260 Central European Journal of Urology REVIEW PAPER COVID-19 Uro-oncology in the era of social distancing: the principles of patient-centered online consultations during the COVID-19 pandemic Roman Sosnowski1, Hubert Kamecki1, Steven Joniau2, Jochen Walz3, John Dowling4, Mark Behrendt5, Zachary Klaassen6, Joan Palou7, Hendrik van Poppel8 1 Department of Urooncology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland 2 Department of Urology, University Hospitals Leuven, Leuven, Belgium 3 Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France 4 Europa Uomo, Antwerp, Belgium 5 Chairman EAU Patient Information, Groene Hart Ziekenhuis – Gouda Afd. Urologie, Gouda, The Netherlands 6 Department of Surgery, Division of Urology, Augusta University – Medical College of Georgia, Augusta, GA, USA 7 Oncology Urology Unit, Department of Urology, Fundació Puigvert Universitat Autònoma de Barcelona, Barcelona, Spain 8 Department of Urology, University Hospital K.U. Leuven, Leuven, Belgium Citation: Sosnowski R, Kamecki H, Joniau S, et al. Uro-oncology in the era of social distancing: the principles of patient-centered online consultations during the COVID-19 pandemic. Cent European J Urol. 2020; 73: 260-264. Article history Introduction The COVID-19 pandemic poses significant challenges to healthcare facilities and as per social Submitted: June 13, 2020 distancing measures, many consultations are now being carried out via means of telemedicine. As some Accepted: June 29, 2020 urologists may not be skilled with remote consultations, there is a need for recommendations on patient- Published online: July 28, 2020 centered online medical counseling. Material and methods We have identified eight areas of excellence and defined the principles based on our experience. Results A professional setting should be provided, in which the privacy of the patient can be ensured. Accompanying persons should be encouraged into the consultation. Proper introduction could serve not only to verify the personality of the patient, but also to provide them with a sense of confidentiality. The Corresponding author interview should be held in a way to overcome the limitations of non-physical encounters, and pande- Roman Sosnowski Maria Skłodowska-Curie mic-specific issues should be taken into consideration. When arranging plans, the physician should judge National Research accordingly in regards to what type of management is inevitable or safe, as well as available at this point; Institute of Oncology strict follow-up should be arranged. As home isolation may lead to unfavorable changes in lifestyle, this Department issue should be addressed too. The patient should be guided on how to self-educate. Concluding the visit of Urooncology should be aimed at proper evaluation of the patient’s comprehension of the consultation. 5 Roentgena Street 02-781 Warsaw, Poland Conclusions It is vital to pursue consistency in providing care to patients. While online counseling may phone: +48 22 546 23 31 seem challenging, if one adheres to the principles of patient-centered practice, telemedicine may become roman.sosnowski@gmail.com a valuable tool in maintaining the best-quality care amid the ongoing pandemic. Key Words: COVID-19 ‹› telemedicine ‹› social distancing ‹› non-physical encounter INTRODUCTION gen, the paramount instrument for prevention of further disease spread is the maximum limitation As the total count of confirmed coronavirus disease of interpersonal physical contact. This social dis- 2019 (COVID-19) cases is still rising worldwide, tancing, apart from the need for providing care to given the highly contagious character of the patho- COVID-19 patients, is another significant challenge Cent European J Urol. 2020; 73: 260-264 doi: 10.5173/ceju.2020.0171 261 Central European Journal of Urology for healthcare facilities, which now are not only Accompanying persons. Counseling issues that postponing elective cases in order to secure access relate to cancer may cause significant anxiety to the to ventilator-level care [1], but also cancelling ap- patient. Moreover, given the advanced age of many pointments in medical offices in attempt to pursue uro-oncology patients, they may also present some social distancing measures. These preventive pro- degree of cognitive impairment or distress. In these cedures are of particular importance in the elderly circumstances, it may be desirable that the patient and in cancer patients, as this population is at in- is permitted, or even encouraged, if they wish so, creased risk of serious complications due to COV- to be accompanied by a close person during the ID-19 [2]. Thus, given the high priority of medical online consultation to provide emotional support, care in oncology, the emerging role of uro-oncology improve the effectiveness of communication and practitioners is to overcome the limitations of social help in decision making. Unfortunately, the degree distancing with telemedicine – a healthcare modal- of the accompanying person’s participation in the ity of established safety, efficacy and convenience encounter will be greatly dependent on the capabil- [3, 4, 5]. The authors of this text are aware that ity of the tool used for communication. This is es- a substantial population of urologists does not feel pecially an issue with telephone consultations, and experienced with telemedicine. Thus, we propose the role of the physician is to guide the conversa- some basic principles of patient-centered online tion in a way that allows the accompanying person consultations, in order to help provide and main- to participate, for example by asking the patient tain the best-quality outpatient care to patients to pass the phone to the partner or to turn on the with urologic malignancies. speaker function. Visit introduction. The significant role of intro- MATERIAL