In my nearly quarter-century as a primary care pediatrician, I have always aspired to be present and complete. I do my best to keep my eyes on the patient, to listen to every concern, to examine each child from head to toe, and to communicate as clearly as possible.
Covid-19 has forced me to practice a different kind of medicine — the kind where you keep your distance and do exactly what is “essential,” but no more. These changes have been necessary, for now, but there is much we have yet to learn about their long-term implications.
Through February and March, as Covid-19 marched closer to Philadelphia, where I work, my colleagues and I dismantled the practice we had built over decades. We kept patients home at all costs. If we had to do in-person visits, we limited our time in the exam room. We stayed six feet away whenever possible. We covered our bodies with gowns, gloves, masks, and eye shields. Some of our young patients seemed curious — they searched our eyes for the people they knew and we did our best to reveal ourselves. Others turned away and covered their faces. We have had to accept that we cannot engage in quite the same way.
An essential component of this new doctoring has been the shift toward telehealth, the ultimate distancing tool. When the federal government adjusted privacy rules and reimbursement fees for virtual care, we implemented video visits almost overnight. Our patients and their parents signed up in droves for remote access. Our triage nurses now have a third category — “appropriate for video care” — in addition to “home care” and “needs to be seen.”
We have embraced telehealth as a way to still “see” families while keeping them home and away from places where they could be exposed to SARS-CoV-2, the virus that causes Covid-19, like public transportation or doctors’ offices. Video care has saved lives by curtailing the spread of the disease.
But as I sit in my bedroom and complete a virtual visit, clicking the red button and watching the screen go dark, I mourn the vast space between myself and the families I care for. I worry about the elements of the in-person visit I have had to cast aside. I wonder if we always know what is “essential” and what is not, who to keep home and who to bring in.
Some children, such as those with behavioral or psychiatric concerns, are particularly well-suited to telehealth. For them, the decision is simple. Similarly, children with symptoms we would typically have addressed by phone — runny noses, mild rashes, and low-grade fevers — may be even better cared for with a look through a video screen.
It is the patients I would previously have evaluated in the office that leave me hoping I’ve been thorough enough. I would have seen them in person for a reason. Perhaps a full set of vital signs or a complete physical exam seemed relevant to their care.
There is so much we cannot see in a video screen, so many things we cannot feel.
One of the fundamental tenets of primary care pediatrics is that children with seemingly minor illnesses can be sicker than they appear. This is why we teach our trainees to examine the skin of every child with fever, looking for tiny red dots that can indicate a life-threatening infection. This is why we show them how to knead the belly of every toddler with constipation, searching among the mobile lumps for a more ominous mass that feels smoother and fixed in place. This is why we have them darken the room and peer at the retina of every adolescent with headache, looking for the crisp round circle indicating normal pressure inside the skull.
Health care settings are also touch points, safe spaces where we identify threats to our patients’ lives that may be separate from their chief complaints. The thin red scratches across a teenager’s wrist that we notice as she sits across the exam room and adjusts her long sleeves. The oval bruises on a mother’s upper arm. They may have come in for fever or earache or immunizations, but we are trained to notice, to ask, to protect.
It is the details I may not be identifying on physical exam that keep up me up at night during the distanced care of Covid-19 telehealth visits.
Everything we do in medicine we do after careful analysis of the risks and benefits. In April, the threat of leaving the house was greater than the benefit of in-person care for a majority of complaints. But as the risk of Covid-19 lessens and eventually — if we’re lucky — becomes a distant memory, the calculus will continue to shift.
Once it is safer to come to the doctor’s office, we need to ask ourselves several questions: Which patients will still be best served at home via telehealth? With which illnesses? For how long and how often?
The longer this pandemic stretches on, the more entrenched virtual care becomes. Some already refer to it as the new normal. But before we accept as permanent a change made in crisis, we need to be sure that by keeping our patients distant we are doing no harm.
To be sure, evidence supports many benefits of telehealth, benefits that will outlast this pandemic. It is incredibly convenient. It reduces location-based barriers and allows us to “see” patients who would otherwise be unable to travel. And it can offer a window into homes that bring us closer to our patients. When children show me their puppies and Lego creations, or when my own child comes bursting into the room, we all come away knowing each other a little bit better.
But I long for the days when my goal is once again to remove barriers between myself and my patients, not to create them. I miss the feeling of ending visits knowing I have done more than what was essential, that I have stayed the extra minutes, looked my patients in the eye, examined them head to toe, and provided the most thorough care possible.
I aspire to be a different kind of physician: the kind I used to be.
Dorothy Novick, M.D., is a pediatrician in Philadelphia.