key: cord-0061559-r7xclfsy authors: Fallowfield, Dame Lesley title: Enhancing your ‘webside’ manner: communication during COVID‐19 date: 2021-01-26 journal: nan DOI: 10.1002/tre.784 sha: 8d18b7948dbc7717785b7c7e2f9a160627a99cec doc_id: 61559 cord_uid: r7xclfsy Virtual communication and interacting with patients while partially hidden behind a mask are now part of everyday clinical practice as a result of COVID‐19. Healthcare professionals need to develop new strategies to ensure that non‐verbal cues and the reassurance that subtle body language can provide are not compromised. T he current COVID-19 pandemic has irrevocably changed all aspects of our personal and professional lives. The simplest acts that contribute so much to establishing or cementing our relationships with sick and anxious patients -a smile, an empathic glance, a handshake or literally a helping hand -are now either indiscernible behind masks or forbidden without personal protective equipment (PPE). For many patients and their informal carers, full PPE can seem threatening rather than reassuring (as well as uncomfortable for the wearer). Limiting the presence of family and friends during face-to-face (F2F) consultations, or restricting them from visiting patients in hospital, may increase fear and is isolating for patients in need of support. Although the remote/virtual care and management that has been forced upon all of us does offer some advantages, there are many problems to address, including proficiency when using the new technologies. In this article I discuss how we will need to adapt and change the ways we communicate difficult and complex issues with patients, and how we might maximise the opportunities presented by the 'new normal' and enhance our 'webside' manner. Good communication is a core clinical skill. Numerous studies 1 have shown that when done well it: improves accuracy of data collection; helps elicit the problems most pertinent to patients; influences their emotional and physical wellbeing; affects adherence to treatment regimens, monitoring and lifestyle changes; improves patients' overall experiences of care; reduces risk of litigation and medical complaints; and, finally, lessens burnout in healthcare professionals (HCPs). The human connectivity that is so important to patients with life-threatening disease has been substantially compromised during the pandemic. Physical distancing and wearing of masks and other PPE significantly inhibits both verbal and non-verbal communication. Figures vary but most studies suggest that around 65% of communication is non-verbal, 2 and even a simple handshake can profoundly affect patient perceptions of HCP engagement. In a randomised study of more than 1000 patients, 3 physicians were viewed as less empathic when wearing masks compared with when not wearing them. Masks can muffle speech, which is especially difficult for anyone with hearing difficulties who may also rely on lip-reading to enhance clarity or interpretation. In the absence of facial cues or touch, there is a greater need to focus on other paralinguistic aspects of discourse, including more emphasis on tone and inflection, slowing the speed, and increasing loudness without sounding patronising. Many Communication • nuances of the spoken word are easily missed without facial expression, so eye contact will assume an even greater importance. Some HCPs have developed innovative ways to try to solve this problem. Figure 1 shows a community children's nurse specialist who was deeply concerned that her chronically sick young patients could not see her face, so she printed off a variety of Memoji stickers to place on her visor or to get children to point towards. 4 Some hospitals now also provide their patients with 'face-sheets' that permit easier identification of staff members, and it is always useful to reintroduce yourself and colleagues to patients when wearing PPE. Telephone and video consultations have become the way in which many interactions between HCPs and patients are now taking place. Such changes had started prior to the outbreak of COVID-19, with healthcare systems worldwide implementing a digital-first policy to speed up patient throughput. 5 Box 1 details some points to consider before conducting remote consultations. Even the most adept communicators may need to modify not just their style but also the emphasis and content of these interactions. Many of the comments already mentioned regarding communication while wearing PPE are pertinent during virtual consultations, especially those regarding the paralinguistic cues of tone, loudness and pacing. Telephone consultations might often seem an easier, more practical way of 'seeing' patients, but the loss of any visual cues -in particular, how the patient is receiving the information being given -makes it especially unsuitable for giving difficult news. The use of video seems more optimal but there are challenges. At the start of any interaction, a simple acknowledgement of the difficulties when not seeing someone F2F is useful, as well as checking that the volume is loud enough for the patient (and you) and that the cameras are close enough. Not all patients (or hospitals) have good equipment for digital consultations, and those with poor bandwidth -often caused by software updating, background apps running or video streaming -may experience irritating delays and lags. This also produces jerky and unsynchronised pictures and speech, which can inhibit interpretation of the non-verbal cues and facial expressions that are so important when pacing complex or difficult information or news. In a large in-depth study of remote interactions in three NHS settings (diabetes, antenatal and cancer) it was demonstrated that both patients and HCPs needed to make things explicit that were typically implicit during a F2F meeting, such as reading out or holding up notes and results, or politely asking the patient to be quiet while the doctor checked notes or computer records. 