Abstract
Background:
Tele-oncology became a widely used tool during the COVID-19 pandemic, but there was limited understanding of how patient–clinician communication occurred using the technology. Our goal was to identify how communication transpired during tele-oncology consultations compared with in-person appointments.
Methods:
A convergent parallel mixed-method design was utilized for the web-based survey, and follow-up interviews were conducted with cancer patients from March to December 2020. Participants were recruited from the University of Florida Health Cancer Center and two national cancer organizations. During the survey, participants rated their clinician's patient-centered communication behaviors. Open-ended survey responses and interview data were combined and analyzed thematically using the constant comparative method.
Results:
A total of 158 participants completed the survey, and 33 completed an interview. Ages ranged from 19 to 88 years (mean = 64.2; standard deviation = 13.0); 53.2% identified as female and 44.9% as male. The majority of respondents (76%) considered communication in tele-oncology equal to in-person visits. Preferences for tele-oncology included the ability to get information from the clinician, with 13.5% rating tele-oncology as better than in-person appointments. Tele-oncology was considered worse than in-person appointments for eye contact (n = 21, 12.4%) and virtual waiting room times (n = 50, 29.4%). The following qualitative themes corresponded with several quantitative variables: (1) commensurate to in-person appointments, (2) uncertainty with the digital platform, (3) lack of a personal connection, and (4) enhanced patient experience.
Conclusion:
Patient-centered communication behaviors were mostly viewed as equally prevalent during tele-oncology and in-person appointments. Addressing the challenges of tele-oncology is necessary to improve the patient experience.
Keywords: telemedicine, tele-oncology, mixed methods, patient–clinician communication
Introduction
Telemedicine, the use of technology to deliver clinical care remotely,1 sharply expanded during the COVID-19 pandemic.2,3 Relatedly, tele-oncology, a type of telemedicine used between cancer patients and clinicians conducted over videoconferencing applications,4 also rapidly increased during this time.5 For example, over a year and a half, video visits increased from 40 to ∼5,000 in one large Northern California hospital early on during the pandemic, largely because of expanded health insurance coverage.6 As oncology visits conducted via Zoom and other videoconferencing software became commonplace, standards and guidelines for the practice were published. Recommendations included deregulating geographic rules around medical licensure, amendments to the Health Insurance Portability and Accountability Act of 1996 (HIPAA),7 developing key performance indicators, and having support available to troubleshoot technology issues.8
However, factors related to the patient experience and incorporating patient-centered communication were not well established. Communicating via videoconferencing software changes the way patients and providers interact.9 Therefore it is important to understand expectations of communication to structuring interactions with greater specificity to enhance the quality of care.3 Prepandemic, limited research examined clinician–patient communication in tele-oncology visits.3 Research on tele-oncology focused on the favorability of the technology,10 satisfaction,11 the ability to address geographic disparities,12 and opportunities to promote cancer prevention strategies.13 Still, questions remain about patients' experiences using tele-oncology.
Thus, this mixed-methods study aimed to understand patient's perceptions of how tele-oncology consultations compared with in-person appointments. Specifically, we conducted a web-based survey that measured patient-centered communication behaviors and performed follow-up interviews to answer the following questions: (1) How does communication differ in tele-oncology visits compared with face-to-face visits? (2) What are the benefits of communicating via tele-oncology? and (3) What are the challenges of communicating via tele-oncology?
Methods
Study design
A convergent parallel mixed methods design14 was used. In convergent parallel designs, two strands of data (quantitative and qualitative) were collected and analyzed independently.14 Our quantitative strand was a web-based survey, and the qualitative strand included open-ended text responses from the survey and follow-up interviews with participants who completed the survey.
Participants and recruitment
Participants included individuals 18 years or older who were diagnosed with cancer and had at least one had at least one tele-oncology visit with a clinician between March 2020 and the time of data collection (July 29 to September 2, 2020). Recruitment methods included the following: (1) the University of Florida Health Center's (UFHCC) consent research registry—a database of patients who volunteered to be contacted about research opportunities; (2) an online posting on The Leukemia and Lymphoma Society's online community (LLS); and (3) an e-mail recruitment distribution to members of the International Waldenstrom's Macroglobulinemia Foundation (IWMF) by the organization. The research was approved by the University of Florida's Institutional Review Board (IRB202001641).
