The doctor-patient relationship and barriers in non-verbal communication during teleconsultation in the era of COVID-19: A scoping review

Review question

The research question for this scoping review is: What are the reported barriers to non-verbal communication in telemedicine? Additionally, the review aims to explore the strategies proposed in the literature to overcome these barriers, including recommendations for improving communication technology, providing training to physicians and patients, or implementing changes in healthcare processes.

Concepts

The World Health Organization (WHO) mentions that telemedicine serves to “Provide health services, where distance is a critical factor, by any health professional, using new communication technologies for the valid exchange of information in diagnosis, treatment and prevention of disease or injury, research and evaluation; and continuing education of health providers, all in the interest of improving the health of individuals and their communities”.¹¹ Telemedicine emerges to fight against geographical barriers.¹² In the evolution of both medicine and telecommunication technologies, various types of telemedicine have been developed, such as teleconsultation (interaction that occurs between a doctor and a patient in order to provide diagnostic or therapeutic advice through electronic means),¹³ tele-education (distance training that uses information and communication technologies so that people advance in their training process),^14,15 telemonitoring (set of actions carried out by a health professional through use technologies, to provide the patient with advice and counseling with fines for health promotion, prevention, recovery or rehabilitation of diseases)¹⁶ and telesurgery (involves a surgeon operating from a remote location, either the next room, another hospital, another location or another continent).^17,18

On the other hand, in non-verbal communication, aspects of the communicative exchange other than words that are capable of conveying meaning are understood. These include aspects of body language such as hand and arm gestures, facial expressions or body posture, and other related aspects such as accent, tone, volume, or speed of speech. The importance lies in the fact that it allows the patient to express her feelings through body and facial manifestations, which constitute a crucial component in the doctor-patient relationship. It should not only serve to obtain information that the doctor needs in the performance of his duties, it should also be used so that the patient feels listened to, to fully understand the meaning of his illness and so that he feels a co-participant in his care.¹⁹

Protocol and registration

Our study was developed according to the recommendations according to the ‘Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA)’, the checklist is in Reporting guidelines.⁵⁴ Because PROSPERO does not accept the registration of Scoping Review protocols, we opted to register it in the open access repository Figshare with the identifier of digital object (DOI) 10.6084/m9.figshare.13670362.

Search strategy

A systematic search was carried out considering data from the beginning of time until February 2021 in the following electronic databases: MEDLINE/Pubmed, Ovid, APA, EBSCO, Web of Science and SciELO. No restriction was applied by language type or region. Additionally, the references of the included studies were evaluated to collect more bibliographic material. The search strategy included Medical Subject Title (MeSH) terms for “telemedicine”, “telehealth” and “teleconsultation” and related terms is available at the Extended data.⁵²

Selection of documents

Eligibility criteria

The participants considered in this scoping review included adult patients with chronic diseases who received care through telemedicine. Case series, cross-sectional studies, retrospective, and prospective cohorts that addressed barriers in any aspect of non-verbal communication in teleconsultation were included; but if it didn’t mention the doctor - patient interaction, these were excluded. We also excluded review articles, clinical trials, abstracts of congresses, letters to the editor, editorials, and systematic reviews.

Study selection

The electronic search results were imported into the EndNote 20 reference management program; then, duplicate studies were removed according to the procedures described by Bramer et al.²⁰ After that, we filter by titles and abstracts according to the inclusion criteria and finally potential documents were evaluated in full text to assess the eligibility. Two authors (JGV and CGO) assessed the eligibility of the studies independently using the selection criteria. The results were reviewed by a third investigator (IPT), who resolved any disagreements. The flow chart from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement was used to inform study selection.^21,54

Data extraction and quality assessment

The data extraction was carried out by two researchers independently (JGV and CGO) and they were added to a Microsoft Excel document. by name of the first author, year of publication, country, study design, sample size, sex, dimensions, and aspects of non-verbal communication reported, barriers to an adequate understanding of the message, proposed strategies, among others. If it was necessary, we sent an email to the corresponding author to collect additional information.

