Patient Perspectives Regarding Clinician Communication During Telemedicine Compared With In-Clinic Abortion

Abstract

OBJECTIVE:

To explore patient perspectives regarding patient–clinician communication during telemedicine medication abortion compared to traditional, facility-based, in-clinic visits.

METHODS:

We conducted semi-structured interviews with participants who received either live, face-to-face telemedicine or in-clinic medication abortion from a large, reproductive healthcare facility in Washington State. Using Miller’s conceptual framework for patient-doctor communication in telemedicine settings, we developed questions exploring participants’ experiences of the medication abortion consultation, including the clinician’s verbal and non-verbal interpersonal approach and communication of relevant medical information, and the setting where care was received. We used inductive-deductive constant comparative analysis to identify major themes. We summarize patient perspectives using patient–clinician communication terms outlined in Dennis’ quality abortion care indicator list.

RESULTS:

Thirty participants completed interviews (aged 20–38 years), 20 of whom had medication abortion by telemedicine and 10 who received in-clinic services. Participants receiving telemedicine abortion services reported high-quality patient–clinician communication, which came from their freedom to choose their consultation location and feeling more relaxed during clinical encounters. In contrast, most in-clinic participants portrayed their consultations as lengthy, chaotic, and lacking comfort. In all other domains, both telemedicine and in-clinic participants reported similar levels of interpersonal connection to their clinicians. Both groups appreciated medical information about how to take the abortion pills and relied heavily on clinic-based printed materials and independent online resources to answer questions during the at-home termination process. Both telemedicine and in-clinic participant groups were highly satisfied with their care.

CONCLUSION:

Patient-centered communication skills used by clinicians during facility-based, in-clinic care translated well to the telemedicine setting. However, we found that patients receiving medication abortion through telemedicine favorably ranked their patient–clinician communication overall as compared to those in traditional, in-clinic settings. In this way, telemedicine abortion appears to be a beneficial patient-centered approach to this critical reproductive health service.

Précis:

Telemedicine appears to be a beneficial patient-centered approach to critically needed first-trimester abortion services.

Today, medication abortion makes up more than half of all abortions occurring in the United States (U.S.).¹ Abortion by telemedicine became more prevalent during the COVID-19 Public Health Emergency (PHE) when the U.S. Food and Drug Administration (FDA) temporarily, and then permanently suspended the mifepristone in-clinic dispensing requirement.² Requests for direct-to-patient telemedicine medication abortion services, in which patients choose where they receive care are expected to increase following the 2022 U.S. Supreme Court case Dobbs decision.^3,4

Despite its growing use, data regarding best practices for patient-clinician communication when providing abortion care through telehealth are lacking. Patient-clinician communication is considered a critical element of patient-centered care, and has been associated with valuable health system outcomes, including increased patient trust, improved treatment adherence, overall positive patient experience, improved healthcare efficiency, and lower cost.^5–7

For abortion care, however, patient-clinician communication considerations are unique because of both stigma and the systemic access issues that often compromise the ability for care to be patient-centered.⁸ Unlike other aspects of reproductive health care, patients often obtain abortion care from someone other than their usual clinician, further compromising comfort and trust.^9–11 By interviewing participants who received direct-to-patient telemedicine medication abortion services, we explored the setting and how clinicians’ interpersonal and communication behaviors affected the patient experience of patient–clinician communication compared to traditional, in-clinic medication abortion care.

METHODS

We conducted a cross-sectional, in-depth, semi-structured interview study of patients who had recently received an in-clinic or telemedicine medication abortion. This study received institutional review board (IRB) approval by the University of Washington (UW) Human Subjects Division (ID: STUDY00013954) and is reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.¹²

The team consists of a Principal Investigator (PI) who is a Complex Family Planning Fellowship-trained physician with master-level training in qualitative research (EMG), a PhD candidate in public health with experience working in abortion policy and qualitative research (AEF), a medical anthropologist and a master’s level qualitative methods consultant (EAJ), a research coordinator with a masters of public health in maternal/child health (MRR), a medical student (EVY) and a family physician who provides abortion care with research expertise in implementation science (IMB). Throughout the study period, we enlisted a Community Advisory Board that represented Latina, young adult, and rural communities, two abortion advocacy organizations and a staff member from the clinic where we recruited participants.

We used Miller’s conceptual framework for the evaluation of patient-clinician communication in telemedicine settings (Fig. 1).¹³ We chose this model because it incorporates core components of patient-centered communication that have been widely quoted in the literature. The Miller framework also includes a category with factors related to the medium (e.g., telemedicine) used for the patient–clinician encounter, a key aspect we sought to evaluate among our participants.

