Let’s face it: Telemedicine isn’t there yet. I’ve been treating patients for nearly a year by remote care and so far I’m underwhelmed. And my patients have voted with their feet — most still want to see me in person. I suspect they’re not happy with the compromised connection that telemedicine delivers.
So I want to unpack some of my ideas on telemedicine. Specifically, how can marginal early experiences can give way to something better?
Let’s start with something that I really believe: Human connection is person-to-person. Whenever human connection is mediated by technology it interferes with how we’ve evolved to be together. From the subtleties of body language to the way a mother and baby interact, so much gets lost through the fuzzy screen. So between a face-to-face visit and a video encounter, the IRL connection always gives me more as a doctor. It just does.
But as we’ll see, there’s nothing wrong with a compromised connection in many cases.
Exhaustion as evidence of a compromised connection
Telemedicine fell from the peak of inflated expectations to the trough of disillusionment in June 2020. But why? For one thing, we’re just figuring out what we’re doing as doctors and advanced practitioners when it comes to caring through a virtual connection.
I wrote about the exhaustion of the telemedicine encounter that I experienced shortly after developing my own telemedicine clinic in the spring of 2020. I couldn’t understand why but figured it was because of all the real-time adjusting I had to do. Dropped words and sentences, technical twangs, and the emotional stress of trying to read physical cues — a critical part of my work.
But here’s what’s important: While an IRL visit gives me more than a telemedicine visit, I don’t always need more.
But improved access can offset compromised connection
Let me clarify something before the technoutopians cancel me on Twitter: Compromised human connection doesn’t mean that there aren’t major upsides to the growth of telehealth. Like my ability to care for more kids, for example. Even if we’re missing some of the nuanced things that humans share when in the same room telemedicine has the potential to offer access where it didn’t exist. This is huge.
A good example of a helpful remote transaction that lacks nuance is the request for a medication refill over a text-based application — I don’t need more than the message to take action. On the other hand, an established teenager from west Texas with ulcerative colitis having a flare needs more than a text exchange with me (trying to assess the problem this way is torture because I have lots of questions). Video is a great solution here since he doesn’t have to make the 7 hour trip to southeast Texas, I know him, and the acute care encounter is truly transactional — I just need the facts to get us to the next point of care. Critical conversations, on the other hand, like end-of-life discussions, disclosure and planning around life-changing diagnoses or the exploration of certain physical problems may be better handled with a face-to-face or hand-to-belly encounter.
As I said here in 2015, engagement around disease is complex so we have to understand what our tools can do and when to use them. This is a new skill of the 21st century health professional.
So while remote care may compromise raw human connection, its ability to scale connection with more patients offsets the compromise. It’s a reasonable tradeoff in many cases and one that defines the disruptive nature of telemedicine in medical practice.
Be careful of the paradox of the present
But it’s important here to own up to my blinded view of telemedicine in 2021.
There’s an effect called the paradox of the present. While the term has been popularized by futurist Amy Webb and used in a number of ways, for our purposes we can say that it’s when we believe how things could be based on how they are now. Or, more plainly put, we have a hard time seeing beyond what we know to be true right now. Kevin Kelly in The Inevitable | Understanding the 12 Technological Forces That Will Shape Our Future talks about how what we know blinds our view of how things could be:
…we tend to see new things from the frame of the old. We extend our current perspective to the future, which in fact distorts the new to fit into what we already know. That is why the first movies were filmed like theatrical plays and the first VRs shot like movies. This shoehorning is not always bad. Storytellers exploit this human reflex in order to relate the new to the old, but when we are trying to discern what will happen in front of us, this habit can fool us.
Evidence of this is the fact that we’ve constructed telemedicine platforms with all the comforts of the clinic, like ‘waiting rooms’ and even doctors with stethoscopes around their neck (“What’s he gonna do with a stethoscope during a telemedicine visit?”)
So we have to understand that as technology evolves it won’t always be this way. New tools will allow new kinds of connection that will shift the telemedicine experience for doctor and patient. Next gen platforms will offer a less compromised connection (or one compromised in different ways). It still won’t be as good as being there, but it will be closer.
Eating the dog food: A pessimistic spin on face-to-face medicine
I started here with the assumption that direct human exchange is the ultimate interface. But we may be witnessing a kind of evolution where humans may be more comfortable engaging asynchronously, or through some kind of tool – a good example being my teen who doesn’t want to talk but will allow an exchange by text. Or, it may still be that we’re better in person but we’ve become frightened by the intimate reality of face-to-face engagement. This idea of hiding behind a screen corrupts my core idea. While we may believe that we are best off person-to-person, we may be losing our ability to have the kind of connection that IRL affords. Or in the words of Sherry Turkle, with remote connection we are drawn to the comfort of connection without the demands of intimacy. If you want to explore this issue you might read Turkle’s brilliant book, Alone Together | Why We Expect More from Technology and Less from Each Other.
The success of telemedicine depends on criticism
Blindly accepting telemedicine in its current form is one of the worst things we can do. As end-users we have to talk about where this technology is strong and where it isn’t. Contrary to the press releases and the ‘made-for-Twitter’ quotes from telemedicine CEOs, this technology needs a lot of work. And understanding this is important because it acknowledges that telemedicine has limitations. And that’s okay. It gives us all a place to start.
The industry sees this as well. An interesting StatNews First Opinion essay last week from the CEO of Doctor on Demand.
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