What a Doctor Learns From Watching You on Video Chat
Patients and doctors are rediscovering the unexpected virtues and hidden pitfalls of homebound care.
In the 1880s, a few short years after the telephone’s invention, futurists envisioned a modern doctor unrestricted by time and space. “That specialist would sit in a web of wires,” the Johns Hopkins medical historian Jeremy Greene told me, “and take the pulse of the nation.” At the time, and for decades after, medical practice remained circumscribed by geography. Black bag in tow, packed with every tool a physician would need, roaming doctors traveled by automobile or horseback and tended to the bedridden wherever they lay. But by the mid-20th century, clinicians stopped trekking from household to household.
“The old-school home visit is just totally impractical,” Charles Owens, the director of Georgia Southern University’s Center for Public Health Practice and Research, told me. “It’s logistically kind of a train wreck.” Cars, public transportation, and sprawling hospital systems eventually converted home visits from a standard of care—40 percent of physician encounters in 1930—to a relic, just 1 percent by 1980. Patients, then and now, flocked to doctor’s offices.
Today, telehealth has resurrected the house call more than a century after it fell out of favor. This newfangled iteration of a bygone practice is less intimate than having a doctor sitting at your bedside, but more personal than sitting on your doctor’s exam table. For some people, virtual home visits are about as uncomfortable as being poked and prodded in a hospital gown, but they allow doctors to once again observe quotidian details of their patients’ health that they might not otherwise glimpse. “The doctor’s office is a stressful place for everyone,” Mark Fendrick, a primary-care doctor with Michigan Medicine, told me. “There are some things we look for that are more artificial in a doctor’s office and more real-world at home.”
Studies have shown, for example, that automated blood-pressure measurements taken when a patient is sitting alone in a quiet place are more accurate. People with white-coat hypertension regularly experience higher blood pressure in clinical settings as a result of anxiety or fear. At-home tests, Fendrick said, can better capture a person’s usual blood pressure.
Along the same lines, some patients seem to perform better on telehealth cognitive tests for dementia, Julia Loewenthal, a geriatrician at Boston’s Brigham and Women’s Hospital, told me. In-office exams can be exhausting, nerve-racking ordeals that sap memory and attention; at home, patients are more relaxed and clearer-minded. “It reduces test anxiety,” Loewenthal said.
A virtual house call can also improve the quality of treatments. Christina Dierkes, a 37-year-old from Columbus, Ohio, usually dreads the end of an intense therapy session. “You bare your soul to this person,” she told me, “and then you’re running into somebody in the elevator and sitting in the car crying and driving home.” Since March, she’s connected with her therapist over the phone, from safe within her pandemic cocoon. “I was at home, in my own space, in sweatpants. It made it easier to imagine I was talking to myself or someone I feel really safe with,” she said.
This advantage is, to some degree, subjective. David Bober, a 51-year-old in Maryland, struggles to find a quiet spot at home where he won’t be overheard or interrupted during psychiatry sessions and is ready to return to in-person therapy. “I’d be happy to sit 12 feet away, on the other side of the room, wearing a mask,” he says. And having to verbalize bodily concerns to a doctor who can’t touch or examine a patient up close can be a source of discomfort. Jon Johns, a 54-year-old in eastern Ohio, had his annual physical—it went well—over videoconference in April. “But what if I was in pain or something was wrong?” he says. “I would be anxious about how well I was describing my symptoms.”
Whatever might be missing from the patient’s descriptions, doctors can glean information through telemedicine that they wouldn’t otherwise have access to. And this might be the true magic of the virtual house call.
The family doctor Carman Ciervo, for example, can’t check a pulse or administer a vaccine through a screen. But over video, Ciervo, a primary care physician for Jefferson Health, in Philadelphia, goes over the prescriptions in his patients’ medicine cabinet one by one. He gauges nutrition by peeking inside fridges. In summertime, Ciervo asks to see thermostats to make sure they’re on and functional. If a patient has mobility issues, he monitors the video’s background for railings or potential tripping hazards.
“Just observing how they climb the stairs can give you a wealth of information,” Ciervo says. “These are all safety problems they might not be aware of, and that might not come up in an office visit.”
Susan Kressly, a pediatrician in Pennsylvania, says her patients—who are often fidgety, anxious, and reserved in her office—are relaxed and outgoing when talking with her from their bedrooms. “When you move the playing field to the patient’s home base,” she told me, “some of that power imbalance and discomfort with the setting goes away.”
The screen also opens a wider window into each child’s personality, Kressly said. Have they been riding the bike she sees in the background and playing with the dog who keeps running in and out of the frame? What’s on their bookshelf? Do they have a sibling to play with or a fort to hide away in? “All of a sudden, you’ve created a personal connection to them as human beings,” she said. “We get a glimpse inside the reality of where patients spend a lot of time—with COVID, a majority of the time.”
However, as the Kansas City University medical historian Kirby Randolph points out, keeping one’s personal life private might be the point of going into a generic doctor’s office. “A lot of patients don’t want the doctor to see their home environment, because they’re self-conscious,” she told me. Domesticating medicine’s turf won’t cure the biases baked into its history—racism, classism, homophobia, sexism, sizeism, and ageism among them—that could color how a clinician interprets a patient’s surroundings.
During the era of traditional house calls, for example, some white physicians refused to enter Black households or treat Black patients, she said. Today, the rooms revealed on video conference broadcast the pay gap between clinician and client (whose income may be dwarfed by their doctor’s six-figure salary). For racial minorities, rural residents, and the elderly—who more often struggle with lower-quality or nonexistent home internet connections—that socioeconomic disparity might be further amplified by IT issues. Once connected, poorer patients, Randolph said, might worry they’ll be blamed for their health problems if a doctor sees an ashtray or junk food on the coffee table.
“The very deep social determinants of health and illness seem so intractable that finding a technological solution that might short-circuit them is enormously appealing,” said Greene, the Johns Hopkins historian. “But technology can be liberating and oppressing.”
Modern medicine has embraced the notion that a person’s well-being is shaped by intimate forces such as upbringing, social circles, and access to transportation and fresh groceries. And yet, most doctors are trained to practice in sanitized, corporate environments and not in the home—“exposed to violence or viruses or the awkwardness of standing in somebody’s house,” Randolph said.
The virtual house call may seem as revolutionary as the 19th-century vision of a modern physician, nested in wires, taking a patient’s pulse from miles away. It challenges the notion that medicine exists only in clinical settings, and offers doctors a view into the space where a person’s health exists as a lived experience. But even virtual medicine takes place somewhere, and that location still shapes the quality of care, for better or worse, from patient to patient. “The idea of meeting the person where they’re at,” Randolph said, “that’s not a preference for everyone.”