Is technology changing the patient-doctor dynamic?

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ike practically every industry, healthcare is steadily adopting digital methods to improve its operations, and Covid-19 has only accelerated the process. The widespread adoption of telemedicine by doctors and GPs, for example, has reduced disruption to medical diagnosis and treatment during the pandemic – but does this move towards tech-focused healthcare always benefit patients?

Telemedicine services, such as video calls and wearable health monitoring devices, have been crucial to maintaining access to care while Covid-19 renders in-person visits largely off-limits. For those living with conditions that make physically attending the clinic or hospital difficult, telephone and virtual appointments can also vastly improve the healthcare experience.

Eleanor, who lives in England, has postural orthostatic tachycardia syndrome, a condition that affects blood flow and can cause symptoms such as fatigue, dizziness and pain upon standing. She says that telemedicine, “if done right”, makes a significant difference to her life.

“With telemedicine I have the energy to engage, get more from my appointment, and can perform certain tests at home whilst the doctor observes,” Eleanor says. “If I need to attend for healthcare, it might allow services to coordinate and make sure that if I travel by ambulance stretcher, I can have several tests in just one visit, given that I am usually there for hours.

“I need services that suit my disability level. Whilst I have a reliable internet connection, I would always choose an appointment that allows me to submit information beforehand, and that is doable without causing me undue harm.”

Although the benefits of digital healthcare have been made especially clear by the pandemic, the widespread shift to these methods can also negatively impact the patient experience and the quality of care provided.

Dr Eugene Ong, an NHS consultant dermatologist, says that while there are ‘huge opportunities’ for technology to maximise efficiency and data capture in hospitals, digital healthcare poses a barrier for those who find certain devices difficult to use.

“A lot of patients, especially the older patients, sometimes struggle with the technology,” he explains. “Often when you have old patients that can't take photographs, you get a very grainy image or poor image quality, and it's nowhere near the resolution that you get when a patient comes in.”

For specialties like dermatology, which rely on sight and touch to make diagnoses, there are also safety concerns associated with limiting patients and doctors to virtual appointments.

“For instance, in mole checks, we look at the whole patient's body, and that's often not possible when you only can see a picture of one or two of the areas,” Ong says. “So incidental lesions, incidental skin cancers that the patient might not know about, may get missed – that’s one of the main safety drawbacks.

“Even in a visual specialty, you rely on literal human touch; you rely on something called palpation, where you run your fingers over a rough area, and that can tell you whether it's a precancerous lesion. You won't get that from an image, so you're losing all those different sensory modalities that can allow you to come to a diagnosis.”

The success of primary care relies on communication and trust between the patient and their doctor – but important interactions, and therefore the relationship as a whole, can be compromised by the distance technology sometimes wedges between the two parties.

“There's no substitute for face-to-face consultations, in terms of seeing the nuances of a person's expression, and what they mean,” Ong says. “History taking you can do over the telephone, but often, the non-verbal aspects of communication of patients – expression, whether patients are happy – are not conveyed very well with telemedicine. Even on a video consultation, you can't see the rest of their body language, you might just see aspects of their face, for instance.”

In a piece published in JAMA Internal Network, US doctor Paul Hyman laments that physical examinations have been ‘ripped away from’ him as his care practice pivots to telehealth. “While I recognise the benefits of telehealth, I struggle to find equipoise,” he writes. “In attempting to keep patients at a distance, I am losing touch with a part of my professional identity.”

Human interaction between patient and doctor is, arguably, nowhere more important than in mental health services. The empathy and understanding that many patients seek when disclosing difficult or sensitive information, such as issues relating to their mental health, can be lost when contact is restricted to a phone or video call. 

Kirsty Teahan (24), who is on antidepressants, says her monthly telephone check-ins – implemented since the pandemic began – consist of different doctors ‘listing off questions they have to ask’. And because the doctor can’t see you in person, she says, it’s easy to lie or omit details about how you’re doing.

“You're just talking to a voice on the phone; it’s very impersonal,” she says. “If something was really bothering you, you just don't feel like you can [say], because a phone call is not the same as talking to someone face-to-face. Sometimes I’ve found that they don't even know what [medication] you're on, because they've never seen you before.”

The lack of consistent, face-to-face contact with a healthcare professional has changed the way Kirsty feels about doctors and has made her reluctant to get in touch and discuss her conditions with them.

“You're just a person on a piece of paper, because you aren't having regular appointments with a doctor who knows you – you’re just another person on their list. A lot of things that I've said to the doctors are just getting written off, because they can't see how it's affecting you, and you just feel a bit disheartened,” Kirsty says. “It feels really like they just aren't taking into consideration your individual situation.”

Similarly, Ong says that valuable information – like a patient’s concerns or expectations of their care – is often lost in telephone consultations.

“Obviously, that will have an impact upon the human relationship between a doctor and a patient, especially in dermatology and other specialties where you build up long-term relationships over a number of years, with patients with chronic conditions,” he explains. 

“If that relationship is compromised in any way, that has an impact on patient trust in a doctor, or the patient might not be comfortable mentioning something that may be of relevance. It creates a barrier in terms of building rapport.”

Less widely implemented, but nonetheless on the horizon, is an advanced technology that seeks to reduce patient-doctor communication even further: the chatbot. Chatbots are used for a number of healthcare purposes, including providing medical information, scheduling appointments, collecting patient data and submitting prescription requests.

While such technology can be useful alongside traditional healthcare, to help reduce workloads and costs, there remain aspects of healthcare where the human quality is expected and needed.

Recent analysis of an AI-powered chatbot for cancer patients concluded that “even after addressing issues and establishing the safety or efficacy of chatbots, the human element in healthcare will not be replaceable”.

Ong predicts that doctors’ regular use of telemedicine is likely to continue post-pandemic, and it looks like he’ll be proven right; 58% of physicians surveyed by McKinsey say they view telehealth more favourably now than before Covid-19, while 57% would prefer to continue offering virtual care after the pandemic.

So, if digital healthcare is here to stay, how do we make sure patients get the most from it? Telemedicine is ‘not a one-size-fits-all’ solution, Ong says; care should be tailored to the individual patient’s needs.

“If a patient's 90 years old and hard of hearing, telemedicine is never going to work, so the patient needs to be seen face-to-face,” he says. “If you've got a high-risk situation where you need to examine a patient’s skin or see a patient fully, then again, the telemedicine situation is never going to work. It needs to be tailored, based on patient preference.”

Technology has, in many ways, made healthcare more accessible, accurate and efficient – but it cannot, and should not, replace face-to-face interaction with a doctor. Rather, healthcare providers must strike a balance between the two – and determine where digital approaches are truly improving healthcare, and where they’re simply filling gaps created by the Covid-19 pandemic and other restraints.

More technology does not always mean more progress, and digital health’s impact on the patient experience must be a key consideration. In the industry’s attempts to make healthcare increasingly efficient, it risks sacrificing the human element at the core of medicine, and therefore disrupting the doctor’s ultimate goal: to provide high-quality care and inspire patients to live better, healthier lives.