Face-time vs. FaceTime

In a December story in the Toronto Star written by Dr. Adam Pyle, emergency medicine and primary care physician working in Toronto—The COVID learning gap even hit Canadian medical students—he makes the point that “the first cohort of medical students whose education was significantly derailed by COVID restrictions graduated this summer.” There is concern that the disruption, restrictions and cancellation of rotations and training will render these new doctors ill-prepared for whatever job description follows. Just as they were poised for the transition from classroom to clinical, virtual became the overarching theme, replacing bedside medicine and the wonders of physical examination, history-taking and the sacred and personal connection to the patient, which for the purpose of this story I will call ‘face-time.’ I still recall the angst-charged first morning at the Ottawa General Hospital in 1968. We’d finally been released from the rigidly structured academia of basic sciences, only to be thrust upon the unsuspecting innocents in the wards of the historic ByWard Market area institution. Clothed in our waist-length whites, pockets stuffed with primers, scopes, hammers and other implements of the trade, we followed, like so many penguins, behind our fast-paced clinical instructors. The Grey Nuns stood silently in starched uniforms and with stern visages as they surveilled another in the long line of noviciate students bound either for glory or purgatory. We moved in four-packs, not so arbitrarily selected, as it was easier to disperse us alphabetically. We were, in effect, blood brothers and sisters in this timeless learning legacy. There was much to transpose from the written scriptures to the hands-on practices of bedside medicine our mentors had perfected over their lifetimes. They did this with ease, as if born with genetic facility to teach and impart knowledge and skill, empathy and compassion. They introduced us to the intimate rituals of the patient/doctor connection. This was the formative foundation on which to build our clinical infrastructure. Every nuance, subtlety, symptom and sign was integral to the story of the patient, which would ultimately lead to a diagnosis and treatment. This cascade of data was generated by interrogation, observation and examination. There were no handhelds, tablets, laptops or electronic device assistants. You were the descendants of Osler, patient-focused observers, “every one you see is a lesson in much more than the malady from which he suffers.” The Drs. Hurteau, Ewing, Curran, Sauve and Conway of our world, and the many others who shepherded us through the wards and corridors, clinics and classrooms, were the architects of our future—and for that, we will be forever indebted. In my life, especially now as I'm frequently reflective, they were the “art” instructors, charged with the responsibility of turning on the light, the curiosity and the passion. The rest was left for us to explore and define as we evolved and gained confidence and understanding in our new-found responsibilities to the patient. All the book time in the library or at the kitchen table could never replace the face-to-face patient interface. More than five decades later, my opinion has not wavered. We left the creature comforts of the clinics two years later, released and dispersed to points unknown, “foreign” outposts for further learning and growth. These were the training grounds, to some the battlefields on which our true mettle was revealed. No matter the discipline, the singular constant was the patient. Each dance began with the most basic of steps as we'd learned at our first bedside. The ritual, once deposited in our memory bank, would never be forgotten, always retrievable when called upon. It sustained through internships, residencies, fellowships and eventually practice. There were, as expected, innovations and enhancements along the way, technology designed to improve, not necessarily replace, the fundamentals, at least theoretically. These were often mere distractions, which could unsettle and upend if the temptations were too vigorously embraced. There were, however, fail-safes, built-in prompts, internalized, easily retrievable, that kept most of us on course, redirecting and always returning, face to face, to the patient at the bedside. But, nothing lasts forever. FaceTime is a proprietary video-call product developed by Apple, released in 2010. It enabled smartphone users to add a video option to their calls, no matter where in the world the parties were situated. It would eventually expand to a group video and audio format. Zoom, introduced in 2011, would take things to a new level, expanding and facilitating meetings and conferences. In the early days, FaceTime shrunk the world. Sitting on a cruise ship off the coast of Santorini or Positano or Montevideo, we were able to “show and tell” with our children and grandchildren the wonders of the world of travel. Domestically, we could visit with our “American” children whenever whim presented. Closer to home, we shared scenes from our cottage decks, our living rooms and our dinner plates with children and friends. We expanded our respective universes in real time. We were able to keep in touch with the aid of a palpable new technology that was both intuitive and accessible, despite lacking in the fundamentals and facility of navigating the seas of change. In medical practice, computerization and the electronic medical record (EMR) designed to improve upon a system that wasn’t necessarily broken, was embraced and adapted on the strength of aggressive marketing by dozens of providers and with support from government, college regulators and medical associations. In practice, the focus was shifting, subtly initially, to templated protocols, pre-selected formats and standardized health records. What previously had been the story of the patient soon became historical fiction, unintentional, but increasingly convenient. There were countless incidents when I was informed by patients that what was written in consultant’s notes, transferred electronic records or pharmacy medication reviews had either never happened or misrepresented the reality of these encounters. There were also the complaints that the doctor was more tablet-focused than patient-centred—eye contact in absentia. Perhaps this would be the fatal flaw in the zeal to replace a long-established principle of medicine—the sanctity of the doctor/patient relationship which began at the bedside or the examining table with the power and the comfort of human touch. In March of 2020, the world was upended by a pandemic most were ill-prepared for. After scrambling for the evasive products of personal protection, we returned to our offices. Notably missing, however, was the patient! I worked the phones and fax machine and communicated by email without any direct patient contact for months. The waiting room was reconfigured, absent chairs and clothes hangers and magazines. While I was struggling with makeshift medicine, virtual systems and platforms were precipitously evolving. Once formalized, billing codes appeared and continued to expand exponentially. And, the world of virtual medicine was not only born, but rapidly matured and flourished. Those colleagues who were living better electronically adapted and thrived, situating themselves in the newly-refurbished comforts of their home offices. When I began to introduce direct patient visits in June 2020, there remained multitudes who continued sequestered at home. And so there they remained over the ensuing months, having established a rhythm of sorts with a slowly increasing ratio of home/office, virtual/direct patient visits. But, the barn door had been opened, out of necessity. Virtual medicine with all its warts and shortcomings has become the medical art nouveau. And it will “go forth and prosper.” There are many caveats, however. As we have already seen, the pandemic left a major “gap” in the formative education of our young medical students, relegating them to a virtual bedside. The core tenets of the classic physical exam: percussion, palpation, auscultation and even inspection were all casualties of virtual medicine. This is similarly translatable to everyday practice which, if unchecked, will become increasingly dependent on technology and less so on the art that is at medicine’s very foundation. Ordering tests without the patient present is a slippery and dangerous slope to negotiate. I have followed the career of Dr. Abraham Verghese since first reading Cutting for Stone more than 10 years ago. I reread it this past summer. Some things get better with age. I have also read his biographical writings, listened to multiple TEDtalks and lectures and have carefully followed his innovative programs at Stanford University. His professional designations include “Program in bedside medicine and PRESENCE: The art and science of human connection.” In a recent email exchange with Dr. Verghese, he comments: “The things we both championed in medicine are under threat, but I am hopeful that the pendulum will swing back”. I close with another Dr. Verghese quote on face-time v. FaceTime: “We’re losing a ritual which I believe is transformative, transcendent and is at the heart of the patient-physician relationship, human touch”. In his words, we must learn to be “present, period.”

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Face-time vs. FaceTime

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HOWARD GOLDSTEIN

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