COMMENTARY

'What Should I Wear to See My Doctor?'

Liza Smirnoff, MD; Leon S. Moskatel, MD; Nada Hindiyeh, MD

Disclosures

July 08, 2021

In a few chaotic weeks, the swift introduction of telemedicine in response to the onset of COVID-19 upturned the traditional method of delivering healthcare.

Barriers that previously deterred large swaths of the population from receiving treatment disappeared. Transportation difficulties, unpredictable weather conditions, and the need to take off from work for appointments disappeared into thin air. New challenges, such as internet and cellular connection fluctuations, technical difficulties, and privacy concerns, have arisen.

Within this telemedicine context, there's also been a significant shift in patient behavior and interactions with physicians.

Medicine has traditionally been a hierarchical profession, with written and unwritten expectations about physician and patient interactions. Before the 1970s, for example, no firm rules about informed consent existed, and a physician could use his or her own judgment about how much to disclose to the patient; this changed with Canterbury v. Spence (1972). Still, a strict sense of formality between the patient and physician persisted. Now, nearly a year into the COVID-19 pandemic, this formality has eroded, as many physicians grew accustomed to working from home and patients grew accustomed to telemedicine.

Throughout our medical training, we have been taught to become comfortable with the human body and seeing patients in various degrees of undress for the purpose of examination and treatment. But it's quite another affirmation to be invited into the privacy of their homes, often including their bedrooms.

Dr Smirnoff encountered this during her first week of headache fellowship, when a patient tried to simultaneously participate in a Zoom work meeting while also attending their telemedicine visit. The visit was not a success, as the patient was flooded with questions from her work meeting while also trying to answer medical questions.

Another patient multitasked her appointment with preparing a large meal for her multiple children, peppering her visit with a cacophony of kitchen sounds while a variety of utensils, including ladles, spatulas, and knives, came into view throughout the visit. Without the formalities of a physical office, the nature of a visit has shifted from the physician accommodating the patient in his or her space to the patient fitting in the physician to his or her living space and routine, akin to welcoming in the country doctor who would render care at the patient's bedside.

In another visit, 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 clues gave us a clearer diagnostic picture and insight into the situational depression and anxiety which had manifested as these symptoms and allowed us to connect her with mental health resources.

As physicians who primarily treat headaches — including migraine, which can often present as a strong sensitivity to light — video visits enable us to be on the lookout for what we informally call the "darkness sign." A young woman appeared on-screen for her visit, dimly lit only by the soft glow of her phone. As her phone's camera adjusted, we saw the windows taped shut and confirmed the lights' unilluminated state, conveying the story of her disabling migraines with a potency her words struggled to convey.

Beyond physical spaces, patients' clothing choices narrate our times. Without the physical medical office space, attire can focus on comfort and convenience, attending to the new conventions set forth by life lived through video conferencing.

One physical examination maneuver we can perform over video involves the patient standing with their eyes closed to assess for vertigo. An older woman who appeared anxious on screen was embarrassed to reveal both her pajama bottoms, worn with her formal sweater, as well as the disarray of papers on her table, which accompanied her disability. This overt comfort can also reveal situations unimaginable in the clinic; one young man appeared at his 9:30 AM visit shirtless, lying in bed, and intermittently barking orders at his mother downstairs!

Other conventions common before telemedicine have also been thrown out the window — for one, the desire to hide unhealthy habits from one's doctor. During one visit, yet another woman appeared in her car, casually smoking a cigarette and continued to chain-smoke during the entire hour of her visit without ever noting or attempting to conceal the behavior. Other patients have appeared in their beds in the dark, despite adamantly promising to be adherent to good sleep hygiene practices, including only using their bed for sleep. Another patient may be drinking coffee despite listing it as a migraine trigger or have visible alcohol in the room behind them.

These glimpses into our patients' unfiltered lives often give crucial and otherwise unobtainable information. Yet, these glimpses disappear with our more tech-savvy patients who commonly use videoconferencing and are thus able to adjust the lighting or camera angle to show only the manicured presentation they want to project.

On the other hand, we have also had many difficult conversations with foreheads, arms, legs, and torsos that either stay still or bounce around the screen as the patient gestures with their hand and their smartphone on which they're conducting the visit.

Conversely, we then wonder what our patients see in our spaces that have been hastily converted to houses of medical practice: Whereas no physician's in-person office would do double duty, Dr Moskatel's office serves as his infant son's room at night, and the changing table and crib are always just out of view of his patients. Dr Smirnoff shares her workspace with two canine coworkers who provide a cacophony of background sounds, including barking, chewing, crinkling, and crunching; wagging tails occasionally come into the video view, and several times, one of her dogs has knocked a lamp over onto her head.

As the light at the end of the pandemic tunnel begins to come into view, we are left to imagine how the doctor-patient relationship will evolve after being taken through the telemedicine prism. Hints of this new equilibrium are starting to be seen as physicians determine long-term how they prefer to navigate telemedicine and in-person visits.

Yet, with the vaccination effort ongoing and continued flare-ups of COVID rates, the exact time frame in which a new steady state will emerge is unknown. A swift return to solely in-person visits could see these changes be just a temporary fad, whereas a balance of telemedicine and in-person could canonize more of these informalities. In the latter scenario, would it be necessary to explicitly establish expectations that would have previously been assumed? Should a formal framework be established of necessary equipment required for telemedicine, appropriate setting for an appointment, and decorum during a patient-physician visit?

How will we, as physicians, steward the relationship with our patients to achieve the best outcome for us both? As physicians who have undergone specialist training conducted almost entirely through telemedicine, we look forward to the opportunity.

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