Post Covid-19 Doctor-Patient Relationship Model. Creation of Social Connection Contexts With Physical Distancing

The coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ¹ has produced a significant change in the way general medicine is conducted. This shift has been remarkably quick towards telecare. The form of the clinical interview has changed, and with it communication and the doctor-patient relationship; Before COVID-19, all communication techniques and doctor-patient relationship, which were considered tried and true to establish a good relationship with patients, involved physical proximity ². Now in many European countries and in the United States face-to-face consultations have been reduced to 10-20%, with most contacts now being provided remotely using symptom checkers, electronic messaging, and phone or video consultations ³.

Communication and the doctor-patient relationship connect the biomedical and psychosocial aspects of clinical care ⁴. The doctor-patient relationship is a complex phenomenon made up of several aspects, among which we can highlight doctor-patient communication, patient participation in decision-making and patient satisfaction. These characteristics have been associated with the communicative behavior of the physician and the autonomy of the patient in medical care ^{5, 6, 7} and it is unanimously accepted that the chances of success in a treatment are directly proportional to the quality of doctor-patient relationship ^{8, 9}.

Today's remote telecare mutually convenient encounters seem far removed from previous ones, which now seem unsustainable. It's about making the most of the new reality. A halo of romantic myth covered the previous psychological concepts of doctor-patient relationship. Despite the supposed models of patient-centered care, in the doctor-patient relationship there is a power relationship that has a social basis that cannot be avoided individually by doctor and patient ¹⁰.

The doctor-patient relationship with social connection but physical distancing, through telecare, could facilitate that such health care is truly considered patient-centered: the GP adopting an attitude where the patient is recognized as a person in an interaction instead of as a medical objective. So to speak, telecare can help the doctor be less a doctor and more of a person. This vision contributes to a participatory and holistic conception and interaction of the patient ¹¹.

On the other hand, the idea that the patient always prioritizes continued care with their general practitioner (GP) is not true at present ¹². The increasing rates of visits to the emergency department suggest that convenience is more important to the patient than an established relationship. There are likely to be some patients who enjoy the in-person relationship, but getting care is the priority. Of course, an established GP can offer telemedicine care that is just as convenient as face-to-face solutions, and patients can receive both ¹³.

For some GPs this new scenario of virtual encounters, which does not allow physical examination, does not make sense. How is hepatomegaly detected, lymphadenopathy palpated, chest percussion, peritoneal rebound caused…? ¹⁴. But, it must be taken into account that many of the clinical examinations that the GP does are normal or confirm what she already he or she suspected from the history. It is very important to remember that 80% of the diagnosis is made by the clinical interview, 10% by the examination and 10% by complementary tests ¹⁵.

In any case, in telemedicine you can do a physical exam: the importance of the general appearance (sick or not, weight, anxiety), respiratory effort; dyspnea (a previously described but largely unknown technique for assessing shortness of breath and hypoxia is the Roth Score: simply requires a patient to breathe deeply and count out loud to 30 as quickly as possible while timing before the next breath; not being able to count to 7 or count for 5 seconds has a sensitivity of 100% and 91%, respectively, for oxygen saturation less than 95%); the environmental factors, including a visual assessment of the home that can not be accomplished in an office visit; have patients (or family members) feel and count their pulse out loud; monitoring your own vital signs and oxygen saturation at home; assess peritonitis by observing the patient as he jumps up and down; ask the elderly patient who is unstable to show the design of her house to identify possible risks of falls, etc. If a patient cannot remember the name of a prescription that needs to be repeated, the patient may be asked to go to the medicine cabinet to retrieve the bottle. And the GP can see other family members during the consultation ^{2, 13}.

In addition, especially in the monitoring and management of patients with chronic diseases, telemedicine can allow shorter and more frequent virtual visits for chronic patients, and can add the ability to connect multiple providers in the care of one patient at the same time achieving comprehensiveness and contextualization more easily than in face-to-face consultations ¹⁶. It also allows reminders about adherence to their treatments and improvement of compliance ¹⁷. On the other hand, telecare can reduce 30% in the "bureaucracy" of face-to-face consultation ¹⁸. Further, the telecare avoid travel, waiting in the room before entering the consultation, wasting time, etc. Non-face consultation sometimes represents an added advantage related to avoiding the need for family members or companions to request permits to leave their jobs, and this also represents a social or labor advantage. On the other hand, telemedicine is an opportunity for the doctor to be more of a person and less of a hierarchical superior of the patient; it is an opportunity to make general practice on a human scale ¹⁹, a more personalized practice which the users themselves play a very active role, instead of just visiting the doctor as only form of contact ²⁰.

Changes in the mode of relationship also imply changes in diagnostic and prescription strategies. In any case, it should be taken into account that the doctor-patient care relationship is a technical instrument at the service of the diagnosis and treatment of the patient and that the doctor-patient relationship can take many valid forms, including the one that can be formed through telecare. Focusing on the comparison in the diagnostic accuracy between virtual visits and in person is a false dichotomy, since in both the same diagnostic steps are maintained. The truth is that it is possible to create and strengthen healing relationships in telehealth encounters, based on what can be called "physical distancing with social connection" ². This moment provides a unique opportunity to build a telemedicine model that empowers patients ²¹.

The heal care transition is now. Such changes are likely to continue as long as the pandemic continues, but to form a new normal ¹⁸ and become permanent, with fewer face-to-face consultations in the future. This scenario includes opportunities and strengths, but also dangers. Face-to-face interactions with the patient have always carried a biological risk of contagion of infections for the doctor and for the patient, even if it was not taken into account. Additionally, our interactions with other people shape our feelings, thoughts, and activities. Interaction with another person can promote a feeling of comfort or, conversely, a feeling of discomfort and vulnerability; being experienced in a face-to-face consultation as a possible conversation partner is quite different from being experienced as a potential source of infection ²².

The model of the doctor-patient relationship is an element of "context creation" ^{5, 23}. Virtual consultations also create a context, which can be equally healing. It is possible to create and strengthen healing relationships in telehealth encounters ². Furthermore, the four basic principles and tools of general medicine for diagnosis and treatment which are the doctor-patient relationship, continuity of care, attention to context, and comprehensiveness ^{24, 25} are reinforced in telecare. Each of these tools are not isolated, but are linked to each other. This supposes an important reinforcement of the system ²⁶.

General medicine has shifted towards telemedicine. This will allow a more routine, flexible, accessible, acceptable, participatory, contextualized, biopsychosocial and humane care. In addition, it permits to being safer against the risk of contagions in the face-to-face consultation. The virtual doctor-patient relationship through telecare is not opposed to face-to-face consultations, which could be a small percentage of the total. Post-COVID-19 doctor-patient relationship models should be useful in helping to intelligently manage uncertainty. The goal is always that each medical intervention and diagnosis should contribute something to the patient. The excellent consultation would be the one where the doctor finds things that are significant for him, and makes it easier for the patient to also find things that are significant for him. The evaluation of interventions must attend to biomedical results, but also to social, psychological, and existential experience of the patient. It is time to change our way of thinking about the doctor-patient relationship ^{27, 28, 29}.

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