Unexpected Moments in Telemedicine

Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.

Edmund Pellegrino (quoted by Richard Byyny¹)

Who would have thought that a telehealth visit might sometimes be more intimate, more informative, more revelatory than an in-person one?

Much has now been written about the utilization of telehealth/telemedicine during the coronavirus disease 2019 (COVID-19) pandemic. One of the authors (RSP) has contributed thoughts about some of its opportunities and problems.^2,3 We shall not re-review here how telemedicine came to be adopted nor its obvious limitations. Rather, we shall present several unexpected telemedicine encounters—some seemed strange, perhaps even humorous,⁴ but upon reflection, these provided clinically important insights about patients that would not likely have occurred at office visits.

These were 6 patient telemedicine visits from one of our practices (NS) during the pandemic in 2020–2022. Identifying features of these patients have been changed to preserve anonymity while retaining the distinguishing elements of the visits.

The Patient Without a Voice. This was a single, middle-aged woman living with adult daughters, cared for over many years for fibromyalgia and depression. A telehealth visit was scheduled to follow up on her generalized pain and long-standing sleep disturbance. The patient was home and was questioned about her problems; all answers came from a daughter who did not appear on the screen. During clinic visits, the patient had suggested that her daughters dominated her home and that she was a virtual tenant in her own house. This was a clear instance where the telemedicine visit was equivalent to a home visit and revealed family dynamics that might not otherwise have been fully appreciated. This insight led to a discussion of the patient’s situation in private when she returned for an office visit, and she was offered appropriate social service and psychiatric assistance.

The Patient With Too Many Cats. This young patient had 6 previous operations on her foot. The scheduled visit was for evaluation of persistent foot pain. The patient had not left the house, nor the room, for that matter, for over half a year since the onset of the COVID-19 pandemic. The telehealth assessment found the patient sitting comfortably in bed, with a commode at the bedside and 6 cats on and around the symptomatic foot. The patient’s significant other hovered nearby to address any of the patient’s needs. These observations likely would not have been deduced at an office visit and, together with other available data, supported that there were probably nonphysical factors contributing significantly to the patient’s discomfort and disability that needed further exploration beyond the medical history and effects of the patient’s prior foot operations. The patient’s despair and hopelessness were apparent, as was the frustration of her significant other. These observations led to psychiatric intervention, antidepressant drug therapy, and psychotherapy.

The Patient in the See-through Nightgown. A young woman was scheduled as a new patient. She had detectable antinuclear antibodies when tested, was concerned about a possible rheumatic disease, and had already been evaluated by several other rheumatologists. When she appeared on the screen, she was lying in bed in a lovely, full-length, transparent nightgown, and smiling. She probably knew she would be seeing a female physician but could not have known whether male physicians or students would be present. After a few minutes of preliminary discussion, she asked if she could introduce her boyfriend, who appeared next to her in bed, in underpants, when the camera was adjusted. This was a rather unusual visit indeed. Why she presented herself with a sheer nightgown in her bed with a man was not discussed; perhaps it should have been. At the next visit, in person, both the patient and boyfriend were dressed appropriately. Perhaps this patient was testing her rheumatologist, perhaps she was expressing her trust in her rheumatologist, or perhaps it was something else. This certainly could not have occurred in an office.

The Patient with the Missing Rash. During a telehealth encounter, this established patient stated that she had a lower back rash that she wished to have examined. She adjusted the cell phone, revealing that not only were there no cutaneous lesions evident but also that she was not wearing underwear. While a bit unexpected, it was quite gratifying to see that this lady felt so comfortable with her rheumatologist in the privacy and intimacy of her home, albeit through a camera. Transitioning to a discussion of her problems and anxieties was easy. This, too, would not have been quite the same in the office, where the traditions and rituals of the examination are prescribed and observed.

The “Almost” Restroom Meeting With the Patient’s Husband. During this telemedicine visit, a well-established patient asked if she could introduce her husband, to which, of course, there was no objection. She related that her husband was in the bathroom and thought a physician would not mind seeing him there. This was surprising, as we do not usually see our patients in the hospital on commodes and bedpans. We see their families in various stages of informality in clinics, offices, waiting rooms, and hospital rooms, but not bathrooms. That this patient felt untroubled by sharing this intimacy regarding her husband was a reflection of the trust in her relationship with her physician.

The Hard-to-Reach Patient. A call to a new patient for a telemedicine visit went unanswered. This was odd since the senior fellow had just spoken with the patient by phone. Another new patient, a woman born in another country and with a pronounced accent when speaking English, had just been evaluated. The missing male patient was called one last time, and this time he answered. He, too, had a pronounced accent and was an immigrant from the same country as the woman just seen. Encountering 2 consecutive patients from the same country seemed surprising until the man laughed and explained that the female patient was his wife. During the visit, she sat by his side on the sofa in their living room. This was sweet. Patients, even when related or married, are not usually seen together. Sometimes, though, with appropriate permission, it can be done and can be very satisfying, as on this occasion.

Practicing medicine through virtual care is still the art and science of trying to help the sick, albeit with the obvious limitation of not being physically present with patients.^1-3 It is from this perspective that we offer synopses of these few brief and somewhat unexpected telehealth encounters. They remind us that there can sometimes be humor in our patient interactions; it is okay and perhaps healthy to identify and acknowledge these moments. And, perhaps more importantly, they teach us that telemedicine visits provide a window into the patients’ lives that sometimes cannot be appreciated in the office or clinic.

These are just a few examples of many during this pandemic. We are informed and helped by how patients’ homes look—the immaculate and organized homes, the patients who have stacks of laundry behind them, those who have many dirty dishes in the sink, as well as how they go about their daily lives—those who are busy cooking, those who are busy with their children, those who have their grandchildren on their laps while conducting the visit, those who sit on the floor, those in bed, and those who are seen in their car, in the parking lot, in the backyard, or in a park. We see patients’ surroundings, bedrooms, families, lovers, spoken and unspoken interactions, pets, wardrobes, and yes—even bathrooms. All these give us a sense of who our patients are so that we can personalize and improve their care.

• Copyright © 2023 by the Journal of Rheumatology