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“He sounded harsh,” my wife said after she hung up the phone with her physician.
In the office, she had found her physician compassionate and warm. But on the phone that day, she felt that the physician was distant and regimented. “Like a soldier,” she said. That rang true as the visit was efficient: prescriptions were renewed, symptoms assessed, and tests ordered. “Perhaps, you are just not used to talking to with your doctor on the phone?” I offered. She shrugged, not convinced. “It felt like a different visit,” she added.
As a palliative medicine physician practicing at a cancer center, I knew what she meant. When the COVID-19 pandemic began spreading across the globe, waiting rooms of medical offices emptied almost overnight, including our own. Many patients with cancer who were not receiving active treatment stayed home, uncertain about their future, often scared and worried. Telemedicine seemed like a perfect solution to stay in touch, offer ongoing care and counseling, and reach out. Health care systems recognized this, and in a blitzkrieg-like move, transitioned many of their nonurgent outpatient visits to virtual.
But neither the patients nor the clinicians were prepared for it.
“I have to ask you a question before we get started,” a long-time patient asked when I reached her via telephone at home: “Are you wearing your white coat?”
We both burst out laughing at the absurdity of the image: a physician sitting at his desk, talking to a patient who cannot see him, and yet still wearing a white coat. “No, I am not.” I replied, suddenly self-conscious and glad I had taken it off just minutes earlier. “But I can put it back on,” I offered. “No need,” she said. “But that’s how I imagine you to be.”
During more than 20 years of practicing medicine, I have worked on 2 different continents and in a variety of medical systems and settings. But one thing has always remained constant: the practice of medicine as an in-person endeavor.
The potential benefits of telemedicine are many and easy to appreciate during normal times; in the times of the pandemic they are priceless. Telemedicine allows for quick contact and maintains continuity of care, especially for patients who have an established relationship with the clinician or practice. This option can be particularly helpful for patients who live in remote areas or cannot easily travel, including frail older adults. Patients can be quickly assessed and supported without the risk of being exposed to the virus. The video encounters also offer a direct glimpse into the lives of patients, an updated version of the traditional home visit, when patients can be now seen in their home environment—their bedrooms, living rooms, and kitchens. Alone, with their pets, or surrounded by children, other family members, and caregivers. Sometimes, all of them at once.
But as our experience grew in the first weeks of the pandemic, it became clear that telemedicine is not for everyone.
“Even if I have to wrap myself in a garbage bag and talk to you through a glass window, I don’t care, I am coming in,” one patient said. “I hate the video visits,” he further announced in a gravelly voice. Another older gentleman whom I have known for years told me as we were planning the next visit: “Well, you know, I like my vitals to be taken.” He had never asked about his blood pressure, heart rate, or temperature before.
But I knew what he was talking about. I missed the ritual too. An imposed order commands the in-person visit, and it travels beyond the verbal: body language, rush of emotions, physical proximity, and touch. If it goes well, there can be a sense of peace for the patient that they are cared for, and satisfaction as meaning emerges for the clinician.1
Compared with the face-to-face interactions, the virtual interactions seem barren, devoid of the richness the personal contact brings. In a specialty like mine, where a lot depends on emotional connection with the patient and their caregivers, the virtual visits demanded more of me and yet felt a lot less fulfilling. And they all seemed to be plagued by annoying technical issues: a weak Wi-Fi signal, dropped connections, wrong phone numbers in the chart, malfunctioning headphones, or a broken phone camera. And what to do about the omnipresent background noise of a lawn mower? As I spent more time doing telemedicine visits, I noticed their cumulative effect wore on me.
Some of my colleagues felt frustrated too. Oncology visits are busy, information-rich encounters. A lot needs to be discussed, explained, comprehended, and planned, none of which is a straightforward task under the best of the circumstances. Accustomed to the sterile environment of a clinic room that offers few distractions, patients on video calls sometimes struggled with finding focus. “My patient was on his walk outside during the visit”—a colleague of mine complained. “I get it,” he added, “it’s spring and we are on lockdown, but we couldn’t get anything done.”
In the middle of the first week of doing telemedicine, I was in my office at the hospital and received a phone call from the clinic’s receptionist. “Mr M is here and ready to be seen,” she cheerfully announced. Mr M, as all new patients referred to our outpatient palliative care clinic, was scheduled to be seen in person. I felt excited, like a medical student who was promised his first actual patient to interview. I ran downstairs to see him.
Mr M, a 62-year-old man, looked youthful, thin, but energetic. He was recently diagnosed with an advanced lung cancer involving a substantial portion of the left lung and growing into the surrounding pleural space. I asked him how he was coping. He said he lived alone. His wife died a few years ago. “Two weeks after our son was killed,” he added. “She died of pneumonia,” he told me. “I guess she was exposed to many people at the funeral.”
I paused for a long moment, silent, needing time and space to process things, and to hold the enormity of what he said somewhere between us. After losing 2 dearest family members in the space of weeks, he was now facing life-threatening cancer amidst a pandemic. “Sometimes things get heavy,” he said, as if hearing my thoughts.
After I examined him, I sat down close to him. Both of us wearing face masks, our eyes met. I reviewed the plan and proposed that we see each other in 2 weeks, and he gladly agreed. I got up to leave, and in an old habit I extended my hand to shake his. He saw my mistake and bent his elbow, stretching it toward me. We bumped in an awkward angular move and laughed under our masks. On my way back to my office, I took the long way around the clinic building, climbing stairs in the usually empty part of our hospital.
Times are chaotic now. For all of us. Our health care systems struggle to provide the best care possible. Telemedicine has proven to be incredibly useful, and it is here to stay. Over time, supporting technology and systems will make virtual visits more efficient, better coordinated, and hopefully, more patient-friendly.
But there is no doubt that the virtual visit is a fundamental alteration to the patient-physician encounter. Recent weeks have brought a massive and hurried adaptation that risks changing the ancient and sacrosanct practice of medicine. And as news, discoveries, ideas, and policies spin around in a flurry, now more than ever we must anchor ourselves in and cherish the wisdom of personal interactions. The place where it all starts.
Corresponding Author: Marcin Chwistek, MD, Supportive Oncology and Palliative Care Program I, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111 (firstname.lastname@example.org).
Published Online: June 25, 2020. doi:10.1001/jama.2020.10619
Conflict of Interest Disclosures: Dr Chwistek reported receiving grants from the National Cancer Institute.
Additional Contributions: I thank my patients for letting me share their stories. I thank Molly Collins, MD, Dylan Sherry, MD, Kathleen Murphy, CRNP, and Michael Vitez, BA, for their editorial feedback. None were compensated for their contributions.
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Chwistek M. “Are You Wearing Your White Coat?”: Telemedicine in the Time of Pandemic. JAMA. Published online June 25, 2020. doi:10.1001/jama.2020.10619
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