Procedures
Survey
Eligible participants were first invited to complete an online survey. The survey included both closed and open-ended questions comprising four major sections: (1) experience using a videoconference platform (e.g., Zoom) for visits with a clinician about their cancer; (2) communicating with clinicians using videoconferencing; (3) communicating with an oncology team using secure messaging; and (4) demographic information. All data collected were used in this study, except for section (3), which was analyzed in a separate study.15 Survey questions were primarily designed by the research team based on the available literature to answer questions of interest relating to satisfaction with communication via videoconferencing, and to compare tele-oncology visits with their most recent in-person visit. Each section of the survey included open-ended text boxes for participants to expand upon their answers. At the end of the survey, respondents were asked if they could be contacted for a follow-up interview. Survey data were collected between July and September of 2020 using the UFHCC consent registry.
Survey data were collected from the LLS population between September 1 and October 17, 2020. Data from the IWMF population were collected on September 30, 2020. Participants who completed the survey received a $25 eGift card for their time. Study data were collected and managed using REDCap (Research Electronic Data Capture), a secure, web-based application designed to support data capture for research studies, hosted at the University of Florida.16
Interviews
Follow-up interviews were conducted between November 2 and December 16, 2020 by one of four co-authors (G.C.-S., C.N.H., T.L., and E.H.). Interviews were offered via phone or Zoom. A semistructured interview guide was developed to gather more in-depth information on survey participants' responses. Participants were asked several questions about how their clinician communicated with them during their tele-oncology appointment, such as (a) what they discussed with their clinician about COVID-19, (b) how they would describe their experiences meeting with an oncologist on a tele-oncology appointment, (c) what challenges they experienced, and (d) how their tele-oncology appointment compared with their in-person appointments. The structure of the guide also allowed for inquiring further into individual participants' responses to the survey. For instance, the survey included a question on who else may have been present during the tele-oncology appointment.
During interviews, participants were reminded of their responses and asked if that was typical of their other visits (both in-person and via tele-oncology), why, and how comfortable they were having a tele-oncology appointment in their homes. All interviews were recorded, professionally transcribed, and de-identified. Those agreeing to the interview were offered an additional $25 eGift card.
Data analysis
In the tradition of convergent parallel designs, both quantitative and qualitative methods were weighed equally, and analysis occurred independently.14 Although interview data were collected after the survey data, no analyses occurred until interview data were collected. By analyzing each strand (qualitative and quantitative) separately, the goal was to triangulate the methods by directly comparing the findings from each method.17 Triangulating from mixed methods enhances data from each and ensures completeness of findings in the study.
Datasets from both samples (UFHCC and national) were combined after conducting chi-squared tests, and frequency statistics were conducted to describe the sample. Quantitative survey data were analyzed using SAS. Frequencies and percentages were calculated for each variable.
Qualitative analysis was conducted on a dataset that ultimately combined open-ended survey data with interview data. All data were analyzed using an inductive, thematic approach consistent with the constant comparative method.18 Specifically, one author (C.N.H.) first open-coded all open-ended text box data from the survey by assigning codes to emergent phenomena. Then in collaboration with the senior author, they developed two coding books (one for benefits, one for challenges) that were validated through closed coding of all data by two additional authors (T.V. and E.H.). Next, two authors (C.N.H. and T.A.) coded the interview data. They began by applying the codebook from the survey data to the interview data, and developing revised codebooks from the interview data where the main themes stayed the same with some differences in properties.
Co-authors (C.N.H. and T.A.) closed-coded all interview data to validate codebooks. Discussion occurred between C.N.H. and T.A. to reconcile differences and to synthesize iterations of the codebook from the open-ended survey items and interview data. Results were discussed with the senior author and the codebooks were refined further and finalized.
To combine our quantitative and qualitative results, a joint display was developed as a visual means to integrate results from both methods, as well as a framework for organizing the results.19 Joint displays are an integrated results matrix that is used to compare closed-ended survey results with open-ended interview findings and to identify points of convergence and divergence.20,21
Results
A total of 158 respondents completed the survey (80 were UFHCC patients and 78 were nationally recruited); 158 open-ended responses were collected, and 33 participated in the follow-up interview (16 from UF; 17 from other organizations).
