Unless it’s done carefully, the rise of telehealth could widen health disparities

The Covid-19 pandemic has pushed telehealth — the remote provision of health care resources, tools, and consultation, usually via digital technologies — from the backwaters of medicine to its leading edge.

Though novel to some health care providers, and considered impractical by others, telehealth will likely endure — and become even more appealing — after the Covid-19 pandemic has faded away. We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health.

The changes that have made possible the wider use of telehealth appear to be temporary. For instance, health insurers, who once declined to fully reimburse virtual visits to physicians, nurse practitioners, and other health providers, are now making exceptions expressly tied to the nature of the pandemic. Yet research and theory from the social sciences on institutional change would predict that there may not be a clear-cut return to “normal” once this crisis is over.

The adaptation to Covid-19 has realigned the power and positions of physicians, nurses, insurance companies, hospitals, and telehealth startups in providing health services to different communities. Providers are establishing new policies and automated systems around triage, virtual visits, and infection control that may become taken-for-granted work routines going forward. Such practices may be laying the foundation for opportunism in the expansion of telehealth markets above and beyond their value in treating disease and saving lives by allowing compensation for unnecessary visits.


Telehealth is a ‘silver lining’ of the pandemic, but implementing it permanently won’t be easy

For some time, technology companies have sought to disrupt the health sector with algorithms and other patient-centered digital innovations. These companies are now rushing to consolidate their positions before the opportunities presented by the pandemic abate.

Some providers and hospitals, attracted by potential reductions in cost and in potential improvements in patients’ health outcomes, were early adopters of virtual visits and other telehealth technologies. With the emergence of Covid-19, providers who had once been prudently looking for an evidence-based way to add value to their practices have been pushed into rapidly developing telehealth strategies to keep their practices afloat. Academic medical centers that had previously piloted telehealth as a strategy to expand their referrals or to decrease readmissions are now leveraging this infrastructure to more intentionally maintain contact with patients who have been seen in their outpatient offices.

There’s no question that the expansion of telehealth could be a force for good. These changes may save lives during this crisis by keeping patients out of health care settings where exposure to Covid-19 may be high. In the post-pandemic era, they could provide greater access and convenience for some patients. But they could also worsen health disparities down the road if not implemented carefully.

In its earliest days, one of telehealth’s missions was to ensure greater access to health care services by populations that otherwise would go without proper or timely care and consultation, such as those who are incarcerated or who live in rural areas. Now it is being used as a tool to supplant in-person visits and expand patient markets, partly in response to consumer demand for convenience and efficiency. This emphasis on expanding patient markets and responding to well-resourced consumers’ demand may put marginalized groups with poor health, no health insurance, or few digital resources at risk.

A market-driven, consumer-centered vision of telehealth could have negative implications for marginalized groups that already face discrimination during in-person medical encounters. Marginalized racial and ethnic minorities are more likely to report discrimination within health care settings, influencing their willingness to trust providers and seek medical attention early.

Discrimination and mistrust could be magnified in virtual doctor-patient encounters, in which patients may not feel they can fully communicate and providers may be less mindful of guarding against implicit bias based on attributes such as race, ethnicity, or educational status.

The potential for racism and class bias to be encoded into telehealth algorithms is also worrisome. Predictive tools are imperfect — although they may be able to predict average patterns across groups, they can neither fully account for the complexity of individuals nor incorporate subtle variables that may assist in the identification and treatment of disease. While doctors misuse of these algorithms is mitigated by clinical judgement and training, a patients’ uninformed use of such algorithms in lieu of seeking professional medical advice could be harmful. This is particularly true of patients who belong to social groups underrepresented in algorithmic data.

Hospitals, insurers, policymakers, and health care professionals must carefully consider how the telehealth policies and routines they implement might have durable — and potentially harmful — reverberations. Research into the costs and benefits of specific telehealth applications at the individual and population levels is essential.

Institutional policies created during this pandemic will have long-lasting consequences on health disparities. We must work to ensure they are net positive.

