It started with a cough, mild but dry. The body aches and chills came two days later, when Aditi Joshi’s fever spiked north of 102 degrees. Soon, the emergency medicine physician lost her senses of smell and taste, piling kimchi and Indian spices onto rice to see if she could detect any heat.
She had contracted the coronavirus, and for nearly two weeks she has been quarantined alone inside her Philadelphia home. But rather than sitting out the greatest fight of her medical career, Joshi has been using telemedicine to continue treating patients with the same COVID-19 symptoms she’s feeling.
“When you get something yourself, you can actually understand what people mean," said Joshi, who works for Jefferson Health. “And for me, there’s something helpful about feeling like I don’t have to sit back and do nothing about it.”
Appointment requests for video “visits” with doctors have exploded in the past week as patients seek answers on COVID-19 while trying to avoid emergency rooms where they could encounter the virus. At the same time, Medicare and private insurers that once did not cover virtual health care have bent the rules for the pandemic. Patients need only a computer or cell phone with a video function.
Penn Medicine’s service saw a tenfold increase in demand to 400 patients a day, while Jefferson’s daily “walk-in” telemedicine visits leaped from 20 to 200, and the number of patients scheduling online appointments ballooned from 50 each day to 2,200. That figure continues to increase by 10% to 15% each day, said Judd Hollander, Jefferson’s senior vice president for health-care delivery innovation.
“We didn’t expect a potentially lethal disease to force us to scale up the system overnight, so we have had challenges,” Judd said. “But so far, we’re making it work.”
Roughly 90% of their virtual visitors have questions about COVID-19 and potential symptoms. About 40% are told to get tested for the virus, while the majority have been encouraged to stay home.
Penn has begun using its telemedicine app to pre-screen every patient who has an upcoming in-person appointment. “We’re trying to prevent those patients from coming into the hallways and mixing with more sick people," said Krisda Chaiyachati, medical director of Penn Medicine OnDemand.
“We’re asking, is this appointment necessary? Is there something we can do virtually to meet those needs?” he said.
’50 times more patients’
Staffing up to meet the needs of the crisis was Problem No. 1, providers say. But because so many clinicians couldn’t be on the front lines in the hospitals, this didn’t remain a problem for long.
Some, like Joshi, had been exposed to the coronavirus or had COVID-19, the disease it causes, themselves. Other doctors — at higher risk for complications because of age or underlying health conditions — were advised to stay out of the emergency rooms and intensive-care units. Still more doctors in retirement volunteered to take calls.
“I wouldn’t want to subject my older colleagues with lung conditions or asthma to be exposed to it,” said Chaiyachati, an internist. “I can take that risk on their behalf.”
At Penn, the telemedicine staffing has swollen from six nurse practitioners to more than 200 clinicians and administrators. “Three weeks to build an army,” he said.
Training — and fast — has become the real issue.
JeffConnect used to do a practice call with patients ahead of their appointments, but with more than 2,000 appointments each day, that hasn’t been realistic. But there has been a higher rate of missed calls.
“We have to fix this and make it better ... but we’re taking care of 50 times more patients than we did last week,” Hollander said.
Last weekend, JeffConnect leaders went to a video studio and shot a 13-minute video to help get the new recruits up to speed. Joshi, who is the medical director of JeffConnect in addition to her inpatient shifts, said the biggest hurdle for her colleagues is the technology.
Some of her colleagues need guidance on how to document a physical exam, she said. “Not everyone’s doing that, because they don’t think they’re doing a physical exam.
“But they are: They’re looking at how they’re breathing, how they’re speaking, how they’re walking.”
Creative ways to diagnose patients
Practicing medicine is practicing medicine, even without physical touch. Even through a cell-phone screen.
“There’s a lot that can be done in terms of evaluating someone," Chaiyachati said. “I’m looking at you, do you look sick, do you sound sick? I’m going to call it here, you should go be seen in person.”
To determine whether a patient is showing symptoms, a telehealth doctor might ask a patient to stand by a window where the light is better, or shine a smartphone flashlight into their mouth while saying “aaah.”
“We can easily see into someone’s throat," Hollander said. Although they can’t listen to the lungs through a stethoscope, there are creative ways to look for shortness of breath. A patient might be asked to inhale and then count “however long until they need to take that next breath.” Most healthy people can get to 30, Hollander said, but someone with the virus might stop at seven: “We’ve sent a few people to the hospital that way.”
Another diagnostic trick is to ask a patient with a headache to stand up and jump. “If it’s meningitis, it’s going to really hurt,” he said. “But if you just have a tension headache and you think, ‘It’s dumb that my doctor made me get up and jump’ and you’re laughing, you probably don’t have meningitis.”
Seeing inside a patient’s home has been an unexpected advantage, Hollander said.
“Everyone I see in an ER is in the same gown, or on the same bed," he said. “In seeing their house, if they’re there with asthma and there’s dust all over the place, that’s different than if it’s totally clean.”
Some of the work is just providing empathy for a patient who’s anxious after watching the news or reading web forums. “I think it’s helpful to acknowledge that the anxiety the patient is feeling is real, and it’s something that I and many clinicians feel, as the people likely to go on the front lines of this and then come home to their families and worry about that," Chaiyachati said. “I’m also in the same boat. We can be in this together, both patient and doctor.”
Nearly two weeks into her quarantine, Joshi’s fever is gone, but the aches remain. Her friends and family send food. When time allows, she takes naps. “I feel like I just want to sleep all the time," she said.
But she keeps seeing patients, knowing she’s helping keep traffic in the ER manageable.
When she takes a call, she tries to figure out what patients are worrying about. “The reality is you can’t control a lot of things, so I listen to people, and try to understand what their fear is."
For her, it’s anxiety to get back into the hospital.
“I just want to get better so I can be onsite,” she said. “My colleagues are out there, onsite, and I can’t be there.”