Oxymorons can elicit laughs: think jumbo shrimp or working vacation. But as a physician who works to advance virtual care, I’ve been thinking about a serious one that applies to virtual visits: distant presence.
Early in the pandemic, I am leading a Zoom meeting, but no one is participating. Ironically, we are discussing — or, perhaps more accurately, I am discussing — how to optimize the doctor video visits we’d quickly rolled out. I feel tired of hearing my voice and fed up with web conferences. One silver lining: no one can see the comfortable gym shorts I’m wearing with my Zoom shirt.
Fast forward a few months. During a midday virtual visit, a patient explains her symptoms to me. She has a lot to say, and I give her time to say it. Too much time. As she pauses, I suddenly catch myself reading an email. I feel ashamed. It’s one thing to multitask during a group video conference. It’s another to do so when you’re the doctor seeing a patient. And it’s even worse when you’re the doctor who is championing virtual visits to his colleagues.
Sir William Osler, the father of modern medicine, said, “Listen to your patient, he is telling you the diagnosis.” Decades later, noted psychologist Carl Rogers developed an active listening approach to help clinicians grasp the full meaning of their patients’ communication. In the mid-2000s, my clinical mentor, Doug Drossman, himself a master communicator, taught me to actively listen by appreciating both the content and the feeling of patients’ messages, tuning into their non-verbal behaviors, eliciting their agendas, and validating their thoughts and feelings. Nearly two decades of practice later, I realize I can only actively listen when I am fully engaged with a patient.
Before the pandemic, almost all health care was provided in person. Although clinical settings are filled with potential distractions — knocks on the door, crying babies, and obtrusive electronic health records — simply having doctor and patient in the same room reinforces behavioral norms that facilitate presence. Making eye contact? Very appropriate. Checking email during a visit? Very inappropriate.
Shifting care online makes full presence much harder. For one, videoconferencing can be exhausting. It forces participants to maintain excessive amounts of eye contact, see a constant mirror image of themselves, remain in one place, and strain to detect and interpret nonverbal cues. When fatigued, the clinician can furtively click a link or swipe their phone for a quick dopamine pick-me-up.
How can clinicians ensure a distant presence during virtual visits? The Presence 5 team from Stanford Medicine recommends they prepare with intention, listen intently and completely, agree with their patient on what matters most, connect with their patient’s story, and explore emotional cues.
That’s a great start. I’ve discovered two additional tactics that help me even more. First, before I join a video visit, I close all other apps and hide them from sight. By redesigning my (virtual) environment this way, I am less likely to get distracted or wander off into a digital black hole. Second, to help me maintain my focus on the patient virtually in front of me, I use a decidedly low-tech solution: I affix a Post-it Note to the top left corner of the screen. On it is a phrase Ram Das popularized in the early 1970s: Be Here Now.
In her book “The Distance Cure: A History of Teletherapy,” Hanna Zeavin writes, “Distance is not the opposite of presence: absence is.” Today’s clinicians are challenged to remain fully attentive to and engaged with the patients they serve, whether seeing them in person or from a distance.
Spencer Dorn is a gastroenterologist, professor, and vice chair of medicine at the University of North Carolina School of Medicine in Chapel Hill, N.C.
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