There is a poverty of body language in telehealth appointments – but there is tenderness too | Ranjana Srivastava

The very first time a patient asked me what I thought about “this new virus”, I advised her that all things considered, it should pass. We sat in a small room with all six of her children to share the good news that after a full year of “wait and watch”, her cancer was static. Consequently, there was no need for the chemotherapy she desperately wanted to avoid. At this, she burst into tears.

“Darling, I come feeling sick in my stomach, but you always make me feel better!”

She left me with a present: her national dish wrapped in layers of foil, while her husband solemnly took both my hands in his. The last to leave, a relieved daughter flung me an impromptu hug.

Now, almost every aspect of that occasion seems unimaginable, even irresponsible.

I am not sure when patients will return; the answer for some patients might be “never”. Food, a common currency of gratitude, is gone and touch transgresses boundaries. The first time I leapt back from contact was awkward, now no one even tries. The “new” virus is now simply “the virus”, an invisible dread.

It has now been more than six months since healthcare experienced a mass transition to telehealth, at least in wealthy countries. In less well-off places, medical care came to a standstill along with employment and education. Australian authorities rightly noted that changes that would have taken a decade happened more or less overnight. Last year, I had demurred when asked to trial just one video consultation. It took weeks to organise and then the patient cancelled anyway. Now, within days, clinics jammed with patients halved and then fell silent. Instead of noise and anticipation, what greeted me was a sheet of paper listing when my patients would “meet” me online.

The adjustment was hard. Many of my patients, who are often very elderly, non-English speaking and socioeconomically disadvantaged, were so perturbed by the concept of telehealth that they opted to wait until “this passed.” This made sense initially but as the lockdown continued, we acknowledged that health concerns couldn’t be ignored, and telehealth was the way forward.

In medicine, the line between “must see” and “should see” is not always clear. An octogenarian widow says that my appointments are her greatest comfort, not least because our nurse always checks in too. Together we save her mental health from sliding but on paper, she is a “routine visit” now relegated to telehealth, which is just not the same. Another patient can ramble a bit, but better than any test, serial visits help me track his cognitive decline and plan ahead. When I mention telehealth, he explains that his VCR is broken.

While elderly patients with travel barriers or needing a quick consult may be considered ideal for telehealth, the situation is nuanced. Physicians like me feel the poverty of body language. Surgeons find it harder to share sketches. Nurses find patients are distracted. More tragically, a schoolteacher died at a rural hospital where the only available doctor was via a video link.

Yet, there’s no denying that telehealth has changed the face of healthcare. And nostalgia aside, it has forced a conservative profession to rethink how it can better serve all patients.

In taking stock of the last few hectic months, we must give credit to the people who made telehealth happen. “Tech support” falls into the invisible but indispensable category of help without which frontline workers would be nowhere.

Patients deserve credit for their willingness to try telehealth and for hanging on during connection, disconnection and everything in between. For many patients, seeing the doctor constitutes an outing as well as an opportunity to discuss seemingly random events that actually provide useful data. Telehealth constrains this but people have been gracious and forbearing, sometimes more concerned about their doctor than themselves.

But my greatest thanks must go to all the people who have enabled my most elderly, disadvantaged, and isolated patients to benefit from telehealth. Without them, I fear many of these patients would have skipped healthcare altogether at a greater cost to society.

Recognising the need for human connection not captured by a landline, sons and daughters have driven across town with a laptop or smartphone to connect their parents for a “proper” appointment. I realised this only when several patients became very upset when I was “running early”. I was humbled to discover that their children had taken a day off work and never again regarded the telehealth appointment as a lesser visit.

It’s remarkable to see how many relatives have been organised with observations and questions written in advance – perhaps the hours saved taking a frail parent to clinic are better spent this way.

Part of being an oncologist is overseeing end of life care via Zoom, which is as inadequate as it sounds. But here too, I have had great help. A son spent every week holding up the camera at all possible angles as his father became bed-bound. There was something quite consoling for all of us that telehealth kept us engaged well beyond the point at which he would have stopped coming to see me.

The grandchildren have been particularly endearing. Every grandparent who has proudly showcased a helpful grandchild to the doctor has a head start on life satisfaction. Then, there is the banter. “Granny, she isn’t accusing you of doing drugs, she’s just asking for your meds.” “Pa, get the camera off your belly!” “Doctor, grandma ran out of time to apply lipstick, tell her it’s OK.” The eye rolls, giggles and tenderness have entertained, moved and united us.

Someday, doctors and patients will be in the same room again, although who knows with what restrictions and anxieties. Importantly, those who can’t attend will be afforded an option they did not previously have, and the experience will become progressively better. Doctors and nurses have shared the lion’s share of praise during the pandemic. We owe a huge debt of thanks to the people behind the scenes who make it possible for us to do what we do.

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