By JEANNE PINDER and BEN GLICKMAN
As telehealth has become more common with the Covid-19 pandemic, both doctors and patients are learning that it has many advantages — and downsides.
While many simple conditions — a child’s rash, for example — might be fairly easy to diagnose and treat with telemedicine, other more complicated ailments cannot be done by remote control — say, an assessment of an orthopedic patient’s post-surgery progress, or a medical exam of a sick child. And with the boom in telemedicine, there have been many questions about how the visit is best done.
“The work now is understanding what can be delivered safely through a virtual platform and what requires a face-to-face encounter,” Dr. Mary I. O’Connor, professor or orthopedics and rehabilitation at Yale School of Medicine, said in a phone interview.
‘I find it tremendous’
“I like it a lot — I find it tremendous,” Dr. Danny Sands, assistant professor at Harvard Medical School and a faculty physician at Beth Israel Deaconess Medical Center in Boston, said in a video interview. “I can’t do everything that way, but I find the bulk of information that you get from a patient is from asking questions and watching them as they respond. There’s a little bit more that you get from the examination, a little bit more from testing, but you should have a pretty good idea of what’s going on with the patient if you do a careful history. Now we have this medium being imposed upon us that actually forces us to depend more on the history. That’s good.”
“I really like dropping in on my patients where they are,’ Sands said. “I’m dropping into their home — I see where they live. Sometimes their kids are in the background, or their spouse, or their dogs. It’s very humanizing.
Sands said that visits with patients are much more convenient for both parties. “The barriers to care are much, much lower,” he said. “From my perspective it’s much easier, too. I dread the commute to the hospital when I have to go in there.” Plus, Sands said, doctors are more focused on their patients because the physician can look at the video screen and the patient’s medical record simultaneously.
“Of course there are limitations,” he added. “I can’t lay hands on you. I can’t comfort you physically. Depending on the bandwidth of the technology, I may not be able to detect the subtle cues — I may not see a tear beading up in the corner of your eye because of the connection.” Sands said that the lack of a physical exam presents another barrier. Although there are workarounds, he said that “it’s not quite the same.”
Sands does not think that in-person visits will vanish completely. “I don’t think it’s a full substitute for actually establishing a relationship,” he said. “But because the barriers are so much lower, I think it’s a boon to the doctor-patient relationship. It’s just easier for us to get together, so let’s schedule a video visit. This needs to be driven by what the patient’s needs are.”
Better in some scenarios than others
Telemedicine is “often adequate, but seldom perfect,” Dr. Jesse Hackell, vice president and chief operating officer of Pomona Pediatrics in Pomona, N.Y., said in a video interview. “It’s a decent way to take care of some conditions. But I find it personally not very satisfying. I don’t see it as a major, long-term, huge part of practice, although I do see it as one of the tools that we’ll have in our toolbox.”
Hackell sees a few areas that are lacking in telehealth. To start, he can’t perform a physical examination, which he views as especially important when treating children. Plus, Hackell often finds that children have trouble remaining focused on the visit. When dealing with mental health issues, he said that children can more easily hide their symptoms over video calls.
The experience varies depending on the platform used, and there are many platforms. This survey found that 174 respondents used 43 different platforms, with Microsoft, Zoom and doxy.me being among the most common.
O’Connor said, “First, we need to recognize that there are some encounters, whether for a diagnostic or treatment decision purposes, that either require face-to-face visits for our best outcomes. Some musculoskeletal care requires a physical exam — the clinician laying hands on the patient to examine, for example, the stability of the knee ligaments, which cannot be done through a video link.
“Second, I think that conversations around important and challenging decisions right now should still be face to face. This is my bias: where I can really read the body language of the patient and their family member to better sense if I’m communicating and they’re understanding the risk versus the benefits. Some people may say that can happen just as well through a video link. I am not sure of that.”
Other examples, she said, include telerehabilitation. That helps patients get better faster at a lower cost, and “we have to bend the cost curve.”
O’Connor herself had a dermatologist appointment via telehealth that was quite successful. “I was pleased and surprised with how effective I thought it was,” she said. “But I already had a relationship with my dermatologist. I don’t know how I would have felt if it was a brand new relationship.”
“So it’s not for everything and everyone,” she said. “I can’t imagine my 89 year-old mother interacting with the system effectively with telemedicine. But for me it was fine.”
There are some other useful telemedicine applications, Hackell said — specialties that don’t quite require the same amount of in person physical examination. Specialties like endocrinology, he said, which is largely laboratory-work based, works better with telehealth. Hackell said that some neurology, behavioral health, and gastroenterology is well fitted to telehealth as well.
On the other hand, Hackell said that specialties that rely heavily on the physical examination — cardiology and pulmonology, for example — likely cannot be done with telemedicine. “There are some specialties where it may be a lot easier to do and be equally good — with the exception of the laying on of hands,” Hackell said. “The laying on of hands goes back to Hippocrates, and it is clearly a part of medical care.”
Hackell also sees telehealth as a useful tool in the future for remote consultations. In remote areas in the U.S., Hackell said, parents may have to travel four to six hours to see a specialist at a hospital. “[Telehealth] really extends the reach of a limited number of specialists to a much greater area,” he said.
For many doctors, telemedicine has long been a regular part of their practice. Dr. Ryan Neuhofel, who practices direct primary care medicine in Lawrence, Kan., is one of those people.
“I’ve been text messaging and emailing my patients for years,” he said In a video interview. “I just developed a certain comfort level. Of course I would like to get to know my patients in person first. But, then, you can call or text me when it is appropriate; often I can solve the problem quickly without an office visit.”
Before the pandemic, many of Neuhofel’s colleagues were not using remote care because they saw it as risky. Now, he said, they all use telemedicine. “Well, what changed? They didn’t all of a sudden develop a clinical comfort with diagnosing a rash by picture over a phone,” Neuhofel asked. “It was out of necessity.”