'What should I wear to see my doctor?'

In a chaotic few weeks, the rapid adoption of telemedicine in response to the COVID-19 outbreak has turned the traditional method of healthcare on its head.

Barriers that previously prevented large parts of the population from receiving treatment have disappeared. Transportation difficulties, unpredictable weather conditions, and the need to get away from work on appointments vanished into thin air. New challenges such as Internet and cellular connection fluctuations, technical difficulties, and privacy concerns have emerged.

In this telemedical context, patient behavior and interaction with doctors has also changed significantly.

Medicine has traditionally been a hierarchical profession with written and unwritten expectations of the interaction between doctor and patient. For example, prior to the 1970s, there were no hard and fast rules for informed consent and a doctor was free to choose how much to disclose to the patient; this changed with Canterbury v. Spence (1972). Still, a strict sense of formality persisted between patient and doctor. Now, almost a year after the COVID-19 pandemic, that formality has been eroded as many doctors have become used to working from home and patients have become used to telemedicine.

Throughout our medical training we have been taught to become familiar with the human body and to see patients in various degrees of undress for examination and treatment purposes. But being invited into the privacy of their homes, often including their bedrooms, is an entirely different affirmation.

Dr. Smirnoff encountered this during her first week on the Headache Fellowship when a patient attempted to attend a Zoom work meeting while attending her telemedicine visit. The visit was unsuccessful as the patient was inundated with questions from her work meeting while trying to answer medical questions.

Another patient multitasked her appointment by preparing a large meal for her multiple children and spiced up her visit with a cacophony of kitchen noises as a variety of utensils such as ladles, spatulas and knives came into view throughout the visit. Without the formalities of a physical office, the character of a visit has shifted from a doctor who takes the patient into his room, to a patient who adapts the doctor to his living space and his routine, similar to a greeting at the country doctor, to bedside care would afford.

On another visit, a middle-aged woman presented to our clinic with a constellation of vague symptoms, including headache and fatigue, that had mysteriously started in the spring of 2020. A quick scan of her video presentation showed a brilliant white gleam of snow-covered trees peering through the sloping windows of her car.

After confirming she was not moving, the patient announced that the interior of her car was the only room where she could find the necessary seclusion for this appointment: the pandemic had school for her four children, all of them under 10 years of age, closed and they have now been home indefinitely. These clues gave us a clearer diagnostic picture and insight into the situational depression and anxiety that had manifested as these symptoms and enabled us to relate them to mental health resources.

As doctors primarily treating headaches – including migraines, which can often manifest as severe sensitivity to light – video visits allow us to look out for what we informally refer to as “signs of darkness.” During their visit, a young woman appeared on the screen, dimly lit only by the soft glow of her phone. As her phone’s camera adjusted, we saw the windows taped shut and confirmed that the lights were off, giving the story of her migraines with a force her words could hardly convey.

Beyond physical spaces, the patient’s clothing choices tell of our times. Without the physical space in the doctor’s office, clothing can focus on comfort and convenience and accommodate the new conventions of life through video conferencing.

One physical exam that we can perform via video is to have the patient stand with their eyes closed to determine whether they are dizzy. An elderly woman who looked anxious on screen was embarrassed to show both her pajama bottoms worn with her formal sweater and the mess of papers on her desk that came with her disability. This open consolation can also reveal unimaginable situations in the clinic; a young man appeared shirtless on his visit at 9.30 a.m., lay in bed and barked orders to his mother downstairs from time to time!

Other conventions that were common before telemedicine were also thrown out the window – for example, the desire to hide unhealthy habits from the doctor. During one visit, another woman showed up in her car, casually smoking a cigarette, and continued smoking for the entire hour of her visit without ever noticing or hiding the behavior. Other patients have shown up in their beds in the dark, despite tenacious promises to adhere to good sleep hygiene practices and use their bed only for sleeping. Another patient may be drinking coffee even though it is listed as a migraine trigger or has visible alcohol in the room behind them.

These insights into the unfiltered life of our patients often provide crucial and otherwise inaccessible information. However, those insights are disappearing with our tech-savvy patients, who use video conferencing frequently and can therefore adjust lighting or camera angles to see only the neat presentation they want to project.

On the flip side, we’ve also had many difficult conversations with the forehead, arms, legs, and trunk either standing still or hopping around the screen while the patient gestures with his hand and smartphone on which he is conducting the visit.

Conversely, we then ask ourselves what our patients see in our rooms hastily converted into medical practices: While no medical practice would duplicate the work, Dr’s table and cot are always only out of sight of his patients. Dr. Smirnoff shares her workplace with two dog colleagues who provide a cacophony of background noises, including barking, chewing, crackling, and crunching; The tail wag occasionally appears in the video view and one of her dogs has thrown a lamp on her head several times.

When the light becomes visible at the end of the pandemic tunnel, we need to imagine how the doctor-patient relationship will develop after being guided through the telemedical prism. Evidence of this new equilibrium is gradually becoming apparent as doctors determine long-term how they prefer telemedicine and face-to-face visits.

However, given the ongoing vaccination effort and continued flare-up in COVID rates, the exact time frame in which a new steady state will occur is unknown. A swift return to face-to-face visits could make these changes just a passing fad, while a balance between telemedicine and face-to-face visits could canonize more of this informality. In the latter scenario, would it be necessary to explicitly formulate previously assumed expectations? Should a formal framework be created that includes the equipment necessary for telemedicine, the appropriate framework for an appointment and the decency during a doctor-patient visit?

How will we, as doctors, maintain relationships with our patients in order to achieve the best outcome for both of us? As doctors with almost exclusively telemedical specialist training, we look forward to this opportunity.

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