Serving Patients Through a Screen
by Danielle Ofri
The Atlantic
My patient’s trip to the clinic had taken her nearly two hours—a subway, a bus, and enough traffic to jack up her blood pressure by an additional 10 points. Plus, she was missing a day of work—and pay—as a contract cleaner. When I asked her if she would prefer a televisit for our next meeting, she nodded gratefully.
To put my biases on the table, I’ve always been a staunch defender of old-fashioned, one-on-one, direct medical care. In my career as a primary-care doctor, I’ve stressed the irreplaceable value of the connection between patient and clinician not just for the human element, but for the documented medical benefits.
However, doctors and nurses would ill serve our patients if we didn’t retain the capacity to change. Years ago, when telemedicine first edged into my consciousness, I pooh-poohed it as a second-rate simulacrum, valuable perhaps for rural communities lacking access to specialists, but otherwise hardly worth the crinkly exam paper it was replacing. Even as the pandemic swelled around us in the spring of 2020, as we panic-dialed our thousands of patients who were running out of insulin and losing access to chemotherapy, I still thought of telemedicine as a stopgap measure.
But two years of video and telephone visits have convinced me that these are valid clinical options. At times, they’re even more helpful than in-person visits. My pre-pandemic self would blanch at these statements, but I’ve come to recognize that connection comes in many forms.
The most important element of connection is the ability to connect at all. Patients lead complicated lives; they may be juggling child care and elder care with unpredictable job schedules and crushing transportation logistics. The competing carousel of daily exigencies leads to frequent cancellations. But most people can find 10 minutes to step outside and talk by phone or video, and I can more easily rejigger my schedule to accommodate their hectic realities when a packed waiting room isn’t bearing down on me. The no-show rate on days when I do telemedicine is nearly zero.
Even when circumstances are not dire, many patients tell me that they prefer the privacy and comfort of their own home. One unexpected—and, frankly, counterintuitive—benefit is the improvement in eye contact. During in-person visits, I’m forced to yank my gaze back and forth between the patient and the computer. In video visits, however, the patient and the computer are aligned in the same direction. We can look at each other even as we flip through lab results and imaging studies. And given that the pandemic still necessitates masking in clinical settings, video visits offer us the rare opportunity to see each other’s faces.
Far from being a cold electronic colossus, video visits evoke the intimacy of a house call. I meet children, pets, spouses, and aides. I get tours of homes and houseplants. I can view the practical challenges of adherence to medical treatment. But most important, I can provide medical care that might have been lost completely had in-person visits been the only option.
Although telemedicine existed before the coronavirus pandemic, it wasn’t used much beyond communities with limited access to doctors. It became standard practice only out of necessity, when in-person visits shut down in the spring of 2020. “We don’t have randomized controlled trials during the pandemic,” Ateev Mehrotra, a professor of health-care policy and medicine at Harvard Medical School, told me. The imperfect alternative is to compare health settings that use telemedicine extensively with those that use it less. “We don’t see much difference,” he said, in terms of general outcomes such as medication adherence, diabetes control, and admissions to hospitals or emergency rooms. In at least one study comparing two clinics—one with telemedicine, the other with only in-person visits—outcomes for diabetes, hypertension, and kidney disease were comparable, and telemedicine patients reported being very satisfied with their care. Surveys of patients suggest that most view telemedicine positively, with convenience being a top factor (though they also have a realistic view of the limitations). One study of patients with diabetes found that telemedicine was able to significantly improve glucose control for both Black and white patients, though racial disparities in outcomes persisted.
In my field of outpatient primary care, the pandemic has forced us to the awkward and perhaps belated realization that many of our routine physical exams (as opposed to targeted exams, such as listening to the lungs of a patient with shortness of breath) are largely ceremonial. With chronic illness making up the lion’s share of health care today, most clinical care lies within the cognitive, conversational aspects of medicine—something that can be achieved in any number of ways.
Philosophically—and practically—telemedicine allows medical professionals to meet patients where they are, and on their terms. When done right, it has the potential to shift some of the locus of control from the health-care organization to the patient. It also offers some flexibility to overburdened clinicians, who can do telemedicine from home if they happen to get grounded by a sick child or a COVID quarantine.
By no means do I want to say farewell to in-person medicine: It remains the bedrock of medical care. But telemedicine has turned out to be much more than a stopgap measure—it’s a robust component of the modern clinical palette. Of course, telemedicine can’t replace visits that require specific physical exams or testing, and it can fall short when we need to discuss sensitive topics or break bad news. Technical hurdles are ever present. Even so, the general sense is that although patients still want in-person visits, they consider telemedicine a great option for some part of their medical care.
Telemedicine is a practical possibility only because insurance regulations were abruptly loosened during the pandemic, allowing reimbursement at the same level as in-person visits. The debate in policy circles now is whether and how to continue this. One frequently cited concern is that telemedicine will simply add more costs to an already bloated system. Patients who wouldn’t drag themselves to the office for a small scrape or sneeze might hop onto a telemedicine visit that really isn’t necessary. Unscrupulous organizations might pad reimbursement by scheduling excessive telemedicine follow-up appointments. Such visits would add costs to the system without improving health-care outcomes. It’s an ongoing topic of study, but in a recent review of more than 40 million Americans’ medical appointments, telemedicine visits for chronic medical conditions did not differ from in-person visits in terms of generating additional follow-up care (more appointments, ER visits, or hospital admissions). When it came to acute medical conditions, the study did find a higher rate of needed follow-up after telemedicine encounters—but this difference was driven largely by acute respiratory complaints during the pandemic that understandably required in-person evaluation. For other acute conditions such as tonsillitis and pyelonephritis, there was no difference between telemedicine and in-person visits.
The final dictate of telemedicine’s future will be reimbursement levels. Will Medicare and insurance companies deem telemedicine equivalent to in-person visits in terms of payment? I believe that they should. The clinical work—prescribing medications, educating about illness—is the same, regardless of whether my patients and I communicate at the bedside, on a video screen, or via a phone line. This is not to say that there shouldn’t be regulations to avoid abuse—perhaps regulations tying telemedicine visits to in-person visits within a calendar year or specifying when telemedicine would not be appropriate.
Mehrotra pointed out that reimbursement for the range of telemedicine services—video visits, phone calls, email messages, remote blood-pressure monitoring—is challenging, because our system is built on the fee-for-service model. “A lot of this problem would go away,” he said, “if we more aggressively went to a bundled-payment model.” In this arrangement, a doctor or a health-care system would receive a monthly payment for each patient. The doctor and patient could then figure out which combination of the various options would work best for that patient, without the administrative headache of endless billing variations.
In aggregate, telemedicine has turned out to be an excellent addition to health care. The kinks still need to be worked out, but the benefits of increased access and avoidance of missed care far outweigh the negatives. Researchers will still dig through the data to figure out how these changes affect our health-care system writ large, but writ small in the confines of my exam room I can tell you that taking care of my patients has become far easier. Despite the public-health and economic challenges of the ongoing pandemic, my patients are having more success managing their complex chronic illnesses.
Telemedicine won’t replace in-person care—and I’d never want it to—but it has become an indispensable complement to in-person care. I hope that policy makers and insurers take note.