Nobody told me there’d be days like these

The following is a guest post from Dr. Lonn Myronuk – the Clinical Documentation Physician Informatics Lead at Island Health. He is also a Consulting Psychiatrist at Nanaimo Regional General Hospital (since 1998), a Peer Mentor for the Practice Support Program since 2013 and a Clinical Instructor at the University of British Columbia Faculty of Medicine, Department of Family Practice since 2014.

Join Dr. Lonn Myronuk as he hosts the next #hcldr tweetchat on Tuesday May 17th at 8:30pm ET.

Enjoy his guest post.

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Telemedicine’s challenges and opportunities for patient–provider interaction in COVID and beyond

The office looks strange this week — the plexiglass barriers at reception, ubiquitous in public spaces through the last couple of years, have been taken down by the clinic manager. Combined with the recent lifting of mask requirements in many settings, it gives the impression that things might (finally!) be getting back to normal.

“Back to normal,” is an expression that packs a lot of complexity into a brief three-word phrase. Whole books have been written on the idea. We think about restorative health and recovery-oriented practices for the populations we serve, because experience teaches us that there is no “going back,” only going forward. Reflecting on this as I greet my new MOA, not separated from me by a plastic barrier today, I realize we have no “normal” from the before-times to reference. As a recent hire, we have never worked together in anything other than pandemic public health limited conditions. This makes me pause. That means that a significant proportion of my patients are in that same situation.

Lord, I’m so tired.
How long can this go on?

– Lee Dorsey, “Working in the Coal Mine” (1966)

There was no let-up for us during the COVID-19 pandemic. We did not decline or defer any consultations because of COVID; clinic hours had to be extended. More than ever, it seemed, patients were motivated to connect with us as the rate of no-shows and last-minute cancellations dropped. Knowing this, I feel an unease when I hear talk of things “picking back up again” with public health restrictions starting to lift, as if there may be segments of society who are restlessly anticipating an increase in everything that has been denied and restricted. Last week a patient bemoaned the fact that they had not been able to get an in-person visit with their primary care provider in over two years, and expressed fear that this posed a risk of worse outcome for their diabetes and cerebrovascular disease. For them, the telephone follow ups they have received feel inadequate. This is almost certainly related to the subjective experience of the therapeutic interaction rather than the objective quality of advice received regarding medication doses or target values for blood pressure and glucometer readings. We have been running flat-out through this, and the possibility that others may have an expectation that we have something more to offer as part of “getting back to normal” sends a sobering chill through me.

As I take my seat in my consulting room I remove my mask and open the scheduler in my EMR. Only two of the day’s appointments are booked to be in-person visits here in the office. The remainder are telemedicine visits, evenly split between video conference and telephone calls. Both of the in-clinic appointments are with patients who have been referred within the last five months, each of them with their own unique reasons for coming in rather than accepting the offer of virtual care at a distance. We have never seen each other’s faces, even though we have had several appointments together — my patients and I have of course worn our masks during direct care visits. There is an odd paradox in this: they have come to see me in my office, and to be seen, yet that hasn’t really happened, at least not in a complete sense.

See me, feel me,
Touch me, heal me.

– The Who, “See Me, Feel Me” (1969)

Perhaps it is because I am a psychiatrist that this is top of mind for me at the moment. Where other disciplines in medicine “lay on hands” and perform physical examinations of patients, we only observe the patient over the course of an interview and record findings as a “mental status examination.” Gauging emotions and interpreting non-verbal signs that are clues to the patient’s inner experience, these functions are heavily dependent on being able to see and hear the patient fully and clearly. It has been harder at times, but overall my sense is that these visits have worked. I have to caution myself that a subjective global impression like this is notoriously prone to bias. In the absence of data it has to remain an open question as to how the (literal and figurative) wearing of masks affects the therapeutic process. This, in the pandemic at least, has been the comparator against which the effectiveness of virtual care has to be evaluated. My recent paper on the effects of telemedicine via videoconference highlights how the experience of empathy in the therapeutic relationship can be influenced adversely, but the alternative of masked in-person visits is less well studied.

