Telehealth Thoughts

Life as a doctor in the times of COVID19.

What a strange world we are in right now- but though we've had to make some accomodations and experience some inconveniences, I think about what the previous generations had to endure during humanity's previous worldwide catastrophes, and I remind myself this is a small price to pay, and this too, shall pass.

As an endocrinologist, almost all I do is lab-based. With the exception of thyroid ultrasounds and biopsies, inserting/removing implanted continuous glucose monitoring devices, pretty much everything else I do does not require the patient to be physically present. So, in times of COVID, my specialty seems well-suited for telehealth compared to my comrades in procedure-dependent specialties. Indeed, we were able to pretty rapidly convert the practice to telehealth visits almost overnight, almost to the point of seeing zero patients in clinic. Indeed, in the last 3 months, I saw only 3 physical patients, and have been "seeing" 15-20 remote patients a day. This has kept our patients safe by having them stay away and minimize exposure, and has kept staff healthy for the most part (only 2 clinic staff came down with COVID). So, I thought it might be helpful or of interest to some- here are some random thoughts on this topic.

Patients are given scheduled times for the visit. Before the time of the appointment, my medical assistants are calling them to do the usual "intake"- going over the medication list, answering some questions regarding how the telehealth platform works, reminding them they have an upcoming appointment.

My default is Zoom; this works well for most patients. The video is relatively good quality an it's HIPAA compliant. There is a whiteboard and screen sharing option- helpful for me when I want to draw diagrams of the thyroid or the hypothalamic-pituitary-adrenal relationship, or when I want to show them their glucose tracings online.

If Zoom does not work (if they can't download, or if the audio is not working which seems to happen 10% of the time), my fallback options are Doximity, or doxy.me, or Facetime or if really nothing else works and if their specific insurance allows for it, a phone call. Phonecalls are poorly reimbursed by the insurance, but medical needs obviously take priority over reimbursements so if a patient needs a visit, the phone will do.

I love what technology has allowed us to do now. For my insulin-dependent patients who are wearing continuous glucose monitors, I am able to view their glucose tracings over the last 2 weeks, seeing their minute to minute trends and how their meals and insulin balance each other out. I am blown away sometimes by the ease of how I can see a person's glucose trends almost in real-time, from 80 miles away. Obviously, the patient needs to be tech-saavy and connected enough- for the Dexcom patients this would be Dexcom Clarity, and for the Libre patients I'd use Libreview. For patients on CGM-augmented insulin pumps, one gets to see not just the CGM tracings but their insulin use. For patients not yet uploading, my MAs would help them set this up prior to my telehealth visit with them.

If labs are needed, and they often are, we can electronically send orders to the lab, or mail them the order, and once the results are received, I tend to call them to update them of the findings. So this is somewhat duplicative since there would be 2 points of contact per patient and adds to the work, but I don't see this being too different from the usual face-to-face.

You read about anecdotes of patients who Zoom in awkward situations. Well, I've had 3 patients Zoom with me wearing only their underwear. All three were middle-aged men for some reason. I've had one woman join the Zoom call while in the car. Driving. Yup. And when I said I'd reschedule the visit, she said it was OK- she could talk and drive. For safety reasons, I obviously declined.

It's been a steep learning curve. But apparently we are doing OK. Obviously, telehealth is not well suited for all, but we did well enough that we were cited by the hospital system as one of the top telehealth clinics in the state- and yours truly gave a presentation on our experiences on this topic last month. COVID has certainly changed our way of life- and I am looking forward to days that are more normal again (someday- not to distant future I hope). In the meantime, looks likes telehealth is here to stay for the time being.