Telehealth has become a core feature of modern medical practice. As the demand for digital health services grows, I wonder how virtual visits could either help or harm our patients, particularly those who have experienced trauma. As a practicing physician, I have seen medical care worsen patients underlying discomfort as well as incite new distress. Whether it’s a physical exam, MRI, injection, or surgery, much of what we offer is imposing. While doctors’ appointments are intended to offer comfort, healing, or even cure, they can also have the opposite effect.
When I conducted my first video visit with a patient in 2018, I saw how trauma could be relevant to telehealth care. A patient and 2 primary care nurses had logged into the virtual portal from a rural clinic room. I logged in from our city hospital, along with a technical assistant. The nurses were testing out a new camera that could perform a virtual examination, so that I could listen to the patient’s heart sounds and look inside his mouth live, from a remote location. As we fumbled with the new equipment for an oral exam, I reviewed the patient’s chart. He had a history of PTSD and childhood sexual abuse. I paused and considered the scenario: we were on video, with multiple people in the room, standing over the patient, and holding a long probe inside his mouth. What if this medical visit was retraumatizing?
Pros of Telehealth:
Most would agree that telehealth offers advantages to on-site care. Virtual visits can expand access by circumventing long wait times and the logistics of traveling to appointments. Connecting with one’s care team from home can provide a greater sense of ease compared to a medical office. Telehealth can also be uniquely beneficial in trauma-focused therapy. In a study of telemental health visits, videoconferencing created a sense of distance that allowed Veterans with PTSD to “let their guard down”.
Cons of Telehealth:
Nevertheless, telehealth care carries potential risks for trauma survivors. Patients may lose the sense of social support and engagement that in-person visits afford. They may not readily find a location that is private from other household members. Individuals with housemates who use violence may not feel comfortable discussing sensitive information. Many have fears of being photographed or recorded while on virtual calls, and it can seem unclear who is or is not in the virtual room. While technology aims to run smoothly, gaps in connectivity can lead to feelings of frustration or mistrust, and for people who lack internet access, virtual therapies may widen disparities rather than solving them.
Recognizing these challenges, I have found it helpful to rely on trauma-informed care as a strategic framework to guide in-person and virtual clinical interactions. A trauma-informed approach can help us provide quality care to trauma survivors, allowing visits to feel more safe, collaborative, and empowering, for both patients and healthcare professionals. The suggestions that follow are adapted from an article I wrote with colleagues about trauma-informed telehealth.
Before joining a video visit, glance at yourself on camera to confirm what the patient will see. Be sure that you are dressed for work, and avoid busy, unprofessional backdrops. Ensure adequate lighting so that your face is clearly visible, and sit far enough from the screen that body language (e.g. hand movements) can be apparent. Utilize headphones to ensure confidentiality as appropriate.
Start the session by welcoming the patient to the virtual space and thanking them for using this care modality. Verify their location and contact information for safety purposes, and obtain consent for the visit. Emphasize that they may choose to end the video and/or visit at any time, and the topic of discussion can change, even abruptly, if needed. Try to look directly at the camera of your electronic device to ensure the appearance of virtual eye contact, and notify the patient if your attention turns elsewhere (e.g. “I am checking my paperwork to see if I received the form you sent in”). Alert the patient to possible ambient noises, including dogs barking, children playing, construction, or typing.
Collaborate with the patient to identify an agenda for the visit, and follow their preferences regarding the extent of the session. Be sensitive to patients’ feelings in revealing their personal space on video; it is usually best to refrain from commenting on their living area. Note any lag time and wait before replying to avoid rushing the patient. Throughout the appointment, use gender-affirming and inclusive language. Consider the social determinants of health and advocate for equitable care using your extended care team and community resources.
Whether you are a proponent of telehealth or not, virtual care modalities are here to stay. Telehealth care carries inherent pros and cons in caring for people who have experienced trauma. When we use a trauma-informed approach to telehealth, we can reduce the risk of unintentional medical harm and expand opportunities for healing and recovery.
Sadie Elisseou, MD is a primary care physician in the VA Boston Healthcare System, a clinical instructor at Harvard Medical School and Brown University School of Medicine, and subject matter expert in trauma-informed care.
Photo Credit: The author provided the photo