Fig. 1:

Adaptation of Miller’s definitions to indicators related to patient–clinician communication within quality abortion care. *Client provider interactions, decision making. ^†Information provision, support, technical competence.

This study used convenience sampling of all patients who had been given the option to receive medication abortion either by telemedicine or in-clinic from a Washington State independent, high-volume reproductive healthcare clinic organization, Cedar River Clinics (CRC). CRC is certified by several networks, including the National Abortion Federation. CRC began offering telemedicine medication abortion services using live, face-to-face video conferencing software in April 2020, in addition to continuing traditional in-person, clinic appointments. Telemedicine appointments require a known last menstrual period within 7 days, regular periods, no symptoms or risk factors for ectopic pregnancy and verbal confirmation of a positive pregnancy test, without requiring an ultrasound exam for gestational dating. Washington State permits nurse practitioners to provide medication abortion services, thus participants’ clinical encounters involved either a physician or nurse practitioner.

To be eligible, participants had to speak and understand English, be at least 18 years old, had either telemedicine or in-clinic medication abortion in the prior month, and agree to an audio-recorded interview. Because we were most interested in evaluating patient–clinician communication with novel telehealth abortion, we purposively enrolled more telemedicine than in-clinic participants. To recruit participants, CRC staff asked every eligible patient to indicate their interest in being contacted by the UW study team when they signed their consent for abortion services. On a weekly basis, CRC staff provided contact information of interested patients to the research coordinator, who then attempted to contact each interested participant up to three times by email, text, or call over a two-week period. Contacted participants completed an eligibility survey in a secure REDCap database,¹⁴ provided informed consent and scheduled an interview using an online calendar platform or by phone. Each participant received a $50 electronic gift card by email following their interview.

The qualitative methods consultant conducted semi-structured, in-depth interviews using HIPAA-compliant conferencing software at a time and place of the participant’s choosing between September 2021-January 2022.

The research team developed the interview guide based on Miller’s conceptual framework. Questions included the decision about the medication abortion service type (telemedicine vs. in-clinic), scheduling and attending their appointment, the clinician encounter, the setting where the encounter occurred, satisfaction with the care and clinical outcomes. Prior to initiating the interview, the qualitative methods consultant provided a brief description of the study team and assured participants their information would not be reported back to CRC. Each interview ranged between 35–60 minutes, was audio-recorded and transcribed. The interviewer recorded field notes after each interview, reflecting on data collection, personal biases, and patterns. No interviews were repeated. After the research team completed all the interviews, CRC provided the team with requested participant characteristic information (Table 1). Although an imperfect measure, we chose to list race/ethnicity as a proxy of shared lived experience to highlight the voices that informed this study.¹⁵

Table 1:

Selected participant characteristics by medication abortion service (N=30)

Characteristic	Telemedicine (N=20)	In-clinic (N=10)
	Mean ±SD	Mean ±SD
Participant age (years)	31.0 ±5.7	27.0 ±5.9
Gestational age at time of service (days)	43.6 ±21.5	43.6 ±15.6
Self-reported prior abortion(s)*	N (%)	N (%)
0	10 (50.0)	7 (70.0)
1 or more	10 (50.0)	3 (30.0)
Self-reported race/ethnicity
Declined to specify	3 (15.0)	2 (20.0)
Hispanic/Latino	5 (25.0)	1 (10.0)
Non-Hispanic/Latino
Additional (unspecified) races and ethnicities	10 (50.0)	N/A
Asian	1 (5.0)	1 (10.0)
Black or African American	N/A	2 (20.0)
White	1 (5.0)	4 (40.0)
Area of residence
Large metro area (1 million+ population)	7 (35.0)	6 (60.0)
Other (<1 million population)	13 (65.0)	4 (40.0)

^*Includes medication and surgical abortions

N/A=No participants identified in this category

We used descriptive statistics to report participant characteristics. We used inductive-deductive constant comparative analysis to identify major themes and summarize patient perspectives consistent with Miller’s conceptual model.¹⁶ The analysts (EAJ and AEF) both coded the first ten interviews, meeting regularly to discuss coding discrepancies until they agreed on the codebook. After that point, they coded independently. The analysts created memos as they coded to track and synthesize thematic discussion and generate consensus. We defined data saturation as the point at which no relevant new themes related to the areas of focus were identified.¹⁷ The analysts presented iterative summaries of the interviews to the larger research team and the community advisory board during the study’s data collection and analysis phases. Dedoose software (version 9.0.62) was used to organize and manage the data . To increase the applicability of our findings to the abortion care setting specifically, we summarize patient perspectives using patient–clinician communication terms used in Dennis’ quality abortion care indicator list (Fig 1).¹⁸

RESULTS

Of 42 patients who enrolled and scheduled interviews, our final study sample consisted of 30 individuals; 20 who received telemedicine and 10 who received in-clinic services (see Fig 2). Table 1 lists the selected sociodemographic characteristics of the study population. Twenty-three participants received their care from nurse practitioners and seven from physicians.

