I recently got a note from my secretary with this message from a patient: “Tell the doctor I have no interest in a phone call or one of those video visits. When she is back to seeing patients again in the office, let me know.”
I’m hearing that a lot lately from patients who continue to delay routine medical care, not due to fears of Covid-19 but because they yearn for the old face-to-face office visit. I worry about what the refusal to have a virtual visit means for my patients’ health and for a strained primary care system trying to care for patients during a pandemic.
The math is both simple and daunting — and can be explained by my waiting room.
Before the pandemic, it had 50 chairs. Today it holds just 12, all of them 6 feet apart. That’s 12 chairs for the patients of 17 doctors to share. We are screening patients for Covid-19 symptoms by telephone prior to office visits, having patients wear masks, and spacing patients apart in the lobby, on elevators, and in the waiting room.
To begin ramping back up, we are scheduling only about one-quarter of the patients we were seeing before the pandemic started so we can study our workflows and make sure we maintain safety for patients and staff. After this cautious time, we will move through Massachusetts’ four-phase reopening plan and increase in-person visits while continuing to maintain safe social distancing. But our practice won’t be returning to its pre-Covid-19 in-person patient volumes anytime soon — not even close.
Fortunately, the capacity of my virtual waiting room for telemedicine visits is not limited by physical space. I can even “see” a patient at night or over a weekend, times when the office would normally be closed and the rest of my staff is unavailable. Yet a significant number of my patients and my colleagues’ are refusing to do telemedicine visits by video or phone.
I think I understand. They miss having office visits in person — and I miss seeing them in person, too! I remember one patient who would break into a smile the moment I walked into the room. “I just feel better the moment I see you. I wish you could stay at my house!” she once told me. And patients would often let me know me, after weeks experiencing some symptom, “It’s gone now — of course it gets better the day I come to see you.” But they still kept the appointment even though the symptom had resolved.
Social connections are important to us. We crave human connection. I have taken care of many of my patients for more than 20 years. That puts me in same category to them as a childhood friend or even a family member. In the past, my encounters with patients during office visits usually included some portion of a physical exam, at least listening to their heart and lungs, so of course it’s not the same thing to be staring at a video screen. A telemedicine visit feels like a shallow experience to some patients who want the “real deal.”
What I try to explain to my most stubborn patients is that up to 90% of my medical decisions are based on my asking questions, reviewing test results, and obtaining medical, family, and social histories — all things I can do virtually. There are even some surprising telemedicine benefits, such as having immediate access to a patient’s pill bottles or glucose meter (no more “I left it at home” excuses).
I have actually been pleased by the quality of the care I can deliver through phone or video based visits, even for chronic conditions like high blood pressure, high cholesterol, and diabetes.
The few in-person visits our practice allows are rightfully reserved for patients needing care that must be done in person, such as someone reporting a breast lump. Patients who decline a telemedicine visit often don’t have an immediate pressing issue. They are choosing to wait — and further delaying their routine care. Such delays could pose an even larger threat to the public’s health over time than the current pandemic.
Cardiovascular disease offers a good example of that. Heart attack, stroke, and other cardiovascular diseases account for more than 800,000 deaths each year in the U.S. — that’s approximately 1 of every 3 deaths, or nearly six times as many deaths caused so far by the coronavirus. Controlling blood pressure, cholesterol, and diabetes are all essential in the fight against cardiovascular disease, yet follow-up visits for these conditions have essentially been put on hold for the past three months. Every week I discover patients who have not been taking their aspirin, blood pressure, or cholesterol medications, some because they are worried about catching the coronavirus when going to the pharmacy. No one knows what effect the months of care delays will have on the number of cardiovascular deaths in 2020, but the numbers could be higher than usual.
Doctors and their patients have also postponed colonoscopies, mammograms, vaccinations, and other preventive health care — potentially delaying the diagnosis of smaller cancers which are often more easily treatable and placing patients at risk for other infectious diseases (like measles) for which preventive vaccines are available.
I am as worried about the health outcomes of patients declining a phone or video visit as I was about the patients who refused to go to the emergency room during the height of the pandemic surge. I understand the desire to go back to the good old days of office visits, but for now this is the new normal. And while it doesn’t look anything like the medicine I have been practicing for the last 20 years, it can work — if we all embrace the change.
As primary care struggles to figure out how to effectively take care of patients, those declining to do routine care through telemedicine are straining the system further and risking their own health.
Amy Wheeler is a primary care physician, unit chief of Massachusetts General Hospital Revere Adult Medicine, and a Public Voices Fellow with The OpEd Project.