Bonezboyz / shutterstock.com
Many practitioners can relate to the epiphany of Roy Basch, MD, the lead character in Samuel Shem’s satirical novel The House of God.1 During his first on-call shift as a medicine intern, long work hours combined with jaded advice from his senior resident leave Dr. Basch feeling disenchanted with the medical profession until he cares for a 50-year-old man with a pleural effusion from newly diagnosed lung cancer. The authentic, meaningful interactions with his patient reestablish Dr. Basch’s sense of purpose as a physician and help him find satisfaction among the chaotic and sometimes comedic events he encounters in the hospital. This turn in storyline highlights the importance and impact of the relationship Dr. Basch and his patient form at the bedside.
Patients and practitioners find satisfaction in the therapeutic bonds they establish at the bedside.2,3 The time physicians spend interacting with patients and their families imparts meaning to their work.2 Practitioners’ job satisfaction is associated with increased provider well-being, greater clinician empathy and improved patient health outcomes.4
Accordingly, the Accreditation Council for Graduate Medical Education has campaigned to support educational initiatives that bring patient care and education back to the bedside in an effort to reorient providers to factors that fulfill and sustain them.5
With the COVID-19 pandemic, virtual care has become an essential facet of healthcare delivery, especially in the form of real-time video visits. Patients report high satisfaction levels with these encounters, and studies have demonstrated that providers can deliver quality healthcare for their patients through virtual care.6
Benefits
This model of healthcare delivery introduces new opportunities to strengthen therapeutic relationships, while enhancing patient care and enriching clinical training. With these benefits, virtual care invites our practice to a new side of medicine: the webside.
When transitioning from in-person to virtual care encounters, patients and practitioners interact through webside manner. Webside manner diverges from bedside manner with a greater reliance on non-verbal communication. Effective webside manner cultivates relationships and reinforces clinician empathy when practitioners actively listen without interrupting, appropriately use facial expressions, maintain eye contact with the camera and utilize vocal tone in their virtual discussions with patients.
Non-verbal communication is amplified at the webside because real-time video focuses on participants’ faces, eliminating some of the physical distance that exists in a clinical exam room. Non-verbal communication skills refined in the virtual care setting can then be applied to conversations held during in-person ambulatory care to enhance patient-provider communication.
Videoconferencing platforms leverage technology to facilitate patient-provider interactions. When the electronic health record (EHR) was introduced to the clinical environment, technology was perceived as a barrier to effective, meaningful communication between patients and providers. The challenges associated with integrating the EHR into patient care as well as the mounting administrative workload associated with the EHR, contributes to physician burnout.7
Notably, virtual care situates all components of patient care into one platform, because the patient encounter and its associated electronic record occur in the same portal. Practitioners interact with their patients, document the encounter, and share laboratory and radiographic information in a single workspace. In addition, these tasks can be completed while communicating with patients and their families, conveying empathy and demonstrating effective webside manner, via a single computer screen.
Several features of patient care encounters that appear disparate in the in-person ambulatory environment merge during virtual care, subsequently increasing providers’ focus on their patients and redirecting the clinician to more rewarding and enriching aspects of patient care.
Drawbacks
Despite the many benefits of virtual care, clinical circumstances may arise when webside manner insufficiently meets the needs of patients. Certain encounters may require a physical rather than a virtual exam, as when evaluating for signs of subtle synovitis. Some patients may be uncomfortable with the technology of real-time video visits, preventing them from interacting with their practitioners in an effective, therapeutic manner.
Conversations associated with high emotion, such as the delivery of bad news or discussions of care goals, may be best conducted in person, where empathy can be conveyed with such actions as offering a patient tissues or a reassuring touch of the hand and where clinic staff are readily available to provide support. As these examples demonstrate, identifying patients and encounters best suited for in-person vs. virtual care is requisite for the effective and safe practice of virtual medicine.
