Patient perception of physician empathy in stroke telemedicine

Abstract

Introduction

We assessed patients’ perceptions of physician empathy during telemedicine consultations as compared to in-person consultations during clinical encounters for acute stroke.

Methods

This prospective cohort study was undertaken at a comprehensive stroke centre hub in collaboration with a distant community hospital spoke site. Eligible participants presented to hub or spoke emergency departments with suspected acute stroke within three hours of symptom onset. Participants were evaluated at the hub site in person or at the remote site via telemedicine by the same group of neurologists. Following acute care decisions, single-visit data including participant-reported assessments of physician empathy were collected within 24 h. The primary outcome was the Consultation and Relational Empathy score. The secondary outcome for the telemedicine cohort was the Telemedicine Patient Satisfaction Measure score.

Results

Between 31 May 2013–13 March 2019, 70 patients completed the study. Fifty patients were seen by telemedicine and 20 patients were seen in person. Median Consultation and Relational Empathy scores (with a possible score of 10–50) were 49 (range 27–50) for telemedicine and 45 (range 26–50) for in-person consultations (Wilcoxon rank sum p = 0.18). Each item of the Consultation and Relational Empathy questionnaire was rated very good or excellent by at least 87% of participants in the telemedicine group. The median Telemedicine Patient Satisfaction Measure score was 54 (range 12–60), with each item rated agree or strongly agree by at least 84% of participants.

Discussion

We found no difference between telemedicine and in-person visits in patient perception of physician empathy in acute stroke care. Therefore, we conclude that empathy can be conveyed by facial expression, voice and attentiveness in a telemedicine encounter and, in the setting of acute stroke care, does not require physical touch or proximity.

Keywords

Telemedicine professionalism empathy patient satisfaction ischaemic stroke

Introduction

Stroke is a leading cause of disability and mortality.^1,2 Acute ischaemic stroke can be treated with tissue plasminogen activator (tPA) when given to appropriately selected patients within 4.5 h of symptom onset.^3,4 However, lack of access to acute neurologic expertise has caused tPA treatment rates in eligible patients to remain low despite the known potential for benefit.⁵

The current revolution in telemedicine (TM) addresses geographical disparities caused by a shortage of physician specialists in rural or underserved areas. Stroke TM, or telestroke, consultations allow patients who experience an acute stroke in an area where needed expertise is unavailable locally to gain timely access to specialty neurologic care.⁶ From the local emergency department (ED), the patient can see and hear the neurologist at the hub stroke centre, which may be hundreds or thousands of miles away, via remote presence technology. During the telestroke consultation, the neurologist interviews and examines the patient through interactive videoconferencing while a ED physician or nurse participates at the bedside. The neurologist then communicates with the ED team and participates in time-critical medical decisions. Telestroke has proven to be a sustainable model of acute stroke care delivery, with excellent inter-rater reliability of National Institutes of Health Stroke Scale (NIHSS) scores between TM and bedside assessments^7–10 and increased correct thrombolysis decision-making by TM as compared to telephone-only consultations.^11–13 In light of these findings, telestroke services have rapidly expanded in the USA and are emerging in many other countries.

TM is a welcome though disruptive innovation.¹⁴ While enabling medical communication across great distances, the benefit of extending the reach of care with timely access to specialists comes at the potential cost of altering the dynamics of the physician-patient interaction. Physicians and patients who have been accustomed to a traditional, face-to-face, in-person visit now face the challenge of communicating health information through an added layer of technology, which at first may seem less personal. The tactile and other nonverbal cues that occur during the human interaction of in-person settings may not translate fully or be perceived in the same way during a virtual consultation, potentially making digitally mediated TM interactions seem detached or uncaring.¹⁵ We therefore embarked on a study to assess empathy during the telestroke consultation compared to that in-person at the bedside.

Of all the components of professionalism, empathy may be the most challenging to communicate via TM because of the physical separation of participants. Physician empathy, which includes nonverbal expressions of concern and compassion, is an essential element in the clinical relationship¹⁶ that has been shown to enhance patient satisfaction and compliance^17,18 and to positively influence health outcomes.¹⁹ How physicians communicate empathy during TM encounters is an important yet unexplored question. Despite abundant literature establishing the clinical efficacy of TM in acute stroke care, there has been a paucity of research into how TM technology affects communication between the physician and the patient. Published studies have found that patients’ acceptance of TM is generally positive across a variety of healthcare settings, particularly in regard to convenience,^20–22 and some studies have assessed patient satisfaction,^23–25 but specific physician behaviours that communicate care and concern have not been examined in detail.

