A Dangerous Evolution?

John J. Miller, MD;

COVID-19 rewrote—and continues to rewrite—the rules as to how medicine can be delivered. Like many of you, I spent the first 14 or so months of the pandemic exclusively engaged in telemedicine, working out of my home. However, as soon as our clinic reopened to in-person patient appointments with rigorous safeguards in place, I returned to that setting. In fact, I was—and frankly remain—befuddled as to how few clinicians, both at our clinic and across the country, have returned to providing in-person treatment when the option to practice virtually continues to exist for them.

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Fortunately, many of my patients returned to in-person visits right away, and when we meet in the waiting room for the first time since the pandemic started, it is a welcome reunion. In my experience, so much more clinical information is accessible and treatment planning is more easily negotiated. Loose ends from the telemedicine days can be quickly tied up.

Still, some patients prefer telemedicine. Each of the 20 or so patients I am scheduled to see a day are given the option to meet in person, on the doxy.me virtual platform, or by voice only over the telephone. It has been fairly consistent over the past 10 months: About a third attend in person, a third I meet with on doxy.me, and a third I meet over the telephone. I have read studies that consistently conclude patients and clinicians are equally or more satisfied with their virtual treatment option than meeting in person. There are likely many reasons for this: no need to travel to the appointment; the ability to wait at home if the clinician is running late rather than waiting in a busy/noisy waiting room; lower no-show rates, which greatly improve clinician productivity; the clinicians’ ability to work from home, eliminating the stress of commuting to work; no need to rent office space; greater ease ending an appointment than in person, and more.

Maybe I am just old fashioned. I enjoy and learn a lot clinically when I walk out to the waiting room to meet my next patient. In that moment of eye contact and recognition, I usually have a good sense as to how they are doing. I observe their energy level, posture, body tension, unusual movements, hygiene, smell, and overall presence as I walk behind them to my office. And, after practicing virtually for 14 months, it has been refreshing to be face to face in the same room to explore my patient’s challenges, stressors, achievements, progress, and fears, and genuinely be present in a way that is not possible through telemedicine.

Let me be clear: I am delighted over the impressive and exponential advancements that have developed in telemedicine over the past 2 years. I support and appreciate the growth in the telemedicine arena, which has greatly improved access for patients who had significant treatment roadblocks due to geographic distance and isolation, institutional deficits in necessary clinicians, transportation issues, health conditions that prevented or required avoidance of hospitals and clinics, and many other barriers. Through virtual platforms, expert consultants are now available to assist hospitals and clinics that lack the resources to hire the wide range of specialists who are commonplace at major medical centers. Innovators are broadening options to enhance access for populations in need of virtual access. During the pandemic, many of my patients were perfectly happy having our scheduled appointments by voice only over the telephone. Remarkably, no-shows and canceled appointments dropped to close to zero.

Yet it was not ideal. I remember the many times when my patients’ inadequate cellular or internet connection interfered with our ability to meet satisfactorily. I had to recommend parking near a Starbucks or Panera to use their wireless network to some of my patients for our next virtual appointment.

In addition, some patients whispered to me that they could not really talk openly, as their partner, roommate, or child was in the room or within hearing distance. I rarely received results from the lab orders I mailed to the patient after the virtual appointment. I had “appointments” with patients at checkout lines in stores, taking a walk with a friend, or while they were in waiting rooms for some other appointment. I lost the intuitive sense that had developed after 8 years of medical school and residency and 30 years of in-person clinical practice that would often provide significant insight into my assessment and treatment planning.

After all, sitting in my office with a patient allows for much communication, especially through our mutual eye contact. Sometimes sitting in silence and gazing into each other’s eyes creates a powerful therapeutic moment. The eyes are a special sensory door for us humans and can facilitate quite a range of emotions, including fear, paranoia, acceptance, joy, and relief.

That is why I am now concerned that telemedicine is, unfortunately, metastasizing into clinics and settings where the option to meet in person is readily available. This is a dangerous evolution away from in-person treatment. Our brains are wired to engage in a 4-dimensional environment using all of our sense modalities. I cannot imagine a parent raising their child virtually or spending the majority of time in a relationship with a loved one or friend virtually. I am not interested in virtual vacations. Scuba diving or hiking on a digital screen or over a telephone, for that matter, does not sound appealing.

Medicine is a healing profession. Qualities like empathy, compassion, acceptance, “sitting” with our patient’s pain and suffering, listening to a traumatic life story, discussing treatment options, being present and attentive to our patients in a way that they feel it, and breathing the same air in the same room and in the same moment while looking at their soul through the windows of their eyes are qualities that are greatly diluted and often absent through a virtual platform.

Dr Miller is medical director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times^TM; staff psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; consulting psychiatrist, Insight Meditation Society, Barre, Massachusetts. ❒