By Estelamari Rodriguez, MD, MPH
As the number of COVID-19 cases in the United States increases, the need for social distancing to protect vulnerable patients from infection continues to grow. Health care facilities across the country have changed their practice to limit contact with patients by transitioning to telemedicine consultations, cancelling elective procedures, and establishing measures of social distancing in the clinic. Taking care of patients with cancer during this period has been particularly challenging. Reports from China, Italy, and New York have confirmed that patients with cancer who are infected with COVID-19 have particularly worse outcomes, thus the need to protect them from exposure even from health care professionals.1-3
My oncology clinic has been transformed overnight to limited patient contact via telemedicine and phone consultations during this COVID era. I take care of patients with lung cancer, most of whom have advanced disease. Our initial consultations are usually involved discussions reviewing the data, risks and benefits of treatment, clinical trials, and goals of care. These interactions are personal and emotional. Oncologists hold the hands of patients from the moment they get a diagnosis of cancer through coming up with a plan for treatment that meets the patient’s goals and offers hope. Many of these consultations include discussions of end-of-life care and advance directives. This deep connection with patients and families during their cancer journey is what first attracted me to this field.
I have found that translating my oncology practice into telemedicine and socially distant consultations has its advantages and disadvantages. Besides protecting patients from potential infection risk in the hospital, telemedicine consultations are convenient and can increase patient satisfaction.4 Patients who live in remote locations, are homebound, or have difficulty getting time off from work can now get on-demand care at home. Telemedicine has quickly become the new standard for a medical home visit, giving physicians a glimpse of the patient’s home situation and allowing physicians to have a more accurate assessment of the patient’s needs at home. Telemedicine consultations can also allow family members to be part of the medical visit in ways they could never do before. I recently had a consultation with a patient who lives in Florida and his two adult children who joined the consultation virtually from Los Angeles and New York. For a moment, I felt that we were all having a conversation in the same living room with the patient. This interaction was not only convenient but very therapeutic for the family.
Nevertheless, cancer telemedicine has its limitations. The most obvious is the lack of personal contact with patients, which is what I love most about my job. In medical school and fellowship, I spent countless hours learning by observation about good bedside manners, a thorough clinical exam, and how to provide comfort and establish trust with patients. These are all skills that can be lost in the virtual encounter. Being present in the room, responding to questions, validating emotions, and sometimes just giving a hug is what makes these interactions special.5 In oncologic care, the lack of personal contact can make difficult conversations even more difficult. I recently had to discuss hospice care with a Spanish-speaking patient and his family at home, and although I am a native Spanish speaker, I found the interaction awkward despite my efforts to establish appropriate rapport online. I felt that for this discussion to be culturally appropriate it required establishing physical and direct eye contact with the patient and his family.
There are also technical challenges to these virtual consultations. Many of our elderly patients who are not used to using computers, or patients who mistrust the medical system, may have a harder time communicating via this medium and may avoid these interactions altogether. Studies looking at the use of electronic health by vulnerable populations have described challenges with health and technologic literacy as a barrier. 6 Telemedicine encounters also tend to be shorter, which gives patients less time to ask questions and digest the information provided. I will argue that during this once-in-a-lifetime pandemic, time and space to address patients’ anxieties about cancer care is more crucial than ever.
There is no doubt that limiting contact with patients via social distancing has saved lives during the COVID pandemic. Insurance coverage of telemedicine, and the technology available to make this possible, will change the way we practice cancer care going forward. How we continue to provide support to our patients with cancer in a virtual environment is the challenge. The generation of oncologists trained by the bedside to conduct a physical exam will need to be retrained on how to provide this same level of care remotely. Effective online interactions require a different level of patient-centered communication.7 We will also have to make a more concerted effort to address the needs of vulnerable populations who may not be comfortable with this medium, due to technologic, language, and cultural barriers. We have an enormous opportunity to increase quality of care and access to care in this socially distant era but it will require more, not less, communication with patients.
Acknowledgement: Thank you to Dr. Christina Pozo-Kaderman, Dr. Frank Penedo, and Dr. Gilberto Lopes for your helpful comments.
Dr. Rodriguez is a medical oncologist and the associate director of community outreach for thoracic oncology at the Sylvester Comprehensive Cancer Center of the University of Miami. Disclosure: Dr. Rodriguez has received personal fees from Genentech speaker’s bureau and is on advisory boards for Guardant Inc and Astra Zeneca outside the submitted work.
- Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020;382:1708-20.
- Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. 2020;323:1775-6.
- Mehta V, Goel S, Kabarriti R, et al. Case Fatality Rate of Cancer Patients with COVID-19 in a New York Hospital System. Cancer Discov. Epub 2020 May 1.
- Sabesan S, Simcox K, Marr I. Medical Oncology Clinics Through Videoconferencing: An Acceptable Telehealth Model for Rural Patients and Health Workers. Intern Med J. 2012;42:780-5.
- Calton B, Abedini N, Fratkin M. Telemedicine in the Time of Coronavirus. J Pain Symptom Manage. 2020; S0885-3924(20)30170-6.
- Tarver WL, Haggstrom DA. The Use of Cancer-Specific Patient-Centered Technologies Among Underserved Populations in the United States: Systematic Review. J Med Internet Res. 2019;21:e10256.
- Penedo FJ, Oswald LB, Kronenfeld JP, et al. The Increasing Value of eHealth in the Delivery of Patient-Centered Cancer Care. Lancet Oncol. 2020 May;21:e240-e251.