Two authors (JGV and CGO) independently assessed the quality of the studies using the Newcastle-Ottawa scale (NOS)¹⁰ for cohorts and its adapted version for cross-sectional studies. It is a validated tool used to assess the methodological quality of non-randomized studies in systematic reviews and meta-analyses. The tool assesses the risk of bias based on three domains: selection of study groups, comparability of groups, and ascertainment of exposure or outcome of interest. Each study is assigned a score based on these criteria, with higher scores indicating lower risk of bias. It was considered as ‘good methodological quality’ if there were 3 or 4 stars in the selection domain, 1 or 2 stars in the comparability domain and 2 or 3 stars in the results domain/exposure; as ‘fair methodological quality’ for 2 stars in the selection domain, 1 or 2 stars in the comparability domain and 2 or 3 stars in the results domain/exposure; and as ‘poor methodological quality’ for 0 or 1 star in the selection domain, 0 stars in the comparability domain or 0 to 1 stars in the result domain/exposition.

For clinical cases, case series, and studies with fewer than 10 participants we used the Murad tool¹¹ which consists of 8 questions divided into 4 domains (selection, verification, causality, and reporting) and a score greater than 5 was considered acceptable.

As the objective of this research is to explore the strategies proposed to address barriers in nonverbal communication during virtual medical care, we do not present quantitative results, but rather the results are grouped into each of the dimensions of nonverbal communication according to a classification proposed by the authors.

General characteristics of the studies

The studies predominantly were of the cross-sectional type with a total of 13 studies, followed by reports or series of cases (n = 5).

The documents were from United States (n = 5), Australia (n = 3), Netherlands (n = 2) and the rest contributed with a single study. One study was from Latin America (Brazil). The total number of participants was 1,404 of which there were reports of 670 females and 303 men. Regarding the age of the patients, it varied in a range from 10 years to over 65 years.

Review findings

Barriers in non-verbal communication in teleconsultation

In this review we suggest a systematization scheme of the dimensions and aspects of non-verbal communication (see Figure 2). Based on that, on the dimension of head and face which include vision, gestures, head, and face movements, 16 of the 18 studies^13–28 reported barriers of this dimension, being the most registered the decreased eye contact and difficulty recognizing facial expressions.

Figure 2. Systematization of the dimensions and aspects of non-verbal communication important to evaluate in the patient during teleconsultation.

In the dimension of voice and speech, 4 of the 18 studies^13,14,16,29 covered this topic and treated aspects about loss of tone or volume, dilation when responding by both participants (doctor and patient) and correspondence during the talk.

In the field of corporal language, 9 of the 18 studies^{13–15,19,21,23,25,27,29} addressed barriers in this appearance, mainly posture (described in patients with chronic pain, depression disorders, discomfort in front of relatives) and hand movement.

The technical dimension was assessed in 9 of the18 studies,^{13,18,21,24–26,28–30} mainly the aspects related to camera focus and lighting from both places involved, as well as the quality of the video. Other points related to this dimension are poor access to the network or ignorance in its use.

Strategies to improve non-verbal communication aspects in teleconsultation

Of the included studies, 7 of 18 mention strategies to improve eye contact and facial expressions.^{13,15,20,24,26,28,29} Among them, posing the angulation of the camera in 7 degrees and widening the field of vision with the use of multiple cameras was proposed to improve focus, observation of the gait when the participant enters and sits, and the position of the patient and companions.

Achieving empathy with the patient has been addressed in 3 studies^13,25,29 and it is mentioned that starting with casual conversations (i.e., telling own experiences) could be effective to gain patient's trust. Adapting to the needs and preferences of the patient in the use of video camera or only audio was mentioned in 1 study.¹⁹ In the dimension of voice and speech, 1 study¹⁴ reported that using an appropriate tone and pausing to wait for answers improve nonverbal communication. For older adults, 1 study²¹ mentions that a personal caregiver is beneficial to ensure the telecommunication process.

Daily telepractice trainings to improve skills in non-verbal communication in the doctor are addressed in 2 studies,^18,22 3 studies^13,16,17 recommend the use of training softwares, and 1 study²³ suggests the elaboration of flowcharts of care for telemedicine. In addition, ensuring adequate connectivity to the internet for the participants is widely cited. For a complete list of the proposed barriers and strategies, see Figure 2.

Assessment of the quality of the studies

For the cross-sectional studies (n = 13), it was found that most of them had poor quality (9/18) followed by studies of fair quality (4/18), we did not find any study with good methodological quality. For the case reports, 4/5 obtained an adequate quality categorization (see Tables 1 and 2).

Main findings

We found that most of the barriers in non-verbal communication in teleconsultation reported in the studies were concerning to facial gestures, gaze, and body posture.