We conducted a prospective cohort study in which we assessed patients’ perceptions of physician empathy during a TM encounter versus an in-person encounter for the emergency evaluation of acute stroke. Anticipating that the TM experience might create a distancing effect and detract from the perception of empathetic behaviours,²⁶ we hypothesised that measures of patient-perceived physician empathy would be lower among TM consulted patients than those of patients evaluated in-person. Gaps in communication, once identified, would be prospective targets for quality improvement as we learn to use TM technology in ways that enhance medical professionalism and sustain patients’ trust. We believe that empathy is an important but previously unmeasured variable in TM. Expression of empathy is essential toward building trust when guiding patients through an acute illness. In this case, that may involve administration of tPA and its potential risk of intracranial haemorrhage in 4.6–6.4% of acute stroke patients presenting within the 4.5-hour window.^4,27

Methods

Study sites

The study setting was a hub-and-spoke TM environment involving the hub, Mayo Clinic Hospital, Jacksonville, Florida, USA and a spoke hospital 130 miles away, Parrish Medical Center, Titusville, Florida, USA. TM consultations are performed routinely between the attending vascular neurologist on call at the hub site and suspected stroke patients in the spoke ED using an InTouch Health RP-Lite (Santa Barbara, California, USA) videoconference unit positioned at the foot of the patient’s bed to allow full view. InTouch Health’s RP-Lite is a mobile, robotic platform that allows bidirectional communication over remote distances equipped with pan-tilt-zoom camera with 10× equivalent zoom, hypercardioid microphone and full-range speaker. The patient views a 15-inch diagonal 24-bit colour display at 1024 × 768 pixels resolution, that is sufficiently bright to be clearly visible during conditions of full overhead lighting in the ED setting which amounts to, typically, 50 foot-candles. The device is US Food and Drug Administration-approved and uses an Internet connection that is Health Insurance Portability and Accountability Act (HIPAA) compliant. This study protocol was approved by the Mayo Clinic Institutional Review Board (ID: 13-001112).

Study design

In a prospective cohort study design, 70 adult patients who received a consultation in the ED (50 by TM and 20 in-person) were surveyed between May 2013–March 2019. Eligible patients were identified via notifications from stroke centre operators for TM consultations and via the hub hospital’s stroke alert system for in-person consultations. Inclusion criteria were age ≥18 years, suspected acute stroke syndrome, and evaluation within three hours of symptom onset. Patients were not required to have a confirmed stroke before enrolment. Exclusion criteria included any significant communication deficits during the time of the consultation, such as blindness, severe speech or hearing impairment, severe dementia or a clearly evident or documented mental health condition significantly impairing the ability to communicate or recall the encounter. Patients were excluded if they had a prior clinical experience with the consulting neurologist. Patients at both sites were evaluated by one of the seven co-investigating Mayo Clinic vascular neurologists who are routinely called for these consultations.

Demographic data were gathered, including patients’ self-reported age, gender, ethnicity, preferred language, marital status, educational level and employment. Clinical data were collected from electronic medical records including: NIHSS on presentation and at discharge; neurological deficits involving language, vision or hearing; consultation duration and time of day of consultation. Case form data were entered into a password-protected REDCap database in which participants were assigned a study number that blinded the investigators to the cohort group during data analysis.

All participants provided written informed consent. Perceived physician empathy was assessed within 24 h of the consultation but, in order not to delay thrombolytic therapy, subsequent to acute medical decision-making whether to initiate thrombolytic therapy with tPA.

Empathy outcomes

The primary outcome was patients’ assessment of physician empathy by the Consultation and Relational Empathy (CARE) questionnaire, which was administered to all patients at enrolment. The CARE measure has been well-validated and extensively used internationally to measure empathy as perceived by patients in the context of a therapeutic relationship.^28,29 Its 10 items are organised in a five-point Likert scale and are scored as 1 = poor, 2 = fair, 3 = good, 4 = very good, or 5 = excellent. The CARE total score was calculated by summing the 10 items with a possible score of 10–50, with higher scores reflecting greater perceived empathy.