6 As someone who has spent many years analysing doctor-patient interactions, it is striking how much the use of silence, • Communication together with non-verbal gestures such as nodding and leaning forward, encourage the patient to engage in an exchange. The unfamiliar format of using video, especially if the camera angles are suboptimal, mean that explicit invitations for the patient to speak are even more important. Even when conducting F2F consultations many HCPs interrupt patients, so they may need to practice leaving just a little more time for a patient to respond to questions and to avoid talking over a patient that may mean they miss crucial things that the patient might be trying to convey. In a normal clinical setting, intimate examinations are often required that are either impossible or inappropriate during a remote consultation. If photographs, live-stream video, screenshots and video recordings are deemed clinically necessary then there are many principles to consider. For example, there might not be a suitable chaperone available, and the use of family members might be too embarrassing. No clear national guidance exists yet regarding care workers assisting patients with undressing for remote consultations, or with them taking and sending images safely and securely. The limitations of IT systems being used by patients and HCPs when taking or storing intimate images also poses numerous data protection issues. NHSx has provided some guidance around information governance generally, and the use of apps such as WhatsApp, FaceTime and SkypeHDX. 7 Excellent guidance regarding intimate remote consultations is also available in an NHS England and NHS Improvement document, published in July 2020. 8 There have been several studies published recently examining the views of both patients and clinicians about the new way of working. In one recent study, 9 clinicians thought that virtual consultations were more efficient and decreased their workload -with 94% finding it practice changing and more likely to be continued post-pandemic. The views from clinicians about virtual consultations and telemedicine seem partly to depend on their familiarity with the process. System faults, the inability to physically examine patients, and anxieties about medico-legal liability are a real concern for some. 10 In the current climate, patients seem fairly accepting of the limitations of remote consultations. A study 9 of 283 patients with sarcomas showed the majority to be satisfied with virtual consultations, citing its convenience, time saving and reductions in travel costs. Despite this, 48% felt that they would not have liked to receive bad news in that way. A recently published interview survey entitled 'The Doctor Will Zoom you now' involved UK patients recruited by local Health Watch groups, and showed more mixed responses from participants about their virtual consultation experiences. 11 Although most were just pleased to have been 'seen' at all in the circumstances, with a majority favouring video rather than a telephone call, others were frustrated by the technology, missed calls or messages without a number to call back. It is quite likely that for the foreseeable future the numbers of F2F consultations will continue to decline, preventing unnecessary contact and reducing infection risks. However, assumptions that new technologies will solve many current problems in the NHS are unfounded as digital exclusion is common. For example, many adults in the UK do not have even basic digital literacy, with 71% of the 4.1 million people who are 'offline' being from low educational or low-income groups. 12 A 2018 survey by the Office for National Statistics showed that approximately 5.3 million UK adults (10% population) had never used the internet. The majority of these were older (79% were aged 65 years or above) and 23% were disabled in some way. 13 Likewise, in 2019, although 79% of adults owned a smartphone only 40% of those aged 65 years and above had access to the internet via their phone. In any case, broadband coverage and speed is still woeful in many parts of the country. Of course, the current pandemic is also changing how we communicate with colleagues as well as patients. Much of the decision making and delivery of care is via a multidisciplinary team (MDT), ensuring that patients benefit from the viewpoints of various disciplines. A functional MDT also enhances the wellbeing of its members and reduces burnout. During the current pandemic, team members may be physically exhausted, exasperated by the new ways of working and worried about their patients and their own safety. These factors may be exacerbated by a loss of physical connectivity and a reduction in collaborative communication with colleagues. The now ubiquitous Zoom or Microsoft Teams meetings can be frustrating. Many of the principles already elucidated when conducting remote consultations with patients apply equally to virtual meetings with colleagues. As well as making sure of confidentiality and security, the meeting participants must be skilled using the technology and ensure that all present are aware of the basic ground rules, such as muting audio when not speaking and using the hand-raise options. Colleagues having difficulty coping with the technology should be easily helped with assistance from a responsive IT department in the hospital. Identifying isolated or burnt out team members in our changed working environment might be less easy. My own research team started a private WhatsApp group to share jokes, photos and comments in an attempt to recreate some of the camaraderie and collegiality normally part of the coffee-room/office experience. It is inevitable that competency in adapting traditional F2F communication to the new virtual modalities is the way in which we will all need to work if we are to sustain safe, good quality treatment and research. Adjusting to this new normal is not always going to be easy for our patients, their informal caregivers or for HCPs. All managers have a responsibility to provide their staff with the necessary IT resources, together with support and training, if they are to develop a good web-side manner to complement a good bedside one. Finally, there is a need to guard against 'Zoom fatigue' -as in virtual meetings the concentration involved, and the lack of subtle social cues, can be quite physically and emotionally draining. Unless the mental wellbeing and educational needs of the healthcare workforce are addressed adequately, then patients and HCPs will struggle to adapt also. Declaration of interests: none declared. 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