Breakdown in the relationship between health professional and patient

It should not be assumed a priori that the use of tele-consultations will result in a breakdown in the patient doctor relationship. The telephone has functioned very well as a communications medium without any documented indications of it decreasing the quality of the communication between patient and doctor. Tele-consultation may even improve the relationship, for example in matters concerning sexuality and family problems, where a psychological ‘safety distance’ may make the patient more open and forthcoming. Therefore the risk of breakdown in the relationship from using a videolink might relate more to communicative skills and lack of formal training in using telemedical equipment rather than the format of the communication itself. However, more research is required if the optimum procedure for interacting with patients by videolink is to be established.

Factors which might cause a breakdown in the health professional/patient relationship compared with normal face-to-face consultations are:

Physical and mental factors

Patients suffering from reduced vision or who are hard of hearing are to a certain extent unable to partake of the information presented in a video consultation. It seems, however, that by displaying questions as text and using sign language these limitations can be overcome. Videoconsultations have been successfully carried out with disabled patients.

Depersonalization

During a tele-consultation the images of both the health care worker and the patient are projected onto a monitor and all interactions between the two parties are indirect. As our perceptions of what is seen on a monitor are very much influenced by our experience of watching TV a tele-consultation might not be experienced as being real by either party. There is anecdotal evidence that elderly patients at times do not accept that a physician, appearing on what looks like a TV screen, can see and listen to them properly. In one instance a resident in an old people’s home participating in a trial requested the female research assistant sitting next to her to repeat what was said by the male physician on the monitor, and finally asked the research assistant, ‘Why are you talking to me with a male’s voice?’

Process of consultation

During face-to-face and telephone consultations patients and health professionals introduce themselves in a natural way as part of the consultation, and in doing so secure the identity of both parties. However, it is frequently observed that this important introductory step is often omitted during a video consultation. The reason for this omission is uncertain but could perhaps be explained by technical distractions or it may reflect the fact that when watching TV the identity of the actors is often not important for understanding what is going on. Both health professionals and patients should be asked to identify themselves at the start of telemedicine session and the patient should be told briefly about the technical aspects of the session and asked about the quality of the audio-visual transmission.

Inability to perform the whole consultation

A videoconsultation is limited by the fact that the entire physical examination cannot be carried out over a videolink. This particularly applies to examinations where palpation is an important component. In such cases the specialist can only rely on the findings of another health care worker whose examination of the patient they have witnessed and in practice this often seems to be satisfactory. These limitations may gradually be removed by future technological developments, which will allow the investigator to carry out examinations indirectly that at present are impossible.