The Role of Telemedicine in Building Trust: An Evolution of the Patient-Surgeon Relationship

Defining the Patient-Doctor Relationship and Trust

At the heart of medicine is the patient-doctor relationship. Trust is a key factor in this alliance as it fosters effective communication, shared decision-making, and positive clinical outcomes. In surgery, patient trust in the surgeon’s skill set and clinical acumen is a critical component of the patient-doctor relationship. Trust is not easy to establish or maintain, and several factors can erode it, such as communication without regard to patient health literacy levels, and lack of access to care. With the rise of telemedicine during the COVID-19 pandemic, technology has adapted to deliver healthcare services remotely. These new interactions in turn require adaptation of the patient-doctor relationship in order to maintain an effective alliance. This paper aims to discuss modifiable factors to maintain trust with patients as the patient-doctor relationship adapts in the growing digital age.

Trust enables surgeons to take better care of patients at some of the most vulnerable moments of their lives. Interpersonal trust is defined as “the acceptance of a vulnerable situation in which the truster believes that the trustee will act in the truster’s best interests.”¹ For patients (i.e., the truster) who must trust their surgeons (i.e., the trustee), factors that engender trust include surgical skill, interpersonal competency, and agency, which refers to a sense of loyalty and acting in the patient’s interest.¹ In addition, trust reflects the quality of the relationships that physicians have with their patients. Together, the two parties address some of the most difficult and life-changing events in patients’ lives. As a result, trust affects medical adherance² and the decision to pursue surgical therapy.³

Recent literature demonstrates a rise in medical mistrust, which is the result of many factors including inequitable access to care, low levels of patient-centered communication, and historical mistreatment of Black and Latinx populations.⁴ Black patients have lower rates of care seeking, preventive screening, and surgical treatment compared with White patients,⁵ likely attributable to the lack of trust Black patients have in their providers compared to White patients.⁴ In fact, trust in a physician has been found to be the strongest predictor of willingness to initiate treatment for HIV infection among Black and Latinx inmates.⁶ In surgery, one study found that Black patients in an urban setting were less likely than White patients to undergo surgery at a high-volume hospital by a high-volume surgeon and more likely to undergo surgery at a low-volume hospital by a low-volume surgeon.⁷ Given past literature citing an inverse relationship between surgeon volume and operative mortality,⁷ disparities in access to surgical care may exacerbate Black and Latinx patient mistrust in the healthcare system, further impacting health outcomes.

The Growth and Impact of Telemedicine

Telemedicine is a promising tool for increasing access and the way it is utilized can have significant impact on the patient-doctor relationship. The Department of Health and Human Services reports that telehealth visits among Medicare beneficiaries increased from approximately 840,000 encounters in 2019 to 52.7 million in 2020.⁸ Though physical separation may exist between patients and providers, telemedicine demonstrates potential to enhance trust by increasing access to care and providing patients with a convenient platform for education and discussion. Furthermore, telemedicine increases the frequency of real-time patient interaction with the healthcare team, allowing for earlier identification of warning signs that may require escalation of care, and increased patient access to specialty healthcare services for individuals living in remote or underserved areas. As patients and healthcare providers interact from different locations, telemedicine reduces unnecessary travel, mobility constraints, and language barriers. While many view a telemedicine visit as a 1:1 encounter between a patient and physician, virtual conferencing capabilities can provide an opportunity to facilitate patient-centered care through collaboration with specialized nursing staff and involvement of loved ones in decision-making.

Telemedicine as a Tool to Build Trust

Technology can help build trust by fostering therapeutic patient-doctor relationships. Discussion with patients about their preferences regarding visit type can help the patient feel involved in decision-making. First, taking time to understand patient concerns can help providers better guide patients along what can often be a difficult, vulnerable, and life-changing journey. Telemedicine gives patients the opportunity to seek medical care while in comfortable surroundings and has particular impact for patients who were previously unable to establish or maintain care with a provider due to scheduling or transportation constraints. Second, it is imperative that physicians assess a patient’s goals, knowledge of their disease process, and health literacy level. Setting expectations and discussing goals of surgery at the onset of care can provide clarity on potential benefits and limitations associated with undergoing an operation.⁹ Patient engagement technology allows for patients to have a better understanding of their care plan and disease process by providing additional platforms for education (often with visual aids) and monitoring. The opportunity to exchange information both synchronously and asynchronously allows for patient-provider interaction outside of a traditional clinic visit. Third, both verbal and non-verbal communication have an important role in building a strong patient-doctor relationship. Factors such as eye contact and facial expression can impact a patient’s perception of their physician and are particularly important to consider in video-based telemedicine.¹⁰ Through the ability to demonstrate commitment to patient care outside a traditional doctor’s office, technology can maintain and strengthen trust building. Telemedicine visits may not be as effective as in-person encounters when disclosing bad news, discussing complicated surgeries, or meeting patients for the first time. However, when seeing a patient in a timely fashion is challenging, telemedicine may be an optimal approach.

Barriers to Equitable Use of Telemedicine

Though telemedicine offers substantial benefit, it requires equipment and network infrastructure to implement. With disparities in access, the digital divide exacerbates inequities in patient access to the healthcare system.¹¹ Often, patients experience connectivity issues and low digital literacy, which can lead to frustration for both patients and providers. These obstacles can exacerbate mistrust due to added complexity for patients in communicating with the care team. On the provider side, a lack of training on telemedicine best practices may worsen patient-clinician relationships.¹² For example, providers may be perceived as disengaged in a virtual encounter if there are distractions occurring in the background.

Pre-visit communication from clinic staff may alleviate patient concerns by providing an opportunity to address doubts regarding telemedicine. In addition, focused education by care navigators may improve patient uptake and confidence in virtual visits. Past literature has demonstrated the efficacy of using locations such as community centers, libraries, and churches as central hubs in which individuals from rural areas can access internet and telehealth services.¹³ Additionally, utilizing audio-only telemedicine, i.e., phone calls, to ask about symptoms, etc. allows patients to benefit from remote healthcare engagement without losing follow-up due to lack of broadband or technological capability. In the immediate post-operative period, this empowers patients residing in remote areas to seek care without the logistical burden of arranging transportation and lodging. Furthermore, it decreases patient dependence on caregivers, who may often feel isolated as they navigate their loved ones’ care.

Harnessing the Power of the Patient-Surgeon Alliance

Trust is at the forefront of the patient-doctor relationship. It involves multiple dimensions, including communication, competence, confidentiality, and honesty. The adoption and implementation of telemedicine across the various stages of surgical care has the potential to enhance trust in several ways, including improving accessibility, continuity, and enhancing communication. However, several barriers need addressing for telemedicine to build and sustain patients’ trust, including pre-existing disparities in healthcare access and determining appropriate clinical scenarios for telemedicine-based visits. Fundamentally, trust in telemedicine relies on patient trust in the physician. As healthcare continues to adapt to technological innovations, it is important to maintain strong, therapeutic relationships with our patients to harness the benefits of these innovations.