A guest column by the American College of Physicians, exclusive to KevinMD.
Pandemics periodically alter the course of history, reshaping society as people struggle to deal with the consequences of a new and often devastating disease. As with past pandemics, over just a few months we have witnessed the rapidly spreading novel coronavirus stretch our social, economic, and political fabric as each part of the world has sought to manage the infection’s protean manifestations in different ways. And we’ve also watched as it has profoundly altered the practice of medicine.
Many of the changes in medicine are obvious, such as the need to rapidly pivot to caring for large numbers of severely ill patients, focusing on finding ways of identifying those with the infection and preventing its spread, and alterations in the mechanisms of providing care for patients, such as the remarkably quick transition to telemedicine and telehealth. Yet perhaps one of the most significant effects the pandemic has had on medicine relates to its impact on the way we are able to actually engage with our patients.
Because of the pandemic, we now live in a world where, because of the potential for asymptomatic transmission of the virus, physically being with patients can pose a real threat not only to them, but also to us as caregivers. We’ve responded by finding ways to provide care in which we are not physically co-located with them. And even when we are with patients, the nature of our interactions is significantly altered by our need to limit contact time, maintain as much social distance as possible, and the necessity of always wearing equipment such as face shields, goggles, masks, gowns, and gloves to protect both them and ourselves.
It’s as if an invisible “coronavirus wall” has been erected between us and our patients. And although certainly necessary, the implications of this “virtual barrier” on our relationships with patients are neither subtle nor insignificant.
From a strictly medical perspective, the loss of ability to closely visualize someone and perform a physical examination when seeing patients by telemedicine, or the need to complete an abbreviated and more focused history and physical examination while encumbered with personal protective equipment when seeing patients in-person increases the risk of failing to actually make an important diagnosis or potentially making an incorrect one.
However, perhaps just as important are the effects these changes are having on the patient-physician relationship.
Beyond scientific knowledge, much of the power of medicine rests in the human connection and development of close therapeutic relationships between patients and caregivers. These relationships traditionally develop by simply spending time together in the same physical space and communicating with each other as fellow humans. This person-to-person presence, coupled with the humanizing aspects of touch as part of the physical examination, helps develop a sense of mutual trust and creates a bond with patients that has a unique healing effect for both them and those providing care.
However, the practical restrictions posed by the pandemic have severely impaired our ability to connect with patients and develop these essential relationships. And unfortunately, they are occurring at precisely the time when our patients need us to care for them with a single-minded attentiveness. In times in which we are confronted with illnesses that are unknown and the medical interventions available are limited, much of the physician role centers on simply “being there” for patients – accompanying them through their illness and assuring them that they are not alone. But the current circumstances of the pandemic make this very difficult to do, which is why so many of us find it tragic when we personally experience or hear about people dying alone and isolated from COVID-19.
So what can we do to overcome this coronavirus-induced “wall” between us and our patients?
We can start by reminding ourselves that despite concerns for our own safety, that many patients feel extremely vulnerable and are truly scared by the pandemic, and the need for a meaningful therapeutic relationship with them is more important now than ever. We need to be aware that a focus primarily on the coronavirus, absent consideration of its personal and emotional implications on the patient before us, may stifle our ability to be truly present with patients.
We can embrace new technology and use it to find novel ways to connect with patients. For example, I’ve never learned so much about my patients and what their lives are like as I have through video visits over the past several months where I can actually see them in their home environment around the people they care about and those who care for them – this would unfortunately happen only rarely prior to the pandemic. And I believe that “seeing” them in a setting outside the office positively changes the nature of our interactions in which they feel much more comfortable in their homes than in the clinic. And I’ve also gotten much better at being able to interact with and get to know my patients through technology in a way that more closely resembles what would otherwise have occurred during an in-person visit.
When seeing patients in-person either in the hospital or clinic, a concerted effort at communicating with patients on a more personal, emotional level is helpful. Because masks and face shields hide our facial expressions (including smiles), it is more important than ever to convey our interest, concern, and empathy in other ways. This includes intentional eye contact, perhaps exaggerating our ability to express ourselves in other ways such as using the rest of our face, head, and hands to communicate, and in particular through the nature of our conversations with them. And touch, even if through one or more layers of gloves and gowns, is still touch, and can provide a sense of attachment with someone who might otherwise feel untouchable or stigmatized as a source of danger for others.
And in those situations where patients may not already know you, there are many proven ways to let them see the “human” behind the personal protective equipment, ranging from prominent display of a picture nametag to having an image of yourself so that patients can put a human face to the person caring for them.
As the pandemic will likely be with us for a while, I suspect that many of these current alterations in how we engage with patients will persist into the future, possibly even after the pandemic subsides. But how we practice of medicine will always need to change over time and with different externally-imposed circumstances. Yet the centrality of the patient-physician relationship to medical care is a constant that both compels and enables us to overcome the barriers to it, including the current and future pandemics.
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