Quantitative survey results
Fifty-three percent of respondents were women, the average age was 64 years, 84% were white with a bachelor's degree (40%), and 69% were married. A full patient demographic summary is given in Table 1, which details differences in key variables across the UFHCC and national samples. Patients' overall satisfaction with the communication of the clinician during the tele-oncology appointment compared with their last in-person appointment was about the same or better (n = 143, 90%). Of the remaining 19 questions, the majority of patients (>50%) rated “about the same” for 15 questions, including “I was treated with sensitivity and respect,” (84%), “I felt listened to” (81%), and “The appointment was long enough to cover everything that was needed” (79%).
Table 1.
Participant Demographics
| UFHCC (n = 80) | NATIONAL (n = 78) | TOTAL (N = 158) | p | |
|---|---|---|---|---|
| Sex, n (%) | ||||
| Female | 46 (57.5) | 38 (48.7) | 84 (53.2) | 0.228 |
| Male | 27 (33.8) | 34 (43.6) | 71 (44.9) | |
| Do not wish to answer | 1 (1.2) | 0 (0.0) | 1 (0.6) | |
| Missing | 6 (7.5) | 6 (7.7) | 12 (7.6) | |
| Age (years) | ||||
| Mean (SD) | 61.0 (16.0) | 67.7 (7.3) | 64.2 (13.0) | 0.00208 |
| Median [Min, Max] | 65.5 [19.0, 88.0] | 68.0 [50.0, 83.0] | 68 [19.0, 88.0] | |
| Missing, n (%) | 10 (12.5) | 13 (16.7) | 23 (14.6) | |
| Race, n (%) | ||||
| Other | 2 (2.5) | 1 (1.3) | 3 (1.9) | 0.037 |
| African American | 8 (10.0) | 1 (1.3) | 9 (5.7) | |
| White | 64 (80.0) | 69 (88.5) | 133 (84.2) | |
| Missing | 6 (7.5) | 7 (9.0) | 13 (8.2) | |
| Education, n (%) | ||||
| High school | 8 (10.0) | 1 (1.3) | 9 (5.7) | 0.052 |
| Other degree | 7 (8.8) | 6 (7.7) | 13 (8.2) | |
| Bachelor | 34 (42.5) | 29 (37.2) | 63 (39.9) | |
| Advanced degree | 25 (31.2) | 36 (46.2) | 61 (38.6) | |
| Missing | 6 (7.5) | 6 (7.7) | 12 (7.6) | |
| Marital status, n (%) | ||||
| Other | 12 (15.0) | 10 (12.8) | 22 (13.9) | 0.004 |
| Married | 49 (61.2) | 60 (76.9) | 109 (69.0) | |
| Not married | 13 (16.2) | 1 (1.3) | 14 (8.9) | |
| Missing | 6 (7.5) | 7 (9.0) | 13 (8.2) | |
SD, standard deviation; UFHCC, University of Florida Health Center.
However, four questions achieved a percentage of 10% or higher when classified as tele-oncology being worse than their last in-person appointment. “The clinician and I were able to make eye contact” (12%), “The clinician typed on the computer during the appointment” (13%), “The clinician and I talked about things other than health or medicine,” (18%), and “I had to wait for the appointment to begin” (29%). Only one question had >10% when rated as better than in-person: “I was able to get the information I needed from the clinician” (14%). A complete summary of the survey results is shown in Table 2.
Table 2.
