Customize your JAMA Network experience by selecting one or more topics from the list below.
In the last few weeks as life has upended across the globe and new normals have begun to shape our days, one of my realities has been telemedicine in a public health system. I work at Cook County Hospital in Chicago, Illinois, and the mission of this hospital has defined who I am as a physician. During my training and early career, it has allowed me to grow while letting my roots remain planted in the soil of public service.
March 2020 passed by in a haze of protocols, inpatient service, masks, gowns, and some transitions, but I still had use of my stethoscope, my eyes, and the comfort I can bring to patients as a physician. April brought an abrupt and near total transition to telemedicine. I am an interventional cardiologist and before this pandemic, telephone calls were a way to check on patients, to talk to concerned caregivers, and to surprise beloved patients on their birthdays. I did not know what to expect from this new reality and approached it with an open mind. There were the initial hiccups of technology accompanied by the realization that patients did not have ready access to tools and technology to enable video visits.
I joked with family and friends about the experience. I savored the cup of coffee I could now sip during visits and grew used to the comfortable attire I could don now that my office visits were conducted virtually. I also shared that I had scratched telemedicine off my list as a future option for when I want to slow down. I felt disconnected from my patients. I felt less like a physician and more like a telemarketer as I started with permissions and scripts with patients I could not see. I sensed their yearning for the reassurance we bring to their lives, especially in times like this. I assuaged the fears of my patients in high-risk groups, which is nearly all of them. I tried my hardest to bring the physician to their home in that telephone call. Yet, as they sent their blessings to us, told me they were praying for all of us, and threatened me (lovingly) with dire consequences if I became infected with coronavirus disease 2019 and left my patients, I could not bring myself to believe that I was practicing medicine and answering my calling. There was a lingering heaviness and guilt where there used to be light and satisfaction in the aftermath of patient care.
There were many joys. For example, the caregiver who could never come to a clinic appointment because they worked 3 jobs could now tune in if they wanted to. On the rare video visit, I would sometimes find cardiology was forgotten as I was joyously introduced to grandchildren before laughingly redirecting my patients to medication reconciliation. This latter task took on a whole new comical aspect as patients hunted for glasses and tried to read labels and check refill prescriptions. None of this telemedicine theater could make up for what my patients brought to my life as a physician.
Two weeks ago, I dialed the number to a new patient. He had been offered an in-person visit and declined owing to legitimate fears. As this patient shared his story in heavily accented English, it was easy to bond but hard to piece together the cardiac history. This is not uncommon for any of us and after trying our best, we both decided that some clarifications would just have to wait until he felt comfortable coming to the office. All I could gather after a lengthy discussion was that he had an illness a year ago in a different state that was cardiac in nature. He had spent a week in the hospital, understood very little but continued to take the prescribed pills diligently, and was doing great. The pills were a β-blocker and an angiotensin-converting enzyme inhibitor that are so ubiquitous in my world that it did not help me reach any conclusion. In fact, to this day my problem list on that visit note states “unknown cardiac condition.” As I prepared to hang up, he asked what could be done about his machine. I paused and asked him to clarify, and he grew frustrated. The machine, he clarified, was the only reason he had waited 3 months for this appointment, which was now reduced to a telephone call. After some hectic back and forth, I gathered that he had a pacemaker or a defibrillator in situ. I added a query in my assessment regarding conduction system disease vs heart failure with reduced ejection fraction and promised him that I would obtain records.
I tried to hang up again as I was running behind for my next telehealth visit. As I assured him he would hear back from my office about an in-person appointment, he sounded forlorn and doubtful and requested my telephone and pager numbers. I supplied both with the gentle instruction to be mindful when using my beeper as it stays on constantly. I requested that he use it judiciously and could reach me on my office number or voicemail for most concerns or queries.
The next morning after a lengthy video meeting (another new normal) I checked my voicemail to find 3 successive messages from the patient. They all sincerely informed me that he was choking and did not know what to do but was at home waiting my instructions. I called him back, mystified why he would be leaving me messages about this until he spelt out his choking as s-h-o-c-k-ing. Now, it made complete sense. I sprung into action and asked him to hang up and call 911. He refused. A little stunned, I explained what was happening to him and now pleaded with him to call emergency medical services. He patiently refused again; dialing 911 was scary to him, as he had never done that in his life. However, he was certain that despite the pandemic, his neighbor would walk with him to the nearby emergency department, a community hospital affiliated with Cook County Health. This is all he would agree to and despairing for his safety, I tried to talk him into at least getting someone to drive him. He made it to our emergency department shortly after that and got the help he needed. The unknown diagnosis was obvious after some routine studies and device interrogation.
As I checked in on him via telephone that evening, I apologized because I had still not met him. I described how we were minimizing contact and my colleagues were keeping me updated. He cut me short with, “I know how you look.” I asked if he had looked me up on his telephone. He laughed and said, “no, I did not need to. I know you look like a guardian angel.”
Just like that, with that quiet exchange, this patient gave me back what the month had seemed to rob me of daily. This is not a story of heroism or drama but of the quiet good we do as physicians every day without even knowing it. It turns out the only right thing I did in that telehealth visit was to shout out my telephone numbers for him and have him repeat them back to me. It reminded me that we are helplines and support systems and, occasionally, all patients trust in this world. While telemedicine may never be the medicine that I love and miss, it serves its purpose and I have committed myself to it with renewed vigor. I hope you all find your doctoring in the months that lie ahead as I can assure you it is alive and well.
Corresponding Author: Neha Yadav, MBBS, John H. Stroger Jr Hospital of Cook County, 1901 W Harrison St, Chicago, IL 60612 (firstname.lastname@example.org).
Published Online: August 26, 2020. doi:10.1001/jamacardio.2020.3535
Conflict of Interest Disclosures: None reported.
Additional Contributions: I thank the patient for granting permission to publish this information.
Yadav N. Hello? This Is Your Cardiologist. JAMA Cardiol. 2020;5(11):1214–1215. doi:10.1001/jamacardio.2020.3535
Monkeypox Resource Center