Reflections on tele-ICU from a fourth-year medical student.
The code started one hour into my first shift in the tele-ICU. A patient had stopped breathing in a small community hospital on Maryland’s Eastern Shore. The patient was three-and-a-half hours by car from the spacious room I saw filled with a dozen computer stations that looked like they may have been pulled from the control room of a futuristic space ship.
As a fourth year medical student, I haven’t had much time in the ICU, either remotely or in person. So when the code began, I did not quite know what to expect. Surely, I thought, the controlled chaos I am accustomed to when a patient becomes unstable in the hospital would be compounded by the distance between the leader of the code and the nursing staff executing it hundreds of miles away.
But the doctor I was shadowing, an intensivist with years of tele-ICU experience, carried the situation as if no space separated the team. I saw the nurse practitioner intubate the patient at the doctor’s command and watched as another nurse began chest compressions with no sign of buffering or lag from the camera that was broadcasting from that understaffed hospital room on the other side of the state. The same cool, dispassionate demeanor of attending physicians that is so reassuring during emergencies in the hospital was on display in that room, no matter the bandwidth of the connection between doctor and patient.
As the nurses stabilized the patient, I was aware of a sense of surprise, not that the scene had been chaotic, but rather, that this moment—tense with the stakes of a patient’s life in the team’s hands and commanding one’s full presence—felt so similar to any of the codes I had been a part of in-person.
When I bring up telemedicine with other medical students, I am typically met with surprise that such full-fledged programs like the tele-ICU actually exist beyond the proof-of-concept stage. And then, after telling my peers about all the exciting new ways in which telemedicine is deployed at the University of Maryland, I typically hear something like, “But how can you really practice medicine without a physical exam?”
In medical school we are fairly indoctrinated with the primacy of the history and physical in our practice, and this skepticism was something I shared as I decided to explore the world of telemedicine more deeply. It wasn’t clear to me that telemedicine could match in-person encounters without the physical touch of the physician, and the intimacy of the patient-physician relationship that such proximity brings.
Now that I have spent some time in the world of telemedicine, I see now all the spaces in medicine where telemedicine can fill holes in the giant bucket of the medical system. I see, too, how the classic physical exam paradigm can be updated to accommodate technological advances like telemedicine.
Just as tele-intensivists monitor patients for instability in the ICU through telemetry, primary care doctors can track diseases like hypertension and diabetes through remote monitoring of blood pressure and A1C—no physical touch necessary—and supplement office visits with regular video check-ins with patients to help motivate and ensure adherence. I started to imagine the ways a quick teleconference could save a busy parent from having to miss work when their child falls ill or how a psychiatrist could bring mental health services to parts of the country that are in desperate need. Of course, there are a great many benefits to laying hands directly on a patient. But we should not decline to evolve as physicians when doing so would be to forgo the potential benefits of new technologies like telemedicine.
Through my experience in the tele-ICU, I began to see telemedicine for what it really is: a technological platform that enables doctors and nurses to attain broader and deeper impact. Indeed, I was instructed by the tele-ICU physicians I worked with to reframe my conception of telemedicine as a medical intervention of its own. Telemedicine is not a medical intervention in the same way that insulin or penicillin are. Rather, it is part of the infrastructure of healthcare, helping to lay the foundation for a broader reach of medical interventions.
However, in its own way, telemedicine has the potential to broadly improve healthcare outcomes by offering things like insulin and penicillin to those who would otherwise not have access. Medical students that I have spoken with have expressed concern that telemedicine could never really be the same as face-to-face interaction with patients.
When I brought this up with one of the doctors in the tele-ICU, she responded that the question for telemedicine is not how similar or different it is to the classic way of practicing medicine in doctor’s
offices and hospitals. Telemedicine is better thought of as venue for healthcare; it is a space, and really not all that different from a doctor’s office and the four walls of an exam room. Considered this way, and assuming that telemedicine is non-inferior to in-person practice, we can instead focus on telemedicine’s role in helping ease the stress on an overburdened healthcare system.
Of course, telemedicine is only as good as a physician’s willingness to use it as a tool in practice. My medical school class had one half-hour long demonstration of telemedicine capabilities during our second year before we were on floor in the hospital and, therefore, before we had much of a sense of the system-wide strains that can be addressed by changing the ways physicians practice.
In order for telemedicine to become a tool that is used on a wide scale, medical students should have greater education in all the ways it is and could be applied. And students should be instructed how to ask the right questions about telemedicine and broader issues in health systems, in the same way that we are taught to take a history from a patient.
More broadly, medical students need a greater sense for the way healthcare works. We spend a great deal of time studying obscure pathology, but very little learning about the complex healthcare ecosystem that we are expected to enter after graduation and residency. Instead of an ad hoc, piecemeal approach to our health systems education, all students should receive some basic formal training.
Once we have achieved these goals, we may one day find it commonplace to be sitting in a quiet room in some far off city, bringing healthcare to all those in need, no matter the distance.