It was the first day after the San Francisco Bay Area declared that residents shelter in place, and I was getting ready to see patients. I generally dress in a dry-cleaned shirt, slacks, and a tie. I’m a pediatrician and feel parents deserve to see a physician in professional attire for all the money they pay for healthcare. Shelter in place, however, meant dry cleaning services might be closed for a long while. So I opted instead for jeans and a sweater—easy to wash and dry at home. Inside my car, I felt uncertain. I was a team leader in my medical group’s response to the pandemic, but I wasn’t sure what awaited me.
I arrived at my medical center, a campus of buildings surrounded by wooded hills, in a suburb 45 minutes northeast of San Francisco. Normally the campus is bustling with patients and doctors. This morning only one building entryway was open. The others had been sealed off. A staff member wearing a surgeon’s mask stood outside the door. Her job was to screen patients and shuttle those with a cough or fever immediately to an isolation room. Stacked on a table beside her were green-paper wristbands, the same ones that concert bouncers affix to our wrists so we can buy beer at concerts. In this case the wristbands identified patients who had been screened and were free to move on to their doctor’s office, one of the imaging labs, or the pharmacy. I tried to shuffle past her but she stopped me. I no doubt looked like a patient. I told her I was a doctor, sifted through my backpack and pulled out my badge. Like a backstage VIP, I moved through the door and into the building.
“How can you possibly know if you don’t see her?”
My schedule was light, in alignment with public health guidelines calling for routine appointments and elective procedures to be canceled or rescheduled. Instead, I had only virtual (telephone or video) visits scheduled. I looked at my first patient on the schedule, a toddler with a three-day history of cough and fever. The problem seemed routine. But in the middle of the coronavirus pandemic, a three-day cough and fever is a red flag, even though data is emerging about the relative resistance to, and resilience from, infection in kids. I picked up my desk phone and connected to the patient’s mother. I muddled through the COVID-19 screening queries. Many were clumsy—Headache? Body aches? Chest pain?—given my pint-sized patient. The mother responded the child’s fever had persisted, and the child had a history of asthma and a prior instance of pneumonia.
My first thought was mother and toddler should come in for an exam. I would check the toddler’s temperature and pulse, lungs and ears. I would suggest imaging and prescribe antibiotics, if necessary. Then, just as quickly, I thought of the Hot Zone screener with her green wristbands. I thought of coming home that evening, infected, to my sequestered wife and two daughters. “Here are some options,” I told the mother. “Normally I would offer you an appointment to bring her to see me. But given the circumstances, I can assume she has either an ear infection or pneumonia, and prescribe antibiotics. Or I can order a chest X-ray; you can take her to radiology and then head directly home. I’ll call you with the results.”
Just as the words came out of my mouth, I felt ambivalent. I had given her diagnoses and treatment options without offering that she visit my office so I could examine her child. Still, I expected the child’s mother to take the easy way out—get the antibiotics. Many times, even with widespread knowledge of the need for careful prescription of these drugs, we find ourselves butting heads with parents who demand them for their children. At the very least I expected the mother to be content with continuing our virtual exam. She wasn’t. “What she really needs is for you to examine her! How can you possibly know if she has pneumonia or an ear infection if you don’t see her?”
I took a long, slow breath. She was right. “Thanks for letting me know,” I said. “I am happy to see her because it’s the only way we can be sure. I just want to make sure you know these are extraordinary circumstances and we want to protect you and us from any risk of COVID-19 transmission. Don’t bring anyone else except your child. And be aware that we have pretty strict screening in place.”
This is, of course, an extraordinary time, and telemedicine is having its moment. Doctors can use it to meet the public health challenge of social distancing. It reduces our need for masks, gloves, gowns, and other protective equipment already in short supply. Institutional barriers are falling: Insurers are beginning to pay for telehealth visits. Last week, insurers issued a rule that would allow for the use of less secure platforms, like Skype and FaceTime, for telemedicine visits. Healthcare thinkers and policymakers now expect a permanent role for telehealth when the pandemic abates.
