In early April 2020, family medicine Kyle Leggott, MD, was logging into a telehealth visit from his Aurora, Colorado, home. He’d shifted to 100% virtual visits but was struggling with one thing.
Connection.
Not the internet kind, but the human kind. The kind that helps you earn a patient’s trust and can be hard to form through a computer screen.
Today, Leggott was meeting with James and Sarah, an older couple at risk for COVID-related complications. Five minutes in, the doorbell rang, the mail carrier leaving a package. Leggott cringed as his two dogs starting barking and racing to and from the door.
Leggott started to apologize, but James’s and Sarah’s faces lit up. “Is that an Australian shepherd?” they asked. Turned out, the pup looked just like their old dog, Roy, who’d been with them for 15 years but recently passed away.
That’s when James and Sarah opened up. Holed up in their mountain home, they hadn’t interacted with anyone in weeks. They missed Roy dearly and seeing Leggott’s dogs brought them joy in a time of anxiousness and isolation. To this day, though James has passed away, Leggott makes sure his dogs are at his feet for every virtual visit with Sarah.
Telehealth use has declined since those early pandemic days, but enthusiasm remains strong. According to an American Medical Association survey, the percentage of doctors using televisits has grown from 14% in 2016 to 80% in 2022. Adoption is now so widespread that only “laggards” are still holding out.
“Patients and providers have had the chance to really understand the value [virtual] care can bring,” said Steven Shook, MD, virtual health lead at the Cleveland Clinic.
It’s true. Telehealth offers convenience, cost-efficiency, and better work-life balance. However, technology has its limits, and often those limits impact our ability to communicate and forge personal connections.
Why Patient Relationships Can Be Harder With Virtual Care
Research suggests it can be harder to listen intently and pick up on nonverbal cues, like facial expressions and gestures, during video calls. Technical glitches like poor audio quality, crashing, or freezing don’t help.
That matters because good patient relationships are key for quality care.
A Harvard review of more than a dozen randomized trials found that positive doctor-patient relationships can produce health effects as beneficial as some treatments. Patients who feel a connection with you may be more likely to share symptoms and trust the treatments you recommend. They also may be less likely to sue for malpractice.
Connection builds trust, said Kent Northcote, MD, medical director in charge of “webside manner” at telehealth provider MDLIVE. “If the trust is not there, patients are not going to care what you say.”
Medical schools know this, Leggott noted. “You learn and have a lot of classes on how to communicate with patients and how to form that relationship. But it’s all about in-person stuff because telehealth wasn’t really here.”
He’s right. In 2019, less than half a percent of all US ambulatory visits were via telehealth, compared with 24% during the pandemic’s first few months. Maybe that’s why 46% of clinicians in a 2019 study chose office visits over virtual for creating “personal connection,” while less than 2% preferred the other way around.
Even if that attitude has shifted since then, establishing patient relationships virtually remains a challenge, according to a 2022 Telemedicine and e-Health survey of internal medicine physicians in New York. And in a future-looking report from Elsevier Health, half of doctors agreed “telehealth will negatively impact their ability to demonstrate empathy with their patients.”
Building Patient Relationships Via Telehealth
Fortunately, fostering connection via telehealth can be done, and Leggott’s story is proof. That’s why Leggott now makes a point of showing his dogs to patients. “If they are dog lovers, it’s a shared connection,” he said. Even if they’re not, it shows that “doctors are human too.”
“Sometimes my kid will be banging on the piano,” said Northcote. Many patients will comment, “My kid plays piano too!”
Telehealth is a lens into the lives of your patients, added Isaac Dapkins, MD, chief medical officer at NYU Langone’s Family Health Centers. “I can see into the patient’s home. I can see what’s working and what’s not. I can see if there are kids running around or someone’s in the room. It gives context.”
Two of Dapkins’ patients — sisters with diabetes — use telehealth to access him while they’re on the move, getting out of a cab or going on a walk. “I walk along with them in their life,” Dapkins said. This provides insight he couldn’t get from inside a clinic.
Shook and Northcote, who both train doctors to communicate better via telehealth, shared some of their advice. See if some of it might work for you.
See something, say something. Spot a painting? Sports gear? A trophy? Ask about it. “It may seem unprofessional,” Shook acknowledges, but it builds rapport. When Shook noticed golf balls, clubs, and tees during a televisit, he bonded with his patient over their love of golf. That may have helped the patient share sensitive health information, Shook said.
Ask for an intro. If another person is in the room, asking your patient to introduce you may lead to helpful insights. Leggott likes to ask partners and family members for their thoughts, and sometimes learns valuable intel the patient may not have brought up.
Smile more. When you smile, your patients will smile, thanks to something known as facial mimicry, the tendency for your brain to mirror the emotions it detects on someone else’s face. Smiles help form connections, and may even improve a person’s ability to recover from stress.
Slow down. In person, body language helps others follow what you’re saying, but in a virtual visit, they must rely more on your voice. “It’s not even the things you say, but it’s the speed and the cadence with which you say them,” said Northcote. “If you’re talking super-fast, [patients] can’t hear you.” Try this: Say “Nine nice night nurses nursing nicely” out loud four times, slow enough that the words are clear. That’s how fast you should speak during a virtual visit.
Read this book. Northcote suggests every doctor read Never Split the Difference by former FBI negotiator Chris Voss. Doctors are negotiators, he said. Negotiation is harder without body language, so what you say, and how you say it, becomes more important.
Invite patients to say no. One tip from Voss’s book that Northcote loves: Ask questions that let your patient say no. For example, instead of asking, “Does this treatment plan sound good?” try, “Would you mind trying this treatment plan?” The word “yes” can feel like you’re making a commitment. Saying no puts people at ease, meaning your patient may be more likely to engage and share concerns. Another example: Instead of “Is that everything?” try “Is there anything else?” The first option prompts a “yes” — which may cause the patient to feel like they can’t reverse course and add or clarify concerns.
Show you’re paying attention. In a small study in the Journal of General Internal Medicine, patients reported feeling like doctors paid less attention to them in video telehealth visits compared with in-person visits. Exaggerate gestures such as nods to show you’re listening, suggest guidelines from the Cleveland Clinic’s Center for Excellence in Healthcare Communication. Or steal another of Voss’s tips and repeat the patient’s last three words back to them. (Patient: “I’m not feeling well.” You: “Not feeling well?”) This helps the patient feel like they’re being heard and gives them a chance to elaborate.
Make eye contact. It may feel unnatural, but if you want to make direct eye contact, you have to look into the camera, not the screen, the guidelines note. If you are trying to really connect or speak with impact, look into the webcam lens. Try sticking googly eyes next to the lens to help you remember where to look.
Use a headset with a microphone. Your computer’s built-in microphone probably isn’t very good—many capture a lot of background noise. Using a headset ensures your words are clear and can make the experience feel a lot more intimate, said Northcote, who uses a Sennheiser headset.
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