I read the news today, oh boy
– The Beatles, “A Day in the Life” (1967)

I was fortunate at the onset of the pandemic to have already been well established in the provision of telepsychiatry. I had been doing videoconference telehealth visits for some time as part of an innovative care delivery model implemented by WorkSafeBC, giving me experience on a few different technology platforms. While my colleagues paused to problem-solve around technology questions (including privacy and security) and then had learning curves with their new systems, we were able to switch to a predominantly virtual service model with minimal disruption. I had learned lessons from my early days of telemedicine — before broadband internet was common we made point-to-point connections over dedicated ISDN lines from my office to special telehealth clinic rooms in remote communities. Room acoustics, video framing, connection quality, and many other factors would affect the experience of patient-provider interaction, but are manageable if approached knowledgeably and intentionally.

These thoughts are all put aside for the moment as it comes time for the first patient of the day. We connect via videoconference, and the technology transports me into the patient’s home. They are in a bed that is set up on the main floor of their home. Severe back problems have forced them to leave the workforce in late middle age with devastating effects on their sense of self and future, and disruption of their daily rhythms of personal, social, and recreational activity. Behind them on a shelf I can see there are a number of familiar boardgames carefully stacked, and I ask about them. Over the next few minutes they share treasured memories of game night with their children, and smile with pride as they describe how strangely engaging the grandchildren now find these old games, contrasting with what they play on their electronic devices. There is some laughter, and they recite the first verse of the TV jingle for one of the classic games: “If you’ve got trouble, wait don’t run…” When I join in for the second verse the laughter briefly reaches that depth where a little bit of tightness is released, and tears of laughter get dabbed. The rest of the session is a rich, authentic exploration of what comes next. For them, there will be no “back to normal.” Literally their back is inoperable, and figuratively there can be no return to life as it formerly had been. “I know there is no going back to normal,” they reflect, “I guess what has been the hardest is not really knowing what the ‘new normal’ would look like for me.”

I’m trying to tell you something ‘bout my life,
Maybe give me insight between black and white.

– Indigo Girls, “Closer to Fine” (1989)

After a session like this, it is hard for me to accept any assertion that virtual care is inherently inferior to in-person visits, at least not for this kind of clinical work. I had an opportunity to come into the home of someone who would have had to endure great physical discomfort to come into the office. Likely, they would not have been able to access service at all.

The point cannot be overemphasized: Virtual care is not experienced as a virtual office visit, despite the metaphors of check-in and of virtual wait room. These visits feel like virtual house calls. I am coming to them, where they are, via technology. They are not coming to me.

Where the “virtual locus” of the telehealth session is felt to be, or whether there is one at all, is not just an academic point of curiosity. It is directly linked to psychological constructs of safety, vulnerability, and intimacy. While it is obvious how my post-MVA PTSD patient benefits from a virtual care appointment that spares them 25 minutes of freeway travel to and from my office, it wasn’t until we had had the opportunity to switch to predominantly virtual visits in the pandemic that I began to appreciate the impact the effort of attending office visits was having on some depressed, socially anxious, and avoidant patients. Seeing them in their homes virtually gives a window into how they are in “their world,” as opposed to mine. As a result, we share a sense that they and their situation are more fully appreciated, and understood. This is the essence of empathy.

Why not use this modality for everyone, then, if this is a more intimate-feeling interaction? The answer is because that isn’t always the case, and because intimacy without psychological safety risks being traumatic. Where the devices and apps needed for virtual visits are foreign to patients they can add a sense of strangeness and artificiality to the interaction that can range from distracting to totally disruptive of the therapeutic engagement. The roughly half of my telehealth patients who are opting for phone follow-up have found it more accessible and/or reliable given their access to technology (devices and network conductivity). Universally they are appreciative of having it as an alternative I will offer them, but I have to accept an uncomfortable recognition that what I can provide over the phone is a less complete service than what videoconference or in-person visits afford. This, I rationalize, is preferable to them being without service of any kind, yet I remain with a sense of not having done my best possible work, circumstances notwithstanding.

