Casual Behaviors in Telemedicine

Research Article

J Fam Med. 2022; 9(8): 1319.

Casual Behaviors in Telemedicine

Patel KP1*, Lee E1,2 and Heavy L3

1Department of Family Medicine, Loyola University MacNeal, USA

2Department of Family Medicine, Loyola University Medical Center, USA

3Department of Public Health, Loyola University, USA

*Corresponding author: Kavita Patel, Department of Family Medicine, Loyola University MacNeal, USA

Received: October 04, 2022; Accepted: November 03, 2022; Published: November 10, 2022


Background: Telemedicine is emerging as a new way for patients to access medical care. When patients are allowed to conduct video or audio visits from home, it can empower them to be more casual in their interactions with their providers.

Objective: The purpose of this study is to identify provider attitudes regarding various telemedicine situations. From this study, a standard of care for telemedicine scenarios may start to be determined which can empower physicians to deal with various scenarios they may encounter.

Design: A mass survey regarding questions related to certain casual patient behaviors and provider comfort and acceptance of these behaviors was sent out to providers at the Primary care, Family medicine, and Internal medicine departments at Loyola University Medical University.

Results: 42 providers responded to the survey who was predominantly white female physicians at the medical center. In regards to patient behaviors, there was a significant difference between the levels of casualness providers ranked themselves versus their comfort level with various patient behaviors. More than half of the respondents had a difficult telehealth encounter but only half of the providers actually attempted to rectify the patient behavior.

Conclusion: Problematic patient behavior during telehealth encounters poses a new challenge to many providers. A better understanding of which patient behaviors and activities cause providers distress is important to assess. However, the next step involves creating set guidelines and protocols to empower providers to speak up during difficult telehealth visits.

Keywords: Telemedicine; Provider comfort; Behaviors; Provider acceptance


Telemedicine is a relatively vast field where patients can receive care in various formats from office-based telemedicine to hospitalbased telemedicine. Subtypes of telemedicine such as teleradiology, telepharmacology, and telepathology are also in practice to offer patients a broad range of services [1]. Historically, different forms of telemedicine have been documented as early as the 1920s [1]. During those times, ships with clinics onboard would utilize radio to obtain medical advice from physicians at shore. The overall goal of telemedicine has always been a simple one: making care more accessible to patients.

Recently, telemedicine has helped office-based practices overcome challenges in many areas where healthcare is inaccessible. For instance, villages in Alaska have been using telemedicine by sending results of otoscopy and audiometry to specialists [1]. Not only that, but a recent study done in Madagascar proved telemedicine to be just as effective in diagnosing cervical neoplasia as an on-site in person diagnosis [2]. In addition, hospital-based telemedicine is now used for stroke care and even ICU management [3]. Even surgical fields are now experimenting with the concept of telesurgery which can help surgeons perform procedures at a distant site.

In general, telemedicine is defined as “the use of electronic information and communications technologies to provide and support health care when distance separates the participants” [3]. This also applies to a time of crisis such as the covid-19 pandemic which introduced a unique set of challenges for both providers and patients. During this time, telemedicine allowed patients to seek care from the comforts of their home while also adhering to social distancing [4].

Physicians in primary care fields have particularly expressed an increasing interest in telemedicine. Per the American Academy of Family Physicians, at least 63% of the pediatrics-primary care physicians surveyed in 2019 wanted to use telemedicine [5]. Overall, as a whole, physicians reported that they believed telemedicine improved access while providing better healthcare outcomes for their patients. Even physicians who did not previously use telemedicine reported that they were likely to begin using it within the coming three years [5]. A larger survey done by the Robert Graham Center, particularly targeting family physicians, showed that amongst primary care providers who used telemedicine, 75% of them believed it also improved continuity of care [6].

In the same survey, physicians have expressed lack of training and reimbursement as significant barriers [6]. Additionally, patients have expressed concerns related to privacy issues, especially when undergoing a video visit at work [7]. Despite these concerns, many patients have also expressed an interest in telemedicine. A study interviewing a group of patients in a primary care setting indicated that patients preferred video visits given that they could get care in the comfort of their homes [7]. Similar interviews were conducted in pediatric subspecialty settings. During these interviews, it was discovered that patients and parents preferred to use telemedicine in addition to in-person visits [8]. Even in more acute settings which conventionally require physicians to be present, telemedicine has begun to play a larger role. Studies comparing physicians using telemedicine for stroke showed that patients did not perceive any empathy difference between an in-house physician versus a physician over telemedicine [9].