In my healthcare system, telemedicine visits have been common for a decade. Even before then, I had been tinkering with video. I wondered why teenagers with acne had to be driven to the office, park, wait in line, and get vital signs just to see what I could see at a distance. So I bought a webcam from Best Buy and plugged it into my office computer. One thing led to another and soon I was working with a team of other doctors and engineers to design a video system that allowed patients to schedule and participate in visits online or over the phone, and even invite family members and other doctors for a conference.
Still, before the pandemic, telemedicine had been viewed by many in the medical community as a niche market. Advocates of telemedicine, particularly in Silicon Valley, pointed out its benefits to Millennials, whose consumerism has been shaped by the immediacy of Spotify, Netflix and Amazon. Millennials were pegged as wanting their healthcare in the same way: On demand, with the press of a button, and from their local coffee shop or tap room.
I muddled through the COVID-19 screening queries. Headache? Body aches? Chest pain?
Doctors, on the other hand, held genuine and healthy skepticism toward telemedicine. Patients, after all, come in all flavors. You can’t deliver a baby, administer chemotherapy, perform a heart bypass, or replace a hip at a distance. Some skeptics pointed to initial evidence that telemedicine was skewing the healthcare cost curve in the wrong direction. By lowering the bar to accessing a doctor, it was increasing unnecessary care and increasing costs.1 Institutional barriers arose. For many years, the private payers and federal and state governments wouldn’t pay much (or at all) for telemedicine, restricting its use.
At the same time, evidence arose to support telemedicine’s effectiveness. Psychiatry, where body language and facial expressions can add a lot to a doctor’s clinical assessment, has been noted as one bright spot. A colleague told me about his video visit with a woman hiking in the wilderness. She had developed a rash she worried might be Lyme disease. While still on the trail, she used her cell phone to stream an image of her affected arm. My colleague told her it was eczema that she could solve with over-the-counter cortisone cream. The patient was relieved. She stayed on the trail and continued her adventure.
A study of telemedicine in the New England Journal of Medicine, of which I’m a coauthor, confirms patients’ satisfaction with video visits.2 It’s not the gold standard of an office visit, but in a world where people are often crunched for time, I’ve seen it get the job done. One morning I had a telephone visit with a mother whose child had been vomiting. I thought the child should come in to see me and began to schedule an in-person visit because I was concerned he might be significantly dehydrated and need IV fluids. But the child’s mom had her own medical procedure scheduled that day and couldn’t make it. Her husband would have had to close his small business and lose income to bring in the child. So, on the fly, we did a video visit. I told the mother to immediately give her son juice. As she did, her son in her lap with his sippy cup, she kept saying to me, “This is amazing.”
As an advocate of telemedicine, I’m glad to see it being widely instituted during this crisis. It provides patients the opportunity and peace of mind to connect with their doctors without leaving their homes. Doctors who’ve been reluctant to embrace it may discover it allows them to do the same. But this time, in the face of my own uncertainty about the outbreak, my patient’s mother forced me to remind myself that telemedicine needs to be a choice made by patients (or parents) in consultation with their doctor.
Thirty minutes later, mother and toddler arrived in my office. The mother had been given a mask and latex gloves to wear. I had mine on, too. The child wore a Disney princess dress. I told her I was honored to have real-life royalty in my office. I ruled out any complications and sent mother and child home with instructions for the child to stay hydrated, take fever reducers, and for the mother to call me in a couple of days, or sooner if anything seemed to change for the worse. For a moment on this strange and uncertain day, we all felt better.
Rahul Parikh is a physician and writer in the San Francisco Bay Area.
1. Ashwood, J.S., Mehrotra, A., Cowling, D., & Uscher-Pines, L. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs 36 (2017). Retrieved from doi:10.1377/hlthaff.2016.1130
2. Reed, M.D., et al. Real-time patient-provider video telemedicine integrated with clinical care. New England Journal of Medicine 379, 1478-1479 (2018).
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