to infection by avoiding hospital outpatient and clinic settings while continuing to deliver assessment, treatment, and follow up of both new and pre-existing patient conditions. Notwithstanding that providers have expressed a preference to return to in-person consultation,¹³ expanded use of telepsychiatry is already envisioned as a legacy that will endure after the pandemic has ended.¹² Given the findings associated with VC of providers experiencing both increased effort and decreased satisfaction, what mitigation opportunities are there so that virtual care can be a sustainable part of future practice? Virtual care via VC holds promise for patients, providers, and health organizations with the proviso that the most challenging aspects of the technology – accessibility for vulnerable and at-risk populations, and the impact of qualitative differences in the therapeutic encounter on provider (and patient) experience – can be addressed. The literature offers recommendations for individual providers to adopt as remedies for difficulty in telepsychiatry (Table 1),^10,45 but these have not yet been tested empirically for effectiveness. The advice for combatting Zoom fatigue in the corporate and academic contexts includes reducing potential distractions that increase cognitive burden, and building breaks into the daily schedule for respite from the videoconference screen.⁵³ A practical means of tempering the impact of virtual care demands on individual providers on a day-to-day basis is to combine telepsychiatry with conventional clinic work. This concept of so-called hybrid practice has been forecast as a form that psychiatric care is likely to take in the future.¹⁶

Table 1.

Example mitigation strategies for challenges arising in telepsychiatry via VC (see reviews by Lozano,⁴⁵ and Markowitz¹⁰ for more detailed discussion).

Challenge	Mitigation
Distractions	Exit concurrently running applications, particularly ones with interrupting alerts
Distractions	Minimize or hide self-view
Pixellation and lag	Reduce other network/Internet use
Pixellation and lag	Use Wi-Fi booster or wired network connection
Emotional distancing	Increase distances from camera for fuller body view
	Keep angle between camera and screen location of remote participant’s eyes less than 5°
	Optimize subject lighting to reduce glare and backlighting
	Wait and observe rather than rushing to fill silences
Physical discomfort	Get up and stretch, move between sessions
	Use ergonomic furniture
	Interleave VC sessions with face-to-face appointments in the schedule

Telepsychiatry presents an ideal setting within which further study and investigation can be done, given that observation and documentation of subjective qualities of therapeutic interaction such as degree of empathy and emotional engagement are parts of routine clinical practice. Methodologically, sound studies to answer questions about the impact of VC on patient and provider experience, and on longitudinal health outcomes of patients and populations, will need to frame virtual care as a sociotechnical system within the complex wider dynamic healthcare system. Telehealth providers and health system leaders need to appreciate qualitative differences between virtual care and in-person care and ensure that quality metrics capture data on VC connections (eg, remote participant device type and location, network bandwidth and response time, video frame rate, and number of dropped calls) in addition to the usual clinical indicators. Maintaining competence in telemedicine is a professional expectation,⁵⁴ and this will entail incorporating new knowledge about the impact of VC and translating it into clinical practice.

Footnotes

ORCID iD

Lonn Myronuk

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