Telemedecine: Connecting Healthcare Providers and Patients

About: Alexandre Mathieu-Fritz, Le praticien, le patient et les artefacts : genèse des mondes de la télémédecine, Mines ParisTech-PSL

Alexandre Mathieu-Fritz’s book, published in March 2021, is all the more relevant given the political and health context in which it is set. Firstly, teleconsultation is seen as one of the tools needed to alleviate the demographic problems facing the healthcare professions, while meeting the challenge of rationalizing the costs associated with access to care. These are two areas of healthcare restructuring that have been driving public policy for almost two decades. Moreover, this practice spread rapidly as a result of the COVID-19 crisis, which made these remote consultation systems both necessary to ensure continuity of care and compatible with the travel restrictions imposed on populations. This “sociological gaze” (Hughes, 1996) is thus imbued with political implications, not only because of the object of study itself—a practice supported by the public authorities—but also because of the interest shown in the ways in which teleconsultation tools are used, people’s reasons for opting out of such tools, and the logics of action that drive these practices and which can be seen as decisive for the success or failure of the policies in question.

Between sociology of health and technology

Continuing his work at the intersection of health and technology, the author proposes a work-based approach. This raises questions about the changes in professional practices that result from the introduction of a new tool, and their effects on practitioners’ experiences, through the prism of the notion of “real work” (Bidet, 2010). The main theme of this book is the relationship that exists at the heart of the activity, bringing together two fields that are a priori far apart, both professionally and organizationally. The first part looks at teleconsultation as a means of fostering cooperation between doctors in a geriatric hospital and a university hospital, while the second part recenters the analysis on the relationship between psychotherapists (psychiatrists and psychologists) and their patients.

Teleconsultation in geriatrics

The first results reported analyze the collaboration between an AP-HP (Assistance Publique – Hôpitaux de Paris) university hospital and a geriatric hospital using a teleconsultation system called Télégéria. The overview given provides both an objective view of the tool’s technical characteristics (features, functionality) and contexts of use (market overview, utilization, patient and user profiles), and a subjective view of the broad spectrum of perceptions with which it is associated (from the opportunity to diversify and broaden the patient base, to resistance caused by the fear of dehumanization). By mobilizing these determinants together in the approach to in situ work, it is possible to identify the types of work required to satisfy the “minimal conditions of interaction” needed to create a “common interactional space” (p. 106). Practitioners are required to perform four types of scoping. Relational and professional scoping (presentation of the actors and their roles), implied in particular by multi-professional consultation, but also instrumental, clinical or organizational scoping, as required by the mediation technique used. Such scoping refers respectively to satisfying the conditions of use of the equipment, recreating “the standard practices of face-to-face clinical examination” (p. 109) and preparing for the appointment.

Delegation, subordination and skills acquisition

Delegation is a key theme in the sociology of work and professions, and plays a major role in the analysis of teleconsultation practices. By combining objective considerations, such as the physical impossibility to touch, and subjective elements, such as the ritual nature of the work, the sociologist postulates a twofold delegation, of menial activities as well as “real work”, based on a dual disclosure directly linked to the need for the verbal exchange imposed by distance. Indeed, as the delegator makes his/her expectations and actions clear to the delegatee, both participants find themselves in a “new arena of technical skills” (Dodier, 1993, 1995), with one having to make his/her request explicit, and the other having to “properly perform” a professional task that is not his/her domain. However, delegation is not limited to simply subjecting practitioners to scrutiny by their peers from other professions. If professionals invest in building a relationship of trust, it can lead to the emergence of a working micro-collective.

In addition to the subordination involved in instant remote communication, teleconsultation practices are driven by processes of skills acquisition and changes in individual roles. The telemedicine assistant, for example, plays a decisive role in carrying out the various types of scoping, helping to offset the fears of dehumanization that run through perceptions of teleconsultation. Although these dynamics do not reduce asymmetry between practitioners or professional compartmentalization, the author concludes that they do affect the way in which this tool is used, prompting geriatricians to carry out an initial assessment before consulting the specialist, thus reducing the number of teleconsultations over time. Alexandre Mathieu-Fritz’s chronological analysis provides a convincing illustration of the link between new tools, changes in activities, and evolutions in professional relations, in line with his methodology based on the reconciliation of scales, and his interest in the professional challenges of situational work.

Teleconsultation in mental health

The second part of the book focuses on teleconsultation in mental health, highlighting the link between technical mediation, “real” work and “good” work, and drawing on the analysis of the previous section. It also emphasizes characteristics specific to the field of psychotherapy. Within this profession, perceptions of the tool are varied. They range from a belief that teleconsultation provides an opportunity to diversify one’s business and facilitate access to care—for French expatriates in particular—to negative reactions from colleagues opposed to the practice, which breaks with established professional standards. The “discovery” by peers that a practitioner is using a digital medium is akin to a “social coming out” (excerpt from an interview with a psychologist/psychoanalyst, p. 208), i.e., the revelation of a previously undisclosed practice. While these reservations may apply to all types of psychotherapist, some are more inclined than others to distance themselves from teleconsultation tools. Psychoanalysis, for example, is based in part on the therapist’s being out of the patient’s direct field of vision, and it is difficult to recreate this spatial and relational configuration with digital tools. In remote therapy, the absence of the practitioner from the camera’s field of vision would leave the patient with a feeling of solitude, which would be detrimental to the therapy’s success. As a result, psychoanalysts who use teleconsultation are more likely to meet with disapproving reactions from their peers than practitioners who use other working methods.

