I have practiced family medicine for 33 years, experienced significant change in technology, business practices and the scope of my clinical work, but one thing has remained constant –sharing the personal space with my patients. This now feels threatened and I feel a loss.
In a determined effort to allow patients to continue to shelter at home, my colleagues and I are learning to deliver a different and entirely new kind of care –remote telemedicine. Remarkably, in primary care the medical evidence indicates that over 80% of diagnoses are arrived at by gathering a careful and thorough history. A thoughtful explanation can then be shared with the patient and questions answered. Tests can then be ordered, referrals (immediate or at a later date arranged) and medications prescribed.
Additionally, already in this short span of time I have walked a patient through a shoulder joint examination, had a significant other press on their partner’s abdomen in a sequential fashion to evaluate for pain, encouraged a patient to count out their pulse to get a heart rate and tell me if the pulse felt regular or irregular, and reviewed photos of patients’ skin which helped me diagnose shingles for one patient and eczema for another.
Admittedly, we cannot do everything we would like. I cannot listen (auscultate) a patient’s heart or lungs, look in their ears, flush out wax or do many other procedures that require hands-on care. Nonetheless, a lot can be accomplished, so, you might ask, what is the problem?
Before modern medicine offered true evidence-based treatments beginning in the late 19th and early 20th century, a clinician’s role was to offer compassion, emotional and, when possible, physical comfort and support to those suffering with illness related symptoms. This was always delivered at the bedside and always included the most basic human behavior, a caring touch.
A century later we now endeavor to describe this more expansively; acronyms such as E.M.P.A.T.H.Y., E-eye contact, M-muscles of facial expression, P-posture, A-affect, T-tone of voice, H-hearing the whole patient and Y-your response are taught to medical students. And at the heart of family medicine is the relationship between patient and clinician.
For 25 years I was privileged to care for my patients in the hospital, in my office, when necessary in the nursing home and in their homes. In each of these locations I was able to be in their physical space. To sit on the edge of the bed in the hospital or nursing home, or at the kitchen table in their home and to be private with them in my office exam room. I got tremendous gratification from doing the simplest of things to demonstrate that my patients and I are cut from the same cloth, after all; helping them when needed to dress and undress for an exam, removing their shoes and socks for a foot exam of skin, circulation and nerve sensation and then putting them back on, the ritual practiced over and over again of listening to their heart and lungs and then summarizing my thoughts and plans for their care. Common to all of this is touching, sharing and being physically with them.
This is why I feel a loss delivering primary care the way I must during this stressful and frightening time. I am grateful to be able to see, hear and support my patients… from a distance. Telemedicine is an innovation that will continue to allow us to meet the needs of our patients, especially those who are distant from us or no longer able to easily travel to us.
I hope, however, that we never allow it to replace or voluntarily substitute for the humanity and relationships that develop from being physically in contact with one another.
H. Andrew Selinger M.D. is Chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University.