Eran Ben-Ayre, MD, discusses the Integrative Oncology Society’s recommendations for telehealth consultation

The COVID-19 pandemic has changed the way clinicians provide care to their patients. As many patients did not feel safe or comfortable traveling to treatment centers, adaptations were needed and healthcare providers had to figure out new and innovative ways to treat them.

Eran Ben-Ayre, MD, co-founder and director of the Complementary and Traditional Medicine Unit of the Department of Family Medicine and director of the Integrative Oncology Program of the Haifa and Western Galilee Oncology Department, Lin des Medical Center Clalit Health Services in Israel, spoke about the motivation behind creating standardized practice guidelines for online consultation and treatment during the COVID-19 pandemic.

Ben-Ayre and his team have partnered with the Society of Integrative Oncology (SIO) and created an online task force to help ease barriers to integrative care during the pandemic. The task force then created a series of guidelines intended to help clinicians who provided consultations on treatments and quality of life.

“Patients, especially in the first wave, were unwilling or 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 to communicate with patients. [This meant] not just talk to them, but deal with them through online media,” said Ben-Ayre, who is also the lead investigator on the recommendations.

The methods for compiling the guidelines involved a 4-phase consensus process that led to 10 recommendations for practice. While the guidelines were launched specifically to accommodate pandemic protocol, Ben-Ayre explains how they can be implemented beyond the current pandemic and into day-to-day strategies.

Can you discuss the motivation for this research? Were you more inclined to conduct it because of the unprecedented pandemic and its induced effects on patients?

The motivation came from the patients, mainly patients on chemotherapy, active treatment, palliative treatment, etc. We have adapted the treatment to these patients after an integrative medical consultation. The idea is to ensure the continuity of integrative care, [and that could mean] once a week, twice a week or for a longer period like 6 weeks, 12 weeks and up to a few years. When COVID-19 broke out, it was a challenge for us to ensure this continuity of care.

It was a big challenge [to learn] how to provide, for example, a manual treatment like acupressure or acupuncture, and that you can really do it through the different applications like WhatsApp, Zoom, Skype. We needed to develop an online strategy and methodology to deliver treatment rather than talk about it. Just looking at the herbal medicine consultation, it’s quite similar to the oncology or palliative care consultation, where you talk and try to get a good [rapport]. But when you go into the realm of actually treating patients with manual treatments – like mind-body treatments or movement treatments like yoga or acupuncture – that’s another world, and we had to establish that methodology. .

We published our experience and then noticed that many groups around the world were facing the same challenge, especially in places where the heart is not just research. What we do is subjective to research, to programmatic research, but elsewhere, [irrespective of] research, really needed to provide treatment. We have established within SIO this online working group with a multidisciplinary team of doctors, nurses, social workers and other researchers. We created the working group to build this new methodology.

How was the 4-phase consensus process determined?

We brought together the experts of the SIO online working group and established the strategy to develop the various [solutions]. We started by reviewing the literature, which was not very [robust because] we are the first to [compiled something like this]. There was [processes] in other fields such as psycho-oncology, but not in integrative medicine. It was more about talking with patients than treating patients directly or manually. We then composed a questionnaire and distributed it to the main centers that provide integrative care all over the world. We received a lot of responses so that we can better understand and assess the main stories and suggestions. We were able to note and define the 10 main aspects of these practices and recommendations.

Could you briefly discuss the 10 practice recommendations described in the study?

The first aspect concerns resistance to telemedicine or online media. This resistance does not only concern patients or caregivers, but it also involves healthcare 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 the 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 those aspects.

The third recommendation concerns the technical barriers before and during the online session. This involves assessing the available technology infrastructure, considering the alternative to online response, and determining how to assign staff members to resolve Internet-related issues.

The fourth is how to prepare [the patient] that it would ensure a calm environment like the one we have physically in our oncology centres. [It’s about creating] a more medical setting for the patient, a setting that will also suggest a more patient-centered approach.

