TECHNOLOGY IN MEDICINE
TELEMEDICINE: DIALING UP THE TRANSITION TO
TELEHEALTH PRACTICE IN EMERGENCY SITUATIONS
AUTHORS Ali A. Farooqui, MD & Oladele Osisami
If we reflect on the
history of medical
practice, we come
across epochs and
paradigm shifts that
change the landscape
of our noble
profession. While
some evolution is organic
and fraught with trial and error, there are instances where
the change is deliberate and calculated. In these situations, progress
is secondary to a challenge to the medical community in the
form of a new technology or a novel disease. Any deviation from
the status quo undoubtedly creates stress and anxiety, but it is a
testament to physicians that we are able to adapt to meet the shortcomings
of our system and innovate to deliver care to our patients.
COVID-19 dealt the world a sudden, lethal blow. Our elected
officials asked for near paralysis of our everyday lives, but medical
care cannot stop, sick people cannot wait. Illness does not respect
time nor person. So when our patients could not come to us, we
decided to go to them via technology and telemedicine. Psychiatrists
are fortunate in this regard because our profession already
had an established infrastructure for delivery of care via virtual
means. Providers have been delivering care to the rural parts of
our state using telepsychiatry for some years, and most psychiatrists
are familiar with the idea of telemedicine. Usually this care
is delivered in a comprehensive health care setting, with a patient
in a doctor’s office interacting with the specialist via webcam. This
pandemic required us to take the virtual relationship to a new level
as even comprehensive health care centers were quarantined.
The pandemic compelled us to treat our patients remotely. As with
any major transition, however, we encountered growing pains that
were not limited to just our institution, but also to the profession
as a whole.
By 1980, house calls accounted for 0.6% of patient-doctor interactions.
Excluding niche concierge style practices, the concept
of a home visit is practically obsolete. Telehealth allows medical
professionals to cross a threshold that would be otherwise inaccessible.
Through our computer screens, we see a patient’s home
environment. This privilege can be used constructively in understanding
the limitations and barriers to medical care. In psychiatry
particularly, a patient’s living environment can reflect mental
health: seeing it is helpful.
Inherent to a patient-doctor relationship is the actual relationship:
i.e. the therapeutic alliance that is founded on trust, autonomy
and mutual respect. There is a risk that a virtual visit would
damage rapport. Some patients might undoubtedly miss the social
interaction that comes from a doctor’s visit, a break from the monotony
of daily life. Paradoxically, experience suggests that most
patients prefer the digital interaction. They feet at ease in their
home environment and prefer fitting a doctor’s appointment into
their already busy and mobile lives, rather than going out of their
way and paying money for gas and parking to see us.
For psychiatric patients, a conversation is invaluable, and there
is no alternative. The veil of telehealth provides a virtual safe space
for the patients that results in a less clinical affect. They have intimate
conversations with providers, rather than a recounting of
symptoms. Comfort with technology in everyday life undoubtedly
contributes to a patient’s ease. They don’t have to worry about how
they look to us; they can see it for themselves. This allows us the
deviation of our gaze from the camera to the screen, resulting in a
perceived lack of eye contact.
One major drawback with our interjection into the patient’s
home is the inability to control that environment for the patient’s
safety. We can ask a family member to step out of the room. If a
patient does not feel safe at home then the protection of a physician’s
office can be a temporary refuge where sensitive topics such
as trauma, abuse and substance use may be discussed. We know
the audience in our offices, but we may not be able to survey the
privacy in a patient’s house. Some may not want certain medical
information divulged over video teleconferencing, which makes it
necessary to first obtain consent for the encounter and may limit
discussion of personal health information.
Widespread use of telemedicine is indeed a paradigm shift; its
prevalence remains to be seen as the COVID-19 pandemic continues.
One clear consequence is the awareness that we need training
on the use of technology for patient evaluation. Some medical educators
have suggested and outlined competencies for the use of
telehealth, but as yet there is no standardized curriculum. There is
no playbook or formalized school of thought on how to integrate
the added diagnostic clues that videoconferencing presents to the
current model of medical decision-making. In this new setting,
the inherent power and formality of the profession is stripped. The
encounter is more personal, more human. It requires a different
frame of mind to synthesize the encounter. We require a level of
professional comfort to quell anxieties that our patients may possess,
but more likely, we require training on how to pacify our own
apprehension regarding telemedicine.
Dr. Farooqui is a resident at the University of Louisville Department of Psychiatry.
Oladele Osisami is a second-year medical student at the University of Louisville
School of Medicine.
JUNE 2020 9