Matthew Clair is a sociologist and assistant professor of sociology at Stanford University. Brian W. Clair is an orthopedic surgeon at Lahey Hospital and Medical Center in Burlington, Mass. Walter K. Clair is a cardiologist, professor of medicine at Vanderbilt University Medical School, and executive medical director of the Vanderbilt Heart and Vascular Institute.

I’m Training as a New Doctor in the Shadow of a Pandemic

My generation of physicians is entering the field at a historic moment. Covid will likely follow us through our careers.

The transition from medical student to physician, even in normal times, is a profound one; Covid-19 projects a whole new improbability to this moment. I graduated from medical school early to briefly join the ranks of New York City frontline workers in April, as the pandemic reached its peak. I had dreamed of being a doctor for more than half my life, and as a college student volunteering in a hospital, I conjured up gallant stories of my first weeks as a physician. Instead, Covid-19 ruthlessly dashed my expectations.

The gravity of this moment is now starting to sink in as the majority of medical residents start their training on July 1. I’m among a class of more than 35,000 other newly minted physicians who are entering hospitals across the country this summer amidst the worst global pandemic in over a hundred years. It’s not lost on us that we sit on the precipice of a major change in our lives during a critical moment in history.

Though it may seem unflattering to admit, I take some delight in joining the medical profession in this historic moment.

Like everyone else, we are afraid. We are scared of getting sick or passing Covid-19 to a loved one; scared for our psychological health; scared for our educational trajectory. I fear my early residency training will prepare me more for a career in palliative care than in my desired specialty of cardiology. But of course, we are also motivated, energized, and eager to help.

There is no “normal” way to become a doctor. Nor is there a “right” time to make the transition from a naive student to a physician who is confronted by life or death decisions for their patients daily. Humility takes on a heightened significance for new physicians in hospitals. Our radical advances in medical technologies over the last century have provided little solace or tangible benefit in our fight against Covid-19. In fact, we have resorted to medieval plague eradication techniques, like social isolation and quarantine, to successfully combat this scourge.

My first venture into the hospital was a crash course in medical humility. I was confronted again and again by critically ill patients, and each time I had to wrestle with the basic truth that there was almost nothing to be done. Senior physicians and older residents reminded me of this as so many of my early patients died, but in the moment, their guidance offered little comfort.

Many doctors adapt to this enormous responsibility by developing a steely exterior, or worse, a god complex. My own experiences as a patient gave me early exposure to this open secret within the medical world. I imagine doctors believe such confidence and poise project well for their patients, but it’s often to a fault. My hope is that a silver lining will emerge from the pandemic: It’s harder for this culture of narcissism to persist when young physicians are being trained around such high death rates, or having to constantly confront medicine’s limitations. Perhaps this generation of physicians will usher in a new age of medical humility and leave the paternalistic patient-doctor relationship in the past once and for all.

But medical humility is not the only trait young physicians need. It is equally crucial that young doctors have the chance to bolster their competence and confidence by being able to help their patients. However, confidence comes out of experiencing medicine’s astounding capacity, not its constraints. Covid-19 has and likely will continue to rob us of this crucial confidence boost for some time to come.

The intensity of training during a global pandemic is undoubtedly a double-edged sword for young physicians.

After the SARS outbreak in Toronto in the early 2000s, one study showed health care workers had significantly higher levels of burnout, PTSD, and psychological distress, which lasted more than two years after the outbreak was contained. Similarly, residents who trained during the AIDS epidemic in the 1980s and ’90s reported not only high levels of lasting psychological distress, but also decreased autonomy, breadth of training, and trust in medical technologies. No studies from that era capture whether these early challenges influenced their practice patterns, or for how long. Based on conversations with physicians who trained during that time, my sense is the AIDS epidemic has been profoundly impactful on their careers.

One of my mentors often reflects on his medical training during the AIDS epidemic by citing Shakespeare’s St. Crispin’s Day speech: “We few, we happy few, we band of brothers.” For most of medical school, I had a tinge of envy and awe when I heard about the intensity of his training. Now, I’m experiencing it myself.

