Communication strategies during the COVID-19 pandemic: Unforeseen opportunities and drawbacks

Abstract

The current coronavirus pandemic has forced a dramatic shift in the way clinicians practice medicine, including the way we communicate with our patients. The pandemic has both facilitated and challenged serious illness conversations between providers and patients. Furthermore, telemedicine has emerged as a major practice across the globe. Benefits of which include greater involvement of supporting family members while drawbacks involve socioeconomic barriers that limit high quality interactions between provider and patient. This commentary aims to highlight the evolution of communication strategies over this unique time in hopes of promoting reflection and change to improve our communication strategies at the individual and institutional level.

The current coronavirus pandemic has forced a dramatic shift in the way clinicians practice medicine, including the way we communicate with our patients. Living through this pandemic has reminded us that circumstances can change almost instantly. Fragility we have not experienced in a long time, insulated by modern medicine, has vanished. The coronavirus pandemic is a reminder of life's unpredictability.

Serious illness conversations

The pandemic has both facilitated and challenged serious illness conversations between providers and patients. Clinicians are often hesitant to disclose prognosis, which has been demonstrated to affect the decisions patients and their families make in the setting of serious illness [1,2]. The pandemic has encouraged, if not necessitated, clinicians to have more conversations about the hypothetical. COVID has prompted increased dialogue about the “what ifs” without attributing blame or failure to medicine. “If you were to contract coronavirus, it is possible you could become very sick. Would it be ok if we spent some time discussing what's important to you if that were to occur?” This has allowed us to frame discussions for serious illnesses ranging from treatment of metastatic cancer to initiating hospice care. “I share in your hope that your cancer responds to chemotherapy, however, I also worry that the side effects of treatment may limit your ability to reach your other goals, such as avoiding rehospitalization.” Communication has frequently been difficult in cases of serious illness, in part due to the hesitancy to bring up failure of treatment or the limitations of medicine. The coronavirus pandemic has provided a new opportunity to ask, “What matters to you most?” that, in many ways, feels more palatable to both clinicians and patients.

Telemedicine: Opportunities and pitfalls

The pandemic has changed not only the content of communication, but also the methods of communication. As an avalanche of cases spread across the United States, social distancing was recognized as a key factor in decreasing viral transmission. To mitigate unnecessary exposure for patients, clinicians, staff, and the community, telemedicine has come to the forefront of hospitals and clinics around the country. Telemedicine is the use of technology to provide remote care. Prior to the coronavirus pandemic, telemedicine was largely absent from the United States health care system [3,4]. As coronavirus became exceedingly pervasive in 2020, the Centers for Medicare and Medicaid Services and private insurers expanded their coverage to make telemedicine visits reimbursable and, thus, telemedicine utilization vastly expanded.

The use of telehealth in the clinic has come with unforeseen benefits for patients and their families. In New York City, during the height of the pandemic, many patients were hesitant to leave their homes, let alone take public transportation, to present to clinic and patients who fled to less populous areas weren't willing to travel extended distances for an in-person visit given governmental restrictions on travel. In light of this, telemedicine emerged as a regularly utilized tool to ensure continued follow-up without overwhelming the hospital system, patient, or clinician.

As the use of telemedicine continued through the year, additional benefits were realized. Patients were more easily able to involve family members in their care, regardless of where they lived. Much of the economic burden associated with coming to the hospital or clinic, such as needing to take time off from work or the cost of travel, was alleviated. Additionally, for patients near the end of life, the stress of traveling and potentially being exposed to COVID-carriers in transit or in the hospital, was reduced through the use of telemedicine visits (Table 1 ). For these, and other, reasons, patients have been very satisfied with the incorporation of telehealth into routine clinical practice [5].

Table 1.

Opportunities and drawbacks of telemedicine.

Opportunities	Drawbacks
•Able to provide healthcare to remote patients •Patients avoid exposure to other personnel during transportation and clinical encounter •Clinicians minimize number of personnel they are exposed to •Decrease economic burden (transportation and time off work) for patient and family members •Involvement of supporting members in the patient's care	• Social and economic barriers to high-quality visits: including • Access to technology: • Internet server • High-quality audio and video • Privacy within one's work/home to freely discuss medical issues • Successfully operating telemedicine technology •Establishing/maintaining clinician-patient relationship •Hospital-based reimbursement

Of course, widespread implementation of telemedicine has also introduced new challenges, including difficulties in technology operation, concern over security of video-conferencing platforms, and issues pertaining to reimbursement [6]. Additionally, there is a large social barrier to telemedicine visits. Patients unable to access a telemedicine account or server, or who only have access to audio and not video conferencing might have a lower quality visit with their clinician than they otherwise would in-person. This inequity not only stems from access to technology for telemedicine visits but also healthcare disparities at large.

From the clinician standpoint, the use of telemedicine for serious illness conversations can present unique communication barriers. It can be more challenging to read nonverbal communication questions during a telemedicine visit than an in-person visit. Connectivity issues can detract from the conversation or make shared decision making more difficult. Certain decisions, such as pursuing third-line chemotherapy v hospice care, require strong physician-patient relationships, which might be more challenging to develop through remote interaction.

Looking toward the future, it is clear that there is an important role for telemedicine in providing routine clinical care. As we proceed through this pandemic, efforts should focus on establishing which patients, and which types of visits, are best suited for telehealth and in whom it may result in less effective care. Hospital systems should address the concern of provider uncertainties and investigate how we can mitigate healthcare inequities to provide telehealth visits to any appropriate patient.

Conclusion

From the unpredictability of contracting coronavirus to the explosion of telemedicine, communication in medicine has been dramatically influenced by the coronavirus pandemic. Through this unsettling time, we have been forced to evolve our communication strategies and have the opportunity to emerge stronger because of it.

Contributions

(I) Conception and design: All authors; (II) Administrative support: Julie Bloom; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Funding

No funding was received in relation to this article.

Conflict of interest

No authors have a conflict of interest or potential conflicts related to this article. No competing interests to declare.

Biographies

Julie Rachel Bloom, MD: Dr Bloom is a resident physician at Icahn School of Medicine at Mount Sinai, training in radiation oncology. Her clinical areas of interest include communication skills in oncology, palliative radiation oncology, understanding radiation toxicities in combination with immunotherapy and brachytherapy. She has received several awards including the J. Zukowski Endowed Scholarship during medical school as well as research fellowships.

Emily Jean Martin, MD: Dr Martin is a certified hospitalist of internal medicine, currently practicing at the University of California, Los Angeles. She is board certified in internal medicine, and hospice and palliative medicine. Her research interests include communication skills frameworks, education training models to teach communication strategies and medical education.

Joshua Adam Jones, MD: Dr Jones is certified in radiation oncology and hospice and palliative medicine, currently practicing at the University of Pennsylvania Medicine where he is the chief of palliative services and director of quality assurance/quality improvement for the department. His clinical interests include palliative radiation oncology, supportive oncology and implementation of palliative radiotherapy education.