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Telemedicine is on the rise, but it has limits. (Getty images)

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Telemedicine’s big moment

As doctors limit in-office visits to prevent coronavirus spread, many join the telehealth movement

Andrew Boyett is still paying for a fleeting mistake he made while studying abroad in France 15 years ago. Driven by all the hubris a 20-year-old could muster, he and some classmates decided to climb a moss-covered exterior wall at what remains of Richard the Lionheart’s castle. But after climbing 40 feet, Boyett remembered that what goes up must come down.

Boyett jumped several feet and landed upright, but he still feels the pain of the resulting herniated disk in his back. That pain flared up again earlier this year. When his doctor’s appointment finally arrived in April, the coronavirus had hit the United States, and medical practices were closed to most in-office visits. Boyett’s doctor consulted with him through an online platform. Boyett said the convenience—not having to leave work—will make him a repeat telehealth customer.

COVID-19 has consumed our collective attention, but chronic and routine ailments still gall patients. The effort to avoid coronavirus transmission in doctors’ offices has promoted the expansion of telemedicine—where health professionals provide medical consultations by internet and phone.

Andy Kahn is an ER physician turned telemedicine provider. He left hospital practice in December 2017 and transitioned to virtual visits full time. His work typically goes through busy seasons: In September, calls begin rolling in from teachers and students who picked up a bug at school. October through March, Kahn sees an increase in flu-related calls. Things typically slow down in the summer months, with patients calling in for ailments like poison oak, swimmer’s ear, and altitude sickness.

Beginning in March of this year, though, he noticed a spike in the number of patients using telehealth services due to their doctors closing office doors to nonemergency needs. Once things began opening, patients still wanted to avoid waiting room exposure. Kahn has also noticed more providers joining telemedicine networks. From April 2019 to April 2020 telehealth usage increased by more than 8,000 percent, according to the nonprofit FAIR Health.

Tara Cavazos, a nurse practitioner, runs a Dallas clinic. Before the pandemic, her office was equipped for telehealth, but those visits made up only one or two appointments per week. By mid-March, though, Cavazos and her partners took nearly all appointments virtually. Her office was authorized to do COVID-19 testing, so it was important to limit in-office exposure for healthy patients.

“We quickly decided either you’re going to come through the back door and get COVID swabbed, or you’re going to be telehealth, and there’s no in-­between,” Cavazos said.

Virtual consultations are convenient and often more affordable than an urgent-care visit. And, Kahn noted, “nearly everyone has an internet connection with their phone or their laptop,” making it easy to connect to a telemedicine provider who can then send a prescription electronically to the patient’s local pharmacy.

So much is lost over a telephone encounter.

But telehealth presents some challenges. Cavazos found that virtual visits have put an additional strain on her office’s front desk staff, who often must walk less tech-savvy patients through creating an account login for the online platform, ensuring they’re using a computer with a camera or a smartphone or tablet. She was relieved when the federal government announced in late March it would waive privacy law restrictions against providers using less secure technologies—like FaceTime or Google Hangouts—in patient consultations. The goal, stated Office of Civil Rights director Roger Severino, is to maintain medical care access for “older persons and persons with disabilities.”

Cavazos said her older patients are often accustomed to talking to their grandkids over FaceTime already, so that option made adding new telehealth patients less of a burden on her staff.

Some providers worry the growth in telehealth will widen the chasm between underserved patients and quality care. Dallas nurse practitioner Katy Vogelaar said her low-income patients—many of them refugees—don’t have reliable internet access. Often, they do not even have a phone. Language barriers also make communication by phone difficult for her clientele: “So much is lost over a telephone encounter,” she said.

Cavazos agrees: “We didn’t go into healthcare to be behind a computer. Healthcare requires a holistic approach: seeing, touching, talking to a patient.”

Her practice currently tries to sustain its providers by rotating who is on telehealth duty and using a standing desk. Even on days that feel monotonous, Cavazos said most providers endure, knowing they’re providing a valuable service to patients.

“I’ve never had a day really where I haven’t wanted to go to work, even in the midst of this pandemic,” she said. “I still love what I do. It just looks different.”