However, challenges arise as telemedicine becomes increasingly integrated into healthcare. Even before the increased prevalence of telemedicine, certain patient encounters have proven to be challenging for many physicians. It has been shown that up to 15% of encounters can be classified as a difficult patient encounter for various reasons [10]. These visits tend to lead to poorer health outcomes for patients; however, long term outcomes were not necessarily addressed in this cohort study [10]. Similar studies showed that physicians who had more difficult patients were more likely to face burnout [11]. These physicians also believed they were not providing patients with the best care possible, but this was shown to be false as there was no difference in care provided by these physicians [11]. When telemedicine is introduced into these difficult scenarios, a new challenge arises.

Difficult telemedicine patient encounters have yet to be truly studied or classified. Limited research exists on providers’ attitudes towards various telemedicine scenarios, such as patients being in public settings and patients being partially undressed during the encounter. Provider comfort level with these scenarios has not been addressed.

Materials and Methods

A survey which included questions regarding patient comfort with chaperone use and telehealth and with casual patient behaviors and telehealth was sent out to invited participants via email using an online survey platform. The survey-maintained anonymity, but the email contained information to consent participants.

Invited participants included Loyola Departments of Primary Care, Family Medicine, and Internal Medicine ((n of 345 IM=253, PC = 92). After about 1 month, due to low response rate, the email with the survey link was sent out again. Any Loyola physician, physician's assistant, or nurse practitioner with internet access and an email in one of the three listed departments were eligible to participate. The research study was approved by the Loyola University Chicago Health Sciences Campus Institutional Review Board (IRB).

Statistical Analysis included Using SAS Studio, descriptive statistics were obtained. The frequency counts for all descriptive data were obtained. ANOVA tests were used to determine the relationship between provider acceptance levels regarding patient behavior. ANOVA tests were also used to determine the relationship between provider comforts conducting the telehealth visit when experiencing different patient behaviors. All tests were calculated at the alpha=.05 level, in conjunction with estimated 95% confidence intervals.


Characteristics of Respondents: Initially, 345 practitioners which included physicians and nurse practitioners were sent out the survey. 42 providers responded to the survey of which 85.71% were physicians practicing in family medicine, internal medicine, pediatrics, internal medicine subspecialty, and other specialties. The remaining 14.29% of respondents were nurse practitioners also practicing in the respective specialties. Family medicine and internal medicine physicians were the primary respondents being 33.33% and 35.71% respectively. The age distribution was divided by decade with most of the respondents being in their thirties at 33.33% in comparison to the other age groups. More than half of the participants were female at 69.05% in comparison to males at 30.95%. The majority of participants were white at 83.33% while a little more than half of the participants were in practice for more than 10 years.

Almost all of the providers had greater than 1 month of telehealth experience at the time of the survey. Majority of them had started using telehealth in April 2020. Survey participants were also asked to rank their own modesty as well as attire. Providers typically ranked themselves as neutral or conservative with almost 80.95% identifying in one of these two categories in comparison to being liberal or very conservative. None of the survey members identified as being very liberal. Our data also showed that there was a significant difference between the provider age and how they ranked their own modesty with older providers identifying as being more conservative. Providers were also asked to rank their own casualness with patients. 88.09% of them considered themselves neutral or casual while none of the providers considered themselves as very casual or very formal. There was a significant difference between how providers ranked their casualness versus their comfort level with behaviors such as eating and drinking, being partially undressed, being fully undressed, and another person aside from the patient being undressed during the encounter.

Acceptance of Patient Behaviors: Provider acceptance levels were assessed for various behaviors patients exhibited during telemedicine encounters. Survey participants were asked to identify these encounters as acceptable, unacceptable, or dependent on the situation. A little more than half of the providers believed that it was unacceptable to conduct tele health visits in public. 92.85% or almost all of the providers believed that it was unacceptable for patients to speak to others in the room about unrelated topics during the visit. Similarly, the majority of providers viewed being partially undressed, fully undressed, suspected being fully undressed, and someone other than the patient being undressed in the background to all be unacceptable behaviors. There was a significant age difference between providers who found patients being partially undressed during the tele health encounter unacceptable versus providers who believed it depended on the situation. Older providers deemed this behavior as dependent on the situation. 78.57% viewed patients being in the bathroom during encounters as acceptable and no one believed it was unacceptable behavior. Eating or drinking and driving were generally considered unacceptable behaviors at 66.67% and 59.52% respectively. Responses towards patients being in bed were the most widespread with the majority of the providers believing that it was dependent on the situation at 52.38%.