Educational Use
Virtual care can enrich medical training and prepare learners to deliver care across diverse settings. It allows trainees to develop their webside manner and virtual care skills, competencies requisite in their future practice of medicine in the virtual environment. Preceptors may also use some of the functionalities within teleconferencing platforms, such as the option to pause video and audio input, to support the educational techniques of direct observation of elements of the history and exam.
In addition, the virtual environment lends itself to webside presentations, where the learner shares the clinical history with the faculty preceptor in the presence of the patient. This style of presentation has been shown to improve teaching efficiency, as well as patient satisfaction.8 These techniques allow educators to more efficiently teach learners and optimize trainee assessment while enhancing the experience of patients, learners and preceptors. Virtual care supports clinical training and equips future practitioners with the skills needed to care for patients in the evolving clinical landscape.
In Sum
Virtual care, specifically the use of real-time video visits, can lead clinicians back to the bedside or rather back to the webside. As during in-person care, practitioners can convey empathy, build therapeutic and educational relationships with patients, and find meaning in their work in the virtual environment.
The technology of virtual medicine integrates many aspects of patient care, fostering an approach for patients and providers to interact with each other while facilitating clinical training.
Patients appreciate the care and communication extended to them in the virtual environment, as well as the opportunity to contribute to trainees’ learning.
With these benefits, providers, trainees and patients should recognize virtual care as a tool that enriches medical education, improves satisfaction and supports patient care in the clinical environment.
Lisa Zickuhr, MD, is an assistant professor of medicine, director of the rheumatology curricula and associate director of the medicine clerkship at Washington University School of Medicine, St. Louis.
Jason Kolfenbach, MD, is an associate professor of medicine and director of the Rheumatology Fellowship Program at the University of Colorado, Aurora.
Marcy B. Bolster, MD, is an associate professor of medicine at Harvard Medical School and director of the Rheumatology Fellowship Training Program at Massachusetts General Hospital, Boston.
Disclosures
Dr. Zickuhr received support for her time spent on research from the Rheumatology Research Foundation’s Clinician Scholar Educator Award (CSE2122).
Dr. Kolfenbach received support for his time spent on research from the Rheumatology Research Foundation’s Clinician Scholar Educator Award (CSE2122).
Dr. Bolster received support for her time spent on research from the Rheumatology Research Foundation’s Clinician Scholar Educator Award (CSE2021). She also receives honoraria from Custom Learning Designs for consulting; from ABIM for her work on the Longitudinal Assessment Approval Committee; from PracticeUpdate for her work as associate editor; from the ARP for her work as associate editor of the Advanced Rheumatology Course; and from Merck Manual.
References
- Shem S. House of God. London, England: Black Swan; 1985.
- Hipp DM, Rialon KL, Nevel K, et al. ‘Back to Bedside’: Residents’ and fellows’ perspectives on finding meaning in work. J Grad Med Educ. 2017 Apr;9(2):269–273. doi:10.4300/JGME-D-17-00136.1
- Chipidza FE, Wallwork RS, Stern TA. Impact of the doctor-patient relationship. Prim Care Companion CNS Disord. 2015 Oct 22;17(5):10.4088/PCC.15f01840.
- Riess H. The impact of clinical empathy on patients and clinicians: Understanding empathy’s side effects. AJOB Neurosci. 2015;6(3):51–53.
- Belfer JA, Sooy J, Rialon KL, Xi AS. Back to bedside: Defining success. J Grad Med Educ. 2019 Feb;11(1):111–113.
- Wood PR, Caplan L. Outcomes, satisfaction, and costs of a rheumatology telemedicine program: A longitudinal evaluation. J Clin Rheumatol. 2019 Jan;25(1):41–44.
- Zulman DM, Shah NH, Verghese A. Evolutionary pressures on the electronic health record: Caring for complexity. JAMA. 2016 Sep 6;316(9):923–924.
- Peters M, Ten Cate O. Bedside teaching in medical education: A literature review. Perspect Med Educ. 2014 Apr;3(2):76–88.
