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.
Great article. Phone or video consults avoid spread of a pandemic, and save time (on Doc, staff and patients), and still provide contact and exchange, and always allow for in-clinic follow-up as needed. Patients stubbornly demanding only in-person consults are taking risks for their existing or new afflictions – and that may have consequences they might later regret. However, in this information age also doctor’s offices / clinics can do more on-line to increase awareness (clinic websites, emailed newsletters). They seem to lag compared to i.e. dentists.
Your view of the patient experience and mine are completely opposite. I have had treatment for over a year for a major medical problem which has required frequent in-office visits. I have to arrange for a ride, put on my good clothes, etc. which in addition to travel time is a burden on me. I live in fear of the SARS-CoV-2 virus and picking it up in the clinic, but one bright spot is the relief from having to be called into the office for meetings that can be handled over the phone. I consider meeting with a nutritionist, receiving test results, etc. to be a huge waste of my time. Unless you’re performing a procedure like an exam or a blood draw, don’t call me into the office! You may think you’re not actually doing your job without a waiting room full of patients, but you are valuing my time and effort at zero.
A proportion of your patients prefer in-person visits. Just like a proportion of people like vinyl records. But technology marches forward, and for people like me, I’d rather do as much virtually as I can. My time is my most expensive belonging, and if something can be done as well or better via remote consult I’ll take that option. Acknowledged that not everything can be done remotely, and for that I’ll travel to a clinic, or a mobile business model might be developed.
A well versed PA with supervision from the provider. My mom had a PA coming to our home and skilled nursing because of her conditions and I worked closely with home health care companies, care giver, insurance, the PA and the doctor. I was the liasion. So many phone calls so much time but, it was necessary. Mom now has quality of life. Models do need to change but,
not to telehealth only. There has to be liaisons who really know the entire picture or it just does not work. My mom needed antibiotics prophalaticly. Specialists said she should just suffer. UTIs are the worst. Infectious Disease Doctors did not know we had tried everything to avoid prophalatics. Mom is on a catheter. She is 88. We are talking about quality of life. Who wants to live in pain and suffer with a UTI? Finally, we had two urologists agree with the PA and with me. Mom no longer is confused, sleepin all the time etc. The
infections disease doctor actually had prescribed a prophalactic at one time but an error was made in her office and the paper work was not filed or sent to the urologist! I also have encountered Nurses at insurance companies that do not know what CMS covers. They don’t know what retired teachers in Illinois do have benefit wise and get angry with me when I read straight from the policy in a tone that I hope is respectful. All we need is well trained, people in these positions doing the filing and answering phones that are not there just doing a job. What happened to making it a career? Caring about human beings. I don’t have to be right but, I would hope a nurse can read. I would hope Drs. do Doc on Doc but, they don’t anymore. Our system needs people who care to help Doctors do what they do best. Not people collecting a paycheck and being gatekeepers. Thank you. Joanna Newton, MC
Thank goodness your mom had you to be her advocate!!
Yes models need to change but also agree telehealth isn’t the only thing. If a patient needs a face to face to be comfortable going to see doctor for routine care how is NOT scheduling them respecting “do no harm”??
PA’s are fantastic in most cases-I actually get my primary care from a Nurse practitioner that I adore. Also think we (country) will be shifting to more of a homecare model with FULL support that is needed – and insurance to pay for caregivers/aides/doctors etc to come to the home vs housed in hospital or nursing care homes!
How did the prostate exam go?
Why is it that back years ago we had people sick with the flu ,virus, cold etc. . But many of my friends who lived in the city or the town who didn’t get outside ,miss school
because they had flu. Never thought about it until now. Now at 88 I haven’t been worried and don’t worry. Or am I just lucky think about it. I’m in the sun alot because I have three horses . take a lot of vitamin d and had it checked to make sure it’s really high.
Ms Wesley-do you still ride the horses? I’d bet your exposure to lots of viruses when younger and your activity now have you healthier at 88 than many at 28!!
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