I felt like an anthropologist the first few times I tried telemedicine.
Instead of seeing patients in the office, my home territory, I peered into their lives for a little while. There could be a dog wagging in the background, the living room comfortably occupied and vivacious, or it could be in a room perfectly coiffed, sun and sky in a picture window, the kitchen distant in the background.
It was an odd sensation, as if I were an unwelcomed guest hiding in the bushes, but they’d invited me in. It was my own anxiety, my own boundaries being challenged, I guess. At first I thought of my visit as a modern house call, a plumber walking into the master bath to fix a shower, only with the client revealing deeply shielded debilities and anxieties.
The home context is helpful. I could see a patient struggle to haul herself to standing from a favorite chair or clomp haltingly to the next room with a walker, nearly tripping over thick carpet. I can test walking and observe patients in my office, but patients don’t live in exam room 38. Sometimes, patients mask how impaired they are there. That artifice vanishes at home.
At first, I had to engage with the camera and the patient both. We were flat to the other, an image. But as I became accustomed to it, the medium became a little warmer and I became a participant. They were asking me to help them and I would try, just as in a live visit.
I tried to think of what a house call might have been like 100 years ago. The doctor would show up in a cloak with a bag of rudimentary tools and the family would shepherd him (nearly always him) to the room of the ill.
There was so little he would have been able to do. Alexander Fleming discovered penicillin in 1928. It would have been an aspirin and a hot water bottle or maybe he would refer the patient to the hospital for appendicitis and a 15% chance of mortality, 20 times higher than for a modern appendectomy. The laying on of hands was an essential part of a house call, though. The doctor was making observations, yes, but touch was suffused with meaning for the patient too, like a priest administering sacramental oil or water.
In spirit or in flesh, the main tonic a doctor prescribed in 1920 was a human comfort to the afflicted. The new house call is something altogether different and more.
There are certain things that I cannot do on a virtual house call. Anything that requires touch requires a live visit. I can inspect a wound, but I can’t probe a misbehaving one or take out stitches. I cannot assess muscle tone for spasticity or rigidity, and it’s hard to nail down exactly which nerve root sensory function is impaired.
Even though I’ll document an “objective sensory deficit” if testing sensation reveals one, it’s still the patient who is telling me where sensation is impaired. Sensation is subjective by definition. Sometimes the video is a little clunky or there are IT issues. Before anyone commits to surgery, we have to meet live and make sure we’re comfortable with a diagnosis, with each other, and with the utility of surgery. Surgery itself continues to be live and physical, visual and tactile. There is no Zoom neurosurgery – yet.
Despite these limitations, the virtual house call also creates some real advantages. Neurosurgery patients often have impaired mobility. Some live far away from a major medical center, most have regular life responsibilities that an office visit interferes with. There are other costs of a live visit, too: parking, fuel (provided the patient has access to a car), the frustration of getting lost or caught in traffic, highway tolls, and the carbon toll on the environment. Telemedicine alleviates a lot of these headaches while requiring us to give up very little in terms of diagnostic accuracy or human connection.
It’s remarkable that a modern digital technology, so often anonymous and menacing, is bringing us together in a meaningful, analog way that recalls some of the humanity of medicine. Telemedicine is here to stay, and I don’t feel like an anthropologist anymore — we’re more engaged with our patients than ever before.