Fig. 2:

Study participant recruitment and enrollment flow diagram.

We identified four separate domains of patient-clinician communication. Within these domains, we identified 8 relevant categories and 17 factors representing the perceptions of patients who received either telemedicine or in-clinic care. Domains, categories, factors, and illustrative quotations are listed in Table 2. Based on our findings, we summarize best practices for patient–clinician communication for medication abortion services (Box 1).

Table 2:

Representative quotations, comparing telemedicine and in-clinic medication abortion care

Category	Factor	Telemedicine	In-clinic
Domain 1: Service geographic accessibility, efficiency of services, perception of space where care is received
Setting	Geographic accessibility	“I wanted telehealth appointments because I live very rural. And I live on a farm and so access to services is really hard to get here and the community that my farm is near [a town that] is against all kinds of access to services like [abortion care].” (Participant 32, Telemedicine)	“Since I had to drive [more than 60 miles] to the clinic, [the in-clinic visit] …was like a whole day I spent doing that to take that first pill. Which if I had done it online and if I could take the pill at home, then I could have still gone about my day regularly and not wasted a day.” (Participant 26, In-clinic)
Setting	Efficiency of services	“I liked the flexibility of doing things virtually, so I was able to just do it while I was at work. I didn’t have to take time off because I [have to be at work during] the time that clinics are open.” (Participant 08, Telemedicine)	“[While at the clinic I felt] like cattle herding, go in, get it done, go out and go to the next room. She didn’t really say anything to me or walk me through anything, which I would have liked. But then [when you do get explained things], it felt redundant because you already get a big packet of paperwork while you’re waiting… everyone is just reiterating the same thing, walking through the exact same thing. From Google I read it, I read it in the packet, I get told in the rooms and with the doctor, they tell me the same thing. So it kind of was redundant.” (Participant 11, In-clinic) “Everybody was kind. Ultrasound tech was wonderful. And then I met the [clinician]. She was strained, I could see. She kept telling me, “I know it’s you, I have not forgotten about you.” And every time she passed by, she gave me some reassurance and very thorough, made sure I understood all the instructions. I just think it was just the waiting in between, that it could have been better.” (Participant 09, In-clinic)
Setting	Privacy	“The doctor did tell me we were in a secure location, there wasn’t anybody else around that had to deal with the appointment or anything. So I felt completely comfortable continuing on with the appointment via telemedicine.” (Participant 15, Telemedicine)	“In the waiting room and there were 12 other women…And I was in that waiting room, I think for about half an hour. And then someone else came and brought me into an office type room. So there was the main meeting room, the ultrasound room, the second waiting room, and now I’m in an office room.” (Participant 10, In-clinic)
Setting	Perception of space where care received	“I took the call on my lunch break from work…I was comfortable at a friend’s apartment using her room…It was ideal for me…If it was in person, I would’ve been more emotional. I’m glad that I was in a safe place that if I needed anything, my friends were there…I felt very secure…Also I could be close to home versus traveling across the state to have this appointment…I would’ve had to get time off work. I didn’t want to get in trouble with work. A video call made it way better.” (Participant 03, Telemedicine)	“[The clinic space could have had] a more human touch to it. Like, hey, maybe there is like a vending machine or just something to distract yourself a little bit. Like they had a TV, but it wasn’t on and it’s just you get kind of antsy waiting there of course…just maybe a little cozier or something to put you at ease a bit more.” (Participant 30, In-clinic) “The building was kind of set back away from the road. And there were two ladies with signs, right by the sidewalk, by the road. So I was in my car and I was just turning. But yeah, I saw a couple of protestors as I was leaving.” (Participant 40, In-clinic)
Domain 2: Client-clinician interactions, decision making
Client-clinician interactions	Respectful care	“[For the clinician] time seemed like it wasn’t a concern. It wasn’t like, ‘Oh, I only have 15 minutes. Do you have any other concerns?’ It was more making sure I felt comfortable, giving me that reassurance, going over the procedure, asking me if I had any questions.” (Participant, 22, Telemedicine)	“I felt more heard than I ever have by any [clinician] ever prior talking to [Clinician Name] about birth control options....She gave me exactly what I asked for, which was a three month trial. And said I could come back for the rest of the year if I decide I like it.” (Participant 37, In-clinic)
Client-clinician interactions	Positive interactions, promote an atmosphere of trust	“…I felt really comfortable with the doctor. He introduced himself, asked me about myself, told me about the process that he was going to go through…He was really knowledgeable, but also intentionally answered my questions in an accessible way. His whole demeanor was really calm and personable…He wasn’t trying to hurry me along to get to his next appointment. And whenever I’d ask a question, he’d wait a second, he’d say something positive to indicate he had heard my question, and then he would think for a second and then he would answer thoughtfully.” (Participant 08, Telemedicine)	“She gave me time to ask questions and was reassuring that [abortion is a] pretty common thing, and it’s not super scary…Her demeanor was supportive and she humored me with whatever I had to say. She behaved like a friendly mother… She gave you space and was not being overly scientific. I don’t mind that in any other kind of medical interaction, but I think [abortion] needs a little bit more air to breathe and a little bit more human touch.” (Participant 30, In-clinic) “… when I was with the doctor, she was making sure, ‘Are you comfortable with this? Are you understanding this?’ Not just speaking at me, she was definitely checking in repeatedly, ‘Are you getting this? Is this what you want?’ So that was nice.” (Participant 11, In-clinic)
