In an interview with CancerNetwork®, Eran Ben-Ayre, MD, spoke about guidelines for clinicians treating patients by way of telehealth during the pandemic, and how they can be adapted for future practices.
The COVID-19 pandemic changed the way clinicians delivered care to their patients. As many patients did not feel safe or comfortable traveling to treatment centers, adaptations were necessary and health care providers needed to determine new and innovative ways to treat them.
Eran Ben-Ayre, MD, co-founder and director of the Unit of Complimentary and Traditional Medicine in the Department of Family Medicine and director of Integrative Oncology Program at Haifa and Western Galilee Oncology Service, Lin Medical Center of Clalit Health Services in Israel, spoke with CancerNetwork® about the motivation behind creating standardized practice recommendations for online consultation and treatment during the COVID-19 pandemic.
Ben-Ayre and his team partnered with the Society of Integrative Oncology (SIO) and created an online task force to help mitigate barriers to integrative care during the pandemic. The task force then created a series of guidelines that were meant to help clinicians who offered consultation on treatments and quality of life.
“Patients, especially in the first wave, were not willing to or were afraid to come to the oncology center. We had to develop [a new technique] and we struggled [with] that and how to develop a way that we could communicate with patients. [This meant] not just talking to them, but treating them through the online media,” said Ben-Ayre, who is also lead investigator on the recommendations.
The methods for compiling the guidelines involved a 4-phase consensus process that led to 10 practice recommendations. While the guidance was launched specifically for adapting to pandemic protocol, Ben-Ayre discusses how it can be implemented beyond the present pandemic and into everyday strategies.
Ben-Ayre: The motivation came from the patients, mainly patients undergoing chemotherapy, active treatment, palliative treatment, and so on. We tailored treatment to these patients following an integrative physician consultation. The idea is to provide continuity of integrative care, [and that could mean] once a week, twice a week, or for a longer period of time like 6 weeks, 12 weeks, and up to a few years. When COVID-19 broke, it was a challenge for us to provide this continuity of care.
It was a great challenge [to learn] how to provide, for example, manual treatment like acupressure, or acupuncture, and that you can really do that through the different applications like WhatsApp, Zoom, Skype. We needed to develop a strategy and an online methodology to provide treatment rather than to talk about it. If we just consider herbal medicine consultation, it’s quite similar to oncology consultation or palliative care consultation, where you talk and you try to achieve a good [rapport]. But when you go to the realm of really treating patients with manual treatments—like mind-body treatments or movement treatments such as yoga or acupuncture—this is another world, and we needed to establish this methodology.
We published our experience and then noticed many groups all over the world were dealing with the same challenge, especially places where the core is not just research. What we are doing is subjective to research, programmatic research, but other places, [irrespective of] research, were really in need of providing treatments. We have established within SIO this online task force with a multidisciplinary team of physicians, nurses, social workers, and other researchers. We established the task force aiming to build up this this new methodology.
We gathered the experts from the SIO online task force and established the strategy to develop the different [solutions]. We started by reviewing the literature, which was not very [robust because] we’re the first people that [compiled something like this]. There were [processes] in other fields like psycho-oncology, but not in integrative medicine. It was more about how to talk with patients rather than how to treat patients directly or manually. We then composed a questionnaire and distributed it to leading centers that provide integrative care all over the world. We received a lot of responses so that we could understand more and assess the main narratives and suggestions. We were able to write down and define the 10 main aspects of these practice and recommendations.
The first aspect is about resistance to telemedicine or to online media. This resistance is not just patients or caregivers, but it also involves the care providers. The first recommendation, and each recommendation that follows with specific suggestions, is about how to overcome this resistance to telemedicine.
The second recommendation deals with ethical, medical, and legal issues, which are quite important here because you don’t see the patient in person, but you have to deal with these aspects.
The third recommendation involves technical barriers before and during the online session. It’s about assessment of available technological infrastructure, considering the alternative to online intervention, and how to assign staff members to address online related issues.
