“There’s a surplus of telehealth visits across the system,” my colleague mentions casually in the midst of a weekly staff meeting.
Really? I think. I guess that’s a good thing, I reason, lower utilization must correlate with fewer people in the community with COVID-19 symptoms ... but wait a minute, why is there a 92-year-old on my schedule?
“We offered them a telemedicine visit, but the family requested a face-to-face visit instead,” my medical assistant offers quickly, already knowing where this is heading.
We had been doing this for 11 months. I knew we hadn’t vaccinated this senior, we hadn’t even heard from him in over a year.
Why on earth does someone so high risk want to come in? I wondered.
Let me be clear and honest, right from the start: I think telehealth is the greatest thing that has happened to primary care since the Choosing Wisely guidelines. Telehealth helped keep me and my patients safe from unnecessary exposures to an incredibly contagious disease for months. A face shield and a reusable mask is, and was, no real defense in a small clinic without clinical-grade ventilation. Telehealth helped keep our practice afloat financially when the pandemic began and has continued to do so season after season.
I have always been incredibly motivated by the vision of the patient-centered home, of striving to put the desires and realities of my patients’ lives at the center of care coordination and disease management. But the pandemic prompted me to ask new questions: Can patient-centered care be prioritized over my own safety? Should it be? Telehealth is the stopgap measure that resolved questions like those for many of us in primary care in the early days of the pandemic.
The ethical question of patient versus personal safety in outpatient medical care, while worthy of its own dissertation, has begun to quiet now that most of the clinicians in my group are fully vaccinated. Many of my colleagues argue that now that their own risk is lower, we need to let patients make their own choices — and if they choose to come in, we need to move to allow for that access.
But if it wasn’t totally safe for patients before the rollout of vaccines, what makes it safe for our patients now? If I am not sure that I can keep them safe here in my office, or that the risk of exposure and complications of illness is even fractionally close to the benefit they would receive from seeing me in person … shouldn’t I tell them no?
I think most of my colleagues would agree that we would not prescribe a drug that we determined was unsafe for a patient based on their health and risk factors. On some level, this is paternalistic, but in light of the data, we call it patient safety. People keep telling me that in this case, the situation is different. How? The difference seems to hinge on who defines risk and who defines benefit.
First, there is the risk component. Based on local public health data of case volume and percent positivity, the risk of exposure to COVID-19 remains very high in my county. My county has decided to allow restaurants and bars to re-open in-person dining. Nonessential businesses are open for in-store shopping. My clinic continues to expand the number of face-to-face visits available each day. To me, it feels like the narrative has shifted from “do no harm” to “we have to learn to live with this” and “let people decide for themselves.” Every day, I see patients who abuse alcohol and drugs. I see patients who buy hundreds of dollars in supplements found on the internet; who take “leftover” antibiotics in their home; who rely on medications brought in from around the world in the luggage of friends and family. My patients often make choices that don’t align with my clinical training or understanding of health. But I don’t turn these patients away. Instead, I work hard to share my knowledge, listen to their concerns, and collaborate with them to reduce risk and improve health outcomes. We operate from a risk-reduction model, not a risk-intolerant one. To be clear though, I am not enabling these patients’ behaviors. If the bartender reserves the right to cut their patron off when they have hit the unquantifiable “know-it-when-you-see-it” threshold, shouldn’t I get that option, too? Is it paternalism or patient safety?
Then comes the benefits part. I hear my patients say, “I need to see you. You need to check me.” In my mind, seeing many of them on video feels like enough to maintain our relationship and keep them healthy. In their mind, it does not. In my mind, having them come in for asynchronous care, for things like a weight check, vaccine administration, or follow-up labs, feels like the risk reduction I crave, and, in my mind, provides the same quality of care. In their minds, it is not enough.
Where is the disconnect between the confidence I feel in providing care for most of my patients, most of the time, remotely — and the belief of most of my patients that most of the time remote care is inadequate care?
I love telemedicine because I can see my patients in their homes, their cars, the break rooms of their jobs. I love telemedicine because they don’t have to get on a bus, take a day off from work, or figure out childcare to do the work of titrating insulin or antidepressants, to treat a rash, or request a referral. Global pandemic or not, primary care is about the long haul, and the reason so many folks lose care or never establish it in the first place is because we have historically made it too hard to access. Now, telemedicine is here! It’s reimbursable! And yet, so many patients and providers are saying “no thanks.” I’m flummoxed and I’m frustrated.
The risk of exposure to COVID-19 has not, for many patients in most facilities, changed. So we need to keep trying to sell this model. We need to research and understand what makes telehealth more or less successful. Are beliefs about health modifiable? Is the problem access to technology? Something else? We need to continue to ask these questions to make the telehealth model a viable long-term reality, rather than throw it away as a momentary stopgap.
Has the increasing emphasis on remote care been well-received by your patients? Do you think telehealth is more godsend or more scourge? Share your thoughts in the comments section.
Dana Kroop is a family NP based in Chicago, Illinois. Originally trained in the history and philosophy of science at University of Chicago and Cambridge University, she spent her first professional years working in education at The Field Museum of Natural History. Driven to use science communication to best empower individuals, she then decided to become a family NP, training at the University of Illinois under a HRSA funded ANEE Traineeship, and then completing her post-graduate residency at Community Health Center, Inc. Dana is a bilingual Spanish speaker and currently works at a Federally Qualified Health Center on Chicago's West Side. She is a 2020–2021 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz