My patient’s journey to the clinic had taken nearly two hours—a subway, a bus, and enough traffic to raise her blood pressure by another 10 points. She was also missing a day’s work – and pay – as a cleaner. When I asked her if she would rather watch TV the next time we met, she nodded gratefully.
To put my prejudices on the table, I’ve always been a staunch advocate of old-fashioned direct medical care. In my career as a general practitioner, I have emphasized the irreplaceable value of the patient-clinician connection not only for the human component but also for documented medical benefit.
However, doctors and nurses would serve our patients poorly if we did not retain the ability to change. Years ago, when telemedicine first entered my consciousness, I dismissed it as a second-rate simulacrum, valuable perhaps for rural communities without access to specialists, but otherwise hardly worth the crumpled exam paper it replaced. Even as the pandemic swelled around us in the spring of 2020, as we called thousands of patients who were running out of insulin and losing access to chemotherapy, I still thought telemedicine was a stopgap solution.
But two years of video and phone visits have convinced me these are valid clinical options. Sometimes they are even more helpful than personal visits. My pre-pandemic self would blanch at those statements, but I’ve come to realize that connections come in many forms.
The most important element of connection is the ability to connect in the first place. Patients lead complicated lives; You may be juggling childcare and elder care with unpredictable work schedules and overwhelming transportation logistics. The competing carousel of daily demands leads to frequent cancellations. But most people find 10 minutes to get outside and talk by phone or video, and I find it easier to adjust my schedule to their hectic realities when a crowded waiting room doesn’t come my way. The no-show rate on days when I do telemedicine is close to zero.
Even when circumstances are not so dire, many patients tell me that they prefer the privacy and comfort of their own homes. An unexpected – and frankly counterintuitive – benefit is the improvement in eye contact. During personal visits, I am forced to shift my gaze from the patient to the computer. In the case of video visits, on the other hand, the patient and the computer are aligned in the same direction. We can look at each other even as we’re flipping through lab results and imaging studies. And with the pandemic still requiring masks to be worn in clinical settings, video visits give us a rare opportunity to look each other in the face.
Far from being a cold electronic colossus, video visits evoke the intimacy of a home visit. I meet children, pets, spouses and helpers. I get tours of houses and houseplants. I can see the practical challenges of adhering to therapy. But most importantly, I can provide medical care that might have been lost entirely if in-person visits were the only option.
Although telemedicine existed before the coronavirus pandemic, it wasn’t used much outside of communities with limited access to doctors. It only became standard practice out of necessity when in-person visits were discontinued in spring 2020. “We don’t have randomized controlled trials during the pandemic,” Ateev Mehrotra, a professor of health policy and medicine at Harvard Medical School, told me. The imperfect alternative is to compare healthcare facilities that use telemedicine extensively with those that use it less. “We don’t see a huge difference,” he said in terms of overall outcomes like medication intake, diabetes control, and hospital or emergency room admissions. In at least one study comparing two clinics — one with telemedicine, the other with in-person visits only — results for diabetes, hypertension, and kidney disease were comparable, and telemedicine patients reported being very satisfied with their treatment. Surveys of patients suggest that most are positive about telemedicine, putting convenience first (although they are also realistic about the limitations). A study of patients with diabetes found that telemedicine significantly improved glucose control in both black and white patients, although racial differences in outcomes persisted.
In my area of primary care, the pandemic has forced us to the uncomfortable, 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 respiratory distress) are too ceremonial . With chronic disease making up the lion’s share of healthcare today, most clinical care resides in the cognitive, conversational aspects of medicine—something that can be accomplished in many ways.
Philosophically – and practically – telemedicine allows medical professionals to meet patients where they are you are, and on their terms. If done right, it has the potential to shift some of the locus of control from the healthcare organization to the patient. It also offers some flexibility for overworked doctors who can perform telemedicine from home if they are grounded by a sick child or COVID quarantine.
In no way do I want to say goodbye to personal medicine: it remains the foundation of medical care. But telemedicine has emerged as much more than a stopgap — it’s a robust part of the modern clinical palette. Of course, telemedicine cannot replace visits that require specific physical exams or tests, and it can fall short when we need to discuss sensitive issues or break bad news. Technical hurdles are always present. Despite this, the general impression is that patients, while still wanting in-person visits, see telemedicine as a great option for some of their medical care.
Telemedicine is only a practical option because insurance regulations were abruptly relaxed during the pandemic, allowing for reimbursement at the same level as in-person visits. Whether and how this should be continued is now being debated in political circles. A frequently cited concern is that telemedicine simply adds additional costs to an already bloated system. Patients who wouldn’t trudge into the office for a little scratch or sneeze could jump on a telemedicine visit that really isn’t necessary. Unscrupulous companies could boost reimbursement by over-scheduling telemedicine follow-up appointments. Such visits would add cost to the system without improving health care outcomes. It’s an ongoing study topic, but in a recent review of physician appointments for more than 40 million Americans, telemedicine visits for chronic conditions were no different than in-person visits in terms of generating additional follow-up care (more appointments, ER visits, or hospital admissions). When it came down to it acute medical conditions, the study found a higher rate of required follow-up after telemedicine encounters – but this difference was mainly caused by acute respiratory conditions during the pandemic, which understandably required an in-person assessment. For other acute conditions, such as tonsillitis and pyelonephritis, there was no difference between telemedicine and in-person visits.
The ultimate dictate for the future of telemedicine will be reimbursement levels. Will Medicare and insurance companies see telemedicine as equal to in-person visits in terms of payment? I believe they should. The clinical work—prescribing drugs, educating about diseases—is the same whether my patients and I are communicating at the bedside, on a video screen, or over a phone line. This is not to say that there shouldn’t be rules to prevent abuse – perhaps rules 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 spectrum of telemedicine services – video visits, phone calls, email messages, remote blood pressure monitoring – is challenging because our system is fee-based. “Much of this problem would go away,” he said, “if we moved more aggressively to a pooled payment model.” Under this arrangement, a doctor or healthcare system would receive a monthly payment for each patient. The doctor and patient can then figure out which combination of the various options works best for that patient, without the administrative hassle of endless billing variations.
Overall, telemedicine has proven to be an excellent complement to healthcare. The kinks have yet to be worked out, but the benefits of improved access and avoiding missed treatments far outweigh the downsides. Researchers are still digging through the data to find out how these changes are affecting our healthcare system, broadly, but on a small scale in my exam room, I can tell you that caring for my patients has become a lot easier. Despite the health and economic challenges of the ongoing pandemic, my patients are having greater success in managing their complex chronic illnesses.
Telemedicine will not replace in-person care – and I would never want to – but it has become an indispensable complement to in-person care. I hope that policymakers and insurers will take note.
