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Our hospitals have had their finest hour in the care of acutely ill inpatients during the COVID-19 pandemic, including dealing with allocation decisions fairly and transparently, maximizing good outcomes and remaining cognizant of the enduring ethics of healthcare. The honorable traditions of self-effacing conduct and acceptance of some level of personal risk by healthcare professionals have justifiably been lauded within the professions and in the broader society. We have endeavored to meet the needs of patients competently, efficiently and without consideration of disability, ethnicity, citizenship status, social or economic position, or other judgments of a patient’s social worth.
Where we are, and will be, in the care of patients in an ambulatory setting in the post-COVID-19 era remains unresolved. The new normal is telemedicine. The reasons are understandable, including the need to protect our patients from COVID-19 exposure, to protect our staffs and ourselves, to have safe waiting areas, to have adequate personal protective equipment and to accommodate simple matters, such as cleaning examination rooms.
The path forward in the new age of telemedicine evokes a new set of ethical concerns. Although presently necessary as a matter of safety for everyone, including patients, those who would accompany patients to outpatient clinic encounters, ourselves and our support staffs, it has not as yet been demonstrated that telemedicine is the clinical or ethical equivalent of face-to-face medical encounters. Neither has it been sufficiently demonstrated that it can be delivered with the same level of clinical competence as can face-to-face ambulatory care—competence being the first moral obligation of healthcare professionals.
Medical Professionalism
To suggest nothing will change in a new world of predominantly telemedicine is an assertion that currently cannot be supported. From the time a patient enters a physician’s office until their departure, important social dimensions to the encounter play out. These include greetings from familiar members of the staff and those who schedule follow-up visits and arrange for consultative referral, laboratory and imaging appointments. Patients have long-standing relationships with our support staffs and to diminish them with electronic, device-generated registration, referral and sign-out diminishes the therapeutic relationship.
The encounter itself, where decisions are made to continue current management or to make major changes in treatment plans, is different in telemedicine. Are such changes made confidently in remote encounters, and are patients and physicians confident making such decisions? During a telemedicine encounter, we can perform data entry and order studies, referrals and treatments, but the baseline uncertainty is fraught with new concerns generated by not being there.
The encounters of doctor and patient in telemedicine are transactional; the question remains whether they can be transformative and instrumental in enhancing human flourishing, one of the noble goals of medicine. The line between a telemedicine visit and a reassuring callback to a patient is blurry. If we now charge patients for the courtesy of a callback to provide results of completed studies, including the reassurance that results are normal or improved or to learn whether a newly prescribed treatment has helped, medical practice will resemble the billable-hours model of law practice. This is not to disparage law practice, but medicine has been different. This change risks commodifying the historic essence of medicine.
As we attempt to maintain the relational side of medicine, we must ask whether face-to-face visits will be limited to those needing some technical procedure. This seems an underutilization of the skills of some of the most humanistic physicians, such as those who provide primary care, allocating them to remote, electronic device-dominated modes of practice.
Although presently necessary as a matter of safety for everyone … it has not as yet been demonstrated that telemedicine is the clinical or the ethical equivalent of face-to-face medical encounters.
Physicians will need to ensure that other aspects of their relationships with patients are not undermined. These include how we address the needs of the worried well, a common and important part of practice. Whether the same degree of reassurance can be provided remotely is unclear. Conversely, is telemedicine the best venue for disclosure of bad news to patients?
Telemedicine is unlikely to improve consistent care for the inconsistently compliant patient; a missed phone contact or lack of a follow-up laboratory study will be more difficult to track in a patient not physically present.
How the occasional adversarial encounter with patients can be managed remotely will need attention, whether regarding disagreements about recommended treatments, needed studies or referrals, or such contentious matters as reducing use of scheduled drugs or adherence to changing guidelines and best practices.
Finally, because telemedicine is less relational than face-to-face practice, we must be concerned about patient satisfaction. We must confront questions about whether patients will remain loyal in such two-dimensional relationships, whether more doctor-hopping and fragmented care will ensue and, more ominously, if exposure to malpractice litigation will be increased.
Quality, Financial & Productivity Implications
Telemedicine raises concerns about providing high-quality care. Practical obstacles exist, including the observation of subtle abnormalities on skin and joint examinations in rheumatology patients, the measurement of weight and blood pressure, and detection of edema in patients with cardiovascular disorders. Examinations of the diabetic foot and cutaneous ulcerations are difficult to perform remotely. Even with current video televisits, these observations cannot be accomplished.
In rheumatology, most evidence-based instruments for measuring disease activity cannot be used apart from face-to-face encounters.1
More broadly, dual risks with telemedicine must be addressed. The risk of overtesting and overtreatment wrought by uncertainty due to not seeing a patient exists. The opposite applies as well: It is intuitively difficult to think that important findings and treatable problems will not be missed.
Then the question of how clinical trials will be conducted absent face-to-face encounters with collection of objective patient data remains open. And a corollary concern is that participation in clinical trials will go down—the price paid for real-time, face-to-face clinical encounters in academic medical centers.
Already, insurers, especially those who cover indigent subscribers, are reducing reimbursement for COVID-19-related telemedicine visits. This will create new productivity pressures on employed physicians, particularly on those whose patients lack access to sophisticated technologies for telehealth visits.
A legitimate concern is that unrealistic productivity targets will be set for providers of care to low-income patients whose insurance provides only nominal reimbursement. The only offset for this will be increased volume of such visits, with implications for quality of care and patient and physician satisfaction with such encounters.
