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In the second part of our series on physician burnout, Rheumatology Network interviews Jack Arnold, MBBS, MRCP, Clinical Research Fellow at the Leeds Center for Rheumatic and Musculoskeletal Medicine, Massimo Radin, PhD, Research Fellow at the University of Turin (UNITO), and Andrew Konkoff, PhD, Executive Vice President and Chief Value Medical Officer at United Rheumatology to discuss their thoughts on telemedicine as it relates to burnout in the rheumatology community.
Telemedicine, while an important tool early in the COVID-19 pandemic, has various disadvantages for rheumatologists. “Rheumatology is not one of the subspecialties that lends itself best to a telemedicine-only approach,” Konkoff said. “During the pandemic, it was an extremely important lifeline to stay connected to our patients. But now that the elements of the pandemic have been routinized and normalized, now that we have drugs to treat patients with COVID, drugs to prevent the development of COVID if people are exposed, and vaccinations to greatly limit the risk, the risk- benefit of a telehealth visit that reduces the risk of exposure to COVID-19 and transmission of COVID-19 compared to an in-person visit that allows for a more accurate assessment of disease activity has changed.”
Radin notes that creating personal boundaries between patient and clinician is critical to preventing burnout. In this new virtual world of telehealth, the rheumatologist can feel as if he never fully leaves the office environment because he is essentially always available to his patients. He explains, “one of the few things we’re taught in medical school is that you shouldn’t take the patient’s pain home with you. But it is easy to say, but another thing to really feel. Sometimes it’s just inevitable. That’s why I think we should have a support system [in place for] to relax if you’ve had a hard day.
Does telemedicine help minimize burnout or exacerbate it?
Jack Arnold, MBBS, MRCP: One of the successes of the burden of the pandemic is telemedicine. It is very good, but it must be applied in a very specific way. If you have patients who are stable and have been stable for a long time, who are just continuing their regular regimen, [telemedicine] is great. They don’t have to come to the clinic, the consultation can be shortened and it’s a little easier for them. But on the other hand, if you get someone who’s unexpectedly bad or has a problem, it can be a bit frustrating because then you can’t rate them the way you’d like. I then find myself booking this person to see me anyway.
In some ways I’m reducing the workload, but in another sense I’ll bring them in because I feel like I need to evaluate them more thoroughly or we need to do blood work in labs or things. And this then duplicates the load. It’s really a give and take thing with telemedicine. I mean, I’ve always been reluctant to use it at all, because ideally we’d like to see everybody, but I think there are, when you use it smartly, there are ways that you can really get something out of it, and it can be effective.
Massimo Radin, MD, PhD: I didn’t use telemedicine before COVID, but during COVID we used it quite often because many of our patients were advised not to enter the hospital [due to an increased risk of infection]. It actually adds a lot of stress to management because it’s like you never leave the office and patients can contact you at any time of the day. [For example], if I’m on vacation, I don’t have to worry too much about my patients. But then, if I see my cell phone beeping because I’ve just received an email from a complicated patient who isn’t feeling well, it’s inevitable that I’ll think twice. This is very wrong from my work point of view because then I am at work 24/7. That’s something we really have to be careful about when we talk about these things. It needs to be out there for patients to see because sometimes patients forget what the good and better ways are to contact us. There should be a barrier from clinician to patient.
Andrew Konkoff, PhD: I think we need to understand that telemedicine and rheumatology are different than telemedicine in the behavioral health sciences and different from dermatology, for example. There is a fundamental reduction in what we can do as rheumatologists if we cannot lay our hands on a patient and examine them directly. It’s not absolute, and it’s certainly better than nothing, but within care you have nothing, a phone-only visit, a telemedicine visit with video, a telemedicine visit with labs available, and then an in-person visit. There is this spectrum of how careful and accurate we can be in our assessment of a patient, and we need to understand that spectrum.
We need to find that perfect hybrid ratio between telemedicine and in-person presence, and that’s part of optimizing care in today’s world. As for the specifics of how telemedicine has changed the equation in terms of burnout, I think it depends on the clinician and how well they’ve adopted telemedicine best practices and how comfortable they are with telemedicine. It’s certainly a different experience to communicate with someone over a video link than in person. There are certain inefficiencies that have not been fully overcome in telemedicine.
For example, we personally have a waiting room and several examination rooms. In most telemedicine systems, we have not replicated this to achieve the same level of efficiency. If I’m going to see you for a telemedicine visit, but I realize I’m missing a critical lab test that that visit is for, it’s very difficult to interrupt that visit, jump into another room with another patient and discuss their problems, and then back to you quickly to stay efficient in getting through the way we do in the real world.
The other thing that was not initially appreciated during the pandemic is that when we stack visits one after another after another from a telemedicine perspective, if breaks are not built in appropriately, it becomes a continuous, one big visit. This can lead to some burnout issues.
For some of our less tech-savvy clinicians, it can be an added stress to have to manage the video link. Likewise, patients sometimes have trouble managing their end. The inefficiencies associated with this can be very frustrating at the clinician level and can add stress to your day and can increase feelings of burden.
Check out the full interview below
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