A Shifting View on Telemedicine

In March 2019, a robot entered a patient’s room in California and a doctor on its screen told him and his granddaughter that he was dying.

This experience, posted to the granddaughter’s Facebook page, was treated as a scandal. Newscasters questioned the humanity of a health care system that would do such a thing. Words like callous, heartless and cold were used to describe this apparent lack of compassion and care.

Bad news, it seemed, should be delivered only by compassionate individuals, with good communication skills, who are actually in the room with the patient. Not at a distance over a screen.

Just a year later, Covid-19 changed all that.

We had a highly contagious virus devouring hospital resources, a combination of factors that made hospitals inhospitable to families. Almost overnight, most American hospitals strictly limited visitation.

In the early days of the pandemic, some staff members could not ignore the human toll of isolation they were witnessing, and started using their own cellphones to connect patients with their families, if only for a few moments. This would never have happened pre-Covid, when fears of HIPAA violations and a mandate for personal privacy had always kept personal phones in pockets.

These virtual reunions were powerful and almost always positive — not only for the patient and family, but for staff. They brought humanity to days filled with stress and sadness.

And for the patient, alone in the hospital, the iPad on a stick represented not a cold robot but a portal to their loved ones. Where just last year, communication through a screen felt crass, all of a sudden, it became the only compassionate thing to do. Hospital teams expected families to be resistant, but we discovered receptivity and profound appreciation for the ability to connect, by whatever means available.

Before we all realized it, we had entered the era of tele-health — where instead of an iPad representing coldhearted indifference, it now symbolizes our human desire to connect and communicate. Just as we have found creative ways to continue to connect socially through life-cycle events — video cocktail hours, Netflix parties, Zoom weddings and funerals — we have realized that technology can provide so much more to the care of patients than we thought it could.

At the beginning of the pandemic, when I knew I would have to start interacting with families virtually, I was apprehensive. The hallmark of a palliative care team’s work has always been in-person, human connection. As facilitators of arguably the most difficult conversation topic of all — death — we literally lean into emotions that most people would run from. Unlike most medical interactions, we are not transactional, extracting a vial of blood, a signature on a consent form. Our service is to witness, reflect, and be truly present. We have been trained to provide a certain physicality, pulling up a chair, making eye contact, holding a hand. Could we really do that on a screen?

But our team had no choice, and having no choice can be clarifying. It was clear we needed to bring in the technology and at least try it. We received an emergency grant from the San Francisco-based Stupski Foundation and got to work, deploying 30 new iPads to various teams in the hospital so they would be able to access our services more readily.

The choreography of this experience varied, depending on the technology and staff available. The set up could sometimes feel like we were on a film set, the med student encased in PPE playing the role of camera operator, minus the professional training, holding the iPad shakily over the patient’s face as the Zoom panel looked on. Sometimes I was the person “bringing” others — family members, our chaplain, or our social worker — into the patient’s room on the rolling iPad. Other times I was “rolled” into the room, the virtual consultant, sitting on my couch, my poodle curled next to me.

I was working offsite for our first virtual encounter. The patient had Covid pneumonia and had been in the intensive care unit on a ventilator for weeks. The intern who consulted us warned us that his family was frantic, angry, calling incessantly in search of information. We arranged for all six siblings to join us in our “Zoom room” to meet with us, get a medical update, and see their father, intubated in the I.C.U.

I was surprised by how nervous I was, nervous that I didn’t know what I was doing, that I would be perceived as a fraud. “You’re not even with my father, right now?” I imagined his irate daughter saying to me as I fumbled with the technology.

Before the meeting started, I joined our chaplain and social worker in the “Zoom room” to strategize our approach to this uncharted virtual territory. Having worked together for a decade, we are adept at reading each other’s body language in person, but we knew this would be different, all of us facing forward in a grim Hollywood Squares. We anticipated it could so easily get out of control — family members grieving alone in their homes, anger brewing, even a Zoom-bomber, which I’d been hearing about. We devised a subtle hand signal so that we would be less likely to trip over each other during the video visit. “Ready?” I asked, before holding my breath and pressing “admit.”

To our surprise, it turned out to be less challenging than we expected, as did all the ones that followed. Any initial doubts I had about this medium were erased by the relief of families connecting in this desolate time. True, they didn’t have much of a choice, having been shut out of the hospitals. But their heartfelt appreciation of a physician’s presence was a striking contrast to the national sentiment expressed just 12 months earlier, where an iPad on a stick was seen as a cold robot. Now, it was perceived as a lifeline. One patient said to me as I hovered from home in one of the Zoom squares, “I don’t know who you are, but thank you for bringing my family here to be with me.”

Over the next few months we learned how to better translate our in-person presence to an online format. Where I would normally hug or touch a patient on their shoulder, now I put my hands over my heart. Instead of looking directly into their eyes, I made sure to always look directly into the green light of my computer’s video camera. I stayed quiet as the families wept and spoke to their unresponsive loved ones.

I discovered that I can be compassionate on and off the screen, which made me wonder: Is the most important factor for delivering excellent care physical proximity? Or is it depth of focus, and quality of communication? Is it dependent on technology or the person using the technology?

In this work I have discovered that telehealth is not merely a pale substitute for in-person care but rather a viable alternative, even offering some distinct advantages. It allows patients to see their loved ones from all over the world. It reduces the risk of exposure to Covid or other hospital-borne infections. It also allows us to preserve precious PPE for the primary teams who need it.

Telehealth has been in the background of health care for a while, primarily in rural communities where distance limits access. Now that Covid has pushed it into the mainstream, many more of us have seen and felt its benefits. Health care teams are grateful to have it available, and patients and families are not shocked when an iPad is rolled into a room or they are invited to a Zoom call. While I look forward to a time when face-to-face interactions are the norm again, I am grateful for the wide acceptance of this new tool that will continue to help us support patients and families everywhere.

We’ve learned that it’s not about the medium, it’s about the message, and the way it’s delivered.

Jessica Nutik Zitter (@JessicaZitter), a palliative medicine and critical care doctor in Northern California, is the author of “Extreme Measures: Finding a Better Path to the End of Life.”

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