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A Piece of My Mind
June 25, 2020

“Are You Wearing Your White Coat?”: Telemedicine in the Time of Pandemic

Author Affiliations
  • 1Supportive Oncology and Palliative Care Program I, Fox Chase Cancer Center, Philadelphia, Pennsylvania
JAMA. 2020;324(2):149-150. doi:10.1001/jama.2020.10619

“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.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Marcin Chwistek, MD, Supportive Oncology and Palliative Care Program I, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111 (marcin.chwistek@fccc.edu).

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.

Costanzo  C, Verghese  A.  The physical examination as ritual: social sciences and embodiment in the context of the physical examination.   Med Clin North Am. 2018;102(3):425-431. doi:10.1016/j.mcna.2017.12.004PubMedGoogle ScholarCrossref
6 Comments for this article
Feeling It All
David Fessell, MD | University of Michigan
Thank you for this beautiful piece. I laughed ("Are your wearing your white coat?")...and my heart was touched. "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." Your eloquent words convey the "felt sense." Thank you for sharing, and gently opening us to connection with ourselves and others.
Maureen Swan, MHA | Consultant
Thank you for sharing your experience with tele-medicine. Beautiful essay.
Vijay Thakur, MBBS | Faculty: Counselling
Very few people can put across in words the situation and experiences as you have. I enjoyed reading it and plan to share it with my students
I Also Had To Laugh
Louise Andrew, MD JD | None
When I started doing telemedicine 5 years ago, it seemed quite superfluous to put on a white coat and sit in front of a diploma that announced my qualifications....in reverse! (DM degree?). I proposed to the company that they create some "foreground props" where you could stick your face through a hole of a figure who appeared to be wearing that semi-official badge of qualification.

I had actually opted out of wearing white coats when I opened a private practice after years of Emergency Medicine (often nights, and wearing scrubs). Private patients seemed happy to have
ditched that impediment to communication as an equal. Eventually, I drifted towards a company that concentrates on telephone consultations and rarely uses video.

I must say I also laughed and identified with the feeling of elation that Marcin evinced at the (now INFREQUENT) prospect of examining a live patient. Very like the transition from the anatomy lab to the first clinical rotation.

Never mind the absolute truth that Osler, Tumulty and others taught that most illness can be diagnosed if you simply let the patient speak long enough to tell you what is wrong. Touch is so integral to our profession's ability to help patients to heal themselves, and possibly also to our ability to feel effective as healers, that I suspect for almost all of us, it is sadly missed.

As Peabody said, "the secret of caring for the Patient, is in caring for the patient". And of course, you CAN do this verbally, but it is a skill few of us were taught.

Both as a patient and as a doctor, I will be happy when therapeutic touch, with its sense of normalcy, is ultimately restored to our world.
In person vs telemedicine
Phillip Shepard, MD | Retired Family Physician
I am retired and glad I don't have to deal with the fragmentation of medical care, EMRs, and the insurance company bean counters. When people ask me what specialty I was in I  always answer "Family Practice when it was unpopular". In 1968 there were only 21 FP residency programs on the US. I was among the first to take ABFP Board exams. I practiced very "hands on" medicine in rural areas of the US. The nearest specialists and CT scanners were 90 miles away. The last 15 years I was a volunteer instructor at a public hospital in Cambodia and also provided outpatient care for refugees for the UNHCR. From my point of view telemedicine may be OK as a temporary measure but there are many situations where direct contact is necessary. Not just for the physical exam but for observation of "body language" and other subtle findings, eg:
- The resting pulse of 100+ that was due to hyperthyroidism
- Amenorrhea due to prolactinoma
- Nausea and vomiting and the crossed extensor reflex of a brain tumor
- The unilateral puffy eyelid of hypothyroidism
- Male infertility due to hypopituitary hypogonadism
- Hypertension due to renal artery stenosis.
Patients are going to "urgent care" offices and getting 15 minute visits and often lab tests and imaging studies to "diagnose" or to CYA or increase clinic revenue or fill out an algorithm. Medical knowledge + clinical skill + intuition = efficient (heuristic) diagnosis. People need longitudinal care and "slow medicine" whch will yield a correct diagnosis 99%+ of the time.
I never had any biological offspring but friends and a former patients named four sons "Phillip".
Hybrid Care will be the Core of Future Doctor-Patient Relationships
Peter Yellowlees, MD, MBBS | Professor of Psychiatry, University of California Davis
I enjoyed the reaction of this obviously caring physician to using telemedicine with his patients, and his discovery that it has numerous advantages, especially with home visits, and that many patients actually prefer to talk to their doctors in this way. It is more egalitarian.

I have two questions. Firstly why did the author not use telemedicine with his patients before? It seems very strange that he did not as some patients would undoubtably have asked him to do this. Not everyone likes being treated the same way and as physicians we should offer choices to our patients,
as long as they make clinical sense. Secondly, given that he agrees telemedicine is here to stay, is he going to offer patients the option of receiving hybrid medical care, both in-person and online, depending on mutual choice and convenience. Surely this is the best of both worlds. I do hope we can not stop making the error that so many people, including this author, make, of thinking that we should be delivering care either online or in-person, when we can do both with the same patient over time. We need to start thinking of hybrid care, and talk to our patients about that. That is the doctor-patient relationship of the future
CONFLICT OF INTEREST: Co-Editor of "Telepsychiatry and Health Technologies ; A guide for mental health professionals." Hold several NIH grants to research telemedicine