key: cord-029626-j6b59y7a authors: Cooley, Laura title: Fostering Human Connection in the Covid-19 Virtual Health Care Realm date: 2020-05-20 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.20.0166 sha: doc_id: 29626 cord_uid: j6b59y7a As telehealth becomes more mainstream, finding ways to add compassion and understanding to your communications with patients and colleagues is increasingly important. Here are some evidence-based, relationship-centered tips for enhancing these virtual encounters. in a single day -a 50-fold increase over its baseline rate.5 Other health systems have noted similar rises. Most health care providers and patients have had limited experience with, or preparation for, telehealth encounters. So they are collectively facing communication challenges during the transition from in-person to virtual visits or consultations. 6 The quality of experience in telehealth encounters can be hampered by: 1) the inability to engage in usual nonverbal social behaviors, such as handshakes/fist bumps, leaning in, and facial cues, 2) difficulties in gathering accurate information without a physical exam, and 3) the sense of disconnect and distraction created by technology, such as diminished sense of authentic personal interaction, glitches with video, sound, or internet connectivity, or other distractions like emails on the screen. These barriers during virtual visits compound the existing obstacles to interpersonal interactions, such as cultural and language differences between the parties or clinicians reviewing and updating the electronic health record during appointments. In addition, having providers now virtually enter patients' homes to conduct telehealth visits raises privacy concerns if the patient lives in a communal situation, as well as the possibility that an environment of domestic violence can negatively influence an encounter. On the other hand, patients before Covid-19 generally reported overall satisfaction with telehealth experiences,7 and recent reports indicate those positive perceptions have continued.8 Patients cite the ease with which they can discuss personal problems when mediated by technology.9 In addition, these virtual "home visits" allow patients to avoid traveling to a clinical setting or waiting there with frustration for a provider who runs late. They can also give clinicians a window into their patients' home environment -and potentially helpful clues about the social determinants influencing their physical and emotional health. Human connection is vital to patient-provider relationships.10 Research suggests that conveying empathy and understanding of a patient's health beliefs and values enhances the patient experience and may lead to better clinical outcomes,11 due to increased patient adherence to providers' recommended treatment plans. Despite some barriers, empathy remains viable in virtual communication. For example, Lloyd B. Minor, dean of the Stanford University School of Medicine, describes how emergency medicine clinicians have used computer tablets to video conference with patients grappling with Covid-19: "Our physicians report that as they've used the iPads, they've been able to bring empathy back to the bedside. Many found that being encased in PPE severely constrained their ability to build trust and rapport with patients. Meeting virtually has enabled them to strip away these layers, creating space for empathy at a time when it is needed most."12 When participants discuss the personal and professional toll that Covid-19 has taken on individuals and the team, these huddles can deepen connections and thereby enhance work." Covid-19 distancing requirements have also accelerated the adoption of interactive digital tools to facilitate team connections,13 including the use of video conferencing and online discussion forums.14 Health care organizations hold virtual Q&A sessions to exchange up-to-date Covid-19 information with staff. 15 In addition, team huddles in some primary care settings, previously held in person, have restarted over virtual media. When participants discuss the personal and professional toll that Covid-19 has taken on individuals and the team, these huddles can deepen connections and thereby enhance work. Peer support groups are also happening online. For example, the anesthesia department at UCSF provides weekly virtual support sessions via Zoom conferencing software for faculty and trainees to share concerns, emotions, and experiences.16 Given the challenges of electronics-enabled communications, here are some tips for increasing personal connection in your virtual encounters by video or phone. They are based on relationshipcentered communication skill sets published by the Academy of Communication in Healthcare.17 (Table 1) . Uncertainty, fear, grief, and mistrust are exacerbated during times of societal crisis, such as the Covid-19 pandemic. Since psychological disorders are linked to an increased risk for poor health and performance outcomes,18 paying attention to the emotional well-being of patients and colleagues is more important than ever. Be "present": Prepare for your virtual encounters to ensure the quality of your technical and interpersonal connections. For video meetings, paying attention to your camera set-up, background appearance, ambient noise, and lighting can influence the other person's perception of trust and comfort. Pause to collect your thoughts before entering the virtual space. When we offer brief introductions (or re-introductions) and establish rapport at the beginning of telehealth encounters, we build a foundation for stronger relationships. Use open-ended questions, such as "You scheduled this visit because of XYZ, what else would you like to discuss today?" to encourage more meaningful conversations. Although patients may schedule a telehealth visit for an explicit reason, they may actually have multiple needs, some of which they may be hesitant to express immediately. Clinicians often fail to elicit a list of concerns at the outset, leading to late-arising issues and wasted time during the encounter. 19 In either patient-facing or team-based meetings, when we invite others to share ideas and expectations up front, we are more likely to address their most salient needs. Listen: Listen carefully, avoid interrupting, and pay attention to emotional cues. Clinicians often interrupt patients very early in encounters.20 Virtual sessions present added distractions, such as emails, texts, or even family members, and they intensify the need to listen carefully. Attentive listening allows for better diagnostic assessment of the person's concerns and explicitly demonstrates nonverbal respect. Noticing emotional cues, such as non-verbal indicators (sighs, tears, raised voice, etc.) and words or stories that represent feelings, gives you the opportunity to respond with more accuracy and compassion.21 Respond with empathy: Listening attentively, as described above, prepares us to respond empathically to both the content and emotion expressed in the virtual encounter. Provide a short summary, briefly name the emotion, and offer a supportive statement to help establish a strong human connection. Demonstrating empathy can actually save time by acknowledging the emotion and validating the other person, thereby enabling a more productive conversation.22 Share information: Make sure your patient or colleague understands the material you're conveying. The combination of physical distance and non-verbal communication barriers inherent in telehealth heightens the importance of clear information sharing. Clinicians often use medical jargon without checking on patients' understanding. Technology glitches, such as frozen video streaming or muted audio, may also interfere with delivering information during the encounter. Pausing to ask questions can maximize understanding, which leads to better outcomes for both patients and health care teams.23 The human element of an in-person health care encounter cannot be fully replaced by a virtual one. After all, a provider's gentle (and appropriate) touch can sometimes convey empathy in a way that words cannot. However, identifying and improving one's skills for engaging in meaningful virtual " communications with patients and colleagues can help ensure that human connection prospers in the midst of, and beyond, the changes wrought by the Covid-19 pandemic. Senior Director, Education and Outreach, Academy of Communication in Healthcare, Nashville, Tennessee Disclosure:: Laura Cooley is employed by The Academy of Communication in Healthcare, a 501(c) (3) academic organization that provides communication education resources. 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