Comparison of Tele-Oncology to Last In-Person Appointment (N = 158)
| PATIENT-CENTERED COMMUNICATION BEHAVIOR | HOW DID TELE-ONCOLOGY COMPARE WITH YOUR LAST IN-PERSON |
|||||
|---|---|---|---|---|---|---|
| WORSE, n (%) | BOUT THE SAME, n (%) | BETTER, n (%) | UNSURE, n (%) | NOT APPLICABLE, n (%) | MISSING, n (%) | |
| I was treated with sensitivity and respect | 4 (2.5) | 143 (90.5) | 7 (4.4) | — | — | 16 (10.1) |
| I was able to get the information I needed from the clinician | 4 (2.5) | 125 (79.1) | 23 (14.6) | 2 (1.3) | — | 4 (2.5) |
| I was able to share information with the clinician | 5 (3.2) | 137 (86.7) | 10 (6.3) | — | 1 (0.6) | 17 (10.8) |
| The clinician and I were able to make eye contact | 21 (13.3) | 120 (76.0) | 7 (4.4) | — | 6 (3.8) | 16 (10.1) |
| The clinician understood my emotions | 7 (4.4) | 126 (79.7) | 4 (2.5) | 12 (7.6) | 5 (3.2) | 16 (10.1) |
| The clinician helped me manage my uncertainty | 7 (4.4) | 104 (65.8) | 11 (7.0) | 11 (7.0) | 20 (12.7) | 17 (10.8) |
| I was involved in making decisions as much as I wanted | 4 (2.5) | 133 (84.2) | 7 (4.4) | — | 10 (6.3) | 16 (10.1) |
| I was able to ask questions | 3 (1.9) | 137 (86.7) | 14 (8.9) | — | — | 16 (10.1) |
| I was able to share my concerns | 5 (3.2) | 140 (88.6) | 5 (3.2) | — | 1 (0.6) | 19 (12.0) |
| I felt listened to | 3 (1.9) | 138 (87.3) | 10 (6.3) | — | — | 19 (12.0) |
| The clinician showed empathy | 3 (1.9) | 138 (87.3) | 9 (5.7) | 1 (0.6) | 1 (0.6) | 18 (11.4) |
| I felt comfortable communicating with the clinician | 7 (4.4) | 137 (86.7) | 8 (5.1) | — | — | 18 (11.4) |
| The clinician presented him or herself professionally | 1 (0.6) | 146 (92.4) | 5 (3.2) | — | — | 18 (11.4) |
| It was clear to me when the visit was over | 4 (2.5) | 136 (86.1) | 8 (5.1) | 4 (2.5) | — | 18 (11.4) |
| The appointment was long enough to cover everything that was needed | 4 (2.5) | 135 (85.4) | 11 (7.0) | 2 (1.3) | — | 18 (11.4) |
| The clinician and I were able to communicate effectively | 9 (5.7) | 132 (83.5) | 9 (5.7) | — | — | 20 (12.7) |
| The clinician and I talked about things other than health or medicine | 30 (19.0) | 84 (53.2) | 9 (5.7) | 3 (1.9) | 24 (15.2) | 20 (12.7) |
| The clinician typed on the computer during the appointment | 22 (13.9) | 59 (37.3) | 1 (0.6) | 43 (27.2) | 26 (16.5) | 19 (12.0) |
| I had to wait for the appointment to begin | 50 (31.6) | 83 (53.2) | 11 (7.0) | 2 (1.3) | 6 (3.8) | 18 (11.4) |
| Overall, I was satisfied with the communication with the clinician | 8 (5.1) | 129 (81.6) | 13 (8.2) | 2 (1.3) | — | 18 (11.4) |
Qualitative interview and open-ended data results
Qualitative analysis revealed four themes. Two of the themes were associated with the benefits of tele-oncology, whereas the other two themes related to its challenges. Benefits included (1) commensurate to in-person appointments and (2) enhances the patient experience. Challenges of tele-oncology included (1) lack of a personal connection and (2) uncertainty with the digital platform. Detailed codes, definitions, and examples are provided in Table 3.
Table 3.
