Abstract
First impressions are based on many, often subtle, factors. Perhaps it is a handshake, a gait, or a smile that helps us to form opinions. Perhaps the environment itself shapes our assessment. Although the details differ, one thing is consistent: first impressions are often formed instantly. Behavioral experts refer to quick evaluations of nonverbal behavior as “thin slices” and have shown they offer important information to help a person make reliable judgments about others (Ambady and Rosenthal, 1992). The medical community has long been aware of the impact of nonverbal behaviors in patient-clinician interactions, and research has even linked these behaviors with perception of overall interview quality (Collins et al., 2011), patient satisfaction (Larsen and Smith, 1981; Mast, 2007), and adherence (McCabe et al., 2012). The topic is more relevant than ever in the wake of increasing enthusiasm for telemedicine—remote medical visits through live videoconferencing. Telemedicine is being embraced across disciplines, including clinical genetic counseling. Advantages of leveraging this technology include removing barriers to access, addressing health care provider shortfalls in underserved geographical regions, and reducing costs (Daniel and Snyder Sulmasy, 2015). As health systems and health care professionals work to implement telemedicine into practice, it is wise to consider, and plan for, the patient-clinician dialogue challenges inherent with communicating across a screen.
The concept of “thin slices” of behavior was introduced by Ambady and Rosenthal (1992) in their metanalysis on the accuracy of predictions of various objective outcomes in the areas of social and clinical psychology from short observations of expressive behavior and has since been studied in other interactions. Conclusions drawn from thin slices are believed to be reliable because it is difficult for humans to suppress nonverbal behaviors. Therefore, nonverbal behaviors such as gestures, postures, and expressions can reveal much about a person's internal disposition (DePaulo, 1992; Saville and Balas, 2014).
In the medical field, a natural two-way street exists between patients and clinicians. Clinicians study their patients' facial expressions to assess disposition and, conversely, patients may feel validated or marginalized from observing a clinician's body language and expressions (Travaline et al., 2005). Nonverbal communication, therefore, plays a significant role in many elements critical to patient-clinician interactions, including rapport building, conveying of unspoken emotions, and, in conjunction with verbal communication, improving collaboration (Mast, 2007; Montague et al., 2013). Beyond the nonverbal, conversation between a patient and their clinician during even a brief first encounter has been shown to contribute to trust and rapport and to shape long-term relationships and health behaviors, and thus communication skills have increasingly been made a priority for clinician training (Travaline et al., 2005; Roter and Hall, 2006; Dang et al., 2017).
Research on the practice of video-mediated communication, as well as its application in medicine, underscores a potential roadblock the clinical genetics field may encounter with telegenetics: communication techniques that work well in person may not translate seamlessly into the virtual world. Video-mediated communication tends to be less effective than in-person communication because it may be harder to interpret critical nonverbal behaviors when communicating through videoconferencing instead of in person (Isaacs and Tang, 1994; Sauppé and Mutlu, 2014). Patient-clinician telemedicine interactions also have been shown to be more clinician centered—with clinicians tending to speak more than they typically would during an in-person interaction—and to use fewer patient-centric behaviors such as empathy and praise (Agha et al., 2009; Liu et al., 2016). When patient centricity is compromised, critical components of a patient-clinician interaction deteriorate. Genetics patients often feel fear, guilt, and stress, and may encounter ethically challenging decisions. Strong patient-clinician rapport is crucial to ensure patients feel empowered and informed throughout the process, and the often unfamiliar elements of telemedicine may make establishing and maintaining this connection more difficult.
We agree with researchers such as Hilgart et al. (2012) who point out that, given the significant promise of telegenetics and the relatively small body of research on it to date, prospective comprehensive studies examining long-term behavioral and psychosocial outcomes of patients who use it will be informative. Investigating the extent to which telegenetics impacts patient-clinician communication, and how to improve it, if needed, will be equally important.
Recent findings in one type of genetic counseling (cancer) offered through remote real-time videoconferencing highlights the advantages and challenges of a telegenetics model. One randomized trial compared telegenetics encounters with in-person encounters for individuals referred to cancer genetic counseling in rural oncology clinics. Authors found telegenetics was acceptable to patients and cost less than the standard in-person model. However, attendance rates were worse in the telegenetics group (Buchanan et al., 2015). A second study revealed a high level of satisfaction and patient-clinician rapport among women receiving telemedicine genetic counseling for hereditary breast and/or ovarian cancer. Women in the study also expressed that telegenetics offered them convenience, and reduced travel and associated costs (Zilliacus et al., 2010). These findings illustrate important considerations for expanding access to precision medicine approaches through telemedicine. They also speak to the value that can be derived for patients and clinicians alike when telemedicine approaches are implemented thoughtfully.
As telegenetics continues to grow, patient and clinician video-mediated communication skills will naturally become more refined. Building on, adapting, and practicing on camera tried-and-true patient-clinician communications techniques is likely a good starting point for those looking to sharpen their telemedicine skills. As is evaluating whether distinct patient populations (e.g., varying ages and socioeconomic statuses) experience telemedicine differently, and how clinician skills and approaches may need to be adapted accordingly. Furthermore, genetic counseling degree programs are increasingly incorporating telemedicine into their clinical requirements, equipping a new generation of clinicians to understand the nuances of video-mediated communication. Sharing the successes and challenges of these training efforts will help uncover and address potential barriers in real time. Finally, the unique background and empathic communication expertise of clinicians such as genetic counselors present significant opportunities to lead telemedicine research, education, and implementation.
Telemedicine is here to stay. Further research on its impacts on the patient-clinician relationship and prioritizing video-mediated communication skill building will go a long way toward ensuring satisfied and informed patients, from the first “thin slice” to the last.