AND METHODS duction at the start of an online consultation is to ensure the patient is fully aware that they are speak- Based on our experience in regards to online or tele- ing to an actual physician and that the encounter is phone counseling we managed to identify eight areas a true outpatient visit. Such an introduction pro- of excellence. Within each area we defined principles vides the patient with a sense of privacy, which is which we found vital to maintaining proper remote essential for conducting a reliable interview. This patient care. can be further achieved by an explicit reassurance of the confidentiality of the encounter. At the in- RESULTS troduction, it is also vital to ascertain the personal data and identity of the patient, as the non-physical Setting. Much of the set-up measures depend character of the consultation may pose a risk of er- on the tool used for communication, which can be ror (this is especially an issue in case of telephone either videoconference or a telephone call. These encounters). Also, the physician needs to be fully platforms will likely vary by geographic location. introduced unless the patient knew his doctor be- While videoconference best allows the consulta- forehand. Additionally, it may be reasonable for the tion to resemble a physical encounter and include physician to confirm the patient’s consent to use an the role of non-verbal communication, a telephone online visit in lieu of regular clinic visit. conversation may be most suitable in patients not Interview. While the routine principles of a medi- familiar with modern technologies (e.g. some of the cal interview apply to a non-physical encounter elderly or rural population). As a general rule, the as well, there are some special issues that should be aim of the set-up is to provide a professional setting taken into consideration when performing an on- that both enables adequate communication and en- line consultation. Firstly, depending on the com- sures patient privacy. This is important as many munication tool and the features of the medical re- urologic conditions and symptoms are of great in- cords software used, some data such as a laboratory timacy. tests or imaging results may not be provided online. An ideal setting for the counseling physician can In such cases, extra time and as much effort as pos- be achieved, among other things, with proper at- sible should be put into fully collecting this data tire, adequate lighting and framing, professional vi- verbally from the patient, without omitting data sual background, protection from background noise that could seem irrelevant and paying special at- or voices, as well as limiting external or personal dis- tention to the units used on lab reports. Secondly, tractions that could make the physician seem unfo- social distancing and thus perceived isolation may cused on the patient. The use of telecommunication be a risk factor in developing or exacerbating a pre- instead of physical contact must not deprive the en- existing depression or anxiety disorder [6], which is counter of its professional character. a special concern in the population of uro-oncology 262 Central European Journal of Urology patients. Both cancer patients [7] and elderly indi- of a primary bladder tumor, an abdominal ultra- viduals [8] demonstrate high rates of depression and sound may be considered in place of a cystoscopy, anxiety disorders, thus every interview in the era as its sensitivity has been reported to be very high of COVID-2019 pandemic should be aimed to screen [11]. Thirdly, as the availability of particular man- the patient for possible mental health issues, so that agement modalities may be currently limited, the they could be timely referred to a psychiatrist. Third- urologist must ascertain that the recommended di- ly, the inability to perform a physical examination agnostic and treatment plan is feasible, for example is a major limitation of an online consultation. How- by postponing currently unavailable imaging test- ever, this may be overcome by guiding the patient ing and substituting it with more accessible work- on self-examination, either by verbal instructions up. In addition, the patient must be reassured that or by asking the patient to reproduce maneuvers even despite major limitations, the offered plan not presented in the videoconference. While some parts only does not leave them without help, but still pro- of the examination, especially digital rectal examina- vides the best care currently available. Vice versa, tion, may not be feasible, others, like costovertebral if presence in a healthcare facility is inevitable, reas- angle tenderness or testicular examination may be easily performed by the patient. Fourthly, as we are living in a pandemic status, it is reasonable to also Table 1. Examples of uro-oncology patient organizations screen for COVID-19 symptoms. Fifthly, depending Organization Website address on the perceived quality of communication, in order to mitigate the risk of misunderstanding, it would be European Association of Urology Patient https://patients.uroweb.org/ Information reasonable for the physician to paraphrase the col- Europa Uomo – The Voice of Men with lected data and to ask the patient to confirm its cor- Prostate Cancer in Europe https://www.europa-uomo.org/ rectness. International Kidney Cancer Coalition https://ikcc.org/ Arranging plans. In general, the best treatment – IKCC options offered to the patient as part of an on- World Bladder Cancer Patient Coalition line consultation will not differ from what would – WBCPC http://worldbladdercancer.org have been established during a physical encounter. European Cancer Patient Coalition However, the availability of many diagnostic and https://ecpc.org/ – ECPC treatment modalities is going to be substantially Bladder