At Radmoudumc they prefer to see the patient remotely

An older man appears on the screen, sitting in his living room, with a bookcase in the background. He has had liver surgery, his lungs have been irradiated, and now he is waiting for the results of the last scan.

“Do you understand me?” the man asks.

“I hear you well,” responds liver and pancreas surgeon Martijn Stommel via his screen. “It’s nice that it works again.”

Two new – small – abnormalities were found on the man’s left lung, and a previous abnormality has grown. “It could be that it is not good,” Stommel says to his 67-year-old patient. “But that cannot yet be said with certainty. We are concerned about it.” He suggests doing a new scan in three months. Stommel: “Good luck with the uncertain message I have given you.”

About fifteen minutes have passed. “This man asked a lot of questions and there is plenty of time and space for that in a video consultation,” says Stommel. He sits in one of the many small and well-insulated video call booths, where doctors from Radboud University Medical Center in Nijmegen have digital contact with their patients. The cubicles are located in the ‘Garden Room’, a quiet place in the hospital (with plants and art) where doctors can make calls without being distracted.

In addition to his work as a surgeon, Stommel has been conducting scientific research into video calling in a medical context for many years. He is also the initiator of a major project within the Radboud university medical center and the Arnhem Rijnstate hospital to significantly increase the number of digital consultations. Currently, 4 percent of consultations at Radboud university medical center (about 1,850 per month) are video calling appointments. In three years’ time – the project started last October – this should be 20 percent (more than 9,000 per month). Together with the 33 percent that are already handled by telephone, more than half of the appointments will soon be ‘remote’. “The goal is to have as few people as possible come to the hospital unnecessarily,” says Stommel.

The project, which costs more than €300,000, fits in with a broader trend towards more digital care. Minister Kuipers (Healthcare, D66), who resigned on Wednesday, is strongly in favor of this. At the end of last year, not he himself but his hologram opened the Digital Access Festival in Healthcare in Utrecht. “Nowadays we do almost everything digitally,” wrote he wrote on LinkedIn afterwards. “We do our banking via the internet, book our holidays online or file our tax returns digitally. Why is this not always self-evident in healthcare?” Video calling is good for the environment and the wallet (patients drive fewer kilometers) and saves hospitals money and staff (fewer employees for counters and outpatient clinics, for example, fewer square meters required). Kuipers previously wrote in a letter to the House of Representatives already that “not enough is being done yet to make hybrid [deels fysieke, deels digitale] to make care a permanent part of healthcare and that this must change quickly.”

It won’t be Martijn Stommel’s fault. He treats people with cancer, people who are having surgery, radiation, or chemotherapy. So heavy treatments.

Yet he prefers to speak to his patients via a screen and not in the hospital. “People are often stressed when they have to go to the hospital,” he says. “They are afraid that they will not be able to find their way, that they will not be on time due to traffic jams, or that they will not be able to park their car. And once inside, they find such a hospital overwhelming with all those white suits.” The result: “Many people no longer feel comfortable in the consultation room.”

No, then digital. Then his patients sit at home in their familiar environment, they listen better and they remember more of what he says. “You are therefore more equal as doctor and patient, both in your own environment, both dependent on each other and the technology. In a consultation room, as a doctor I always stand a little above the patient; they are on my property.”

How can you be sure you have the right person on screen for you?

At the same time, Stommel gets an insight into someone’s life. He uses this to make sometimes difficult conversations a little easier. He says he has “good memories” of a recently deceased man whom he spoke to for years via video calling. “I know exactly where he always sat, what it looked like in his home.” There was a branch of a tree hanging on the wall, which Stommel thought was a work of art – it turned out to be just a broken branch. But it was a great topic of conversation. “Then someone will tell you about it. And then about his hobby, gardening. That deepens the bond.”

And not unimportant: it is often better for the patient himself: “I think it is very strange to have someone drive back to the hospital two weeks after an operation for a check-up. Someone has not yet recovered, has only just returned home, it is all very stressful. If I have operated on someone, I always suggest a video consultation two weeks later to ask how the recovery is going and to discuss the results of the tissue examination.” He himself “shouldn’t think about having to come to the hospital for all his appointments just because the doctor says so. Unacceptable.”