I went back to the doctor,
To get another shrink.
I sit and tell him ‘bout my weekend,
But he never betrays what he thinks.
Can you see the real me, doctor? Doctor?

–The Who, “The Real Me” (1973)

As I work my way through the day’s appointments, a recurring theme emerges. When we discuss plans for subsequent follow-up, in addition to the usual question of when we should schedule, we now have to address the modality of the visit. Will it be telehealth, or in-office? How should we decide this? The conversations mostly follow the thread of patient preference — some like the convenience of no travel time, some remain apprehensive about entering a healthcare venue when there are media reports of COVID-19 cases rising again. For one patient, I insist on an in-office follow-up with their spouse to accompany for collateral report. There is a question of cognitive dysfunction potentially affecting drivers licensing, and today’s telephone visit isn’t adequate for that kind of evaluation. Another patient accepts a videoconference follow-up, but I doubt will follow through — all three video conference appointments with them to date have failed to transpire for one reason or another, and have defaulted back to telephone contacts. The referral source identified the patient as having a hoarding problem, among other things. In this case, I suspect that the intimacy of bringing a stranger (me) into their home is simply too much to tolerate at this stage of the therapeutic relationship. By accepting what is (to me) a sub-optimal mode of engaging with the patient am I colluding to enable ongoing dysfunction, or am I “meeting them where they are” to foster a collaborative patient-centered approach?

At the end of the day, I look over the new referrals that have come in. Week by week the volume has risen. Only a minority are explicitly for telehealth assessments of remote or shut-in inpatients. I need to respond to each provider, indicating if the referral has been accepted or not, and what the anticipated wait time will be to be seen. A few of them are outside of my scope of practice, and can be excluded on that basis. Most are not. Turning to the scheduler once again I see how few slots there are in the calendar. This is when it hits me: with the new pervasiveness of telehealth has come the unanticipated challenge of how to incorporate into ongoing practice the care of those who would otherwise never have attended, or not have followed up. How will we balance the conflicting imperatives of non-abandonment of the aloof patient modestly engaged virtually, and provision of timely accessibility for those more motivated to embrace traditional in-clinic services?

As a practitioner this is easier to answer because our first duty is to our patients — those who we have established treatment relationships with — above those where no such relationship yet exists. For healthcare systems and their steward leaders it is not so simple, as there is a responsibility for the entire community served, including those requesting/awaiting service.

Telehealth is not a like-for-like substitute for in-person care models. There are things telemedicine visits can do which clinic appointments cannot, and conversely. In the pandemic-driven pivot to telemedicine, telephone and videoconference appointments were offered in lieu of clinic visits, and we have all (patients and providers) now gained lived experience of how these modalities compare and contrast. As we turn our sight forward to what the “new normal” will be for clinical practice, it is clear that it won’t be equivalent to having two exam rooms in an office — one actual and one virtual — where patient and provider are indifferent to whichever is used at a given visit. We are going to need to learn how and when to prefer one modality over the other, just as we do for other aspects of treatment, based on objective evidence. Well selected measures carefully collected on program quality and clinical outcomes are needed in our systems, and that knowledge must be shared in the literature so can it guide us all as we make our way forward together.

On Tuesday May 17 at 8:30pm ET (for local time click here) we will be discussing the following topics on #HCLDR:

  • T1 It can be argued that empathy is the foundation for all physician-patient relationships. Have the virtual care solutions that have emerged as a result of COVID-19 made empathic communication more or less difficult?
  • T2 What can physicians or patients do to make telehealth visits as personable and valuable as in-person visits? Is that even a good benchmark?
  • T3 How can governments, hospital leaders, and business leaders who are planning for the sustainable incorporation of virtual care, address the negative effects of this care modality?
  • T4 What guidelines should be in place that can help physicians (and patients) decide whether a telehealth or in-person visit makes more sense?

Image Credit

Photo by Tima Miroshnichenko: https://www.pexels.com/photo/a-woman-in-white-laboratory-gown-8376261/

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