The fourth is how to prepare [the patient] that it would ensure a quiet setting like we have physically in our in our oncology centers. [It’s about creating] a setting which is more medical for the patient, a setting which will also suggests a more patient-centered focus.
[Recommendation 5 is a] specific recommendations on how to begin the online session, how to define expectations, [cover] the treatment goals with the patient, and facilitate patient’s attentiveness despite the remote setting.
Recommendation 6 is about ensuring effective communication during the session. We have all kinds of tips and suggestions about how to do that. Promoting specific treatment effects is a very important aspect of our seventh recommendation. Nonspecific effect is about the atmosphere, but specific is about how to provide effective treatment [such as] with an acupuncture point to induce a specific effect of anti-nausea. How to do that effectively is a very important aspect of this guideline.
Recommendation eight is about involving the caregiver who is becoming more important in the online setting. Recommendation [9 is] about how to conclude the session, how to plan the next session, and how to ensure continuity of care which is the last recommendation. The final recommendation is to enable a very fruitful connection and treatment for the next sessions.
It can help us in providing treatment to patients who are not able to come to the oncology center. We must acknowledge ethically that our commitment is not just for the people who live near [Memorial] Sloan Kettering or MD Anderson or near our center in Haifa, but that we have commitment for the whole periphery. People who are treated in the center would like to have more opportunities to receive continuity of care as if they live near [a leading medical center]. It’s about the suburbs, the villages, and the patients who are not able to come because of economic restrictions and caregiver difficulties. It’s not a substitute to encourage some treatment, but it can empower that.
There is a change in in the way that we think. We expect patients to come to our center, and [for us] to be the healers who provide treatment. We have become, through this online process, more like teachers who can educate our patients or instruct them how to self-treat through our guidance in the online media. We didn’t just say to patient ‘don’t come, do it yourself’; we are with them. We schedule a treatment at 9 o'clock in the morning and they see the practitioner who is still guiding them on how to do the procedure or the treatment accurately and effectively and safely. That’s a big change in the way we communicate with patients. The online treatment, the telemedicine in this sense, promoted this change of being more active in our role [for] the patient and the caregiver.
First, it’s about education and implementation. At SIO, we are emphasizing the need to explore and to publish clinical guidelines. We had these clinical guidelines about breast cancer, and now we are about to publish guidelines about care in the palliative setting and about cancer-related fatigue. There is another guideline committee [compiling information for recommendations on] emotional concerns. The task here is how to implement these recommendations to real-world practice, not just in the in the nice oncology centers that have been created in the [United States] and North America, but how to be able to do that through Europe, the Middle East, Asia, India, Africa, Australia, South America, and Central America.
The online route is a very important aspect of implementation. The implementation process, and what we understand today especially in the SIO global task force, is that we have a commitment to implement these guidelines. From step 1, when you create the committees who later recommend these guideline recommendations, you [ensure broad implemention that outside your nice and quality center in North America. [These recommendations already consider] implementation barriers and how to educate healthcare practitioners all over the globe. With these nice recommendations, how do you create a dialogue between these centers and the evidence-based center in North America?
The online adventure that we have experienced during the last 2 years is one of the examples of why implementation is so important [because it creates] a bi-directional dialogue between North America and [these centers]. It’s not only recommendations that come from US to all over the world, but also vice versa. The online issue is just one example of how to facilitate this dialogue. Indeed, the committee was an example of a very fruitful collaboration of health care practitioners that come from multiple backgrounds, and in countries and cultures.
I would like to encourage people to be involved more in the in SIO activities, to be involved in our committees and task force, and to contribute to this ongoing dialogue between professionals, cultures, and different clinical settings. On one side, there is the need for the commitment of evidence-based medicine, on the other side is our commitment for patient-centered care and patient tailored treatment.
Ben-Arye E, Paller CJ, Lopez AM, et al. The Society for Integrative Oncology practice recommendations for online consultation and treatment during the COVID-19 pandemic. Support Care Cancer. 2021;29(10):6155-6165. doi:10.1007/s00520-021-06205-w