Barriers to non-verbal communication during teleconsultation

Head and face: Vision, gestures, movements of the head and face

In person, the gaze and eye contact are used more when speaking than when listening,²⁸ while during video call they are used to the same extent in both processes. This overuse of the visual channel in a digital medium increases the cognitive load and difficulties the process of interpreting verbal messages.³¹ Furthermore, many times during teleconsultation, the doctor is in the situation of reviewing and documenting the clinical records while must empathize and collect additional information from the patient. In this process, the directionality of the gaze does not always go towards the patient, and this can be interpreted as lack of interest to them.

Facial expressions or gestures are useful because they reflect the patient´s internal state³²; as well as their preferences. For example, a smile can tell us that the patient agrees, and a sigh can signify a desire or something that teleconsultant cannot reach.³³

Body language: Posture, limb movements, clothing and additions and physical self-contact

An individual's posture and dress can be used as a source of information about personalities and moods. But in video conferencing systems the screens are too small to provide this information. During the teleconsultation the physician only observes the face and perhaps the shoulders of the patients; this diminished visual field prevents us from obtaining useful information about this aspect of non-verbal communication.³⁴ Although there are electronic devices incorporated into gloves that attempt to identify sequences of movements based on the position and angles of the joints these are difficult to use.³⁵ Patients who use gestures to communicate, such as in sign language, involving rapid movements of the upper limbs (temporal features) and hand shapes (spatial features) are those that are most affected in the current covid19 pandemic.³⁵ Finally, self-contact, touching either by crossing arms or holding hair or face reflects emotional alterations during medical care.³⁶

Voice and speech: Intonation, volume, response time and correspondence

The tone and volume of the voice make it possible to identify which of the interlocutors dominates the conversation. It has been reported during teleconsultations in which physicians had high conversation dominance there is less correspondence and speaking time for patients, resulting in poor information gathering.³⁷ Patient intervention is less when they are not allowed to speak, do not feel empathy during the consultation or do not receive kind words. In addition, health personnel tend to complete the consultation faster when patient responses are very short. This would explain poor patient-doctor interaction and poor collection of information for the clinical records.³⁸

Also, video call conversations are more disruptive compared to via phone consultations, especially when the streaming is slow. The secondary channel or backchannel during a remote conversation occurs when a participant is speaking, and the other participant responds by interrupting the speaker. The dialogues get more troubles when there is backchannel.

Technical aspects: Camera focus, video quality and lighting

The technical aspects of image and video can influence non-verbal communication during teleconsultations. The low video quality of both participants does not allow them to see the facial expressions or the full body of patients.³⁹ Such drawbacks are described as barriers to creating a relationship of empathy with another person or rapport.²⁴

Some patients may not be familiar with ICTs or may not have the components necessary for an adequate exchange of information (microphone, webcam, high speed internet). As a last resort, health personnel could select the communication mode that the patient feels most comfortable with, not being the ideal way to obtain information in several cases.³¹

Suggested strategies to improve non-verbal communication in the teleconsultation process

The strategies identified to improve the quality of care during virtual consultations cover multicomponent aspects. At the head, we have those aimed at the practical improvement of non- verbal communication skills such as the use of training software and setting training hours.²⁹ It is necessary because health personnel are afraid of losing the patient information if they fail to observe accurately, moreover when they must watch the screen and write information from the patient at the same time.³⁸

Before starting the teleconsultation, it is important to check out the audio and video components to ensure that the doctor's image is in the middle of the screen and enlarged so that it is clearly visible. In addition, it has been described that the use of technology must be in optimal conditions to guarantee a better process, therefore correct internet connectivity and high-quality images and videos are essential.

Applications, such as Emopain dataset,⁴⁰ analyze facial recognition and generate interpretations of the patient's emotions,⁴¹ mitigating the further confusion of the effect of acting with the camera.³³ The applications would also serve to control specific diseases promoting their self-care and self- monitoring.⁴² Laptop’s image readers have increased considerably the availability of facial images as a data source about the status of an individual. The large touch screens of the current devices have provided more visual methods and interactive tools to assess patients.⁴³ Although, there are no systems based on smartphones designed to detect facial expressions and only a few smartphone systems identify facial expressions.

Empathy and creating a friendly environment for the patient can be achieved in multiple ways. Introduce yourself and greet both patients and their family members and saying goodbye at the end is basic. It should be explained that the query face-to-face will be covered in the video consultation and that the level of service will be the same. In the first consultation it is important to spend some time talking about family, home and other social issues to build a good relationship (as you would face-to-face consultations). To maintain visual contact with the patient it is necessary to place the patient's image as close to the webcam as possible so that the patient feels that they are face to face. Additionally, the camera can be zoomed in and out to capture non-verbal signals.

