Lessons Learned as Medicine Embraces the Prefix “Tele”

Sohrab Gollogly, MD

As the steady drumbeat of reports of escalating numbers of patients tested, tested positive, admitted to hospital, then to the ICU, and then succumbing to respiratory failure from COVID-19 becomes a rhythm that paces our daily lives and expectations for the future, another transition is taking place. Parts of the medical system in the United States that are not caring for the acutely sick — the ambulatory clinics, outpatient practices, and family medicine offices — have embraced telemedicine nearly overnight. This may prove to be a forcing function that brings consumer web sensibility to medical practice and makes good on the promise that one day at least some aspect of a doctor’s visit could feel like using a ride hailing app.

I’m a private practice orthopedic surgeon in a multi-disciplinary group practice. When California’s shelter at home restrictions went into effect, we stayed open. If regular medical practices aren’t functioning, more people will go to the ER, and the more people that go to the ER and co-mingle with patients with respiratory complaints, the more potential there is for viral spread.

Atul Gawande was ahead of the curve in his publication in the New Yorker on how Singapore and Hong Kong could keep medical workers from becoming infected in the course of a normal medical practice, and we adapted his observations and recommendations. In our practice, that meant screening patients for COVID symptoms, having patients check in and then wait in their cars, maintaining six feet of separation between staff and patients as much as possible, wearing masks and gloves during physical exams, and paying meticulous attention to sanitation, hygiene, and hand washing. We are not overwhelmed. Geography may prove to be destiny in this outbreak, and so far California has seen caseloads are below surge capacity. When I see photographs in the New York Times of Elmhurst hospital, my heart breaks for those physicians, nurses, and staff members are trying to cope, stay healthy, and care for the sick when basic order has been lost and everyone has to improvise.

As shelter in place went into effect, we converted as many visits as we could to telemedicine appointments. With no preparation, we used the tools we have available to us: Zoom, Google Meet, FaceTime, and last but not least, Ma Bell. Buoyed by an overnight relaxation of the restrictive rules for documentation, privacy, security, pre-authorization, and place of service, patients suddenly did something they have been waiting years to do: FaceTime their doctor instead of waiting in a waiting room.

We’ve learned a lot of lessons in the last two weeks and here are four of them from the first quarter:

  1. It’s not efficient. It’s hard to be a physician and provide technical support for someone on the other end at the same time. Significant investments are need in infrastructure for triage, scheduling, and sequencing.
  2. It’s not efficient, but it sure is effective. You can learn a lot, and provide a lot of the essential services of medicine via video conferencing, such as history taking, diagnosis, treatment plans, prescriptions, and follow-up instructions.
  3. The patients like it more than the doctors do. It may be a function that many of the patients I’ve had telemedicine visits with during the last two weeks have been cooped up at home, but beneath the anxiety there seems to be a genuine feeling of “finally”.
  4. I hope it’s here to stay. I sincerely hope that regulation doesn’t shut down this blossoming once the current crisis passes. Medicine needs a digital infrastructure that feel more like Google and less like Epic and none of these work-arounds would have been possible in a pre-COVID environment.

Stay healthy. Wash your hands. Hug your kids.