[Recommendation 5 is a] specific recommendations on how to start the online session, how to set expectations, [cover] treatment goals with the patient, and facilitate the patient’s attention despite the distance.

Recommendation 6 concerns ensuring effective communication during the session. We have all kinds of tips and suggestions on how to do this. The promotion of specific therapeutic effects is a very important aspect of our seventh recommendation. The non-specific effect is about the atmosphere, but the specific is about how to provide effective treatment [such as] with an acupuncture point to induce a specific anti-nausea effect. How to do it effectively is a very important aspect of this guideline.

The eighth recommendation concerns caregiver involvement, which is becoming increasingly important in the online context. Recommendation [9 is] 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 allow for a very successful connection and treatment for future sessions.

How do you think these recommendations will be useful in the future?

This can help us provide treatment for patients who cannot come to the oncology center. We must ethically recognize that our commitment is not just to people who live nearby [Memorial] Sloan Kettering or MD Anderson or near our center in Haifa, but that we have a commitment for the entire periphery. People who are treated at the center would like to have more opportunities to receive ongoing care as if they lived nearby [a leading medical center]. These are the suburbs, the villages and the patients who cannot come due to economic restrictions and the difficulties of caregivers. It is not a substitute for encouraging certain treatments, but it can reinforce it.

There is a change in our way of thinking. We expect patients to come to our center, and [for us] be the healers who provide the treatment. Through this online process, we have become more like teachers who can educate our patients or teach them to self-treat through our guidance in online media. We didn’t just tell the patient “don’t come, do it yourself”; we are with them. We schedule a treatment at 9 am and they see the practitioner who always guides them on how to do the procedure or treatment accurately, effectively and safely. It’s a big change in the way we communicate with patients. Online treatment, telemedicine in this sense, has fostered this change of being more active in our role [for] the patient and the caregiver.

In the future, are there plans to continue to adapt these recommendations as they apply to the real context?

First, it is about education and implementation. At SIO, we emphasize the need to explore and publish clinical guidelines. We had these clinical guidelines on breast cancer, and now we’re about to release guidelines on palliative care and on cancer-related fatigue. There is another steering committee [compiling information for recommendations on] emotional concerns. The task here is how to implement these recommendations in real-world practice, not just in the beautiful oncology centers that have been created in the [United States] and North America, but how to do this across Europe, the Middle East, Asia, India, Africa, Australia, South America and Central America.

The online route is a very important aspect of the implementation. The implementation process, and what we understand today, especially in the global SIO working group, is that we are committed to implementing these guidelines. From step 1, when you create the committees that will later recommend these guideline recommendations, you [ensure broad implemention that outside your nice and quality center in North America. [These recommendations already consider] barriers to implementation and how to educate healthcare professionals everywhere. With these great recommendations, how do you create a dialogue between these centers and the evidence center in North America?

The online adventure that we have lived in the last 2 years is one of the examples of the importance of the implementation [because it creates] a two-way dialogue between North America and [these centers]. These are not only recommendations that come from the United States to the whole world, but also vice versa. The online question is just one example of how to facilitate this dialogue. Indeed, the committee was an example of a very fruitful collaboration of health practitioners from multiple backgrounds, countries and cultures.

Is there anything else you would like to add?

I would like to encourage people to become more involved in SIO activities, to get involved in our committees and working groups, and to contribute to this ongoing dialogue between professionals, cultures and different clinical settings. On the one hand, there is the need for the commitment of evidence-based medicine, on the other, our commitment to patient-centred care and patient-adapted treatment.


Ben-Arye E, Paller CJ, Lopez AM, et al. Society for Integrative Oncology practice recommendations for online consultation and treatment during the COVID-19 pandemic. Cancer Supportive Care. 2021;29(10):6155-6165. doi:10.1007/s00520-021-06205-w

Comments are closed.