Tele-trust: What is Telemedicine's Impact on the Physician-Patient Relationship?

Telemedicine is a virtual interactive method through which a patient can be examined, monitored or treated with the clinician and patient in separate geographical locations.


Introduction
Telemedicine is a virtual interactive method through which a patient can be examined, monitored or treated with the clinician and patient in separate geographical locations [1]. Applications of telemedicine generally fall into one of three categories: medical consultation, monitoring and counseling, and service specific applications such as radiology, neurosurgery, psychiatry, etc [1]. The potential applications and benefits provided by telemedicine are ample and well documented. To the extent that telemedicine fills gaps in access to care, one important justice-based benefit is that it mitigates geographical access disparities for persons living in rural areas or low income countries [1,2]. However, because telemedicine necessarily alters the context of the traditional face-to-face physician-patient trust-based relationship, a procedural shift may transform the substance of that relationship [3]. Given the high stakes, serious consideration should be given to mitigate any potential negative impacts to the physician-patient relationship.
Similar to many physician codes of ethics around the world, the American Medical Association's physician code of ethics explicitly recognizes the importance of trust in the physician-patient relationship: "The relationship between patient and physician is based on trust, and gives rise to physicians' ethical obligations" [4]. There are two different types of trust: interpersonal trust shared between individuals, such as the physician and patient, and system or institutional-based trust, which is broad in nature and refers to an abstract collective [5]. Positive correlations associated with a trusted physician-patient relationship include treatment adherence, longer provider relationship, and perceived effectiveness of care [6]. Negative correlations associated with a distrustful physician-patient relationship are lower rates of care seeking, preventative services and surgical interventions [6].
One study examining public assessments of trust in the healthcare system demonstrated that participants invoked an assessment of their physician's patient-centeredness, which included assessments of professionalism, whether physician provides adequate attention to patients, and perceived level of expertise [7]. This finding tentatively indicates that micro-level interactions between a physician and patient tend to shape views about trust in the macro-level healthcare system [7]. While further research in this area will be required to confirm this link between interpersonal and abstract trust assessments, if empirically verified, concrete interactions may facilitate an assessment of trustworthiness such that interpersonal healthcare interactions shape one's perception of system-level trustworthiness. If corroborated, this further emphasizes the significant implications of fostering a healthy physician-patient relationship.
According to a 2012 Institute of Medicine workshop summary on the role of telehealth, there are seven barriers for telemedicine: money, regulations, hype, adoption, technology, evidence, and success [8]. In terms of telemedicine adoption, research data demonstrates that there is a disparity between patient's desire for adoption of telemedicine and healthcare provider's willingness to use telemedicine with patients [9]. In an on-line mental health discussion forum, 75% of participants found it easier to discuss their personal problems on the internet than face-to-face [9]. Conversely, citing concerns of depersonalization and potential damage to trust relationships, physicians participating in an ICU remote monitoring study were reluctant to embrace telemedicine [10]. The majority (two-thirds) of physician participants in the ICU telemedicine study opted to have the least amount of remote monitoring for their patients [10]. The observed reluctance and reasons cited indicate that a perceived potential exists for telemedicine's mediated communication model to detrimentally affect the traditional fiduciary (trust-based) relationship. One negative consequence might be the transformation of the fiduciary relationship into a more contractual or quasi-contractual relationship by severing what has traditionally been a fundamentally "personal" therapeutic encounter. A shift to a contractual relationship could impact the nature of healthcare and basic conceptions of trust associated therein by transforming the therapeutic relationship to an episodic encounter rather than an ongoing relationship.
While telemedicine is still in its relative infancy, because telemedicine necessarily alters the context of the traditional face-toface physician-patient trust-based relationship, important consideration should be given to its potential impact on the fiduciary relationship and proactive measures taken to limit any negative impacts. Further telemedicine research studies regarding physician perspectives and participation of both new and experienced patient and physician telemedicine users would enhance the literature.