In addition, the use of “Télé-med”, the name given to the mental health teleconsultation system under study, is plagued by technical, clinical and therapeutic concerns. These communication tools spark fears over how to master them and manage their malfunctions (technical concerns), which can have a direct impact on the practitioner’s focus on the patient and his/her therapeutic approach (clinical concerns). However, psychiatrists and psychologists are motivated to overcome these fears by the considerable variability in their understanding of their profession, and by their emphasis on curiosity. To discover the potential of these tools, practitioners need to adapt their audience, the nature of their interventions and their professional practices, and adopt an “experimental posture” (Mathieu-Fritz & Guillot, 2017). Professionals believe that the teleconsultation tool is not suitable for serious cases, and leads to a “desacralization” of the therapeutic process among patients when carried out online; in turn, this can result in a desire for quickness and a shift in expectations towards coaching. However, this assumption cannot be strictly attributed to either teleconsultation or psychotherapy, but is part of a more general context involving the rise of the “’consumerization’ of care” (p. 236), “a general trend that is replacing the traditional practitioner/patient relationship, which was a personal and lasting one, with a temporary, opportunistic relationship based on mere service between a client and a provider” (Convert and Demailly, 2003). Moreover, by dividing the space between practitioner and patient, Télé-med tends to weaken the therapeutic framework, whose stability is vital to establishing a “therapeutic alliance” (p. 216), a hallmark of “well-done” work. This observation seems to be closely related to the idea of a shift away from the “doctor-patient bond” that underpins the relationship. As is the case with cooperation between a geriatrician and a specialist, additional scoping may be required to compensate for distance-related problems (poor sound reproduction, misunderstandings, loss of information, problems with clinical intuition on the part of the psychotherapist). The technology creates new types of work—therapeutic, clinical, informational, organizational—performed both before and during the consultation, with sometimes unpredictable and urgent consequences. Faced with these difficulties, which can only be compensated for by the therapist’s own investment, some give up using the tool altogether.

However, the author also points out the “paradoxical virtues” (p. 231) of digital mediation for both patient and professional, such as facilitating verbal communication, enabling patients to speak freely, and social and interactional disinhibition. He thus proposes to go beyond questioning the “possibility” of distance therapy, opting instead for a reflection on the transposability of existing practices. In the end, his findings point to only partial transposability, achieved at the cost of technical, interactional, organizational and professional adjustments. The job is not hindered by such technology but is subject to constraints; it is made possible by adjusting the postures of attention adopted and the efforts of concentration made, and requires foregoing certain therapies (with families, couples or children), tools and methods (such as neuropsychological testing—which some practitioners believe can be partly delegated to the patient—or the use of the depression, anxiety, and stress scale (DASS)) or even the tool itself.

Technology and epistemology

It therefore seems appropriate to note that, due to the nature of his object of study—teleconsultation tools—and the approach he adopts, which combines these technologies with the activities of practitioners and the professional issues involved, the author addresses two epistemological problems central to sociology. First, he seeks to avoid the pitfalls of sociodeterminism and technodeterminism by basing his analysis on the combined study of the technical, legal and organizational structures that make up the “social worlds” (Strauss, 1992) under study. In this way, he invites us to take a cross-sectional look at the political, professional and practical aspects of work activities. This approach, in turn, requires overcoming a second methodological challenge: that of reconciling macro-, meso- and micro-sociological scales. (Para)medical practice is thus examined through the sociology of professional groups, which also strives for multiscalar reasoning, bringing together the concepts and objects of the sociologies of work and professions. In addition, the interactionist approach, associated with the work of Andrew Abbott and Anselm Strauss, offers a wealth of concepts relevant to the description of work and based on an interest in the processual dynamics that drive it, which is particularly well-suited to this analysis of unstabilized practices. Indeed, as the title of the book “Genèses des mondes de la télémédecine” (“Origins of the worlds of telemedicine”) reminds us, these work “tools” are not yet established as such, but are “in the process of being made” (Akrich, Callon, Latour, 2006). Finally, by positing the agency of technical devices, the sociology of translation enables the theoretical structuring of these questions and the organized presentation of results relating to heterogeneous objects, where the passage from one actor to another takes place via translation devices.
In conclusion, the analyses carried out show that teleconsultation is a new component of the practitioner’s environment and is resulting in a profound redefinition of their work, its organization and their professional practices. As this postulate is built on the linking of notions and mechanisms derived both from a sociotechnical approach and from the principles of the sociology of professional groups, it will appeal to a broad readership, whether their interest lies in work, professions, digital technology or public health. The potential of this research to reach a diverse audience is further strengthened by the “pervasive” nature (Boullier, 2016) of technology, i.e. its tendency to permeate all human activities, both individual and collective. Technology is both an object and a tool of public policy in a variety of fields, from citizen participation to access to rights. Thanks to its structuring role in various social worlds, a detailed presentation of the theoretical and practical issues involved in the study of digital technology is a rich source of information for contemporary sociology.