Betsy Lehman Center: How has the recent shift from mostly office visits to more telemedicine visits affected you and the patients in your primary care practice?
Dr. Schiff: First, let’s note that telemedicine predates COVID-19. Physicians have often received or made phone calls to patients, although perhaps more informally.
My patients have always had my cell phone and pager numbers, so when they have acute issues they can call me for urgent advice and/or triage: Should I go to the emergency room? Can my problem wait until our next appointment? Can you prescribe antibiotics over the phone for my urinary tract infection symptoms?
First, let’s note that telemedicine predates COVID-19.
However, as your question recognizes, COVID-19 has dramatically transformed telemedicine in quality and quantity. Partners (recently renamed Mass General Brigham) reports 1,600 patients were seen via video visits in February. By April, that number had swelled to 242,000. Right now, I am seeing my patients exclusively by telemedicine.
Patients have welcomed this shift to modern “house calls” primarily because they feared the COVID-19 infection risks of in-person visits, but for many it’s also convenient not to drive into town, take public transportation, or wait to be seen.
There have been other, more subtle benefits — especially when we can use video — such as access to family members and caregivers who may not ordinarily accompany the patient to office visits. I can ask the patient to go to their medicine cabinet and read me the name of the medicine we’re discussing. I can also get a better appreciation of patients’ homes; several have even introduced me to the special pets I have been hearing about for years. A majority of my patients, however, are not able to use video because they lack computers or smart phones and are not able to use our patient portal.
Betsy Lehman Center: What concerns do physicians have about using telemedicine for diagnosis?
Dr. Schiff: We worry about what we miss when we don’t see patients in person, including the loss of non-verbal cues and especially the absence of a hands-on physical exam. For decades, we have emphasized the importance of the patient’s history, but we risk overlooking important physical findings — either those that we are pursuing based on the history or that we incidentally pick up when we examine patients, such as enlarged lymph nodes, breast or thyroid masses, cardiac murmurs or arrythmias.
The rise of telemedicine also involves structural transformations that may affect the quality of diagnosis. The workflow is challenging. Having trouble reaching patients and dealing with the technical logistics of the call may consume five minutes or more of our 15-minute encounter time. That leaves less time for the real tasks of diagnosis: discussing past and present problems, communicating my thoughts, getting feedback from patients about my assessments and uncertainties, and working out follow-up safety nets to monitor how their symptoms evolve and to see whether my diagnostic thoughts were correct.
There is much more to say and research on this subject, and I look forward to exploring these issues in a number of research projects now underway. PCORI recently awarded the Society for Improving Diagnosis in Medicine a grant to convene a multi-stakeholder group to recommend research questions regarding diagnostic quality and 'telediagnosis' in the wake of COVID-19. We will need to not only raise and prioritize these questions, but also fund and conduct the studies needed to answer them.
Betsy Lehman Center: You recently noted the importance and challenge of sharing the uncertainties — what we don't know — about COVID-19 with patients. How do you approach that with your patients? Are they receptive?
Dr. Schiff: For the past several years our research team has been studying medical uncertainty, including how to communicate our uncertainties to patients. The trick is to be more modest and honest about we do and do not know while still reassuring anxious patients. Our team has included experts in communication and health services research, clinicians who are struggling with how to best communicate uncertainties and medical students who recognize how important this issue is to their future careers. We have studied how master clinicians communicate uncertainty with their patients and have made recommendations regarding new ways to approach uncertainty, including how we might better use the medical notes, which many patients can access via open notes or “end of visit” summaries.
There is one thing we are certain about — patients really do appreciate candor.
We also need to figure out how best to engage clinicians, help them feel more comfortable with diagnostic uncertainty and integrate these communications into the already stressed clinical workflow.
There is one thing we are certain about — patients really do appreciate candor and want this extra information and time for discussion. We have now interviewed several dozen patients and found that this is something everyone wants, even as they vary in their communication preferences: verbal, written, during vs. after the visit, and the extent to which some of the education and conversation about uncertainty should be delegated.
Betsy Lehman Center: You are known for recognizing that real-world problems affect your patients’ health affect your patients’ health. And you’ve practiced medicine for decades in underserved communities. What do you observe about the disproportionate effect of COVID-19 on people of color?
Dr. Schiff: COVID has laid bare the disparities in our society and health care system. The data speaks for itself. Disadvantaged communities are at increased risk of getting COVID-19 or experiencing severe illness, regardless of age: non-Hispanic Blacks, American Indians or Alaska Natives have a rate approximately five times that of non-Hispanic whites. Hispanic or Latinx people have a rate approximately four times that of non-Hispanic whites. Nearly every one of my minority patients has had a close friend, parent or other relative die or become severely ill from COVID, often more than one. This added burden, stemming from life and work circumstances as well as health care access and quality, calls for a multipronged approach to dismantling 400 years of racism and disadvantage.
Political action needs to work hand-in-hand with improved care quality, access and research. I am encouraged to see a surge of broad support for social movements. In fact, as Noam Chomsky recently pointed out, polls show three quarters of people support the recent protests triggered by the George Floyd killing, a much higher percentage than ever supported Martin Luther King’s demonstrations, even when he was at the height of his popularity. People are marching in the streets, demanding real change.
Political action needs to work hand-in-hand with improved care quality, access and research.
Betsy Lehman Center:What are the things that can be done now by health care professionals to right this wrong?
Dr. Schiff: We should continue to support efforts to expose and protest current and past abuses and unfair structures that have led to the present crisis. And we should redouble our efforts to root out and compensate for past and present discriminatory practices. For example, we see a disparity in access to Mass General Brigham’s patient portal. Users are disproportionately white compared to our patients overall. To overcome the barriers and equalize this one small but important aspect of care access and quality will require an active effort.
For patients with complex social needs, visits need to be longer to address various social determinants of health. And of course, visiting longer with me hardly solves the patient’s problems. Multidisciplinary support for housing/homelessness, substance use, financial hardships and other problems would help. Navigators, counselors, home health resources and easier access to medical equipment are the types of extra support my patients need.
We are just beginning to understand some of the ways health care processes further harm already disadvantaged patients. I am particularly interested in how this impacts timely and accurate diagnosis. Working with Beth Israel Deaconess Medical Center, the Harvard Medical School Center for Primary Care and the Northeastern Healthcare Systems Engineering Institute, we are looking to “close the loop” on failed referrals, follow-up of test results and symptom follow-up, which we suspect disproportionately affect patients who are Black or poor. We hope to better understand the work processes that underlie such disparities, for both COVID and non-COVID patients, with an eye to redesigning work systems to overcome them.