Christine Ko, MD, professor of dermatology and pathology at Yale University, reflects on her use of telehealth and how it allowed her to establish and maintain emotional connections with her patients, all at high risk of skin cancer.
Many were surprised by the near 100% closure of all outpatient clinics and elective surgeries early on in the COVID-19 pandemic here in New Haven, Connecticut. In amazement, I and others around me wondered that even surgery to excise breast cancer or malignant melanoma was considered elective, even optional, to the great distress of patients, family members, and their physicians. How is treatment of a potentially life-altering cancer optional?
Of course, this was all to keep everyone safe, or as safe as possible, from a deadly virus that we knew almost nothing about; that we were quickly seeing could polarize nations, communities, and families; and that would lead to untold suffering and tragic losses.
Compared with all that was predicted to transpire in worst-case projections, a temporary closure of outpatient dermatology, for example, seemed well worthwhile. My own Department of Dermatology was able, like others, to convert to telehealth. We could either phone or video visit with our patients, attempting to serve their health care needs while everyone remained protected in their own homes.
Ultimately, phone and video visits do not work well for me and my patients, who are at high risk for skin cancer, for whom I generally need to do a total body skin examination. At least some of my experienced patients agreed with me. We would laugh together, when I would call or video in to see them.
“Yes! There is no way to truly do a comprehensive skin check, or even a partial skin check, today,” we echoed.
Definitely not by phone, without even seeing the patient, but also not by video, where the resolution was too grainy and any lag time made things fuzzy and unfocused.
There is a workaround. Patients can upload photos (into an electronic medical record) of concerning lesions, and with good photos, it is sometimes possible to be sure that something is cancer or not. Once dermatology outpatient clinics partially opened up, those patients with worrisome lesions were seen first, without too much delay.
Due to this valuable asset of supplemental photography, I ended up preferring phone visits. This may also be because of less noise around “the signal,” the signal being the patient’s voice and what I could glean from listening carefully. There is fascinating research on how emotion is rapidly processed in an interaction. Both visual and auditory cues can be used.1,2 When we hear voice alone, accuracy of emotion recognition increases compared with using visual cues alone (eg, analysis of facial expression and body language) or using both visual and auditory cues.3
There are things that are irretrievably lost with telehealth, particularly phone visits. For in-person visits, empathic touch and eye gaze are related to patient satisfaction with the doctor,4 and the telehealth-related impact of loss of one or both of these modalities remains unclear. I know from personal experience, however, that many of my patients were grateful that I was at least trying to reach out by phone. I could even hear my patients smiling! Research supports that we are best at detecting a full-on genuine smile (called a Duchenne smile).5
The world as I knew it rapidly changed in March 2020. As summer 2021 approaches, I am relieved to feel a move toward much-desired normalcy. COVID-19 cases and deaths in the United States are decreasing, many Americans have been vaccinated, and the CDC has changed masking requirements.
Whereas in spring 2020, random strangers on the street would occasionally yell at me and my children if my children were biking without masks on, a year later I was at a boys’ outdoor soccer tournament with more than 90% of the spectators not wearing masks (I still wore one). We all still stood or sat at a distance from one another, but people’s entire faces were a welcome sight.
In my clinic, I have once again been seeing patients in person now for close to a year. Although an N95 mask and eye protection were previously required for any direct-facing patient care that involved the patient removing their mask, vaccination has shifted those requirements.
The big takeaway for me, through the massive changes and differing regulations that we have all experienced, is that my patients and I could still connect, even if it had to be by phone.
1. Liebenthal E, Silbersweig DA, Stern E. The language, tone and prosody of emotions: neural substrates and dynamics of spoken-word emotion perception. Front Neurosci. 2016;10:506. doi:10.3389/fnins.2016.00506
2. Roter DL, Frankel RM, Hall, JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. J Gen Intern Med. 2006;21(suppl 1):S28-S34. doi:10.1111/j.1525-1497.2006.00306.x
3. Kraus MW. Voice-only communication enhances empathic accuracy. Am Psychol. 2017;72(7):644-654. doi:10.1037/amp0000147
4. Lecat P, Dhawan N, Hartung PJ, Gerzina H, Larson R, Konen-Butler C. Improving patient experience by teaching empathic touch and eye gaze: a randomized controlled trial of medical students. J Patient Exp. 2020;7(6):1260-1270. doi:10.1177/2374373520916323
5. Drahota A, Costall A, Reddy V. The vocal communication of different kinds of smile. Speech Commun. 2008;50(4):278-287. doi:10.1016/j.specom.2001.10.001