Health: The limits of telehealth.
Telehealth has been a crucial part of medicine during the pandemic – although it has also been a limiting one.
Last week, in the middle of a coronavirus outbreak in Melbourne, a patient asked me for a hug. Somewhat reluctantly, I said no.
I’ve hugged patients before – after delivering a diagnosis of cancer, when I was leaving a practice, and yes, even at their request – but I haven’t hugged a patient in the 18 months since the pandemic began. To be fair, I haven’t hugged some members of my own family in more than a year.
While I know my behaviour can be justified quite easily, in that moment last week such rationalisations provided little comfort to me or the patient. Indeed, the act of watching a woman dissolve with sorrow while I remained detached, on my swivel chair, felt not only unnatural but cold, even callous.
So much of our behaviour during the pandemic has been awkward and selfconscious. A simple trip to a cafe involves masking, checking-in, sanitising. We accept this in the interest of public health and safety, and because having a coffee with a friend is still preferable to staying at home alone. I would argue that telehealth offers a similar, imperfect compromise. It, too, is clunky and graceless. It, too, is necessary – perhaps even lifesaving. It’s certainly preferable to the alternative, which in some circumstances is no consultation at all.
Australian doctors have been conducting telehealth for decades – discussing results, addressing last-minute concerns, providing urgent scripts and referrals. Until now, though, such work has remained largely unrecognised. Similarly, for a long time patients with disabilities and those from rural and remote areas have been pleading for better access to doctors, including through the use of online technology. Before 2020, however, these requests had fallen on deaf ears. Like working from home, it took the catalyst of the Covid-19 pandemic to make telehealth a reality.
And yet I can’t help but feel ambivalent about the format itself. In the midst of Victoria’s second wave, when Covid-19 case numbers were in the hundreds and an effective vaccine was still a dream, telehealth provided a means of staying connected with patients in a safe, contactless way. It was an enormous relief.
But for me that relief quickly morphed into frustration. The technology was slow, patchy, unreliable. It was 2020 – I thought we’d be better at this by now.
Inevitably, there were moments of absurdity. I distinctly remember how, in the middle of performing a cranial nerve examination, my patient’s internet connection failed. I had just instructed her to show me her teeth, so I could assess the function of her facial nerve. Then she dropped out, leaving a pixelated grimace on my screen. Another time I found myself gesticulating wildly to get a patient’s attention, only to realise he had minimised the screen I was in. While I could see his face in perfect digital clarity, I was invisible – unheard and unseen.
Years ago, when I was learning to scuba dive, my instructor told me that if snorkelling was like watching TV, then scuba diving was like being on the TV. When I was conducting telehealth consultations, this long forgotten analogy came to mind. Like snorkelling, telehealth is a less immersive version of the real thing. It constrains us to the surface while the murky, mysterious depths remain out of reach. It can also feel incomplete. Instead of a whole person, I have to make do with just a face. Sometimes I don’t even get that – settling for a pair of eyes and a magnified forehead.
But telehealth offers other things.
New things. Different things. Things like bookshelves and pets and house plants and works of art. It gives me a window – albeit a small and sometimes blurry one – into the hidden, domestic lives of my patients. And the window is two-way. Like most parents working from home during the Covid-19 pandemic, I have had my share of “BBC Dad” moments – lost and curious children popping up, unwanted, behind my head. The laptop is no longer just a machine but a portal, a direct and scarily immediate connection between work and home.
It’s not always computers, of course. Sometimes it’s just a phone. The sound quality through my ear buds is much better than through the computer speakers and as a result, during audio calls, patients feel unusually close. Limited to only one sense, I have to focus more – on the sighs and the silences and what they all signify. I’ll admit it’s disconcerting at times, pacing the floors of my house with a patient’s voice inside my head.
A few months into the pandemic, I received an email from my medical indemnity provider, warning me and other members about the limitations of telehealth, in particular the inability to perform physical examinations on patients. There was, they advised, a very serious potential for lifethreatening diagnoses to be delayed or even missed. They went on to stress the importance of doctors providing opportunities for face-toface consultations where necessary. As I read the email, I was reminded of an old adage from medical school: More things are missed by not looking than by not knowing.
Telehealth goes against most of the principles I was taught during my medical training. I was often told, for instance, that the consultation begins in the waiting room. Is the patient wearing bold colours or various shades of grey? Is the patient nervously jiggling their knee or snoozing in their seat? Does the patient bound towards the consulting room, or are they breathless after the short walk to the door? Such details were hailed as important clues to a patient’s diagnosis, long before they had even opened their mouth to speak. Similarly, during the brief time I tutored medical students, I coached them to recognise non-verbal cues during consultations. The wringing of hands. The folding of arms. The sudden loss of eye contact.
It is the absence of these cues that makes me nervous about telemedicine. Shortcuts abound. I prescribe antibiotics for urinary tract infections without checking the patient’s urine. I renew scripts for antihypertensives and the oral contraceptive pill without measuring the patient’s blood pressure. Fortunately, by the time the pandemic hit, I had already been working as a GP for more than a decade. I had some experience to fall back on, at least. But I feared for the recently qualified doctors, the ones who needed as much information as they could possibly gather from their patients, the ones who should avoid developing bad habits so early in their careers.
Like many of the behavioural changes prompted by the Covid-19 pandemic, telehealth has proved a necessary but imperfect solution. As grateful as I am for how it has kept me and my patients safe,
I still look forward to the day when I can reserve telehealth for appropriate situations – for patients and doctors who, for whatever reason, have difficulty arranging face-toface visits, and for those consultations that lend themselves to the format, such as the discussion of test results or routine scripts and referrals.
I also look forward to a time when waiting rooms are loud and bustling places again – the scene of accidental reunions between old friends and colleagues, a space where newly vaccinated babies can make bored nonnas giggle. Most of all, I look forward to a day when, if a lonely and distressed patient asks for a hug, I can give her one – safely and freely and without needing to think twice.