Client-clinician interactions	Promote patient’s dignity	“…hearing from another woman [the clinician] that they understand why I am thinking about this option [was important], ‘I totally understand why you’re feeling [an abortion] might be necessary, you have a 3 ½ month old baby,’…she was very relaxed, knowledgeable, and she communicated really well, so it helped make my decision.” (Participant 35, Telemedicine)	“[The clinician] had a social worker feel to her…we were both seated and [she had good] eye contact…she let me vent…I think every woman that makes it there might have some emotional baggage, so just being able to listen to that.” (Participant 9, In-clinic)
Client-clinician interactions	Tailored care	“… I’d already [had a medical abortion] once before, so I knew what I was doing....but I [still] needed more information because ..from the time that I took the first pill to when I take the second dose, the timeframe had changed. That was confusing to me… but I was rest assured because I knew I was getting [printed] information with the medication.” (Participant 42, Telemedicine)	“The [clinician] got me in and out. She was like, ‘I know you’ve been here all day…I can go through everything. Or, since you’ve said you’ve [had an abortion] before, you can tell me if you don’t need me to go through this or if you want me to go through it again.’ I told her I honestly just want to leave. So [she honored that]. She just sped through the things that she absolutely needed to tell me.” (Participant 23, In-clinic)
Decision-making	Interactions absent of bias or coercion, trusting patient to make informed decision	“[The clinician] started off the call by saying, ‘This is a no judgment zone. We just want to make sure it’s your decision and you’re not being influenced by anybody. And as long as it’s what’s best for you, then that would be the right decision.’…That gave me the reassurance that I need to know that I’m making the best decision…it’s a huge weight lifted off my shoulders.” (Participant 22, Telemedicine)	“She asked me how I’m doing, and if anyone pressuring me to come and do it..she reassured me....she asked, ‘Why are you here?’ And I told her, ‘It’s just not the right timing. I have a life to build. I can always have kids later’…I appreciated that a lot.” (Participant 27, In-clinic) “[The clinician] definitely asked when I was going to take the second [set of] pills, just so that she could have note of it and if I had a day that would be best. Since I did have work on the weekend, I wanted to take it as soon as possible so I could be back to kind of normal as soon as possible…I kind of had my mind made up already, so when she asked I kind of had my answers ready that I knew, regardless of if she had any opinion on it.” (Participant 11, In-clinic)
Domain 3: Clinician information provision, assessing support system, technical competence
Information provision	Explanation of abortion process	“She was very thorough with the health information…the information was actually quite overwhelming…there was a really long list of different symptoms that may arise from the pill, the whole process of taking the pill…Even if I were to go to the clinic, there is not really any way around that.” (Participant 04, Telemedicine) “[The clinician] told me, ‘This is how often you will be needing to change your padding.’ And I asked, ‘What’s a lot? Because I have a heavy period…And then he asked me to describe my level of flow. And he said, ‘No, it would be a lot heavier than that…’He was really specific in when I should be concerned and when I shouldn’t be concerned. And the description that he gave was really accurate to my experience.” (Participant 08, Telemedicine)	“…[the clinician] talked through the abortion pill procedure…about what would happen in my body, things to expect before going ahead…I took the first one, and we talked through when to take the next one, and again, what to expect. She was really thorough.... I appreciated that she read the materials with me, instead of handing me some things to read later. I have a copy so that I could look back on it, but really explaining what things mean, taking time to make sure that I understand what’s going to happen.” (Participant 37, In-clinic) “[The clinician] highlighted specific things, the big takeaways from the [written instructions], so that was nice.” (Participant 11, In-clinic) “[The clinician] reminded me, you’re going to want to take it easy and you’re going to expect the bleeding, and the size of the blood clots, how long I could be bleeding for…There was certainly a lot of bleeding, but I was prepared for that…he also told me that I would feel like I kind of like flu like symptoms, so I knew I was going to feel crummy…” (Participant 41, In-clinic)