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AP Photo/John Locher

A healthcare worker directs patients in their cars at a drive-thru coronavirus testing site run by the University of Nevada Las Vegas School of Medicine and the Nevada National Guard. (AP Photo/John Locher)

Health

10 reasons we should still take the coronavirus seriously

Leaders’ missteps have created mistrust, but we still have to fight a pandemic

An Alaskan reader challenged us to share 10 reasons to take the coronavirus pandemic seriously—to believe that it is “not a hoax,” as she put it. Her state’s experience with the coronavirus has encouraged its residents to see it as a faraway problem: The entire state has suffered only 17 deaths so far, whereas a single nursing home in my area saw a higher death toll. 

Part of Alaska’s separation is geographic. Air traffic largely ceased from mid-March until recently, and few would-be visitors braved the lengthy road trip through Canada. (For the curious: Yes, Canada allowed Americans to drive across the border if they promised they were heading straight for Alaska.)

That brings us to the first reason: As Arizona, Texas, and Florida have shown, case counts can rise quickly in places that hadn’t been hit hard. This isn’t mainly from increased testing, because the percentage of positive tests is increasing—not decreasing. Frustration with the economic damage from shutdowns has led to political resistance, just as annoyance with the shutdowns’ inconveniences has led to fatigue among the public. Both mean that we are likely entering a period where the virus spreads more rapidly. My county now reports 100 and even 200 cases per day—far beyond even its April high—but plans minimal restrictions in response.

That brings us to the second reason: The supply of quality personal protective equipment (PPE) remains limited. Improvised fabric masks and bandanas satisfy the letter of the law and are likely better than nothing, but they fall far short of N95 and P100 masks—or even plain old surgical masks—in protecting from airborne transmission. Yet finding good masks remains a challenge, even for hospitals.

A third, related reason: Even where PPE is available, its use remains hit-or-miss. Early signals from Washington, D.C., and the World Health Organization actively discouraged mask-wearing, and commentators seeking to downplay the virus argued that subsequent calls for masks stemmed from politics. Yet experience worldwide has shown that widespread mask use really does make a difference—especially when they’re worn properly.

Let’s move back to what happens if the virus does get past protective measures and consider the argument that it’s “like a bad flu season.” Coronavirus has now killed over 130,000 Americans, despite having only infected roughly one-twentieth of the population. Last year, the Centers for Disease Control and Prevention estimated the flu killed 24,000-62,000 Americans—total, for the entire flu season. 

We’ll call the higher mortality rate reason No. 4, and No. 5 is what happens to people who don’t die. We recover from colds and almost always recover from flu, so we tend to assume that getting the coronavirus and not losing one’s life equates to a full recovery. Not necessarily: As a recent Wall Street Journal article reported, perhaps as many as 15 percent of people who survive the coronavirus have lasting problems such as shortness of breath and irregular heart rate or blood pressure. Since the pandemic has only been a major problem in America for a few months, we don’t know whether “lasting” means a few months, a few years, or the rest of a patient’s life. What we do know is that this virus does not behave like colds and the flu.

Reason No. 6 goes with that fight to get well: Doctors know far more about treating coronavirus than in March, but knowledge is still lacking. Simply discovering whether steroids would help qualified as a major breakthrough. Even now a debate rages about whether doctors should treat severe COVID-19 as acute respiratory distress syndrome or as a phenomenon all its own. That will determine what treatment patients should receive.

The next reason reminds us that we shouldn’t assume they’ll be able to get that treatment: If hospitals and ICU beds fill up, where will patients go? Hospitals in several areas are dangerously close to filling up, with case numbers still surging. On July 5, Austin Mayor Steve Adler told CNN, “I am within two weeks of having our hospitals overrun. And in our ICUs, I could be 10 days away from that.” All of our knowledge and equipment will be in vain if we have nowhere to put patients—or, as hospitals have discovered with their newly minted COVID-19 wards, if they are unable to staff them. Houston Mayor Sylvester Turner said on CBS’ Face the Nation: “We can always provide additional beds, but we need the people, the nurses and everybody else, the medical professionals, to staff those beds. That’s the critical point right now.”