The secondary outcome was patient satisfaction with TM in the specific context of an emergency setting during the evaluation of acute stroke. As the CARE measure was designed for in-person, rather than TM encounters, patients who received a TM consultation were administered an additional questionnaire, the Telemedicine Patient Satisfaction Measure (TPSM). This questionnaire was designed by the investigators with items pertinent to the type of TM encounter under study. The TPSM was based on a previously validated patient satisfaction questionnaire²¹ with the language modified for relevance to patient satisfaction with TM during an emergency consultation. Its 12-question measure uses a five-point Likert scale and is scored as 1 = strongly disagree, 2 = disagree, 3 = no opinion, 4 = agree, or 5 = strongly agree. The TPSM score was calculated by summing the 12 items, yielding a possible score of 12–60, with higher scores reflecting greater patient satisfaction.

Statistical analysis

The study was designed to detect a six-point mean difference in CARE scores between the two groups with at least 90% power, assuming a two-sided type I error rate of 5% and also assuming the distribution and variability of CARE scores to be similar to those observed in the study by Mercer et al.²⁸ The initial planned sample size was 100 patients (50 TM and 50 in-person). Due to competing ongoing stroke studies and departmental relocation, the enrolment rate for in-person consultations was lower than expected, and, based on an interim power analysis in 2016, the steering committee determined that the planned statistical power would be achieved by reducing the in-person cohort to 20 patients, and thus lowered the total sample size to 70 patients. The interim analysis was done blinded to consultation type and, therefore, no adjustment to the type I error rate was needed.

Diverging stacked bar charts were created to summarise the responses to each question on the CARE and TPSM questionnaires. For the primary analysis we used the non-parametric Wilcoxon rank sum test to compare the total CARE score for patients’ perceptions of physician empathy between those who received a TM consultation and those who received an in-person consultation. A two-sided p-value <0.05 was considered to be statistically significant. We additionally compared patient demographics, clinical characteristics, duration of consultation and treatment received between the two groups using Fisher’s exact test for categorical data and a Wilcoxon rank sum test for continuous and ordered data. For calculating either CARE or TPSM total score, if a patient marked up to two items as ‘does not apply' or the item was missing, then the average of the remaining items was imputed for those responses. Total scores were not calculated for patients with more than two items that were missing or marked as ‘does not apply'. Further analyses are described in the results and were done without adjustment for multiple testing.

All analyses were performed using SAS (Version 9.4, SAS Institute Inc., Cary, North Carolina, USA).

Results

The study enrolled 71 patients from May 2013–March 2019. Three patients who were offered participation declined. One patient did not complete the surveys and was excluded from the study. The remaining participants consisted of 50 patients who received a TM consultation and 20 patients who received an in-person consultation. Participants ranged in age from 24–95 years; 39 (56%) were female, 46 (66%) were married or lived with a domestic partner, 16 (23%) had completed at least a four-year college degree, and 26 (38%) were employed at the time of consultation. All patients identified English as their preferred language. Patient demographics and baseline characteristics are summarised in Table 1. Compared to those who received an in-person consultation, those who received a TM consultation tended to be younger (median age (interquartile range (IQR)): 63 years (55–71) vs 75 years (61–84 ), p = 0.04), single or divorced (44% vs 10%, p = 0.01), absent of cognitive deficit (0% vs 15%, p = 0.02) and presented with a lower NIHSS (median (IQR): 1 (0–4) vs 4 (1–9), p = 0.03).

Table 1.

Patient demographics and clinical characteristics.