A further concern is that as costs rise for innovative diagnostic and therapeutic modalities and concerns for total healthcare costs, will reimbursement for telehealth visits become the low-hanging fruit for reduction? And a related concern is whether a medical Darwinism arises wherein the most technology-savvy practitioners thrive to the detriment of the most humanistic physicians.
Educational Implications
Telemedicine will be less personal, less hands-on than traditional patient encounters. One can foresee problems recruiting bright, creative, humanistic students to a mode of practice centered on data entry and managing numbers, and devoid of in-depth relationships with vulnerable patients.
Questions also arise about how we can provide ambulatory education in such an environment and how trainees can master cognitive and clinical skills, as well as patient advocacy absent a live patient.
This mode of practice seems to be fertile ground for burnout. These matters will be particularly germane in facilities where deferred expenditures on needed technology in outpatient clinics have occurred, let alone for the video cameras required for telehealth, to say nothing of technology access problems on the patient’s side.
Social & Fairness Implications
Telemedicine risks widening healthcare disparities. The extreme model of concierge practice offers a limited number of privileged patients able to pay an annual retainer a choice of live or telemedicine visits, which are promptly arranged. One can foresee that for those with less robust insurance a claim will be made that telemedicine is better than nothing. The question is how much better than nothing? New quality metrics will be needed to prove or disprove that claim.
Face-to-face patient encounters could become the exception, with routinized, impersonal telehealth visits the new normal. Are we unwittingly changing the role of physicians to one more analogous to “your call is important to us,” semi-anonymous, customer service representatives?
Healthcare disparities will be aggravated by disparities in patient access to higher quality technology hardware and software platforms. In our inner-city, safety net practice, telehealth visits typically involve older patients whose main link to our practice entails telephone land lines without the capacity for video contact. For patients who are not fluent in English, telemedicine adds an additional obstacle to the personal medical care they need. The evaluation and management of pediatric patients and patients with visual, speech, hearing or cognitive impairments will be challenging in a remote format where direct observation and interaction are not possible.
Finally, more broadly and philosophically, will telemedicine enhance or undermine the importance of solidarity and mutual human obligations, recognition of our universal vulnerability to disease and mortality if increasingly it surrenders to the atomization and anomie that make human community less common? In the age of shopping remotely from home and on-demand movies and entertainment in place of going to theaters, will we be the enablers of, or the resistance to, the social isolation that undermines a sense of community, mutuality and solidarity? Will medicine be episodically personal and predominantly remote, or will that which is uniquely professional and relational in the clinical encounter survive?
How these questions are answered will shape the future of the doctor-patient relationship.
Conclusions
I acknowledge my generational reservations in the new world of ambulatory medicine and that the new normal is far more familiar to newer generations of physicians. At its best, telemedicine can provide heretofore unavailable access for patients in chronically underserved areas and modes of care where electronically accessible laboratory and imaging results can be shared with patients similarly in possession of state-of-the-art devices. It has been a lifeline to our patients in the current pandemic, which has isolated us from our patients and our colleagues.
New technologies and a new generation of physicians more familiar with the deployment of those technologies may ameliorate many of the concerns I have raised. Physicians and patients will watch with interest and a measure of fear and wonder for what evolves.
The burden of proof lies with advocates of the new normal of telemedicine to demonstrate its equivalence in quality, access and cost, the three pillars of excellence—the central position of the care of the patient Francis Peabody cited in the well of the amphitheater at Boston City Hospital nearly a century ago endures.2
A parting hope is that medicine remains, as Edmund Pellegrino has described it, the most scientific of the humanities and the most humanistic of the sciences.3 As such, medicine must remain firmly anchored to its place in the healing relationship at all parts of the human journey.
Our profession has performed admirably in the COVID-19 crisis. Having tentatively won the war in the pandemic, we must not lose the ensuing peace of the post-COVID-19 era in patient care. To claim the care of ambulatory patients will be unchanged in the era of telemedicine is specious; it will be vastly different from traditional modes.
Our professional obligation is to ensure we remain on a trajectory of continuous improvement. The best of medical ethics and a commitment to the primacy of patients has prevailed in the COVID-19 crisis. Will that timeless ethic prevail in the new normal of post-COVID-19 telemedicine? Will the primacy of the good of the patient survive, and more importantly, will it flourish?
Richard L. Allman, MD, MS, FACP, FACR, is a member of the clinical faculty in the Division of Rheumatology at Einstein Medical Center, Philadelphia, where he was an associate director of the residency program in internal medicine from 2002–18. He is also an associate professor of medicine at the Sidney Kimmel College of Medicine of Thomas Jefferson University. He has a Master of Science in healthcare ethics, and he is an editorial reviewer for Annals of Internal Medicine.
References
- England BR, Tiong BK, Bergman MJ, et al. 2019 update of the American College of Rheumatology recommended rheumatoid arthritis disease activity measures. Arthritis Care Res (Hoboken). 2019 Dec;71(12):1540–1555.
- Peabody FW. The care of the patient. JAMA. 2015 May 12;313(18):1868. [Originally published 1927 Mar 27;88(12):877–882.]
- Giordano J. Quo vadis? Philosophy, ethics, and humanities in medicine—preserving the humanistic character of medicine in a biotechnological future. Philos Ethics Humanit Med. 2009;4(12):1–2.
Note: This article is the opinion of the author and does not necessarily represent the views of the ACR or The Rheumatologist.