Though it may seem unflattering to admit, I take some delight in joining the medical profession in this historic moment. I am not alone among my peers and colleagues. In my stint as a junior physician during the height of Covid-19 cases in New York City, older physicians repeatedly said I would look back at this time as a highlight of my medical career. I believe they are correct, however, I don’t want to reminisce about my training with rose-tinted nostalgia as many older physicians do. Our Covid-19 response has been filled with misery and suffering, along with occasional moments of profound joy. I am proud to have played some small role in helping and humanizing my patients thus far, but I’m most excited to arrive at a place where our medical interventions become more nuanced and effective.

There is an interpersonal joy in becoming a doctor at this time as well. It seems there is an endless appetite for medical knowledge and expertise right now. I have been overwhelmed by the number of questions about Covid and epidemiology I have received in the last three months. I’ve also been surprised by the new weight my words carry. In seeing my friends and family take my theories about the prospects of a second wave and the speed of vaccine development as medical fact, I’ve realized I need to be prudent about how I discuss medical information. In the midst of a pandemic, communicating clearly has the power to change public behavior, health policy, and thereby save lives.

The intensity of training during a global pandemic is undoubtedly a double-edged sword for young physicians. On the one hand, I worry Covid-19 will rob us of the important early experience of witnessing the powerful capacity of medicine to do good. On the other, in training through this pandemic, a generation of young doctors might reject paternalism, embrace humility, and understand medicine does not just take place in the interaction between a doctor and a patient, but also in the development of a trusting communication between health care workers and the community-at-large. I remain hopeful that by training during Covid-19, my generation of young doctors will be expert communicators and public health advocates. This is our chance to be vocal in the face of injustice and uncompromising in advocating for the health of the population, particularly those most vulnerable.

Op Ed: Off to a Tough Start: Managing Birth During the Covid-19 Pandemic

As I begin writing this story I sit at my desk in the hospital ready for the next page on my phone asking me to attend a C-section delivery, evaluate a newborn with low blood sugar, admit a youth with a seizure, or a myriad of other issues that might arise during my shift tonight. As a hospitalist physician trained in internal medicine and pediatrics, I cover many areas of the hospital while caring for adults and children of all ages. Tonight I am on-call for pediatrics which includes the pediatric floor, the newborn nursery, and the labor and delivery unit.

What happens if an infant is born this evening to a mother with the novel coronavirus? Perhaps you are pregnant or have a friend or loved one expecting soon and are asking yourself a similar question. Let’s take a look at how things have played out so far during the pandemic and talk about the most up-to-date recommendations on handling this complex situation.

A concerning event

A story was recently published about a woman in Montreal who was separated from her newborn for 55 days. The infant required care in the neonatal ICU because of prematurity. His mother had tested positive for Covid-19 but recovered quickly. Regional policy dictated that this mother would require two consecutive negative tests before being allowed in the hospital to visit her child. Surprisingly, she continued to test positive weeks after her symptoms had resolved. This was not an isolated occurrence as other similar events have been noted elsewhere. The regrettable outcome, in this case, and others like it, was an unnecessary separation of mother and baby during a crucial phase of the infant’s emotional and physical development.

Based on recent evidence, many experts have advised against such policies. The reason being that the PCR (polymerase chain reaction) test performed in this setting assesses for the presence of viral RNA. The test is very sensitive to pick up small fragments of the virus, SARS-CoV-2, but unfortunately, it cannot distinguish between active or dead viral particles. This can lead to persistently positive results even in a patient who has already recovered from Covid-19 and is no longer able to spread the virus to others.

“Someone that is PCR-positive, especially after they’ve recovered, especially if they’re weeks and weeks into their recovery, it’s not likely that they are still infectious,” — Maria Van Kerkhove, epidemiologist, and technical lead of the Covid-19 response for the World Health Organization.