Characteristic	Telemedicine cohort (n = 50)	In-person cohort (n = 20)	p Value
Male gender	23 (46%)	8 (40%)	0.79
Age, years	63 (55, 71)	75 (61, 84)	0.04
Ethnicity
Hispanic or Latino	1 (2%)	0 (0%)
Not Hispanic or Latino	43 (86%)	20 (100%)	1.00
Unknown or not reported	6 (12%)	0 (0%)
Race
White	42 (84%)	19 (95%)	0.42
Black or African-American	4 (8%)	1 (5%)
Other	3 (6%)	0 (0%)
Unknown or not reported	1 (2%)	0 (0%)
Marital status
Married or partnered	28 (56%)	18 (90%)	0.01
Single or divorced	22 (44%)	2 (10%)
English as preferred language	50 (100%)	20 (100%)	1.00
Education			0.12
Did not finish high school	3 (6%)	1 (5%)
High school or GED	17 (34%)	4 (20%)
Some college, associate degree or trade school	21 (42%)	7 (35%)
Four-year college degree	5 (10%)	7 (35%)
Master’s degree	3 (6%)	1 (5%)
Not reported	1 (2%)	0 (0%)
Employment
Not employed	31 (62%)	11 (58%)	0.78
Currently employed	18 (36%)	8 (42%)
Not reported	1 (2%)	1 (5%)
Vision deficit	6 (12%)	4 (20%)	0.46
Hearing deficit	0 (0%)	0 (0%)	1.00
Language deficit	12 (24%)	5 (25%)	1.00
Cognitive deficit	0 (0%)	3 (15%)	0.02
NIHSS on presentation	1 (0, 4), n = 48	4 (1, 9)	0.03

GED: General Educational Development; NIHSS: National Institutes of Health Stroke Scale.

Data are given as median (25th percentile, 75th percentile) or number (percentage). Values of p result from Wilcoxon rank sum tests for continuous and ordered data and from Fisher’s exact tests for categorical data. Responses that were unknown or not report were excluded from the statistical tests for comparisons between the telemedicine consultation group and the in-person consultation group. Value of p for race is based on comparing the proportion of white participants between the two groups.

As shown in Table 2, the length of the consultation tended to be shorter for TM vs in-person visits (median (IQR): 19 min (15–23) vs 25 min (18–37), p = 0.04). The decision to administer tPA occurred in 14% of patients in the TM group and 30% of the in-person group; however, this was not statistically significant (p = 0.17).

Table 2.

Consultation and treatment information.

Characteristic	In-person cohort (n = 20)	Telemedicine cohort (n = 50)	p Value
tPA given	6 (30%)	7 (14%)	0.17
Duration of consult	25 (18, 37)	19 (15, 23)	0.04

tPA: tissue plasminogen activator. Data are given as median (25th percentile, 75th percentile) or number (percentage). Values of p result from Wilcoxon rank sum tests for continuous data and from Fisher’s exact tests for categorical data.

The median CARE total score was 45 (range 26–50, IQR 39–50) out of a possible 50 among those who received in-person consultations and 49 (range 27–50, IQR 40–50) among those who received TM consultations (Figure 1). Each of the 10 items of the CARE questionnaire was rated ‘very good' or ‘excellent' by at least 87% of patients in the TM group (Table 3 and Figure 2). In a further multivariable logistic regression analysis, we did not find a statistically significant association of consultation type with a CARE score of 40 or higher (very good to excellent) adjusting for age, marital status, NIHSS and consultation duration (odds ratio (TM vs in-person) = 1.72, 95% confidence interval (CI) 0.43–7.70, p = 0.48).

Figure 1.

Distribution of the Consultation and Relational Empathy (CARE) scores.

Table 3.

Consultation and Relational Empathy (CARE).

CARE item	Telemedicine (n = 50)	In-person (n = 20)	p Value
1. Making you feel at ease			0.21
Mean (SD)	4.5 (0.8)	4.3 (0.9)
Median (IQR)	5 (4–5)	5 (4–5)
2. Letting you tell your story			0.24
Mean (SD)	4.5 (0.6)	4.3 (0.8)
Median (IQR)	5 (4–5)	4 (4–5)
3. Really listening			0.99
Mean (SD)	4.5 (0.7)	4.6 (0.7)
Median (IQR)	5 (4–5)	5 (4–5)
4. Being interested in you as a whole person			0.93
Mean (SD)	4.5 (0.7)	4.5 (0.7)
Median (IQR)	5 (4–5)	5 (4–5)
5. Fully understanding your concerns			0.52
Mean (SD)	4.5 (0.7)	4.4 (0.8)
Median (IQR)	5 (4–5)	5 (4–5)
6. Showing care and compassion			0.12
Mean (SD)	4.5 (0.6)	4.1 (1.0)
Median (IQR)	5 (4–5)	4 (4–5)
7. Being positive			0.28
Mean (SD)	4.5 (0.7)	4.3 (0.7)
Median (IQR)	5 (4–5)	4 (4–5)
8. Explaining things clearly			0.50
Mean (SD)	4.5 (0.7)	4.3 (0.9)
Median (IQR)	5 (4–5)	5 (4–5)
9. Helping you to take control			0.13
Mean (SD)	4.6 (0.7)	4.1 (1.2)
Median (IQR)	5 (4–5)	3 (4–5)
10. Making a plan of action with you			0.57
Mean (SD)	4.5 (0.9)	4.2 (1.1)
Median (IQR)	5 (4–5)	5 (3–5)

IQR: interquartile range; SD: standard deviation.

