Rigorous efforts to minimise disease transmission in the COVID-19 pandemic have catalysed
the development of comprehensive telemedicine systems.
1
Beyond enabling contactless health care, telehealth increases the convenience of routine
health care, expands access to specialty care, and allows for more diligent regimen
monitoring. These transformational changes will probably endure, with the potential
of an estimated US$ 259 billion in health care spending to be shifted to virtual health
care.
1
Telehealth offers immense promise in bridging health disparities.
2
Yet, simultaneously, telehealth might exacerbate existing inequities because of disparities
in broadband and technology access by race and household income.
2
However, we argue that the promises and pitfalls of telehealth are rooted in something
more fundamental—trust.
Analysis of the Mount Sinai de-identified COVID-19 database found that Black patients
were more than four times more likely than White Americans to seek health care in
the emergency department over telehealth services, even when adjusting for comorbidities
and preferred language. This study, as well as other literature, offers the potential
explanation that the lack of pre-established relationships with physicians, as well
as mistrust of digital platforms, could drive this reluctance to pursue telemedicine.3,
4 Indeed, Black Americans are less likely than White Americans to have strong relationships
with their primary care physicians, potentially contributing to scepticism that high-quality
care can be provided over telehealth. Weber and colleagues’ findings urge consideration
regarding how patient-clinician relationships through telemedicine can impact health
equity, especially given institutionalised distrust among Black communities.
3
To be certain, this paucity of trust is nothing new. Transgenerational trauma experienced
by Black communities has created the perception—and often reality—that health care
entities do not have their best interests at heart.
5
Black Americans have historically adopted novel medical technologies at lower rates
than their White counterparts, due in large part to inaccessibility and well founded
suspicion towards medical innovation.
6
Although distrust negatively affects telemedical outcomes, the inverse also holds
true Orrange and colleagues note that patient satisfaction with telehealth was primarily
influenced by the “degree of trust in their physician”.
7
As such, a paucity of trust is likely to undermine the potential for telemedicine
to mitigate health disparities, underscoring why trust and telemedicine must be developed
and bolstered simultaneously. Although all could benefit in the absolute, mistrust
among Black Americans around telemedicine, and the medical establishment more broadly,
might only exacerbate deep-rooted health disparities.
Patient–clinician relationships are also harmed by the lack of connectedness due to
interaction through a digital interface. In fact, Ladin and colleagues found that
telehealth visits reduce doctor–patient connection and promote dissatisfaction and
mistrust most prominently among those identifying as Black, Hispanic, and Native American.
8
In a discipline like medicine, which is equally humanistic as it is technical, both
physical and emotional care are necessary to achieve optimal health outcomes and bolster
patient–clinician relationships. These findings highlight the need to prioritise a
more empathetic, patient-centred focus in the current deployment of telemedicine.
Leveraging telemedicine to increase the access of concordant physician–patient pairings
could help to achieve greater trust in remote platforms. Telehealth suppliers should
consider offering the option for patients to arrange appointments with concordant
physicians. These pairings can be enabled through the integration of extensive physician
databases, such as IQVIA's OneKey, into telehealth platforms such that minority patients
can find medical professionals with greater ease. It is well documented that minority
patients prefer care from racially and ethnically concordant doctors, and that these
pairings typically result in more favourable health outcomes.
6
This trend is especially salient for the care of Black patients: one study noted that
treatment of Black men by Black physicians can reduce the Black–White disparity in
cardiovascular disease mortality by 19%. Concordant physicians were viewed as more
trusted sources of information and care.6, 9 Unbound by distance, telehealth can enable
patients to more conveniently connect with concordant doctors, facilitating stronger
relationships and trust in these emerging systems.
Although perhaps necessary in the short term, patient–physician concordance is not
a sustainable long-term solution. Medical education reforms will be necessary to ensure
that health professionals are proficient in delivering high-quality care via telehealth
to all patients. In an encouraging step, the Association of American Medical Colleges
published competencies necessary for telemedicine, including considerations of equity
and communication, yet we must ensure that medical practitioners are able to uphold
these standards in practice. Training on provision of care via telemedical platforms
ought to be made compulsory in medical education, with both didactic and hands-on
components. Medical students should have the opportunity to engage with patients of
minority backgrounds to ensure that their care is socially and culturally conscious.
Additionally, it is important that physicians can recognise their own implicit biases
through further integration of implicit bias curricula, such as the Implicit Bias
Training Guide.
10
Robust patient–clinician interactions require physicians to uphold this conscientiousness—especially
given the challenges of interpersonal interaction via digital interfaces. As changes
in medical education curricula provide hope of ensuring that future medical professionals
can provide effective health care over digital platforms, training in telemedicine
should also be integrated into continuing medical education offerings to ensure that
practising physicians can improve their deli very of telehealth.
Yet, the necessity of creating strong patient–clinician relationships extends beyond
the realm of telehealth and relies on trust that is built during in-person health
care visits. In fact, given the dialectical interactions between telehealth and trust
in health services, in-person relationships can also shift patients’ perceptions and
use of telehealth services. Moreover, engaging health care workers of minority backgrounds
as messengers for health care innovations can also greatly boost trust among these
groups.
5
In this sense, in-person care can be leveraged as a mechanism of raising awareness
regarding the benefits of telehealth services.
By ensuring that all medical practitioners can effectively establish strong patient–clinician
relationships through telemedicine, we unlock its potential to further health equity.
However, that work begins by acknowledging the paradoxical nature of the current implementation
and practice of telemedicine: a promise of greater equity through convenient access
to care, yet the simultaneous exclusion of marginalised groups who are hesitant or
lack the resources to use telehealth. As telehealth continues to advance, it is necessary
to ensure that no one is left behind.
We declare no competing interests.