Resistance

To accelerate the development towards digitalization, D66 submitted a private member’s bill in the House of Representatives last year to give patients the right to a digital appointment with a healthcare provider (the Patient Federation of the Netherlands also wants this).

But many doctors don’t think the D66 plan is a good idea, it became clear last year a non-representative poll from medical journal Medical Contact. Marlies Schijven is a surgeon at the Amsterdam UMC and, as a professor at the University of Amsterdam, focuses on digital innovations in healthcare. She understands the resistance of healthcare providers very well. Sometimes a digital consultation is not appropriate, she says. For example, if a doctor wants to have additional tests done the same day. “That is not possible via a digital consultation.” Schijven advocates for patients’ rights indicate with which someone can let us know whether he or she would like a telephone consultation or video consultation, or would prefer to be seen physically. “Compare it to the airplane where you can ask for a seat on the aisle or by the window.” This is already possible at her outpatient clinic in the Amsterdam UMC, and soon also at the other outpatient clinics in that hospital. Ultimately, a doctor decides whether a digital consultation is possible. But, she adds, “if a doctor rejects a digital consultation, he or she must discuss this afterwards and be able to explain it in the consultation room.”

There are more risks associated with digital consultations. Take security and privacy. Schijven: “In the beginning we didn’t really know how we could do that safely. How can you be sure you have the right person for you? Isn’t it twins? Isn’t there a wrong name in the file? Is it safe?” The video calling system at the Amsterdam UMC is now linked to the patient file, and people call in via their own file. “You can’t just call in via Teams or something.”

It is also important to pay close attention to “the turn-taking” in conversations, says Martijn Stommel. “Let someone finish talking and wait for your moment to take over. Otherwise it’s hard to follow and you miss things. In the consultation room you can talk over each other and still understand each other.”

Play equipment

The Radboud University Medical Center cautiously started using video calling in 2014. But the technology was not yet that good and hospital staff “didn’t really believe in it,” says Stommel. “People liked it games and not very interesting.” During the corona crisis, the number of image consultations at Radboud university medical center increased from 50 to 3,000 per month. The momentum is finally picking up, Stommel thought, but he was disappointed: the number of video consultations dropped to 1,850 per month. Not because of the wishes of patients, but because “the organization has returned to its previous form.”

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Arranging the technology and good and pleasant spaces have been very good steps, says Stommel, “but have not led to the desired effect. It depends on behavior and culture. The change in behavior among healthcare providers is important.”

For many people it is still a “far-away show,” says Stommel. And so he first wants to find out why doctors do not make any video calls or make so few video calls. Can they do it? Do they think they don’t have the right patient group? Do they lack motivation? “Then we will look at how we can solve that so that it does happen. Then we can go there too targets to link. Everyone has to believe in it.”

As a patient you have to try it, want to experience the benefits

Radboud University Medical Center is not the only hospital that is faced with reluctance regarding video calling. Many care providers want to “go back to the time before corona,” says Schijven. “They want to provide care in the consulting room. They did not enter healthcare to sit behind a screen. That is understandable, but virtual contact can really be a good contact option in many situations.” It forces hospitals to act cautiously, especially in these times of staff shortages. Schijven: “You don’t want your staff to walk away dissatisfied because they only sit behind a screen.”

Not all patients are enthusiastic either. They don’t have a smartphone or tablet or are unsure whether they can. Stommel: “I don’t insist, but I do encourage them. You have to try it to experience the benefits. Once you’ve done it once, it turns out not to be that complicated.” But, he adds: “If they really don’t want to, then not.” Schijven: “If you want to come to the hospital, you can always come. After all, not every patient can or wants to participate in digitalization. And that’s fine.”

Yet Stommel envisions a hospital with far fewer patients in the future. It ensures that the hospital is a quiet place for sick people to be treated and recover. “You want to avoid unnecessary crowds. The only reason for being here is an action we have to perform here. If you don’t have to, you don’t have to be here as a patient. To put it mildly: ultimately you should be able to reduce a hospital to operating rooms, a few rooms where patients can lie to recover, and the CT scans and MRI scans.”

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