Information provision	Information about possible complications and how to obtain appropriate care	“[The clinician] did tell me that they have 24-hour telephone support, so if I had any concerns or needed anything…that made me feel more comfortable, and it made me feel a lot better about their organization, just knowing that they have people that care enough to be on call 24 hours a day in case you would need something. Because it’s something you don’t want to just call like a friend or a regular doctor to ask about because a lot of people have varying opinions on abortion.” (Participant 16, Telemedicine) “I definitely felt if there were more serious medical problems, then I could reach out to the clinic, but no [I did not need to call them], all of the symptoms that she said would happen, happened, and I was prepared for that…” (Participant 04, Telemedicine)	“[The clinic staff] let me know that there was going to be a 24-hour service line, I could call if I needed any help or if I had any questions or if I was worried about something.” (Participant 12, In-clinic) “[It was particularly helpful they said] to call them if there’s any excessive bleeding over the four to six hour period…. there’s also a 24-hour support line, if something is out of the ordinary or if there’s excessive bleeding, I felt comfortable that I could call them and ask any questions.” (Participant 26, In-clinic)
Information provision	Post-abortion contraceptive care information	“[The clinician] told me that she would send to the pharmacy Plan B just in case I do need it for the future…Not only did she care about the right now, she was trying to make sure I was good for future.” (Participant 22, Telemedicine)	“[The clinician] gave me some plan Bs, which was really helpful.” (Participant 27, In-clinic)
Support	Patient support systems	“[The clinician] asked if I had a support system and she was very concerned about who was going to be my care person. Which I thought was cool because it wasn’t brought up to me in my first two visits at [an outside clinic]. And I thought looking back that was something that would’ve been extremely important… I had a lot of blood loss with my first [medication abortion] and it scared me to death and I didn’t have anybody for helping me… [at this clinic], you have to have a care person. And I think that’s absolutely how it should be.” (Participant 07, Telemedicine)	“[The clinician] did say to have a support person, have someone to take care for your child [during the 4–5 hours of pain when passing the pregnancy]” (Participant 09, In-clinic).
Technical competence	Appropriate pain management	“I think what really helped is the tip that [the clinician] gave for while that process [of passing the pregnancy] was happening, to have a heating pad for the discomfort, because that helped more than anything. I didn’t want to feel nauseous of having more pain medicine, so using the heat pad really, really eased everything.” (Participant 02, Telemedicine) “The only thing that I would complain about is pain. I mean, [the clinician] had Naproxen sent to me, but …Naproxen…just wasn’t what I needed because of how bad the pain was. And like me crying on the toilet because I’m in so much pain and basically screaming, yelling out because of the pain, it shouldn’t be that bad.” (Participant 29, Telemedicine).	“They gave me a tracking form to track my symptoms and track when I took the medication, so that was nice. Really easy process. I do remember there was one scary part on one of the forms that I filled out. It said that this might be the most pain that you’ve ever experienced in your whole life… I’ve birthed two children…it wasn’t really painful at all.” (Participant 40, In-clinic) “It was horrible pain, and Naproxen didn’t do anything. I also took Tylenol…[The clinician] told us we could use a hot water bag…But the amount of cramping and the bleeding, it’s just really hard to manage at home…” (Participant 09, In-clinic).
Domain 4: Outcome indicators: Patient knowledge and attitudes
Client knowledge	Understand information given during clinic visit	“… Another nice thing is they send you a brochure with the medication. It was a quick, easy reference to answer common questions. I’m like, ‘Oh, is this normal when I was taking it?’ I could reference that pamphlet and that was super nice.” (Participant 03, Telemedicine)	“[the clinical staff] gave me a lot of papers to read and I found those really, really good and all the kind of statistics and information and the things that could potentially go wrong. I thought that was really helpful and I felt comfortable because only recently I’ve heard at about the abortion pill.” (Participant 26, In-clinic)
Client attitudes	Patient satisfaction	“I really felt cared for and even respected of how to take care of myself.” (Participant 02, Telemedicine)	“[The clinician] was…easily the best doctor’s appointment I have ever had. If I had to rank the experience, it would be a 10 out of 10 despite the wait.” (Participant 37, In-clinic)
Client attitudes	Level of clinical competency	“I did end up bleeding a bunch and it was crazy. I was grateful that I was aware enough to say, ‘[The clinician] said to call this number on this paper.’ [My husband called it and the nurse explained] to massage my stomach and it will help stop the bleeding and he did that and it worked.” (Participant 25, Telemedicine)	“I didn’t have anything happen [with the first pill], no cramping, no bleeding from that. 24 hours later almost exactly I dissolved the pills in my mouth. After the 30 minutes I swallowed them, and then probably 15 minutes later I threw everything up and I had to Google because I was like, ‘Oh my god, did I just mess this whole thing up?’ But I googled it and it basically was like, ‘Yeah, it’s fine as long as you let it dissolve for 30 minutes.’ So I was like, ‘Well, hopefully that still works.’ That was the only thing that I was like, ‘They didn’t tell me I could throw up then.’” (Participant 11, In-clinic) “Honestly the process seems kind of simple…. if it was super complicated, I’m sure [the clinician] probably could have dumbed it down, but you know, you just really put the pills in your mouth and let them sit there and whatever.” (Participant 23, In-clinic)