Cancer Advocacy Network https://bcan.org/ limited as a result of the ongoing COVID-19 pan- – BCAN demic. Firstly, if considering surgical management as a treatment option, proper triaging should be implemented, for example by the model recently Table 2. Summary of recommendations in regards to main- proposed by Stensland et al. [1]. The reasons for taining standards of patient-centered medicine during online postponing treatment should be enunciated to the consultations patient, not only by highlighting the unavailabil- Make sure the setting is professional, safe and resembles a genuine ity of ventilator-level care, but also by explaining consultation possible COVID-19 risks whereby reassuring the Enable the accompanying person to participate in the encounter patient that not scheduling surgery during an on- Verify the identity of the patient, introduce yourself and reassure about going pandemic is the safest option. Secondly, in confidentiality some patients a physical encounter may appear to If not provided online, carefully collect data regarding tests and imaging be inevitable in order to establish an important di- agnosis or maintain proper follow-up. A good exam- Do not hesitate to ask the patient to perform physical examination maneuvers ple are patients requiring cystoscopy. The authors Evaluate for depression and anxiety disorders of this article suggest that while in patients with confirmed low-risk (pTa LG) bladder cancer the Use proper triaging when scheduling treatment follow-up cystoscopy, other than the first one after Do not order unavailable management plans bladder tumor resection, may be safely postponed Reassure that despite limitations the patient will still benefit from the for a period of a few months, as even active-surveil- offered management plan lance has been reported to be safe in those patients Schedule an early follow-up [9, 10] and thus delaying a recurrence diagnosis Perform a lifestyle intervention may not actually pose danger, in patients with high Provide the patient with educational materials (EAU Patient Information) risk or unknown risk (primary) disease performing Encourage the patient to familiarize with patient organizations a cystoscopy, if possible to maintain adequate safety Make sure the patient understands what has been arranged standards, is a must. In patients with a suspicion 263 Central European Journal of Urology sure the patient that proper safety measures will be Concluding the visit. To what extent the informa- applied, and the arranged intervention is beneficial tion provided to the patient is going to be understood for their health. Fourthly, early follow-up should is greatly dependent on the features of the online sys- be scheduled. Short time intervals between online tem used for counseling. However, regardless of the consultations should be scheduled to not only reas- expected degree of misunderstanding, the physician sure the patient about the consistency of care, but must evaluate whether the patient correctly com- also to minimize any harmful effects of any incor- prehends the arrangements. This can be achieved rect data interpretation, which may be an unlikely, for example by asking the patient to repeat or para- but still are a possible limitation of an online con- phrase the recommendations. If possible, a summary sultation. Arranging a short call a week or two after of the consultation or the recommendations should the consultation is a reasonable way to eliminate be provided on-line to the patient, as well as appro- the risk of misinterpretation and to ascertain the priate contact details, should the patient have any patient’s compliance, which is especially important doubts or late questions. in patients who express doubts or anxiety, or in pa- tients with advanced or high-risk disease. DISCUSSION Lifestyle intervention. Social distancing, as well as the fear of leaving home may lead to decreased The ongoing COVID-19 pandemic has entirely dis- levels of physical activity. Limited access to grocer- rupted the consistency of our communication with ies may have a substantial impact on dietary habits. patients. Limited access to health services and so- Reduced direct social support and lack of distracting cial distancing are raising unprecedented signifi- activities may impede a planned or ongoing smoking cant challenges to the whole healthcare system. cessation attempt or even pose a risk of a relapse. Telemedicine is a previously underestimated, but This is why lifestyle intervention should become a now promising tool which may at least partially routine part of every online consultation in the era of help in overcoming these new difficulties. When the COVID-19 pandemic, especially in the population adhering to several important principles of online of uro-oncology patients, who are particularly prone counseling, telemedicine has an opportunity to be- to negative effects of smoking and increased cardio- come a safe and efficient tool in establishing and vascular risk (e.g. patients on androgen deprivation maintaining proper care in the challenging popula- therapy). A brief smoking intervention, e.g. five A’s tion of patients with urologic malignancies. We are [12] should be performed. The patient should also be aware that this population comprises a heteroge- encouraged to involve themselves in physical activ- neous group of patients, and while some appoint- ity. The development of indoor activity guidelines for ments are simple follow-up visits that can be easily elderly or comorbid patients should become an ur- and safely managed online, other patients, especial- gent priority for healthcare organizations. Another ly some new patients or patients presenting with important point when considering lifestyle interven- complications may require a physical encounter tion is screening for possible