The use of telemedicine (TELE), the provision of health care through 2-way telecommunications, increased exponentially during the COVID-19 pandemic [1]. Many expect that these changes will persist beyond the COVID-19 pandemic [2]. Prior studies of TELE visits in various medical specialties have demonstrated relatively favorable patient satisfaction with this type of encounter [3-6]. The impact of TELE on patient experience in integrative medicine is less examined.

To address these concerns, this study assessed the impact of visit modality, TELE video visits versus face-to-face (F2F) encounters, on patient experience at an integrative medicine practice at a single academic medical center. Given the vital role of the patient-clinician relationship in integrative medicine, it was hypothesized that TELE might result in reduced patient experience compared to the traditional, F2F encounters.

Patient experience measures, as defined by the Agency for Healthcare Research and Quality, “encompasses the range of interactions that patients have with the health care system...” and, when positive, is associated with better clinical outcomes [5]. It is important to note that patient experience, as measured through publicly available surveys such as Press Ganey surveys, can be significantly impacted by TELE [7]. In particular, the relational aspects of care including verbal and nonverbal communication can be affected [8]. This is relevant for integrative medicine, which emphasizes whole-person care and views the therapeutic patient-clinician relationship, including touch and presence as central to the healing process [9]. Appropriately, there is concern that TELE can adversely affect the integrative medicine patient experience [8,9].

Over the 36 months, a total of 1066 surveys were completed and returned (TELE: n=333; F2F: n=733). Overall, 73% (n=778) of respondents were female with an average age of 57.6 (SD 13.84) years. Most patients were English-speaking (n=1059, 99.3%), White (n=988, 92.7%), and not Hispanic or Latino (n=985, 92.4%; Table 1). Differences were observed in race and ethnicity (Table 1). For race, these differences appeared to be driven primarily by other and unknown categories. There was slightly more variation in proportions for the TELE visits compared to the F2F visits, which were primarily not Hispanic or Latino. TELE visits also had a higher proportion of commercial insurance payers. No other differences existed between the 2 visit types in participant demographics. There was significantly higher satisfaction with access to care for TELE visits compared to F2F visits. There were no differences in satisfaction with the care provider or overall experience (Table 2).

When examining the specific aspects of using technology during TELE visits, there were no differences in audio quality, visual quality, or ease of talking to the care provider based on sex. There was, however, a difference in video quality based on age, where those 80 years and older, rated significantly lower video quality compared to all other age groups (Table 3).

To better understand and improve the experiences of integrative medicine patients, this study assessed associations between visit modality (TELE vs F2F encounters) and patient experience measures. Despite the significant role of the patient-clinician relationship in integrative medicine and the role of touch and presence, the hypothesis that TELE would be associated with lower patient experience compared to traditional, F2F encounters did not bear out. On the contrary, these exploratory data suggest high-level patient experience scores can be achieved at a level comparable to F2F encounters, for consultative integrative TELE.

Integrative medicine emphasizes the relational aspects of care, and prior studies of TELE in other patient populations have highlighted concerns that patient experience and, specifically, the patient-clinician relationship can be negatively impacted by TELE. TELE has been previously described as “impersonal” [8]. Researchers have noted a decrease in verbal expressions of empathy during TELE encounters [11,12], and understandably, TELE limits clinician opportunities to express empathy through nonverbal communication skills, such as touch [8,13-16]. Interestingly, despite these potential limitations, physicians in this study achieved top-level TELE patient experience scores across all care provider metrics, including “Concern the care provider showed for your questions or worries.” While this study did not specifically evaluate physician communication skills, prior experience research completed by members of this study team demonstrates that implementing empathic, patient-centered communication improves patient experience [17], and it is well known that empathic communication skills can be taught [18]. All physicians who provided clinical care to patients in this study completed an in-person, 8-hour course in empathic F2F communication as a part of their orientation during onboarding. While this training was prior to the COVID-19 pandemic and did not include instruction in empathic communication during TELE visits, it still may have positively influenced the TELE patient experience as indicated by these data. An important question remains about which communication skills truly correlate with a better patient TELE experience. Additional studies, particularly ones in which top-performing TELE clinicians are observed, could serve to identify best communication practices for TELE visits.

With these favorable preliminary data, it is then important to ask, when is TELE particularly useful for integrative medicine? A recent systematic review of 44 TELE studies suggests that TELE can improve clinical outcomes, communication, and access to care [19]. It is known that lack of in-person access to integrative medicine can contribute to integrative health disparities [20] and with growing comfort and availability of integrative medicine TELE visits, there is a real opportunity to increase access to experts in integrative medicine; however, this is not without concerns. Some argue that digital resource limitations and lack of access to TELE can perpetuate disparities, rather than alleviate them [20-22]. Others suggest that TELE adoption may also be limited among some older adults [23]. This study did not examine whether any older patients might have, in advance of the appointment, changed from TELE to F2F based on personal preference. The older adults in this study, however, did report positive experiences similar to that of younger patients.

This exploratory study has limitations. Data were collected at a single academic medical center in Arizona with a largely White, college-educated patient population and, in this sample, a high race concordance between patient and physician. These results might not be readily generalizable to other patient populations. Replicating this study in other, more diverse integrative medicine clinical practices would significantly contribute to understanding patients’ experiences with, and barriers to, integrative TELE. In addition, our data did not include metrics on “wait time” for patients with TELE visits, only for those with F2F visits. For F2F visits, 87% (n=637) of patients selected the top box score for wait time. As prior research has suggested that TELE visits can serve to reduce wait time, thus improving the experience, future studies should include this measure [24]. Finally, the relatively small sample size biased results toward the null. As TELE integrative medicine grows, larger studies are needed. Finally, our study does not distinguish between “new” and “return” patient visits, which may serve to impact patient experience with TELE visits [25].

In conclusion, top-level patient experience can be attained with TELE integrative medicine visits, suggesting TELE can facilitate access to integrative medicine for those who live in areas with fewer integrative clinicians. In addition, for patients who prefer not to leave their homes for medical visits, TELE helps to facilitate compliance with ongoing medical care. Correlating positive experience findings with specific behaviors used during TELE visits would further our understanding of the integrative medicine patient experience. In the meantime, efforts should be made to ensure a policy that promotes the ongoing provision of TELE in integrative medicine.