Box 1: Best practices for patient–physician communication for medication abortion encounters based on 30 in-depth interviews at a single healthcare facility.

Patient–physician interactions: First minutes of the visit, create a non-judgmental, supportive, safe communication space Customize visits to meet patients’ emotional/social needs. Some patients require straightforward facts and others need more emotional support Listen, pause Allow time/space for the patient to ask questions Express trust, validation and empowerment toward the fact this is the patient’s decision to make Use check-back, have the patient summarize what was discussed

Provide the patient necessary information: Obtain baseline knowledge of what the patient knows and doesn’t know about medication abortion Create awareness around the fact that most patients have already done extensive research Many patients already had an abortion, so consider asking about that first and tailor the visit accordingly Co-create a plan, order of events and ensure the patient knows what to expect in terms of passing the pregnancy at home Communicate first, yet flexible timing of events and symptoms [example, “Typical bleeding occurs between x # of days and y # of days but can also happen between z # of days and a # of days. If it is beyond a #, call the clinic.”] Ensure the patient understands the details of taking the pills Ensure the patient has all the supplies potentially needed, especially for pain relief Post-abortion care is important- discuss birth control information and future fertility with the patient

Support: Ensure the patient knows how to get their questions answered Ensure the patient has social/emotional support in place Ensure the patient has a support person present at home during the procedure Reinforce that even though this is a home-based service, adequate time off work and childcare is needed High pain levels often necessitate last-minute medication or supplies so ensure someone can run to the pharmacy if needed

Setting: If telemedicine: Send patients clear instructions about what programs to download before the telemedicine appointment and how to log onto the appointment If in-clinic: Send patients clear directions that include how to find the clinic and get into the clinic Consider instructions with pictures Communicate to patients what to expect inside the clinic (wait times, # of rooms/flow of visit, # of providers they will see)

Domain 1: Medical Consultation Settings

Factors related to the medical consultation setting includes: (1) geographic accessibility of the appointment with the clinician, (2) efficiency of services and (3) perception of space where care was received in terms of privacy and comfort, all of which affected participants’ attitudes about the consultation visit. Factors related to telemedicine consultation settings contrasted considerably with in-clinic (Table 2, Domain 1).

Participants who received telemedicine reported feeling like the care was accessible and efficient. They appreciated choosing where their medical consultation occurred. Examples of telemedicine consultation settings included one’s own bedroom, a friend’s home, or their car. Participants chose these spaces because they were quiet, familiar, convenient, away from kids or workplaces, providing a more controlled and relaxed consultation compared to the in-clinic setting. Many emphasized that telemedicine allowed them to talk more freely and openly, and feel more confident about the privacy of their abortion decision. For example, one participant shared, “I definitely felt at greater ease doing a telemedicine appointment when it came to going over the information…just because I was more comfortable in my own environment versus having to go to a doctor’s office” (Participant 15, Telemedicine).

