On hidden psychological costs of virtual healthcare: A call to action
Meeting medical needs is a hot topic in virtual care. Equally important but less discussed, however, are basic psychological needs. Self-Determination Theory (SDT)1 - the leading theory of human motivation and well-being - tells us that autonomy (sense of volition), competence (sense of efficacy), and relatedness (sense of connectedness) are universal needs, and hindrance of them will come at significant functional costs: to our engagement, relationships, health and wellness.2 Unfortunately, while fostering these needs is highly beneficial in primary care3,4,5 - and perhaps more now than ever before - barriers to meeting these needs in today’s virtual healthcare landscape (e.g., with private sector healthcare, current governance of compensation mechanisms, and inequities in access and digital literacy, to name a few) are worryingly present.
The pandemic has forced us all to adapt, and virtual platforms have enabled us to safely care for our patients. Virtual care has also proven to be convenient, effective, and even preferable by some patients and doctors,6 although the validity of “satisfaction” surveys used to assess these outcomes might be viewed as inherently problematic (as evidenced in the education field).7 And yet, many feel that virtual medicine is not as humanistic, nor as giving to the patient-doctor relationship.8,9
In their February 2021 edition: “Virtual Care in the Patient Medical Home,” The College of Family Physicians of Canada spoke to this, stating that, “the core relationship between a provider and their patient, and the resulting continuity of care, remain key to delivering quality care…” and, “virtual care tools have the capacity to support and reinforce patient autonomy…”.10 However, the reality is that how virtual healthcare climates impact basic psychological needs, such as autonomy, in both patient and physician motivation, behaviour, and well-being, is not well understood.
In a recent study which addressed this question, comparing 66 patients (32 virtual vs. 34 in-person) in their perceived autonomy-support and relationship need fulfilment (autonomy, competence, relatedness) with their family doctor, virtual visits were found to be significantly less autonomy-supportive.11 This highlights that while virtual care may indeed be adequate for meeting patients’ medical needs - even in a Patient Medical Home (with continuous, comprehensive care) - it may also be suboptimal for supporting their individual and relationship motivation with their family doctor and care team. Whether this difference reflects patient and/or physician factors (e.g., motivation towards using virtual healthcare) remains unclear.
In sum, virtual healthcare is here to stay, and I am not arguing that it should not be. In fact, I believe it can enhance our ability to be patient-centered, at least in some situations. I simply wish to highlight the digital divides that virtual healthcare may create, for meeting basic psychological needs, and to invite others to join me in looking at this issue more closely. I also think it is imperative that we draw on empirically supported frameworks, such as SDT, if we want to reliably study and understand the true benefits and limitations of virtual healthcare, for all those involved.
Dr. Adam Neufeld is a Chief Resident at the University of Calgary’s Cumming School of Medicine. His research interests are in medical education and motivational psychology.
References
1. Ryan RM, Deci EL. Self-Determination Theory: Basic Psychological Needs in Motivation Development and Wellness. Guilford Publishing; 2017.
2. Deci EL, Ryan RM. The " What " and " Why " of Goal Pursuits: Human Needs and the Self-Determination of Behavior. Psychol Inq. 2000;11(4):227-268. doi:10.1207/S15327965PLI1104_01
3. Williams GC, Minicucci DS, Kouides RW, et al. Self-determination, smoking, diet and health. Health Educ Res. Published online 2002. doi:10.1093/her/17.5.512
4. Williams GC, McGregor HA, Zeldman A, Freedman ZR, Deci EL. Testing a Self-Determination Theory Process Model for Promoting Glycemic Control Through Diabetes Self-Management. Heal Psychol. Published online 2004. doi:10.1037/0278-6133.23.1.58
5. Williams GC, Patrick H, Niemiec CP, et al. Reducing the health risks of diabetes: How self-determination theory may help improve medication adherence and quality of life. Diabetes Educ. Published online 2009. doi:10.1177/0145721709333856
6. Uscher-Pines L, Sousa J, Raja P, Mehrotra A, Barnett ML, Huskamp HA. Suddenly becoming a “Virtual doctor”: Experiences of psychiatrists transitioning to telemedicine during the COVID-19 pandemic. Psychiatr Serv. Published online 2020. doi:10.1176/APPI.PS.202000250
7. Hornstein HA. Student evaluations of teaching are an inadequate assessment tool for evaluating faculty performance. Cogent Educ. 2017;4(1). doi:10.1080/2331186X.2017.1304016
8. Bertman S. Pursuing Humanistic Medicine in a Technological Age. J Patient Exp. Published online 2017. doi:10.1177/2374373517699269
9. Simpkin AL, Dinardo PB, Pine E, Gaufberg E. Reconciling technology and humanistic care: Lessons from the next generation of physicians. Med Teach. Published online 2017. doi:10.1080/0142159X.2017.1270434
10. College of Family Physicians of Canada. Virtual Care in the Patient’s Medical Home.; 2021. https://patientsmedicalhome.ca/files/uploads/PMH_Virtual-Care-Supplement_ENG_FINAL_REV.pdf
11. Neufeld A, Bhella V, Svrcek C. Pivoting to be Patient-Centered: A Study on Hidden Psychological Costs of Virtual Healthcare and the Patient-Doctor Relationship. Submission In Preparation. 2021.
