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Is Telemedicine Better for Delivering Bad News?

Researchers in Michigan say the phone call works better than the in-person visit for delivering a cancer diagnosis. But while doctors agree it improves the timely delivery of vital news, some say the process might be robbing them of that all-important human touch.

- Is a bad diagnosis best delivered in person or by telemedicine? According to researchers at the University of Michigan in Ann Arbor, the telephone may work better.

Writing in the November issue of JAMA Oncology, Naveen Krishnan, BS, Angela Fagerlin, PhD, and Ted A. Skolaris, MD, MPH, say telephone consults “can potentially relieve much of the anxiety associated with in-person consultations while delivering bad news in a timely, compassionate and patient-centered manner.”

In addition, they said, telemedicine enables the doctor to focus on the message, so that the patient better understands the news and can move more quickly into an appropriate treatment plan.

The three researchers, focusing on instances in which biopsy results are explained to a patient, said those moments are more stressful when doctor and patient are face to face. The patient is under a lot of duress, and likely isn’t following closely or fully understanding what the doctor is saying. That leaves the patient with unanswered questions and uncertainty as to what comes next, possibly delaying the most effective care plan.

“Patients are not only trying to absorb devastating news, but also engage in challenging conversation,” they said. In that setting, “the ability to acutely process bad news in then office worsens under emotional duress and ensuing medical jargon.” That means the encounter is much less interactive than it could or should be.

On the other hand, the researchers said, telemedicine “can serve as a buffer” and give the patient more space to process bad news, free of the gaze of the doctor or the uncomfortable aspects of a doctor’s office. The patient can process the information with family and friends, and are better prepared to have a meaningful conversation with the doctor at a subsequent in-person visit.

According to the JAMA article, surveys have shown that patients want to learn biopsy results as quickly as possible – a process that works  better with telemedicine, as opposed to scheduling a visit to the clinic or doctor’s office. Likewise, studies have shown that patients are more focused on message content than “supportive aspects of communication,” such as a comforting hand on the shoulder. “In this respect, telemedicine allows physicians to focus on content rather than non-verbal communication that patients may not appreciate at the initial in-person office visit,” the researchers said.

But do doctors agree that this is the best way to deliver bad news? Two physicians contacted by the Medscape online community have mixed feelings.

Philip Blaler, MD, an attending psychiatrist at New York City’s Memorial Sloan Kettering Cancer Center, said telemedicine enables doctor and patient to discuss biopsy results in a more timely manner, but it doesn’t allow for the “humanistic aspects of medicine” that improve the doctor-patient relationship. A doctor might not be able to properly react over the phone to a patient’s emotional response to the bad news.

Alicia K. Morgans, MD, of Nashville’s Vanderbilt-Ingram Cancer Center, told Medscape the phone call works great in getting the biopsy results to the patient as quickly as possible, but it doesn’t allow for a full conversation between doctor and patient. Doctors want to be able to see their patients and react to their feelings, she said, while the patient might have questions that he or she wouldn’t think of while focusing on the phone call.

The JAMA article cites two established telemedicine providers – the Arizona Telemedicine Program’s Telehealth Rapid Breast Care Process and the Ontario Telemedicine Network’s online oncology service – as examples of successful telemedicine-based oncologic services. But it doesn’t complete the argument that these programs work better when biopsy results are delivered by phone or video consult rather than in person.

The point is made that telemedicine does improve overall cancer care, but there’s a fine balance between presenting a diagnosis and making sure that diagnosis is understood. That distinction may best be addressed on an individual basis – by both the doctor and the patient.

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