In contrast, participants described in-clinic visits as less accessible, inefficient, chaotic, and lacking privacy. Many struggled with transportation, traveling several hours to get to and from the clinic and expressed concern about potentially encountering someone they might know at the clinic. Compared to the shorter time spent with telemedicine, in-clinic appointments required a full day off work, with many describing having to wait for 4–6 hours, being moved to different waiting rooms and seeing multiple clinicians. In-clinic participants reported the setting as confusing, redundant and inefficient, with “lots of shuffling around.” One participant shared feeling indifferent about the in-clinic setting, and thus did not connect with their clinician, stating: “I really didn’t care who I spoke with. Honestly, I just wanted to get out…Get it done.” (Participant 23, In-clinic). Many in-clinic participants expressed frustration about perceived COVID-19 restrictions of not being allowed to bring snacks, a support person, or their children, which would have made them more comfortable.

Domain 2: Patient–Clinician Interactions and Decision Making

This domain includes factors related to patient screening, how patients are treated by clinicians and staff, and respect for patients’ ability to make decisions about their care. We did not detect major differences within this domain between participants who received their care through telemedicine versus in-clinic (Table 2, Domain 2).

Participants were given thoughtful, thorough and complete answers from their clinicians and felt respected and heard. Participants described emotionally empathetic, attentive, and non-judgmental interactions facilitated by clinicians with strong interpersonal skills. Telemedicine and in-clinic patients valued clinicians who personally customized the medical information to meet participant needs, concerns, and histories. A few participants preferred encounters that were brief and direct. In those instances, clinicians pivoted to that communication preference: “The doctor had a very straight to the point, matter-of-fact tone, and for me personally, that was helpful” (Participant 01, Telemedicine).

Domain 3: Clinician information provision, Postabortion Contraceptive Care, and Technical Competence

Within this domain, we compare factors related to participants receiving complete information about the medication abortion process and post-abortion contraceptive care, where to call if questions or complications arise, and quality of pain management. We did not detect differences within this domain between participants who received their care through telemedicine versus in-clinic (Table 2, Domain 3).

Most participants valued highly clinicians’ thorough explanation of the medication abortion process and symptom management. They appreciated when clinicians clearly and chronologically walked through the steps of medication abortion, including how to take the pills, when to expect symptoms to begin and end, and how to manage typical and atypical symptoms. They valued realistic, detailed information about how much blood to expect, especially compared to what is “normal,” intensity and length of pain, frequency of vomiting or diarrhea, and when symptoms typically subside. Most participants also appreciated clinicians’ suggestions regarding how to set up a supportive environment, such as requesting time off work, reassigning childcare responsibilities, and identifying a support person. Participants overwhelmingly applauded knowing about the clinic’s 24/7 nurse hotline for abortion-related questions, although few utilized it. “I didn’t feel as if I needed to (call) because I went online and I found my answers pretty easily…and everything seemed to be fine” (Participant 01, Telemedicine).

Many patients reported appreciating that the visit was not just about the abortion itself but included information about post-abortion contraceptive options: “We spent the bulk of the time talking about birth control…I said I wasn’t super worried about the abortion. I was more worried about birth control options because that’s something that I have struggled to figure out” (Participant 37, In-clinic). Participants expressed clinicians who took “extra” time to set up a contraceptive plan helped them feel confident that they would not need to pursue future abortions.

Clinicians seemed to lack technical competence related to adequate pain control, regardless of service type. Telemedicine and in-clinic participants equally made a point to mention the pain control recommendation given by clinicians was something they would have changed about their service. Participants appreciated hearing their options to treat the pain and cramping associated with pregnancy expulsion, such as heating pads, massage and over-the-counter medications and some conveyed adequate pain control. Nonetheless, a number of participants in both groups wished they had better access to pain relief (Table 2, Domain 3).

Domain 4: Outcomes Related to Patient Knowledge and Attitudes

Health outcomes include participants’ feeling like they understood the information provided, overall satisfaction, and having trust and confidence in the clinicians (Table 2, Domain 4).

Participants in both groups reported they had sufficient and accurate information that allowed them to comply with the medication regimen. They also reported the ability to recall clinician-shared information to manage symptoms at home and remain autonomous throughout their abortion. When asked if they felt prepared regarding pill taking and abortion side effects, most participants felt their clinicians provided sufficient levels of detail and they were, in turn, able to describe those details during the interviews, while others used clinic handouts or conducted web-searches. Regardless, some telemedicine and in-clinic participants reported being unprepared for amount and duration of vaginal bleeding and pelvic pain.