Best practice

During this health crisis, how should women in labor be cared for if they choose to deliver at a hospital? Multiple organizations including the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) have provided guidelines for managing birth in the midst of the pandemic and these guidelines generally agree with one another. What follows is a compilation and summary of their recommendations.

Are pregnant women considered high risk? Studies thus far have suggested that pregnant women with Covid-19 are not at increased risk for complications when compared to the general population. However, some data indicate that pregnant women may indeed be at a higher risk when compared to nonpregnant women of the same age group. Because more research is needed, the CDC currently includes pregnant women on their list of people who need to take extra precautions to avoid exposure to SARS-CoV-2.

On arrival at the hospital, those with symptoms of Covid-19 should undergo testing. Many hospitals also test women in labor even if they do not have symptoms of Covid-19, but this practice is not considered mandatory by the guidelines. For expectant mothers who either test positive for SARS-CoV-2 or have a pending test, the number of visitors should be limited — generally to just one family member or support person. Because there is no evidence that the virus can be transmitted across the placenta, delayed cord clamping may still be performed.

What is known about risk in newborns? In general, babies infected with Covid-19 recover without issue, but there have been reports of rare complications and even death in infants. This can be worrisome and troubling to expectant mothers which is why it is important to discuss ways to reduce the risk of exposure as much as possible.

Infants born to mothers who have confirmed or suspected Covid-19 should be tested within the first 24 hours of birth, and if negative, have an additional test within the first 48 hours of birth if the infant is still in the hospital. For infants who test negative, it is recommended that a discussion regarding the risks and benefits of separation be held between the mother and medical providers. Separation can occur by multiple methods and to varying degrees including keeping the infant in a separate room, placing the baby in an isolette, keeping the child greater than 6 feet from the mother, and having the mother wear a mask. As you might guess, if the infant and mother both test positive for SARS-CoV-2, separation is not indicated.

Guidelines also recommend a discussion about the risks and benefits of breastfeeding. While early data suggests that the virus cannot be transmitted through breastmilk, clearly, it remains challenging to avoid exposure through the air or by contact while feeding at the breast. Choosing to breastfeed remains reasonable as long as precautions are taken to reduce the likelihood of viral transmission such as hand hygiene and a cloth mask for the mother. Placing a mask on the infant is not recommended.

“Given the benefits of breast milk, when feasible, breast milk should be fed to infants regardless of maternal COVID-19 status.” Sonja A. Rasmussen, MD, and Denise J. Jamieson, MD, Caring for Women Who Are Planning a Pregnancy, Pregnant, or Postpartum During the COVID-19 Pandemic, Journal of the American Medical Association, June 5th, 2020

When can a mother with COVID-19 discontinue separation precautions from her infant? This is not the easiest to explain but here is my best attempt to break it down: The mother needs to either go 72 hours without a fever (without fever-reducing medication) and at least 10 days since her first symptom (or the first positive test in the case of an asymptomatic patient) or have two consecutive negative tests for SARS-CoV-2 at least 24 hours apart.

For mothers with planned pregnancies, except for those whose infants have arrived prematurely, none were aware at the time of conception that they would be giving birth during a global pandemic. Moreover, this crisis can heighten the already strong emotions often experienced by those whose pregnancy was unplanned. While missteps in caring for mothers and their newborns cannot be entirely avoided, healthcare providers and systems continue to adapt and improve. This shifts the focus away from the harsh reality of the pandemic and back to where it belongs — the welcoming of a beautiful new life.

  • By: Bo Stapler

Masking Is Not Just a Matter of If, but What Kind and When

We are making headway (maskway?) here in the United States, with more consensus that masks are key. Collectively, we can drive transmission down big time by wearing them. But if we accept that the average person—talking about myself here—can’t wear a mask 24/7, then we need to make sure we have the best masks possible, and that we wear them when it is most critical.

Masks are important because they both block transmission to others and protect the wearer. They don’t do either perfectly—the better the mask, the better it works—but perfect is the enemy of good enough to keep the R0 below one. So, masks are better than no masks. That’s the most important point.

