On May 24, 2024, a new Code of Medical Ethics (KEL) was published, which stops treating telemedicine as an exception to in-person examination, and recognizes it as a support, complement or extension of patient care, the foundation of which remains personal contact (Article 9 KEL).

This change is important for hybrid medical care, combining inpatient visits with remote contact, especially among patients with chronic diseases.

Remote contact with patients is already an integral part of care for most doctors in Poland. As many as 80% of them say they have been in remote contact with their patient at least once to supplement in-person visits. The most common channels of contact are SMS, e-mail, commercial messaging (WhatsApp, Messenger) and medical messaging^.1

Written patient contact has a number of use cases and carries with it not only advantages regarding care management from a physician's perspective, but is also effective in improving health outcomes among patients with chronic diseases such as diabetes, hypertension and heart failure^.2

Despite the proliferation of written contact between doctor and patient, the current literature on telemedicine communication focuses mainly on face-to-face video visits, leaving a gap in training and education on chat-based interactions.

Therefore, in this article, we will present a set of practices and examples of how to effectively move the patient conversation from the office to the medical chat room, maintaining professionalism, safety and empathy. You will also find useful downloadable materials at the end of the article.

‍ Talkingto a patient in the office vs. in a medical chat room

In order to have an effective chat conversation with a patient, it is necessary to understand the new context in which the doctor and patient find themselves. First, written contact lacks non-verbal language (gestures, facial expressions, tone of voice), so it requires new skills to read the patient's emotional state and demonstrate so-called digital empathy. Second, written contact is characterized by greater linguistic consistency and better speech structure, which makes it much easier for the patient to absorb information. Third, written communication takes place asynchronously, i.e. the doctor and patient are in different places, and the conversation can be staggered (the patient writes at one point in time, and the doctor writes back when he has the opportunity). From the differences presented, recommendations are made for effective yet empathetic chatting with the patient.

‍Preparingfor a chat conversation

The first step to start working remotely with a patient is to establish rules for communication, such as the preferred way to address the patient, situations requiring remote contact and in-person contact, and handling emergency cases. Legal restrictions on choosing a channel such as SMS or commercial messenger are also an important point of discussion(we write more about this in this article).

Starting the chat

The starting point is to determine the procedure depending on whether the conversation concerns an acute or chronic condition or prevention, reminders or education. In the first case, it is crucial to pay special attention to the patient's emotional state and to strive for synchronous message exchange (the shortest possible interval between the patient's message and the doctor's message). In the second case, the conversation can be asynchronous and as factual as possible.

Getting to know the patient's problem / taking a history

According to Article 42(1) of the Law on the Medical and Dental Profession, a doctor decides on the state of health of a certain person after first examining him or her in person or examining him or her through ICT or communication systems, as well as after analyzing the person's available medical records. In a conversation with a patient via chat, the doctor uses the same procedure for collecting an interview as in the office. Due to limited opportunities to examine/see the patient, it is useful to use in-depth questions, ask for clarification or send photos/recordings of symptoms when identifying a problem. Ready-made structured questionnaires are also useful for remote interview collection. If this is not sufficient, the doctor should decide to change the channel of contact (e.g., to telephone contact or an in-person visit).

Reconciliation of proceedings

When prescribing a procedure for a patient, it is useful to know the three basic principles of effective chat communication.

Structuring the information

To make it easier for the patient to read and absorb the information, it is a good idea to give it a structure. This can be done by dividing the text into points (1,2,3) and sub-points (a, b, c) or by graphically separating the most important information from the rest (e.g., using dashes).

Use of graphics

A message that contains text alone has a message effectiveness of 50%, while a message containing text and graphics increases its effectiveness to 80%^.3 Therefore, if possible, include in your message graphic instructions (e.g., how to measure your blood pressure or how to prepare for a test), graphics depicting the effects of a drug or the course of a disease.

Using the correct form of the verb

In chat communication, it is necessary to write messages in a comprehensive and specific manner that does not leave the patient with questions (so-called low-context ^language4). It is especially worth paying attention to the form of the verb. Instead of using the first person plural (e.g., "We're going to do a test"), from which it is not clear who should make the appointment and perform the test, it is better to write exactly who the action concerns (e.g., "I'm making an appointment for you for a test at the clinic" or "Please perform a blood count at the lab").

Chat Summary

The summary of the chat conversation with the patient should include a basic question as to whether all recommendations and information are understood and whether they need additional clarification. Since the doctor cannot read uncertainty from the patient's nonverbal language, it is a good idea to ask the patient at the end if he or she has any other questions or needs that were not addressed in the course of past communication.

When talking to a patient's parent or guardian (e.g., caregiver of an elderly person), it is also a good idea to make sure that all caregivers receive the information provided.

The summary should conclude by indicating the next steps for the patient, including when and how the patient should consult for questions, abnormalities or for a follow-up consultation.

Digital empathy

During face-to-face interactions in the doctor's office, physician empathy involves understanding the patient's experience, connecting with his or her emotions and responding in a caring manner. Empathy goes beyond mere politeness or interest and requires active acknowledgment of the patient's thinking and emotions^.5Studies show that empathy improves patient experience, treatment adherence and health outcomes^.6

Therefore, as medical communicators are used, in addition to providing correct, evidence-based information, it is equally important to consider how that information is communicated, according to the emotional needs of patients.

Digital empathy thus means understanding emotional states, and communicating and acting on that understanding through digital media and technologies, such as chat^.6 It is crucial in maintaining a trusted doctor-patient relationship despite the lack of face-to-face interaction in the office.

This table summarizes techniques and examples of showing empathy to a patient during a medical chat.

Professionalism, or emoticons and the form of writing

‍Emoticons

To keep the conversation professional and respectful of the patient's needs and communication habits, the use of emoticons in medical chat should be more of a reaction on the part of the doctor than a proactive action on his part. If the patient uses emoticons to depict his emotional state or to set the tone of his speech, the doctor can also include them in his messages.

‍Linguistic correctness.

In contrast to the patient, the doctor's written communication should be characterized by linguistic correctness.

‍Writing style

Capital letters in written communication on the doctor's part can create connotations of orders, anger, shouting, so they should only be used in message titles for better structure and readability.

‍Timeto respond.

When writing with a patient, it is worth taking into account and respecting the different rates of response.