Wilcoxon rank sum tests were used to compare CARE items between the telemedicine group and the in-person group.

Figure 2.

Consultation and Relational Empathy (CARE) responses.

The TPSM had a median total score of 54 (range 12–60, IQR 48–58) out of a possible 60 among patients who received a TM consultation. Each of the 12 items of the TPSM was rated ‘agree' or ‘strongly agree' by at least 84% of patients in the TM group (Table 4 and Figure 3).

Table 4.

Telemedicine Patient Satisfaction Measure (TPSM) among 50 patients who received an acute stroke consultation via telemedicine.

TPSM item	Telemedicine (n = 50)
1. Telemedicine enabled the doctor to see me sooner than I had expected
Mean (SD)	4.1 (1.1)
Median (IQR)	4 (4–5)
2. I felt comfortable talking with the doctor over the telemedicine system
Mean (SD)	4.2 (0.8)
Median (IQR)	4 (4–5)
3. I could hear clearly what the doctor said over the telemedicine system
Mean (SD)	4.3 (0.9)
Median (IQR)	4 (4–5)
4. The doctor spoke in a professional manner over the telemedicine system
Mean (SD)	4.4 (0.9)
Median (IQR)	5 (4–5)
5. I could clearly see the doctor over the telemedicine system
Mean (SD)	4.3 (0.9)
Median (IQR)	4 (4–5)
6. The doctor looked professional over the telemedicine system
Mean (SD)	4.4 (0.9)
Median (IQR)	5 (4–5)
7. The doctor was intelligent and capable
Mean (SD)	4.4 (0.9)
Median (IQR)	5 (4–5)
8. The telemedicine equipment did not make me feel more anxious
Mean (SD)	4.1 (1.0)
Median (IQR)	4 (4–5)
9. The care I received through the telemedicine consultation was as good as a face-to-face visit
Mean (SD)	4.0 (1.0)
Median (IQR)	4 (4–5)
10. I felt confident that my personal health information was confidential when transmitted over the telemedicine system
Mean (SD)	4.3 (0.9)
Median (IQR)	4 (4–5)
11. The doctor on the video and the emergency room staff worked together as a team
Mean (SD)	4.3 (0.9)
Median (IQR)	4 (4–5)
12. Overall, I was satisfied with the telemedicine consultation
Mean (SD)	4.3 (1.0)
Median (IQR)	5 (4–5)

IQR: interquartile range; SD: standard deviation.

Figure 3.

Telemedicine Patient Satisfaction Measure (TPSM) responses.

In comparing scores by female and male patients (Table 5), we found no significant difference in any of the CARE items. Interestingly, median TPSM scores were higher for females compared to males, although the difference was not statistically significant.

Table 5.

Comparisons of Consultation and Relational Empathy (CARE) scores and Telemedicine Patient Satisfaction Measure (TPSM) scores between males and females according to consultation type.

Score	Consultation type	Male Median (IQR), n	Female Median (IQR), n	p Value
CARE score	In-person	41 (38–47), n = 8	47 (40–50), n = 12	0.13
	Telemedicine	50 (40–50), n = 22	49 (40–50), n = 27	0.82

TPSM score	Telemedicine	48 (48–57), n = 23	56 (48–59), n = 27	0.14

IQR: interquartile range.

Wilcoxon rank sum tests were used to compare scores between males and females.

Discussion

We found no statistically significant difference in patients’ perceived level of physician empathy between those who had a TM consultation and those who had an in-person consultation. Both groups reported high levels of perceived empathy, and those who received care by TM reported high levels of satisfaction. These results suggest that TM can be used in ways that assist rather than intrude into the consultation and that the visible presence of technology in the room does not necessarily diminish patients’ perceptions of their physicians’ expression of understanding, compassion and willingness to help.