We would greatly benefit from better masks. Folded up T-shirts work, but the better the mask, the less the viral transmission. This is especially true for essential workers and those at high risk of severe disease. Higher filtration masks are key.

How do we get better masks? This will have to happen either through the federal government — which seems unlikely, unless officials invoked the Defense Production Act — or through the private sector. Investors and companies should be racing toward making these, with a huge market opportunity in addition to the massive public health benefit.

Masks are not just needed to stop Covid-19 cases, hospitalizations, and deaths. They are also our ticket to actually reopening safely, getting back to work, and doing the things that we love to do. Without a vaccine, masks are our next, most pragmatic and achievable step to burning out the epidemic.

Masking is not an all or nothing behavior, either. I keep seeing people running outside alone with masks on, yet not masking indoors while socializing with friends and family. When you mask is almost as important as if you mask. If people can only realistically mask for X number of hours, then they must do so when transmission risk is highest.

This means masking indoors. This may very well mean masking around family or relatives as well, especially if they are in vulnerable risk groups and you live in a high-transmission area. In addition, this means masking while riding public transportation and at work.

Masking while alone in your car or when you are on a walk by yourself or for the second you pass by someone on the street is less useful. Your mask here likely won’t do too much as your risk of transmission is already very low.

So in short: Masks work, better masks work better, and masking during high-risk transmission situations matters more than during those which are low risk. Lastly, don’t shame those not wearing a mask. It won’t work. A genuine conversation may go further—but keep your own mask on.

Scientists warn Corona Virus is spread through airborne transmission indoors

Hundreds of international scientists are urging the World Health Organisation to revise its guidelines about the airborne transmission of coronavirus.In an open letter, 239 experts from 32 countries point to new research that shows an infected person exhales airborne virus droplets when breathing and talking that can travel further than the current 1.5m social distance requirement.The research, from Queensland University of Technology,  shows poor ventilation in public buildings, workplace environments, schools, hospitals, aged care homes, or activities such as singing, contribute to viral spread.

Social distancing signage is seen  at Mount Buller.
Experts say the 1.5m social distancing rule may not be enough. (Getty)

Improved ventilation is vital for protecting against airborne infection transmission, the scientists warned.Led by Professor Lidia Morawska, the experts say the 1.5 metre social distancing rule is not far enough.”Studies by the signatories and other scientists have demonstrated beyond any reasonable doubt that viruses are exhaled in microdroplets small enough to remain aloft in the air and pose a risk of exposure beyond 1m to 2m by an infected person,” Professor Morawska said.”At typical indoor air velocities, a five-micron droplet will travel tens of metres, much greater than the scale of a typical room while settling from a height of 1.5m above the floor.”

A member of the ADF administers a COVID-19 test at Melbourne Showgrounds.
The group of scientists say an infected person exhales airborne virus droplets when breathing and talking that can travel further than the current 1.5m social distance requirement. (Getty)

Signatories to the appeal come from many disciplines including different areas of science and engineering, including virology, aerosol physics, flow dynamics, exposure and epidemiology, medicine, and building engineering.

A sign for COVID-19 Testing in Melbourne.
Experts still recommend hand-washing. (Getty)

Professor Morawska said there are affordable simple measures that can be taken to lessen the risk of airborne infection in buildings:

  • Provide sufficient and effective ventilation (supply clean outdoor air, minimise recirculating air) particularly in public buildings, workplace environments, schools, hospitals, and aged care homes.
  • Supplement general ventilation with airborne infection controls such as local exhaust, high efficiency air filtration, and germicidal ultraviolet lights.
  • Avoid overcrowding, particularly in public transport and public buildings.

“Hand-washing and social distancing are appropriate, but it is view, insufficient to provide protection from virus-carrying respiratory microdroplets released into the air by infected people,” she said.The appeal is to be published in the journal Clinical Infectious Diseases.