“During the pandemic, it was an absolutely critical lifeline to stay connected with our patients. But now that now that elements of the pandemic have been routinized and normalized, the risk benefit ratio of a telemedicine versus an in person visit has changed.”
In the second part of our physician burnout series, Rheumatology Network interviewed Jack Arnold, MBBS, MRCP, a clinical research fellow at Leeds Centre of Rheumatic and Musculoskeletal Medicine, Massimo Radin, MD, PhD, a researcher at the University of Torino (UNITO), and Andrew Concoff, MD, Executive Vice President and Chief Value Medical Officer at United Rheumatology, to discuss their thoughts on telemedicine as it relates to burnout within the rheumatology community.
Telemedicine, while an important tool in the beginning of the COVID-19 pandemic, has distinct disadvantages for rheumatologists. “Rheumatology is not one of the subspecialties that best lends itself to a telemedicine-only approach,” Concoff stated. “During the pandemic, it was an absolutely critical lifeline to stay connected with our patients. But now that now that elements of the pandemic have been routinized and normalized, now that we have medicines to treat patients with COVID, medicines to prevent the development of COVID if people are exposed, and vaccinations to robustly limit risk, the risk benefit ratio of a telemedicine visit that reduces risk of exposure to COVID-19 and transmission of COVID-19 versus an in person visit which allows a more accurate assessment of disease activity has changed.”
Radin notes that creating personal boundaries between the patient and clinician is crucial to prevent burnout. In this new virtual world of telehealth, the rheumatologist may feel as though they never fully leave the office environment because they’re essentially always available for their patients. He explains, “one of the few things that they did teach us in medical school is that you shouldn't bring a patient’s pain home with you. But it's easy to say, and it's another thing to really feel it. Sometimes it's just inevitable. That's why I think that we should have a support system [in place for] winding down if you’ve had a difficult day.”
Jack Arnold, MBBS, MRCP: One of the successes of the pandemic burden has been telemedicine. It's very good, but it needs to be applied in a very specific way. If you've got patients who are stable, and have been stable for a long time, who are just continuing their regular therapeutic regimen, [telemedicine] is great. They don't have to come into the clinic, the consultation can be condensed, and it’s a little bit easier for them. But on the other hand, if you get somebody who is unexpectedly poorly, or they're having a problem, it can be a little bit frustrating because you can't then assess them in the way that you would like to. I then find myself booking that person to see me anyway.
In some senses, I'm reducing the workload, but then in other senses, I will be bringing them in because I feel I need to assess them more thoroughly, or we need to do blood to labs or other things. And that then duplicates the workload. It’s a sort of give and take really with telemedicine. I mean, I've always been really reluctant to use it at all because we'd, ideally, like to see everybody but I think there are, when it when you use it smartly, there are ways that you can really get something out of it and it can be effective.
Massimo Radin, MD, PhD: I didn't use telemedicine before COVID, but during COVID, we did use it quite a lot because many of our patients were advised to not come into the hospital [due to an increased risk of infection]. It actually adds a lot of stress to management because it's like you're never out of the office and patients can reach you at any time of the day. [For example], if I’m on vacation I don't have to worry too much about my patients. But then if I see that my cell phone is beeping because I've just received an email from a complicated patient that doesn't feel good, it’s inevitable that I will think about it. This is very wrong from my work perspective because then I'm on the job 24/7. It’s something that we should really look out for in talking about these things. It should be out there for the patient to see because the patients sometimes forget how the good and better ways for them to contact us. The barrier should be there from clinician to patient.
Andrew Concoff, MD: I think we must understand telemedicine and rheumatology is different than telemedicine in the behavioral health sciences and different than dermatology, for instance. There is a fundamental decrement in what we can do as rheumatologists if we can't put our hands on a patient and examine them directly. It's not an absolute, and it's certainly better than nothing, but on the continuum of care, you have nothing, a telephone-only visit, a telemedicine visit with video, a telemedicine visit with laboratory testing available, and then an in-person visit. There’s this spectrum of how careful and exact we can be in our assessment of a patient, and we have to understand that spectrum.
We need to find that that ideal hybrid telemedicine and in-person ratio, and that's part of optimizing care in the modern world. When it comes to the specifics of how telemedicine has changed the equation from a burnout perspective, I think it depends on the clinician and how well and they've adopted the best practices of telemedicine and how comfortable they are with telemedicine. It's certainly a different experience to interface with someone over a video connection than it is in person. There are certain inefficiencies that haven't been completely conquered in telemedicine.
For instance, in person, we have a waiting room and multiple examination rooms. In most telemedicine systems, we haven't reproduced that to yield the same level of efficiency. If I'm going to see you in a telemedicine visit, but I realized that I'm missing a critical laboratory study that is what this visit is about, it's very difficult to pause that visit, jump into another room with another patient and discuss their issues, and then bounce back to you quickly to stay efficient in moving through the way we do in the real world.
The other thing that wasn't appreciated initially during the pandemic is that when we line up visits one after the next after the next from a telemedicine perspective, if breaks aren't built in appropriately, it becomes this nonstop, one large visit. That can yield some issues with burnout.
For some of our clinicians that are less tech savvy, it can be an additional stressor to have to manage the video connection. Similarly, patients sometimes have trouble managing their end of it. The inefficiency associated with that can be very frustrating at the clinician level and can add to the stress of your day and can add to the feelings of burden.