Survey of rheumatology patients and clinicians reveals concerns about the diagnostic accuracy of remote consultations

Serious doctor on the phone_AS

A survey of rheumatology patients and clinicians has revealed concerns about the diagnostic accuracy of phone and video consultations.

The sequential mixed methodology study, published in Rheumatology, combined analyses of survey responses and in-depth interviews. The pretested survey was made available online in April 2021 via disease support groups. A similar online survey for rheumatology clinicians was disseminated through rheumatology networks, including the British Society for Rheumatology, in May–June 2021.

A total of 1340 patients and 111 clinicians responded to the survey. 31 patients and 29 clinicians were interviewed between April and July 2021. The majority of patients were from the UK (96%). The four most commonly reported rheumatological diseases were inflammatory arthritis (32%), lupus (32%), Sjogren’s syndrome (9%), and systemic sclerosis (8%).

Building trust 

Significantly more clinicians than patients (90% versus 69%, respectively; p=0.02) felt that telemedicine was worse than face-to-face consultations for building a trusting relationship. Clinicians discussed how nonverbal communication, including ‘reassuring’ touch, was important in building trust and rapport. However, well-established medical relationships were felt to be protective against the limitations of remote appointments.

Around 50% of clinicians and patients rated clinicians’ listening skills as worse with telemedicine. Fewer than 10% rated it better with telemedicine than with face-to-face consultations. Patients indicated that telemedicine followed an impersonal ‘tick list’ and felt more ‘rushed’. Patients’ ratings for telemedicine were significantly lower than clinicians regarding time available to discuss patient concerns (mean difference 0.49; p<0.001). Other patients expressed disappointment regarding changes in their clinician’s behaviour using telemedicine.

Both patients (86%) and clinicians (93%) felt that telemedicine was worse than face-to-face consultations in terms of accuracy of assessment. Misdiagnoses and other inaccuracies were reported, and often attributed to the absence of examinations and visual cues.

The risk of diagnostic errors from lack of examinations and tests was further increased by frequent underplaying of symptom severity by patients. Willingness to report symptoms, including mental health symptoms, was reported as worse/much worse with telemedicine by approximately 45% of patients and clinicians. Clinicians also found it more difficult to identify mental health concerns remotely.

Results showed that 16% of patients and 18% of clinicians felt that telemedicine was better than face-to-face apoointments for remembering discussion points, and for comfort with symptom reporting (12% and 10%, respectively).

More convenient 

More than 60% of patients and clinicians considered telemedicine more convenient than face-to-face consultations, citing advantages such as protection from infection, no travelling, and reduced waiting times. However, clinicians significantly overestimated the convenience for patients compared with patient views (mean clinician rating of 3.86, mean patient rating of 3.49, mean difference=0.37; p=0.001).

Clinicians highlighted the importance of a quick response to ‘flaring’ patients with a rapidly worsening condition, but only about half of patients were confident that they would receive a quick response to an urgent request for medical advice within 24–48 hours from their GP or hospital team. Some patients reported that they struggled to get through administrative systems to receive any kind of response or appointment.

‘Our research exposes the inherent risks and benefits of telemedicine for patients with complex conditions, which may have important implications for patients who have other serious or unpredictable long-term conditions’, said lead author Melanie Sloan.

‘As the NHS develops a telemedicine strategy, we hope there will be a thorough assessment of the clinical and psychological risks and steps taken to mitigate those risks, as well as action to address the possibility of worsening existing health inequalities for those less likely to be able to benefit from remote consultations’, she added.

The research team concluded that telemedicine’s acceptability and safety can be improved by training for clinicians: it may offer some patients more choice, but must involve careful selection of which patients to offer telemedicine to and further consultation with clinicians and patients on its use.

One senior clinician participating in the study put it succinctly: ‘The rapid digitalisation and use of telemedicine must stay, but appropriate patient selection is key. It is perfect for some but disastrous for others.’

This article originally appeared on Univadis, part of the Medscape Professional Network.

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