With the sweeping rise of COVID19 telemedicine has taken healthcare by storm. During the local surges, this served as a mandated way of maintaining safe distancing. But as things come back to a new normal and as we decide where telemedicine fits in to a clinic structure it might be worth asking: should patients have the option for in-person care. Is refusing telemedicine in favor of being physically seen a choice patients should be able to make?
It’s an important question because as we begin settle in to a fixed role for telemedicine in the post-COVID world, centers are beginning to shape processes around telehealth.
The things we assume about telemedicine
To to answer the question about refusing telemedicine, let’s start with three assumptions that we make about patients and virtual encounters. ￼These assumptions give shape to our our policies. These are assumptions that I have personally worked with and seen my peers and patients make.
Assumption of approval
We assume that telemedicine is what patients prefer.
The belief that patients prefer to be cared for in the context of their home isn’t always the case. There may be sensitive issues or the hidden agenda that doesnt show well across a screen. Some may want the reassurance of having part of their body looked at despite our insistence that a telereview is fine. Complicating things is the fact that patients may not always want to divulge those details to the scheduling personnel.
Assumption of equivalence
We assume that telemedicine is as good as in-person care.
during the pandemic we fell in to the habit of believing that most of what we do in person can be done just as well virtually. And what can’t be done by screen comes out in the wash with a CT or MRI. This was started out of necessity. So there is a bias to try to assess virtually some conditions that may best be assessed IRL.
This bias can creep into the minds of patients as well who have the belief that everything can be done virtually. Sometimes medicine needs to be inconvenient as I suggested here:
While I’ve been an advocate for tech-mediated access to care, there‘s something to the occasional deep dive. Chart open and and attention transfixed, a time and place to catch-up and drill down. Convenience is good, but a careful connection from time-to-time trumps convenience. Inconvenient healthcare, it seems, may have its place.
Assumption of capacity
We assume the patient is able to participate in a virtual visit.
I’ve learned through my care for patients in remote parts of Texas, some families lack the internet access and equipment to complete a telemedicine visit. And when scheduling they are often too embarrassed to disclose that they don’t have broadband or a computer. I ultimately figure this out when the family appears through the low resolution lens of an 8-year-old iPhone carried on a patchy cellular network. In another circumstance I had a older generation set of foster parents who had never used video communication and couldn’t figure out how to turn on the sound (I called them by phone and walked them through it!). Tech insecurity is a bigger issue than thought initially when we started doing telemedicine.
So there are many reasons why a patient may prefer an in person visit. Our assumptions about the magic of telemedicine are not always right. While we should work to accommodate the preferences of the patient, patients need to understand that there are conditions and circumstances where an in-person visit is not necessary. And patients should be offered the right of refusing telemedicine.
Is our insistence on telemedicine use patriarchal?
Will our telemedicine policies pull us back to an imbalanced doctor-patient relationship? This brief essay from Rammya Matthew in British Medical Journal stirred my thinking about this problem. And this quote is good.
Will the obsession with digital inventions undermine shared decision making and take us back to a more patriarchal way of practising medicine, in which the doctor knows what’s “best” for the patient without really knowing the wider context in which a patient presents?
My answer: In the short term, yes. But after the COVID dust falls we need to create more structure that respects the interests and will of the patient.
Telemedicine is a moving target. What works or doesn’t work today may have a very different solution or experience a year from now. Flexibility and rapid reiteration our processes will be critical to successful adjustment and growth.
If you like Refusing Telemedicine check out the 33 charts Telemedicine Archives.