alcohol abuse, as social anyway, but still we believe that online consulta- distancing or home isolation might be a substantial tions, if performed properly, may play a great role risk factor. during the ongoing pandemic. Self-education and support. While people spend While the current impact of social distancing more time at home and limit their professional and so- on medical counseling is undoubtedly negative, this cial activity, the additional spare time gained could be challenge, if successfully overcome now, may intro- utilized for self-education. Providing the patient with duce valuable opportunities for the future. When educational materials could not only act as a valuable the dust of the ongoing crisis settles and we become supplement to the consultation, but also could help more experienced with the principles of telemedicine, the patient to become familiar with their condition we will have to reflect on the true priorities of our and available management options, as well as prepare practice. How strict of a follow-up is actually nec- them for asking questions during the next visit. Mate- essary in uro-oncologic patients? Are we doing too rials available at: https://patients.uroweb.org could be many unnecessary in-person follow-up consulta- used for this purpose. Moreover, in order to make up tions? To what extent can the follow-up visits be re- for limited social activity, the patient should be guided placed by phone calls or video conversations, in order to familiarize themselves with the activity of patient to safely ease the burden in our offices and to provide organizations. The list of several global or European the patients with more convenience? These, among patient organizations is provided in Table 1. We en- many other questions, will need to be addressed af- courage physicians to become familiar with their na- ter we successfully manage to overcome the difficul- tional, regional or local patient organizations as well. ties of the current situation. 264 Central European Journal of Urology In the meantime, we should aim our effort at con- CONCLUSIONS tinuing to provide care to our patients and at keep- ing them and their family physicians aware that our Based on our experience, we have presented instruc- offices, despite having limited patient access, are tions on how to maintain the best standards of pa- still functional, and at least for the purpose of ur- tient-centered care when counseling uro-oncology gent matters they can be easily accessed by means patients via means of telemedicine. The summary of online or telephone communication. Not provid- of recommendations is provided in Table 2. Bear- ing a patient with any kind of diagnostic process ing in mind that it is vital to pursue consistency or leaving them without necessary treatment may in providing care to the patients, we believe that lead to seeing more advanced cancer cases once the our guide could serve as a practical aid in maintain- COVID-19 peak has passed. While being protected ing best-quality care amid the ongoing pandemic. from COVID-19 with social distancing, patients may If we successfully manage to overcome the difficul- become at risk of having lost their window for cure ties of the current situation and establish the role and dying because of delayed diagnosis. Therefore, of telemedicine in providing care to our patients, we we would like to stress, that increasing access to may be able to turn this challenge of inexperience telemedicine, education of physicians and adapting into a promising opportunity for the future. guidelines should be an urgent priority for govern- ments, as well as health and professional medical Conflicts of interest organizations. The authors declare no conflicts of interest. References 1. Stensland KD, Morgan TM, Moinzadeh A, of virtual online consultations 9. Hernández V, Llorente C, de la Peña E, et al. Considerations in the triage in a NHS acute trust: the VOCAL et al. Long-term oncological outcomes of urologic surgeries during the COVID-19 mixed-methods study. Healht Serv of an active surveillance program pandemic. Eur Urol. 2020; 77: 663-666. Delivery Res. 2018; 6. in recurrent low grade Ta bladder cancer. Urol Oncol. 2016; 34: 165.e19-23. 2. Liang W, Guan W, Chen, et al. Cancer 6. Santini ZI, Jose PE, Cornwell EY, et al. patients in SARS-CoV-2 infection: Social disconnectedness, perceived 10. Hurle R, Pasini L, Lazzeri M, et al. a nationwide analysis in China. Lancet isolation, and symptoms of depression Active surveillance for low-risk non- Oncol. 2020; 21: 335-337. and anxiety among older Americans muscle-invasive bladder cancer: (NSHAP): a longitudinal mediation mid-term results from the Bladder 3. Liddy C, Drosinis P, Keely E, et al. analysis. Lancet. 2020; 5: E62-70. cancer Italian Active Surveillance Electronic consultation systems: (BIAS) project. BJU Int. 2016; 118: worldwide prevalence and their impact 7. Nikbakhsh N, Moudi S, Abbasian S, 935-939. on patient care-a systematic review. et al. Prevalence of depression and Farm Pract. 2016; 33: 274-285. anxiety among cancer patients. 11. Gharibvand MM, Kazemi M, Motamedfar A, Caspian J Intern Med. 2014; 5: et al. The role of ultrasound in diagnosis 4. Greenhalgh T, Vijayaraghavan S, Wherton J, 167-170. and evaluation of bladder tumors. J Family et al. Virtual online consultations: Med Prim Care. 2017; 6: 840-843. advantages and limitations (VOCAL) 8. Perkovic R, Sucic A, Vasilij I, et al. study. BMJ Open. 2016; 6: e009388. The incidence of depression and 12. Quinn VP, Hollis JF, Smith KS, et al. anxiety among the elderly in the Effectiveness of the 5-As tobacco 5. Shaw S, Wherton J, Vijayaraghavan S, area of Livno, Bosnia and Herzegovina. cessation treatments in nine HMOs. et al. Advantages and limitations Mater Sociomed. 2018; 30: 176-179. J Gen Intern Med. 2009; 24: 149-154. 