Qualitative Benefits and Challenges of Tele-Oncology
| BENEFITS | ||
|---|---|---|
| THEME | PROPERTIES | QUOTE |
| Commensurate to standard in-person appointments | • No major differences • Routines are similar |
“It was just the same as if I had gone into the office.” |
| Enhances the patient Experience | • Comfort and convenience ○ Home environment ○ No travel ○ Reduced COVID-19 exposure • Screen sharing • Clinician's attention |
“I really value the convenience and also the reduced anxiety concerning COVID.” We didn't have to drive all the way down to the cancer clinic…it could be up to an hour's drive.” |
| CHALLENGES | ||
|---|---|---|
| THEME | PROPERTIES | QUOTE |
| Lacks a personal connection |
• Not appropriate for new relationships • Physical examinations are sometimes necessary |
“I would not want to meet a doctor for the first time via video” |
| Uncertainty with the digital platform | • Internet issues • Virtual waiting rooms • Concerns about digital security |
“You're waiting for them to connect and it's like 15 minutes later and nothing's happening…did the technology go wrong? Or are they running behind?” |
Benefits
Theme 1: Commensurate to in-person appointments
Tele-oncology appointments fulfilled patients' objectives and it did not seem to matter that the interaction took place virtually. For participants who were comfortable using computers and videoconferencing technology, the appointment was straightforward. Referring to her virtual appointment, participant No. 12 said, “It was just the same as if I had gone into the office” and participant No. 4 said, “I don't think it's different than in-person…I felt like I was really talking to [the doctor], they were right there with me.”
Theme 2: Enhances the patient experience
Because participants felt tele-oncology was mostly equivalent to an in-person appointment, additional benefits of seeing a doctor in their home became apparent. Participants appreciated the convenience of saving time using tele-oncology because as participant No. 10 said, “[Driving] is an hour and a half or two hours…but if I'm sitting here at my desk …20 or 30 minutes later and I haven't gotten out of my slippers.” Not having to physically be in a doctor's office also meant avoiding the “Risk of catching something in [the] waiting room,” as participant No. 2 stated. Sitting in the comfortable surroundings of their homes rather than an examination room contributed to participants feeling at ease, which led to higher engagement. Communicating via tele-oncology also enhanced the feeling of closeness. Participant No. 16 said, “[The doctor] seemed more personal than in-person…It was a friendly, personable thing.” The patient experience was also enhanced through tools like screen sharing—images, charts, and bloodwork results would conveniently appear on their screens during discussions.
Challenges
Theme 1: Lack of a personal connection
Despite the benefits of tele-oncology, participants believed that the context of the appointment impacted whether tele-oncology was appropriate. For instance, not having a well-established relationship with the clinician could cause uncertainty. Thinking about using tele-oncology with a doctor they have never met before, participant No. 11 said, “I'm not sure that I'd be comfortable with that.” Another reiterated this sentiment, saying, “It is a little harder…to connect with someone…when you're not face to face. There's a benefit of being face to face…a sense of trust…when you put that person on a screen, it takes a little bit away of that sense of trust.” Participants also believed that tele-oncology may be inappropriate if the purpose of the appointment was to discuss bad news. Participant No. 3 said, “If things took a turn for the worse, I would want to come in for that individual comfort with the doctor.” Also, participants indicated that physical examinations were sometimes necessary, which obviously cannot occur using tele-oncology.
Theme 2: Uncertainty with the digital platform
Challenges using tele-oncology also included issues such as uncertainty regarding wait times and privacy concerns. Participants cited internet outages, slow connections, and cumbersome processes to using tele-oncology. Once connected, virtual waiting rooms increased patients' anxiety. Participants did not know when the clinician was going to arrive, causing participant No. 12 to wonder if he made an error or if the clinician was just running behind schedule. Related to privacy, participant No. 10 read several articles about Zoom meeting rooms being hacked, which made her uncomfortable about whether her medical information was confidential.
Integration of quantitative and qualitative results
Several high-frequency categories from the survey and the qualitative data aligned. The qualitative theme, lack of a personal connection, was supported by high ratings of tele-oncology being worse than participants' last in-person appointment in regard to fewer discussions about nonhealth-related topics, the clinician typing on the computer, and less eye contact. However, the theme, enhances the patient experience, was corroborated by >13% of respondents for the variable, “I was able to get the information I needed from the clinician” as being better than using tele-oncology. The majority of the quantitative results that ranked tele-oncology as about the same as the last in-person appointment were associated with the theme, commensurate to in-person appointments. The only quantitative survey item that comprised both positive and negative aspects of tele-oncology was, “I had to wait for the appointment to begin.” Participants mentioned the ease of being in their homes for the appointment but also acknowledged wait times and technology issues. Table 4 provides a full summary of the joint display that presents the quantitative variables and their linked qualitative themes.
Table 4.
