Editorial

GREAT EXPECTATIONS

anna evans PhilliPs, mD, ms

Digital rectal exams cannot be performed via telemedicine. Nor can subtle palpation of a fluctuant or indurated wound site, or auscultation of the pitch of bowel sounds. Telemedicine is not the same as an in-person visit. I have had patients take telemedicine visits with me from their kitchen island, their living room, their back yard, their basement, their garage, and multiple individuals have done so from their car in the parking lot at their workplace. Patients have done their video visits while conference calls at work are held on mute, multi-tasking during their work-at-home days. They have taken telemedicine visits while grocery shopping, even while walking their dog. A diabetic patient of mine with bad vascular disease took his while chain-smoking cigarettes and drinking Mountain Dew.

The coronavirus pandemic has pushed physicians to their limits in recent months and sometimes beyond, creating a sea of need into which many doctors have waded, armed with optimism, altruism, and perseverance. The expectation that physicians can and will rise to any occasion to meet a challenge where their talents might be of use continues to exist. And yet neither the challenges nor the expectations have abated in the two-plus years we have faced the pandemic. The growth of telemedicine represents just one of the ways in which new demands are made of physicians, but our system has not yet caught up to acknowledging and accounting for what this means for clinical medicine moving forward.

In recent months, the coronavirus pandemic has touched all of us: rules for entering grocery stores, sending children to school, attending a concert, have all changed…then changed again. Our expectations of how we fly in airplanes, how we shop for groceries and clothing and household goods, and how we stay in touch with our family members have changed during this time. Our expectation for what it means to receive high-quality health care from a physician, however, has not. Healthcare workers – specifically physicians—have been tasked with continuing on during the pandemic. There is no coronavirus exception for the measurement of the number of cases I start on time – despite the fact that there is additional personal protective equipment to don and added complexity for every aspect of the morning routine from daycare drop off to entering the hospital. There is no coronavirus exception for the calculation of my adenoma detection rate that is performed to identify my skill as a colonoscopist, despite some patients delaying colonoscopy during the past two years to avoid healthcare environments. There is no forgiveness for the delay in a cancer diagnosis despite patients requesting telemedicine visits in place of in-person exams. There is nothing new with physicians stepping up when all else fails; but there’s been almost no time to reflect on how this duty and honor has been affected by the pandemic.

The rise of telemedicine has facilitated access to health care and specialist care in an unprecedented fashion that in some ways has been a huge gain for the system. For those physicians in specialties with high demand, this represents a new expectation of availability and flexibility that may not be deliverable at the rate or quality at which it is desired. For a person with an anal cancer, a wound infection, or a distended abdomen, who prefers to have a video chat instead of driving to the office, their reticence to present in-person often results in diagnostic uncertainty and additional delay. They are often unwilling or unable to adequately show the area of concern via video that could have been examined in the privacy of the

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From Page 7 office by the consulting physician. Patients and health care systems both are looking for shortcuts, but no good ones exist if high quality health care is the goal. In these situations, it requires a physician with a broad differential diagnosis, who can deftly navigate the logistics of video meetings (including patient instruction and guidance), or the complex scheduling systems necessary to perform high volumes of diagnostic testing that must be done in person to answer questions not solvable via video.

And yet, medicine remains a calling for many of us who have stayed in our positions throughout this time. Most physicians do not enter the profession expecting their job to be easy, their days to be predictable, or the demands from patients or employers to be easy to meet. The profession is one that demands constant and unrelenting compassion from individuals who must be ready to serve the needs of those who come to them. With whatever energies remain to each of us after this grueling time, we must remember to turn to our inner sense of creativity, ingenuity, inventiveness, and our reserves of kindness to focus on what matters most: the treatment of patients in our care.

During the pandemic, the health care problems I frequently diagnose and treat continued to happen despite the spread of coronavirus.

People continued to develop colon cancers, pancreas cancers, and devastating pancreatitis at rates similar to before the pandemic. There were several patients who braved the hospital to present in-person for our visits. These in-person visits provided some of the most profound connection I have ever felt with patients. Though the care may not have differed at all, from those individuals I saw in-person, I have received notes, messages, and in-person thanks for the care and work that was done on their behalf during that time. Even if clinical outcomes were the same, there was something lost for me with a video visit. As we grapple with how to make the pandemic a part of our lives and not a hold on them, I suspect these deeply human interactions will remain the foundation for meeting the great expectations we have for patientcentered health care.

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