By Tarek Haykal, MD

The COVID-19 pandemic has forced humanity to adjust and change numerous aspects of our daily lives; normalcy has been redefined with a lasting impact. Every socioeconomic strata and sector has been affected, including health care. But health care practitioners found versatile methods, including telemedicine, to deliver care to their patients, especially those requiring frequent surveillance. Rapid adjustments through data-driven solutions in oncologic care and delivery systems have allowed patients to receive care in outpatient settings. Much of oncology care happens in the clinics, which to its core strengthens the physician-patient relationship. Telehealth services, by phone, video, or text, have been established for several years. However, they were never equipped for primetime use.

For trainees such as myself, who began fellowship training during the COVID-19 pandemic, the rapid adjustment to an entirely new delivery system required trainees and faculty to ensure continuity of care. That did create more burdens on new trainees who are just starting to learn more about oncology care without the stress of learning a brand new implemented modality for delivering care to patients. When a new oncology trainee takes over the clinic of a graduating fellow, the transition is always met with many challenges; however, the biggest challenge is how best to find rapport and create a new connection and trust, promptly, with a patient with cancer who may have already achieved an excellent level of trust and respect with their previous provider. Unfortunately, telemedicine did not help us with this transition and instead made the process take a longer time, mainly because of the lack of in-person interaction with our patients, and how can anyone trust someone they have never met before? I still remember a patient with early breast cancer that was treated with surgical resection and then adjuvant endocrine therapy who had rescheduled her appointment many times, and did not want to come in for her provider visit and exam. When I called her to inquire as to why, she stated mainly because she did not want to meet a new provider that she did not know and did not feel safe or comfortable to be present for an in-person visit in the middle of a pandemic.

As a first-year fellow in hematology and medical oncology at Duke University, our continuity clinic is a half-day per week. While training in residency in the pre-COVID era, one was not prepared or trained to deal with telemedicine as a new modality for clinic visits, which created many hurdles for physicians and for many new fellows in training. One of the main challenges was having to break sad news or to have goals-of-care conversations with patients with cancer without seeing them in person. Sure, oncology care can be safely done remotely, but one wonders if all our work had become virtual and lacked genuine human connection and touch, how can a provider console a patient or provide them comfort when we are virtually delivering them bad news? For patients on maintenance therapy whose disease was still responding well, then great, they could get their blood work done closer to home and chat with their provider briefly over a phone or video call and safely skip an in-person visit. But on the other end, when you need to go through critical restaging imaging or if something were to change significantly on a routine surveillance imaging (like a new liver metastasis while on treatment for colon cancer), then an in-person visit is very much needed.

Another concern that I always had was how to complete a thorough physical examination and assessment for our patients. While I agree that our physical exam did not change much in our assessment and treatment plans in many instances, how can we examine our patients for a rash or swelling to ensure that they do not suffer severe complications from our treatments? I guess there will be some limitations that we won’t be able to overcome with telemedicine.

While I personally don’t prefer practicing via telemedicine, and have asked almost all my patients to come for face-to-face visits once it was safe to do so, it is important to acknowledge that this was the best alternative we could have in the middle of a pandemic. Technology was accessible enough to have that option for both patients and providers, especially for patients who were doing well and only needed routine follow-up. Telemedicine also was there to help patients who lived far away and ease the burden of travel to meet their provider, when this can be done safely from home. Multiple papers have queried patients with cancer about their experiences with telemedicine. Surprisingly, most patients in one survey had a very high satisfaction level from virtual care compared with in-person care. Most patients reported the relief in avoiding having to come for an in-person visit to a hospital setting in the middle of a pandemic.¹ Another paper echoed similar results, where only a minority of patients with cancer felt that the absence of physical clinic visits harmed their treatment, and actually, most patients wished to continue telemedicine services.²

Unfortunately, it is not the same response when oncology providers were surveyed, as their responses were mixed. Despite established convenience and improved access to care, many disagreed on the clinical effectiveness and potential limitations of the virtual physical examination, limiting their ability to empathize and understand their patients.³ It is not surprising to see the results of those surveys and the contrast between the perceptions of patients versus those of providers. Medicine was never meant to be practiced virtually and therefore being suddenly forced to practice it in an unorthodox fashion was very burdensome and added another layer of complexity for providers and trainees. Not all patients had the technology to have full video visits; in many instances, I was only about to conduct the visit via phone call and that made things even more limiting. At least in a video visit I am able to see the patient’s face and make sure that they are doing well. Not all clinics knew how to adapt to this model, and to this day, I still see some limitations in how certain clinics handle these visits in the middle of a busy clinic day. I work now in a different clinic that is affiliated with Duke University, in a rural area, and telemedicine there practically does not exist. Honestly, it is probably not essential here, because most patients live close enough to clinic, and after 18 months of the pandemic, patients are more comfortable with coming for clinic visits in-person rather than virtually. 

While telemedicine provided us with an alternative that allowed us to continue delivering care for our patients during the pandemic, it could be a modality that stays even beyond. If so, we also have to recognize that the implementation of telemedicine has significant limitations, including technical complexity, the increased burden on patients and staff, and broadband access, particularly in rural communities.⁴

In conclusion, because most oncology care can be done virtually in a safe manner, telemedicine gave us the most significant opportunity to deliver care to our patients with cancer with minimal compromise, in the midst of the worst pandemic in modern history. Given the fast and safe implementation of telemedicine into our daily routine and making it a valuable tool for patients and providers alike, out of much-needed necessity, one can only wonder if telemedicine will continue to thrive, improve, and become even more implemented into oncology care and oncology training in the future, way beyond the COVID-19 pandemic. If so, we should start to implement and teach this modality earlier in training, so that new trainees can have all the tools needed to navigate and use telemedicine without any fear or limitations.

 I personally still favor face-to-face visits with my patients. This is one of the most valuable blessings in medicine, the ability to connect with another human being, to celebrate their happiness, console them in dark times, and most importantly, create trust, one of the core strengths for a strong patient-physician relationship.

Dr. Haykal is a second-year hematology and medical oncology fellow at Duke University. He graduated from medical school in Lebanon and conducted his internal medicine residency at Hurley Medical Center/Michigan State University. He aspires to become an academic clinical researcher and trialist, focused on the care of patients with solid tumors by studying and applying innovative immuno-oncology and targeted therapies. Follow him on Twitter @TarekHaykal1. Disclosure.

References

1. O'Reilly D, Carroll H, Lucas M, et al. Virtual oncology clinics during the COVID-19 pandemic. Ir J Med Sci. 2021;190:1295-301.
2. Hasson SP, Waissengrin B, Shachar E, et al. Rapid Implementation of Telemedicine During the COVID-19 Pandemic: Perspectives and Preferences of Patients with Cancer. Oncologist. 2021;26:e679-e685.
3. Heyer A, Granberg RE, Rising KL, et al. Medical Oncology Professionals' Perceptions of Telehealth Video Visits. JAMA Netw Open. 2021;4:e2033967.
4. Patt DA, Wilfong L, Toth S, et al. Telemedicine in Community Cancer Care: How Technology Helps Patients With Cancer Navigate a Pandemic. JCO Oncol Pract. 2021;17:e11-e15.