Quantitative–Qualitative Joint Display
| QUANTITATIVE |
QUALITATIVE |
|||
|---|---|---|---|---|
| VARIABLE | WORSE, n (%) | THEME NAME/DESCRIPTION | EXEMPLAR QUOTE | ANALYTICAL INTEGRATION |
| I had to wait for the appointment to begin. | 50 (29.4) | Enhances the patient experience: The comfort and privacy of the home environment, lack of travel, reduced risk of exposure, screen sharing, and the clinician's fixed attention makes for a positive experience | “The ability to [see a doctor] from the comfort of your house is beyond a shadow of a doubt a huge benefit” | Divergence across quantitative and qualitative findings. Although tele-oncology affords numerous benefits, it is balanced by several disadvantages |
| Uncertainty with the digital platform: Prolonged stays in virtual waiting rooms were frustrating and lack of digital security was worrisome | “You're waiting for them to connect and it's like 15 minutes later and nothing's happening…did the technology go wrong or are they running behind?” | |||
| VARIABLE | WORSE, n (%) | THEME NAME/DESCRIPTION | EXEMPLAR QUOTE | ANALYTICAL INTEGRATION |
|---|---|---|---|---|
| The clinician and I talked about things other than health or medicine. |
30 (17.6) |
Lack of a personal connection: Meeting in-person is a more appropriate environment when patient–clinician relationships are not well established | “There's a benefit of being face-to-face that gave me…a sense of trust…when you put that person on a screen…it takes a little bit away of that sense of trust” | Qualitative results focused on the importance of a trusting relationship, which was reinforced by the quantitative results, which indicated that patient-centered aspects that contribute to trust, such as eye contact and relationship building through social talk were worse in tele-oncology compared to in-person |
| The clinician typed on the computer during the appointment. |
22 (12.9) |
|||
| The clinician and I were able to make eye contact. | 21 (12.4) |
| VARIABLE | BETTER, n (%) | THEME NAME/DESCRIPTION | EXEMPLAR QUOTE | ANALYTICAL INTEGRATION |
|---|---|---|---|---|
| I was able to get the information I needed from the clinician | 23 (13.5) | Enhances the patient experience: The comfort and privacy of the home environment, lack of travel, reduced risk of exposure, screen sharing, and the clinician's fixed attention makes for a positive experience | “[The clinician] seemed to be really attuned to the whole process…and [was able to] show images or charts from the screen” | Qualitative and quantitative results converged. The highest quantitative score registered for tele-oncology being better than in-person was the ability to get information. Qualitatively, clinicians were focused on patients the entire appointment |
| VARIABLE | ABOUT THE SAME, n (%) | THEME NAME/DESCRIPTION | EXEMPLAR QUOTE | ANALYTICAL INTEGRATION |
|---|---|---|---|---|
| The clinician presented him or herself professionally |
146 (85.9) |
Commensurate to in-person appointments: Tele-oncology appointments do not significantly differ from in-person appointments | “It was just the same as if I had gone into the office” | Results converged, as the highest quantitative scores were registered in the “about the same” category. Qualitative data suggested that tele-oncology was similar to what occurs during in-person appointments |
| I was treated with sensitivity and respect |
143 (84.1) |
|||
| I was able to share my concerns |
140 (82.4) |
|||
| I felt listened to |
138 (81.2) |
|||
| The clinician showed empathy |
138 (81.2) |
|||
| I was able to ask question. |
137 (80.6) |
|||
| I felt comfortable communicating with the clinician |
137 (80.6) |
|||
| I was able to share information with the clinician | 137 (80.6) |
Discussion
We surveyed patients with cancer and performed follow-up interviews to gain an understanding of how tele-oncology visits compared with in-person appointments. Using a convergent parallel mixed-method design allowed us to triangulate findings and identify areas where tele-oncology improved and worsened the patient experience.
Overall, patients found tele-oncology to be equivalent to their last in-person appointment. Most variables achieved ratings of 60% or higher in the “about the same” category, such as sharing information with the clinician, sharing concerns, feeling listened to, and displays of empathy. In particular, the ability to easily share medical information via screen sharing enriched discussions between patients and clinicians. Digital platforms with features like screen sharing have been shown to improve the quality of care by enabling greater to test and imaging results towards shared decision-making.22 The COVID-19 pandemic forced the world to embrace videoconferencing technology and changed delivery methods for education and business operations,23,24 as well as health care.