Make sure the patient has an adequate understanding of their diagnosis and treatment is essential to transfer effective information. The use of visual aids such as images and/or drawing on whiteboards can support verbal explanations.⁴⁴ Summarize the information given and check with small questions to patients can evaluate the understanding process, especially when dealing with older adults. If the consultation involves the discussion of sensitive issues, we recommend considering doubling the evaluation time, this is helpful for aging and terminal patients. Before completing the query, please suggest opportunities to address future concerns by providing contact details from local healthcare providers and other specialists.⁴⁵

The physical distance between the participants of the teleconsultation compromises the visual and auditory information. Lack of physical contact (hand shaking and physical examination) affects the emotional and psychological bond between physicians and patients. Therefore, teleconsultation requires greater patient participation since doctors cannot perform the same physical examination as in an encounter face to face.⁴⁶ It is recommended to advise patients to participate in the consultation virtual with a close relative who can help report data on their physical status.

Privacy in the use of telemedicine involves three aspects: the patient, the platform and provider. In a video call, we suggest analyzing or imagining the surroundings and who is listening to the teleconsultation even if the camera is off, to maximize similarity to a face-to-face encounter. The patient should describe where they are and if they have privacy, as well as to confirm that the time for talking is enough. To ask a question, try to use the names frequently to address to the appropriate person. Minimize distractions, using a predictable location and decreasing electronic distractions by blocking Windows pop-ups or notifications, divert incoming calls or notifications directly to voicemail.⁴⁷ Consider that the patient's environment can have its own distractions, which may not be directly apparent. If there are technical failures during the beginning of the conversation, it is recommended to move to a telephone conversation. If the encounter with the patient includes another healthcare professional, it is beneficial for both professionals to be in the same physical space, to create normality, greater comfort in the patient and avoid another source of distraction.³³

Teleconsultation and the Peruvian social aspect

Teleconsultation is a two-way relationship where it is fundamental to provide the optimal conditions for the best care. Because of the COVID-19 pandemic, great challenges are presented to optimize this service, especially in Peru, which is one of the countries with the highest infected number, higher mortality, less access to health and with projections of worse results than most countries.^48,49

Currently, despite the return of healthcare workers to in-person care, there has been a significant increase in demand for telemedicine in both public and private sectors. The National Telehealth Network of the Ministry of Health (MINSA for its acronym in Spanish), which previously provided a maximum of 250 monthly services prior to the health emergency, now registers one million monthly services across its various modalities. Social Security has also conducted over 2 million teleconsultations in the past year and a half. Despite these achievements, a large portion of the Peruvian population still lacks access to telemedicine and continues to rely on traditional forms of care.⁵⁰

We must consider that the processes of adaptation to changes in behavior or customs in the population take time and often generate resistance in people, because of the comfort that represented their close past. The presence of a threat is not recognized and in some sectors the benefit of the vaccine is doubted. Health professionals must recognize that this context is not the best to begin a type of medical attention that was previously prohibited in the country.

The fear that occurs mainly in the most vulnerable populations generates resistance to any type of information. Distrust of the state is structural, and survival efforts have been always far from any state program that may include them. Our results provide various techniques to optimize teleconsultation; However, digital media, for some people, will be a disadvantage rather than an opportunity, due to the gaps in infrastructure, education, and market access in large sectors of the population, even in the capital itself. For health professionals, a useful strategy would be the development of guidelines based on patient’s profile, considering their degree academic, marital status, comorbidities, and disabilities; with that, it is hoped that the doctor can better adapt to the context of teleconsultation and provide better attention to the patient.

The generation of empathy is one of the important values that must be incorporated between the doctor and the patient to break that barrier that prevents establishing the trusted connection for healthcare. This requires a lot of practice, and it is important that medical schools include in their undergraduate courses for distance medical care incorporating the strategies mentioned in this review. In addition, the use of language according to the patient's social context is also an essential manner to build trust when engaging a conversation with tolerance, use of simple words and examples.

Limitations

The studies included in this systematic review have been observational (cross-sections and case series), ideally, we would have wanted cohort-type studies that will assess exposure to non-verbal communication barriers in telemedicine and measured the results in the transmission of the information and the clinical improvement of the patient; but despite doing a search exhaustive, no studies with this design were found. Only one study corresponds to Latin America (Brazil) and the others come from populations with greater economic solvency, which implies that the technological limitations reported and levels of education of patients are not the same as in our country. Also, strategies to overcome barriers in non-verbal communication in telemedicine should be evaluated in controlled clinical trials.