TM inserts technology between the patient and the physician that can either facilitate information exchange or become a barrier, especially as it limits nonverbal communication, an essential component of the healing relationship. Integrating verbal and nonverbal communication promotes alignment of patients’ preferences with medical recommendations, shared understanding, shared decision-making and the meeting of patients’ emotional needs.³⁰ The paradigm shift of TM technology challenges healthcare professionals to adapt communication skills to this new and evolving setting in order to maintain our commitment to professionalism and to foster the development of trust needed for partnership in medical care.

A number of other studies have explored patients’ satisfaction and experiences with TM in nonemergent settings including stroke rehabilitation,³¹ paediatrics³² and dermatology.³³ Most of these studies assessed less stressful routine clinical encounters in which a prior in-person relationship existed, or gathered data months after the visit.^22,34 In the only previous study to assess patients’ perspectives of TM in acute stroke care, semi-structured interviews were conducted with 11 patients following TM consultation for acute stroke. When asked to describe their experiences using TM, patients responded that they accepted the technology in general but perceived an added layer of complexity or a sense of personal detachment.²⁶ The interviews occurred within four weeks of TM consultations, and several patients had little or no recall of the TM experience. By contrast, all of our patients were surveyed within 24 h of the TM consultation and were able to recall the encounter.

As the provision of TM increases and facilitates access to care, physicians must acquire not only the necessary technical knowledge but also communication skills adapted to the technology that express care and concern to patients. Having subjective feelings of empathy is inadequate to establish trust; physicians must also show understanding, express acknowledgement of patients’ concerns and demonstrate the will to find solutions. It is important to recognise that effective skills for expressing empathy through TM will differ in some ways from those for in-person encounters. For example, in our practice we have found that the TM setup prevents direct simultaneous eye contact. When the physician is looking at the patient’s eyes on the screen, the patient sees an image of the physician looking down, away from the camera anchored at the top of the screen. To overcome this, the physician must intentionally look up at the camera during key moments in the discussion, accommodating to the technology to show attentiveness to the patient as a person.

Based on our combined experience, we offer a number of further suggestions for best practices in TM consultations (Table 6). To show respect for the patient, interruptions should be minimised, and during the TM interaction the physician should refrain from reading or sending messages unrelated to the encounter. Referring to the patient and others in the patient’s room by name helps to establish teamwork. Acknowledging the patient’s emotion and anxiety with explicit statements of concern demonstrates empathy, as sitting down or moving closer to the patient are not possible. Smiling communicates warmth and nodding communicates understanding when hand gestures or touch are not possible. Having the care team at the patient’s site explain TM to the patient before the remote consultant appears on the screen can mitigate the apparent strangeness of a technology unfamiliar to the patient.

Table 6.

Recommended best practices for telemedicine communication.

Explain telemedicine to the patient

Remain respectful and attentive to the patient

Minimise interruptions and distractions

Address the patient by name

Imaginatively enter into the patient’s situation

Acknowledge the patient’s situation with explicit statements of concern

Offer sincere acknowledgement of the patient’s worries and emotions

Look directly into the camera when addressing the patient during critical moments

Smile and nod at appropriate moments

Refer to others in the patient’s room by name and involve them in discussion

Offer statements of consolation

Refrain from making statements that might suggest culpability

The current study has several limitations. The sample size was relatively small for exploring specific empathy components in more detail. As the inclusion criteria required patients to have the ability to communicate and recall the consultation, these findings might not be generalisable to other patients with more severe neurological deficits. Further, this study was conducted within the milieu of a pre-existing, well-functioning, collaborative relationship between the hub and spoke institutions, which might have been a factor causing patients to interpret TM consultations favourably. Another potential factor contributing to favourable ratings may have been patients feeling greater appreciation of care received by TM because they were given access to an expert despite living far from the referral centre. For these reasons, these results might not extrapolate to healthcare settings where an effective team relationship has not been established and the remote consultant seems more of a stranger.

In conclusion, as TM services increasingly enter into healthcare, medical professionals will be challenged, not only in technical skill but also in communication skills essential to professionalism.

Conclusion

TM, an emerging paradigm shift in the delivery of healthcare across geographical boundaries, has the potential to constrain caregivers’ ability to convey expressions of compassion and concern. With intentional implementation of best practices, communication of empathy, an essential component of professionalism, is attainable when using TM technology.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work was supported by the Mayo Clinic Program in Professionalism and Values.

ORCID iD

William P Cheshire

William D Freeman

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