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A virtual window into real lives

Telemedicine provides an insight into patients lives that was once only possible through the house call

House calls are an endangered species in medicine. As a trainee in general practice, I remember having a regular monthly rota of non-urgent house calls to older patients who were unable to get to the surgery. A change in GMS contract before I started in independent practice put a sudden stop to these regular “check-ups”. Yet the daily lunchtime house call list meant we were still calling, on request, to patients homes for healthcare problems. And, of course, the out-of-hours urgent calls continued – not all of them necessary or appropriate.

In general, I never minded being called to a sick child out-of-hours. But being asked to see an adult with a sore
throat at 2am was unnecessary, as were the ones where it emerged the problem had been brewing for several
months, yet the patient hadn’t darkened the surgery door since the symptoms began. The drunken request was another abomination – I still remember gnashing my teeth after seeing someone in the early hours of a Monday morning following an accident at the local nightclub.

It quickly became obvious that my urgent presence at 2am had little to do with the minor foot injury and was really about the need to have a doctor document the issue, as the already salivating boyfriend focused on the payout that would surely emerge after a case against the business was taken. Anyway, with the advent of the well-structured co-ops, house call rates continued to fall, making them the exception rather than the rule in current practice.

Yet, despite being a poor use of medical resources, you rarely came away from a call without learning something about the patient and their family. It was often the kind of snippet that would become suddenly relevant, some months or even years later, in the context of a completely different presentation to the one that led to the earlier house call.

And in a fascinating juxtaposition of the old and the new, the surge in telemedicine in the last 18 months or so has afforded us some additional glimpses into patients’ lives. The formality of the consultation has been eroded and there are now many new tales of how patients present at their telemedicine visit. More than one person has tried to simultaneously participate in a Zoom work meeting while also seeing the doctor. This rarely works out as the patient is flooded with questions from their work meeting while also trying to answer medical questions. Another patient multi-tasked her appointment with preparing a large meal for her family, peppering her
visit with a cacophony of kitchen sounds as a variety of utensils, including ladles, spatulas, and knives flashed in front of the bemused doctor.

The formality of the consultation

has been eroded and there are now

many new tales of how patients

present at their telemedicine visit

And what about many difficult conversations we have had with foreheads, arms, legs, and torsos that bounce around the screen as the patient gestures with their hand and their smartphone on which they’re conducting the visit?

Writing in the online journal Medscape, two US neurologists described the following telemedicine encounter: “A middle-aged woman presented to our clinic with a constellation of vague symptoms, including headaches and fatigue, which had mysteriously started in spring 2020.

Quickly scanning her video presentation showed a bright white sheen of snow-covered trees peeking through the sloped windows of her car. “After confirming that she was not in motion, the patient revealed that the interior of her car was the only space where she could find the necessary solitude for this appointment. The pandemic had closed the school for her four children, all under 10 and they were now home indefinitely.”

These visual insights enabled the doctors to correctly focus on anxiety and depression as the likely cause of the
woman’s symptoms.

It’s also potentially more difficult to hide unhealthy habits from your doctor in a remote consultation. One avowed non-smoker appeared on screen casually smoking a cigarette and continued to chain-smoke throughout the consultation without ever noting or attempting to conceal the behaviour. Then there was the patient with
peptic ulcer disease who had several cups of coffee during the telemedicine visit, while a half empty bottle of
vodka sat accusingly on the table in front of him.

I’m sure patients have equally interesting comments about the temporary surroundings we doctors are
obliged to use when confined to our homes. Despite patients’ and doctors’ relative lack of sophistication and the occasional unintended revelation, telemedicine has proved its worth and is here to stay.

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