Overall, telemedicine and in-clinic participants shared high levels of satisfaction of care. Telemedicine participants overwhelmingly reported being satisfied with their abortion visit, many stating that they would pursue it again or recommend it. In-clinic participants, on the other hand, reported that patients should have the option to decide between telemedicine and in-clinic services, with about half stating “next time” they would choose telemedicine. Both telemedicine and in-clinic participants also shared similar attitudes about trusting the clinic to provide high-quality abortion care. Feelings of trust were especially evident with a telemedicine participant who became stressed about waiting online for her clinician who was running 30 minutes behind schedule but had not been notified by the clinic about this delay. Despite feeling uncertain, the participant’s attitude toward the clinic as a place to trust made her satisfied about this particular encounter: “What stuck out to me [as I was waiting for the clinician] is that I felt really confident…like everything was going to be fine and that they were really there to support my choice…” (Participant 32, Telemedicine).

DISCUSSION

Our results show that both telemedicine and in-clinic participants felt respected, heard, understood, and valued by their clinician who provides abortion. The ability to choose the consultation location allowed telemedicine participants to feel like their encounter was more controlled and relaxed, while most in-clinic participants portrayed it as lengthy, chaotic, and lacking comfort. Because this study occurred when COVID-19 infection was still widespread, we surmise that many of the in-clinic participant experiences were due to unpredictable staff absences and social distancing requirements limiting clinic capacity. These in-clinic constraints ultimately compromised overall patient-clinician communication.

Both telemedicine and in-clinic participants had less favorable views about the clinic’s pain control regimen, with several expressing they felt unprepared for the pain associated with medication abortion. This is unsurprising given the limited high-quality evidence regarding adequate pain management during medication abortion.¹⁹ While participants stated they knew about the 24/7 nurse line, for reasons we did not thoroughly explore, participants who felt unprepared about the pain asserted they wish they had more pain medications at the moment of their abortion. This suggests that even if they had phoned the 24/7 line, they would have had to wait for a prescription to be called into a pharmacy for pick up, which may not have met their needs. Future studies should define patient characteristics associated with the need for additional pain medication to better inform clinic protocols.

Patient satisfaction with telemedicine over in-clinic care is consistent with other telemedicine abortion studies.^20, Similar to other comparative telehealth and in-clinic studies, our telehealth participants appreciated reduced appointment times.^21,22 In contrast to a prior qualitative study in which some telemedicine participants stated they felt reduced personal interactions with their clinician than if they had seen them in-clinic, we detected no such difference.²³ This present study found that many of the patient–clinician interactions were consistent with behaviors and attributes associated with patient-centered communication. In essence, we showed that patient-centered communication qualities traditionally provided in the in-person abortion care setting can readily be translated to live, face-to-face video telemedicine.

The present study has several strengths. Based on our recruitment methods, each participant had had a medication abortion within the prior month. We also sampled to saturation and enrolled a relatively diverse participant population. Nonetheless, our study was limited by a convenience sample of participants who sought medication abortion within a single healthcare entity in Washington State, when the nation and state were still under a COVID-19 PHE. Thus, our findings may not be generalizable to all abortion care settings or to a time-period when the nation/state is not under a PHE. Our study evaluated participants who had live, face-to-face video telemedicine abortion care, which may not be applicable to asynchronous, online abortion care. Although we chose a conceptual framework that includes core components of patient-centered communication, we recognize it is a multifaceted construct, making it difficult to succinctly measure.^6,24,25 Ideally, patient–clinician communication is evaluated more comprehensively, using combinations of direct observations of clinical encounters or with standardized patients, validated survey measures that patients complete after the clinician encounter, post-visit patient interviews, and peer-colleague assessments.⁶ Given the stigmatizing nature of abortion services, direct observations between clinicians and patients proved infeasible. Additionally, while there is a growing interest to develop and validate a person-centered abortion scale, such a scale has not been implemented for patients receiving abortion services through telemedicine.²⁶

In conclusion, telemedicine is a beneficial patient-centered approach to critically needed first-trimester abortion services. To be patient-centered clinics should provide telemedicine abortion in the setting of the patient’s choice and apply principles of patient-centered communication, including clinicians being non-judgmental, demonstrating respect and trust, tailoring to meet patients’ needs, and explaining medication abortion processes and post-abortion contraceptive care as understood by patients. Clinics should also provide printed information with instructions about abortion pill use and where to call for questions and emergencies.