Telemedicine for Surgical Consultations – Pandemic Response or Here to Stay?

A Report of Public Perceptions

Meredith J. Sorensen, MD, MS; Sarah Bessen, MPH; Julia Danford, BS; Christina Fleischer, BS; Sandra L. Wong, MD, MS

Disclosures

Annals of Surgery. 2020;272(3):e174-e180. 

In This Article

Discussion

This study is the first to report large-scale public attitudes toward obtaining an initial surgical consultation via telemedicine, specifically in the context of social distancing during COVID-19 pandemic, but with consideration for "normal circumstances." Using a crowd-sourced survey with over 2000 respondents, we confirmed that telemedicine has indeed become more ubiquitous during the pandemic, with approximately half of survey respondents reporting prior experience with telemedicine, noting that 60% of those virtual encounters occurred during COVID-19-related social distancing. A vast majority (86%) of respondents reported being satisfied (either extremely or somewhat) with their telemedicine encounter. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Telemedicine was viewed more favorably for PCP visits than for surgical consultations, with a further decline in preferences for virtual visits with increasing complexity of surgical intervention, even during the pandemic.

Although many have posited that telemedicine will have an enduring presence even as in-person visits are reinstated, surgical consultations require special consideration. Not surprisingly, the vast majority of survey respondents indicated that it was extremely or very important to meet their surgeon and to have their surgeon examine them in person before the day of surgery, which corresponds with our finding that a majority of respondents felt that "establishing trust and comfort" was best accomplished in person. Interestingly, public perception about the converse (how important it was for surgeons to meet and examine patients in person before the day of surgery), demonstrated a slight shift, with a much lower (albeit still majority) opinion about the relative importance of this. Taken together, such perceptions may explain why most respondents felt that telemedicine visits should cost less than an in person one. In this initial exploratory study, we were unable to delve into the reasons behind this perception, but future work will need to explore the impact of the respondents' insurance status and out-of-pocket costs.

Various prior studies have reported high patient satisfaction with telemedicine in the surgical context, citing benefits of money saved/economic benefit,[5,6] reduced missed work,[7] reduced trips to hospital,[7,8] and preventing additional calls or visits to clinicians.[8] However, almost all of this work has been for surgical follow-up visits and not initial consultations, which was the focus of our study.[9,10] A few telemedicine studies in limited settings demonstrate and support its feasibility and accuracy for prescreening of patients with common general surgery diagnoses.[11–14] Indeed, there is very little in the literature related to using telemedicine in more "elective" settings, especially ones in which there is a consultation requiring more shared decision making. Prior studies in primary care settings suggest that there is less information exchange by patients and physicians during video and telephonic visits when compared with in-person encounters,[15] suggesting that patients and physicians may adapt their behavior and expectations based on circumstances, including the relative urgency or severity of presentation and access to care.

Our findings demonstrated the strong effect of telemedicine in alleviating barriers resulting from COVID-related social distancing restrictions to receipt of a surgical consultation. Very few respondents wished to "wait until social distancing ends" even with relatively discretionary and elective procedures such as rhinoplasty and total knee replacement. As a measure of relative sensitivity to mode of care, acceptance of a telemedicine visit, compared to desire for an in-person visit, decreased with relative severity of disease. Even with social distancing in place, over half of respondents wanted an in-person visit for pancreas cancer evaluation, though this was the case in less than a quarter of those with an inguinal hernia and in a fifth of those with a lipoma. Across all 6 scenarios, there were no differences in proportions of respondents who preferred in-person visits regardless of the relative importance they placed on the surgeon meeting patients before the day of surgery, suggesting it was their own desire to interact with the surgeon rather than a perception that it would be critical for the surgeon's decision making.

There was generally slow adoption of telemedicine before the COVID-19 pandemic, related to regulatory barriers and implementation challenges related to technology platforms. However, COVID-related social distancing mandates and the mass suspension of normal ambulatory clinic operations led to the rapid uptake of telemedicine visits, aided by changes in policies around telemedicine visits including broad coverage of services by the Centers for Medicare & Medicaid Services (CMS) on "a temporary and emergency basis." These CMS waivers will need to be evaluated as the pandemic evolves back to more normal circumstances and our findings may be important to consider as this occurs, especially as it relates to surgical consultations and the value placed on an in-person meeting with a surgeon before surgery.

As noted previously, survey respondents placed great importance in meeting their surgeon in person before the day of surgery. This suggests that if the initial consultation were done virtually, an in-person visit may need to be scheduled before surgery or, at the very least, extra time may need to be built in for discussions on the day of surgery. As such, practical considerations around reimbursement for services (related to multiple and duplicative visits) and health care utilization (efficiency and workflow around surgical schedules) will need to be resolved if telemedicine visits continue to be used in high volumes. Moreover, concern for the depersonalization of care with telemedicine has been described both before and during the COVID-19 pandemic, and the ability to establish rapport virtually is understudied across settings.[16]

There are several limitations of this study. Participants in a crowd-sourced survey study are selfselected and make up a nonrepresentative cohort. There is no calculable response rate and results may not be generalizable. However, Amazon MTurk is an increasingly credible means of conducting survey research in healthcare.[17] In addition, rapid online surveys have been proposed as a highly effective way to assess evolving public perceptions during COVID-19 pandemic.[18] Given this methodology, our respondents, by definition, represent a relatively more tech-savvy segment of the population. Although this is another reason our findings may not be generalizable, we hypothesize that people without access to or familiarity with technology would be even less comfortable with telehealth consultations. Another limitation is that this survey relies on the participants' ability to imagine their response in hypothetical scenarios rather than studying the response of real patients actually facing these diagnoses and decisions. That said, public perception is important to consider since policy changes, as would be the case with CMS waivers and regulations around telemedicine services, should take a broader view into consideration. Nevertheless, early reports demonstrate a high level of patient satisfaction with telemedicine; whether this is solely related to a paucity of choice secondary to the pandemic or reflective of broader views on access to care remain to be seen.

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