Reason No. 8 is more optimistic, reminding us that the only way out is not through simply waiting to get sick. Our efforts to develop and produce a vaccine are unmatched in medical history. This matters not just because we are likely to have one—or several!—good vaccines, but because we are also likely to have at least one by early next year, if not by late this year.

Reason No. 9 underlines why the vaccine is worth the wait: While the current surge in cases focuses on the young, experience has shown that it won’t stay restricted to them. Nursing homes can turn away coronavirus patients, but they can’t function without their (typically young) nurses and aides. If cases surge among the young, they will soon surge among all age groups.

Several readers have offered various political viewpoints on the pandemic, but looking at the situation in other countries gives us the 10th reason: Countries that took the coronavirus seriously are limiting both their death toll and economic damage. Several have brought transmission down sharply, in some cases almost to zero: New Zealand, Finland, and Estonia have each had great success. By comparison, countries like Sweden, Brazil, and Iran that effectively chose to let the fires burn have felt great pain. All have one thing in common: They’re far from here, and their decisions weren’t based on American politics. We have the luxury of being able to see what has worked elsewhere. Let’s act based on that.

But let’s do something else, too. Let’s let our speech be seasoned with salt (Colossians 4:6). Missteps by leaders on both sides of the aisle have led to mistrust among the public—mistrust of politicians, mistrust of medical specialists, mistrust of each other. Social media has done what it usually does, dividing instead of edifying, setting us at odds instead of helping us understand one another.

Let’s be the alternative to that kind of talk. Shouldn’t Christians look—and sound—different from the surrounding culture? As we engage with those around us, let’s ask not whether our words support a given political stance, but whether they reflect who we are in Christ.

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Health

Staying sober in a pandemic

The coronavirus outbreak creates challenges for recovering addicts and the ministries that serve them

Danielle York, a 34-year-old from Denver, is a recovering alcoholic. She remembers drinking “from the time I woke up until I went to bed.” But the alcohol made her sick, so York tried to change: She completed several rehab programs but always slipped into old habits when she returned to her former environment and friends. Eventually the state took her two children. 

A year ago, she came to Providence Network, a Christian residential program with six homes in the Denver area. There, York became a Christian, found a job at a marketing research company, and settled into a routine: church on Sundays, group meetings and counseling appointments on weekdays, and visits with her kids on Saturdays. 

“It’s been amazing. [Providence Network] saved my life,” she says. “I never thought I could stay sober for a year.” 

But halfway through her rehab program, the coronavirus pandemic hit. Recovery ministries have lost funding and now must limit in-person gatherings. Yet drug and alcohol addicts need these programs more than ever.

When Denver’s shelter-in-place order took effect March 24, Providence Network stopped accepting new residents and took precautions: Instead of family-style meals, residents ate in two shifts. Celebrate Recovery and one-on-one counseling moved to Zoom, the online meeting platform. Staff members restricted visitor access at resident homes, except for essential things, like plumbing repairs. 

York lost her job on March 17. Suddenly, instead of a highly structured week, she had time on her hands. She now goes to the store and visits her kids, but the rest of her life—church services, counseling, probation classes, meetings with the other women in the house—takes place online. She spends her days alone in her apartment, trying not to think about drinking. “When you don’t have a schedule it’s hard, because your mind plays with you,” she says. “You’re stuck in your apartment thinking, ‘No one would know.’”

Social distancing requirements are short-circuiting Providence Network’s ability to build community. Executive director Derek Kuykendall says the recommended behaviors (“stay home, go in your room and don’t come out”) are symptoms his staff usually associates with relapse. “Isolation is the enemy of recovery,” he says.

Some Providence residents have already relapsed since the shelter-in-place order began, although it’s impossible to identify a direct cause. Like York, many residents lost jobs, and that introduces financial instability, disrupts routines, and removes a source of purpose and responsibility.

Some addicts use drugs or alcohol to feel calm in stressful times, so the pandemic may be tempting them to use. People fighting addiction might despair as they see their progress—keeping a job, building a routine—disappear.

Danielle York is focusing on one day at a time. She gives herself a goal for each day, whether it’s working on her notary license or going for a walk outside: “I have faith that everything’s going to be OK. … I just need to keep going because this will end, and life is going to continue.” 

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