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Perspective | Magazine

As telemedicine takes hold, what are doctors like me missing?

As the COVID-19 crisis pushs medicine to a “new normal,” we need to adapt our care of patients — especially at-risk children.

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“Not everything is coronavirus, Dr. H,” one of the nurse practitioners says as I enter Boston Medical Center’s pediatric floor. It’s a sentiment we all share. Our patients had multiple health needs prior to COVID-19, and we worry that the pandemic is overshadowing them. It nags at us daily as our pediatric department struggles to use telemedicine to provide the wraparound care we normally give in person. At our safety-net hospital, many high-risk patients depend on us to care for their entire families.

The COVID-19 crisis has jolted us into a “new normal” where clinicians don headphones and surgical masks and hunch over in cubicles on phone or video calls with patients, in a medical call center of sorts. But pixelated video visits don’t convey the nuanced nonverbal cues of caregivers suffering from depression, or signs of pediatric developmental abnormalities. Nor do they allow the privacy required for spouses or kids looking to disclose violence — weekly reports of child abuse are down more than 50 percent in Massachusetts. Food and housing assessments often get forgotten and vaccines delayed. We all feel uneasy about each lost opportunity to help us improve the lives of our patients.

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I start my shift with a video call to a new mom concerned about her fussy but healthy 3-week-old baby, whose cries make it hard for his mother to hear my voice. She speaks Haitian Creole, a language I grew up speaking. She’s stressed and alone, worried there’s something wrong with him. Normally I’d take him from her hands, model swaddling and soothing techniques, and talk her through ways to read her baby’s cues. I’d highlight the signs that reassure us he’s on track. But over the phone, it’s impossible to comfort her, and she is unable to mimic the techniques. I ask questions to assess for postpartum depression. She doesn’t meet the threshold, but I’m left wondering: Would she have answered differently on a piece a paper?

Later, one of our social workers calls this mom to check on her mood, but it’s through an interpreter. The hospital’s staff of 60 medical interpreters and language experts are equipped to help, but what might my patient hesitate to say to a third party? I e-mail links to videos showing soothing techniques and promoting self-care, but the best ones available are in English. Yet another barrier.

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Next, I call the home of a 16-year-old with a possible urinary tract infection. She’s had one before and requests antibiotics, but I still need to do a thorough assessment, including a sexual history, so I ask if she’s somewhere private enough to speak candidly. I’m startled by an older female voice responding loudly, “She has no secrets from me, ask her what you need to.” Now I understand why my patient’s responses to my initial questions were so tentative. I tell the teenager I have to review her records, and ask for her cellphone number. Later, I get a more honest history that directly affects her care. I long for the days of speaking privately in an exam room and feeling more certain of the truth.

Later, what should’ve been a simple call with the father of a 2-month-old girl who didn’t show up for her routine physical exam morphs into an hourlong conversation. He’s seen reports about Blacks being disproportionately affected by the virus, and worries it would be dangerous to come in. Fear of the pandemic led his wife to quit her home health-aide job. My explanations of the severity of vaccine-preventable illnesses for children compared with COVID-19 — and our clinic’s many precautions to ensure only well children are seen — fail to sway him; he won’t bring the baby in. Then he discloses how they’re struggling to afford groceries, and his wife’s breast milk supply has started to decrease.

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The downstream effects of policies needed to decrease the spread of COVID-19 aren’t benign. In one afternoon, I faced maternal mental health concerns, adolescent health privacy issues, essential vaccination, and food insecurity. None of these individuals had been diagnosed with COVID-19, but their health care interactions were drastically altered, likely for the worse. Our patients needed us to ask ourselves what we’d need to care for our own loved ones — and then advocate for that.

So we did. Among other things, at BMC, we’ve started a mobile vaccine unit to provide weight checks and vaccines for infants unable to come to the clinic, making it possible for that 2-month-old to get her vaccines and the family to receive a few bags of groceries. I helped create a new free app that highlights developmental changes for moms and their infants over the first six months of life, addressing breastfeeding, family dynamics, going back to work, anxiety, and struggles related to race and immigrant status.

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Despite its limitations, telehealth is here to stay, and there are some benefits. There’s a lot to learn from seeing a family’s home environment, and the endorsement of my treatment plan by what I call “the voice of God” — the grandmother speaking off-camera — is invaluable. Virtual appointments work for simple health ailments and are convenient for working parents or those recovering from childbirth or surgery. But continuing this service will require more fiscal support for innovative measures such as our vaccine van; infant care videos translated into many languages; more support staff such as social workers and patient navigators with diverse language capabilities; and appropriate reimbursement from insurers for the novel, but not lesser, clinical management involved.

After a long day, I head home to my own family. “Mommmyyy!” I’m greeted at the door by my toddler. My husband stops him from rushing into my arms. I hear his stunned cries as I run to change my clothing and wash any traces of the clinic from my skin. Later, I squeeze my son tight and smell his hair, hear his giggles, kiss his soft skin. And I smile and think, Not everything is coronavirus.

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Dr. Cyndie Hatcher is a pediatrician at Boston Medical Center. Send comments to magazine@globe.com.