Data from four large national telehealth providers during January–March 2020 showed that telehealth visits increased by 154% compared with the same period in 2019.25 Our findings that tele-oncology was comparable with in-person appointments reflect how the world quickly adapted to using such technology. Telehealth has been called one of the major positive changes to come from the pandemic.26
Although patients largely adapted, tele-oncology was considered worse than in-person appointments because of the lack of a personal connection, exemplified by reduced eye contact, fewer discussions about nonmedical issues, increased wait times, clinicians typing during the appointment, and uncertainty when the patient did not have an established relationship with the clinician. Our findings correspond to a study of diabetic patients using telehealth conducted at a Veterans Affairs Medical Center. The qualitative study discovered that patients believed clinicians paid less attention to them, there was difficulty establishing a provider–patient relationship, and patients felt less involved during the visit.27 Given that the majority of patient-centered communication research has focused on face-to-face encounters, it is not surprising that tele-oncology has room for improvement in these areas. However, it is important to note that research supports telemedicine in acute and chronic disease management and suggests that it is noninferior to in-person care.2
Tele-oncology, and more broadly telemedicine, is generally well-liked by patients.2 Similar to our findings in which patients appreciated less travel time and reduced risk of COVID-19 exposure, a qualitative analysis of oncology clinicians found that they preferred tele-oncology to in-person appointments for the same reasons.4 Our findings also indicated that patients appreciated the ability to be in their own homes when receiving medical advice. Previous studies have discovered that the physical environment of a medical facility can express messages of shame, stigma, and uncaring, which fosters feelings of stress and vulnerability.28,29 We found that patients felt a sense of comfort being in their own homes, which enabled engagement with the clinician.
Limitations of our study included potential selection bias because of participants volunteering to be interviewed after exposure to the survey. It is possible that participants had strong opinions about tele-oncology that they wanted to express. Participants in our study were slightly younger (64 years) than the median age of a cancer diagnosis (66 years),30 which may indicate different preferences towards tele-oncology. Our study was also cross-sectional and concentrated on comparisons between tele-oncology and the last in-person appointment attended. Perhaps the participants' last in-person appointment was not representative of a typical appointment. Specific information about patients' cancer type, time since diagnosis, and treatment phase were not collected, which could have informed more specific recommendations.
Finally, surveys were administered via the internet and qualitative interviews were offered using videoconferencing software, similar to how tele-oncology was administered. Willing participants might have had higher comfort levels using the internet and videoconferencing technology than those who chose to not participate. In addition, our predominantly white sample does not reflect the inequities to access that communities of color regularly encounter in regard to tele-oncology. Future research should analyze specific behaviors, such as frequency of eye contact, time typing on the computer, and wait times to compare tele-oncology with in-person interactions.
Conclusion
Tele-oncology is a convenient tool that can enhance particular types of patient–clinician interactions in the cancer setting beyond the COVID-19 pandemic. Patients' experiences with tele-oncology were mostly equivalent to in-person encounters. Its continued use even after peak COVID-19 transmissions indicates that tele-oncology will have a large role in the future of health care. Continued attention to ensuring quality communication during tele-oncology appointments is necessary.
Authors' Contributions
The authors confirm contribution to the article as follows: C.L.B., J.M.A., and S.P. devised the study design; C.L.B., J.M.A., S.P., C.N.H., M.M. M.-J.M., and T.S.V. designed the survey; G.C.-S., E.H., T.L., and C.N.H. conducted the interviews; C.N.H. T.B.A. E.H., and T.V. coded the qualitative data, C.L.B., J.M.A., and T.B.A. interpreted the results and co-wrote the article. All authors approved the final version of the article.
Disclosure Statement
The authors have no conflicts of interest to report. No competing financial interests exist. Dr. Paige completed this work while employed at the University of Florida and is now an employee at Johnson and Johnson.
Funding Information
Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under University of Florida Clinical and Translational Science Awards UL1TR000064 and UL1TR001427.
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