In Resilient Vermont Network talk, health care panel discusses telemedicine and other patient-serving adaptations

The coronavirus pandemic forced health care’s practitioners to be both in and on. “In” as in office for visits, routine and emergency; “on” as in on camera, to connect with far-off patients who are checking in from home.

A panel of experts — Norwich Nursing Director Paulette Thabault, Dr. Alissa Thomas, a neurologist and neuro-oncologist and an assistant professor at the University of Vermont Medical Center and Dr. Roshini Pinto-Powell, a professor of medicine and medical education and Dartmouth College’s Geisel School of Medicine — said Monday that the pandemic also had practitioners nationwide rethinking care’s delivery and newly embracing technology.

The talk, moderated by Kaitlin E. Thomas, assistant professor of Spanish, was part of the Academic Resilience Collaborative virtual discussion series, sponsored by the High Meadows Fund. The series is presented by the research arm of the Resilient Vermont Network and coordinated by Norwich’s Center for Global Research and Security. The collaborative aims to push Vermont toward resiliency through interdisciplinary research and shared design.

“(The pandemic) really made us stop and think of what kinds of visits didn’t need to be face to face.” Dr. Roshini Pinto-Powell, professor or medicine and medical education, Dartmouth College Geisel School of Medicine

Alissa Thomas said the pandemic reminded patients and practitioners how many layers comprise basic care — primary care, including sick visits; acute care (e.g., emergency rooms); preventive care. Pinto-Powell said evidence-based practice, which integrates research evidence, clinical expertise and patients’ unique values and circumstances, will shape answers to the which-care-is-right question.

“I tell students … ‘You have to put yourself where the patient is,’” Pinto-Powell said, “and shared decision making truly means sharing information back and forth with an open mind.”

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During Monday’s video-delivered teleconference, Norwich University Nursing Director Paulette Thabault discussed how the pandemic has spawned creative new ways to train future nurses. (Screenshot from video.)

Because the internet is awash with information (Dr. Google’s office hours stretch around the clock), Thabault, who’s been health and safety director of Norwich’s COVID-19 response team, said part of future care will be presenting evidence and informing patients about best practices. Sometimes, she said, practitioners may need to correct patients’ self-diagnoses.

The pandemic, harrowing though it’s been, offered telemedicine as a silver lining, the panel said. Pinto-Powell said that in March, when nonessential care and office visits stopped because of state health guidelines, Medicare began covering telemedicine visits, which encouraged her and her colleagues to use the technology for all patients.

“It really made us stop and think of what kinds of visits didn’t need to be face to face,” Pinto-Powell said, “I have a lot of people who come from Burlington, or an hour away (from Lebanon, New Hampshire, where she works). … Do I really need to bring my 95-year-old to see me in the middle of winter to follow up on blood pressure or diabetes?”

Such patients, she said, could get bloodwork done at closer-to-home clinics; blood pressure reading could be taken with at-home cuffs. In both cases, she’d get the data she needs for treatment.

Preserving innovation

Practitioners wll need to encourage insurers and policymakers to continue covering telemedicine visits post-COVID-19, Pinto-Powell said. Alissa Thomas said the benefits are many. Teleconferencing lets her meet with patients, their spouses and children easily and at once, enriching care decision-making. Also, Pinto-Powell said, having insurers continue to cover telemedicine could create schedule flexibility, opening in-person slots for the most acutely sick patients.

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Dr. Roshini Pinto-Powell, a professor of medicine and medical education and Dartmouth College’s Geisel School of Medicine, said it will be up to practitioners to help policymakers see the continued value of some pandemic-sparked health care innovations. (Screenshot from video.)

The pandemic also sparked creative adjustment in education, Thabault said. Teleconference-assisted simulations, for example, helped broaden clinical practice training’s reach, she said. Continuing the practice post-COVID-19, she added, could help more nursing students complete programs and lessen a persistent national nursing shortage. 

However technology alters delivery, Alissa Thomas said, care will continue to rest on bedrock patients-primary care doctor relationships. Having that “home base” relationship, she said, helps patients better navigate care as it expands to include specialists, tests and options.

“These are really hard things to take on, especially when they’re sick,” she said.

Because illness occurs in context, Pinto-Powell said, the primary physician-patient tie is even more important. In 20-plus years at Dartmouth-Hitchcock, she’s seen patients age and has grown familiar with their personalities and health histories. Because she understands the circumstances preceding the patients’ visits and can better deliver care; because of her long relationships with patients, she can ensure that discussions about major illness or end-of-life far precede their potential anxiety.

Fighting isolation

Although the panelists said they’re glad for telemedicine’s possibilities and glad that the pandemic hit Vermont and New Hampshire less forcefully than it hit other places, they said they hadn’t realized how isolated stay-distanced policies would make them feel.

“I didn’t appreciate how much it meant to be able to come out of a room with a patient, sit next to my nurse and say, ‘Wow that was really hard. That patient was really struggling,’ and both … share that experience together,” Alissa Thomas said.

Alissa Thomas said she feared isolation might have been worse for students from out of state. They move far from families and friends, work in stressful hospitals packed with direly sick patients and go home, emotionally drained, to cope alone.

Video has helped restore some vital missing practitioner-patient connection, she said, letting her and other practitioners look into patients’ eyes and ask, “How are you?” or “What are you doing?” Also, Pinto-Powell said, cameras allow looks that COVID-19 has rendered impossible in person.

“On video, you can see your whole face and mouth,” Pinto-Powell said. “In clinic, we have masks, and then shields. And a lot of my older patients, my 90-year-olds, they really rely on seeing your mouth.

“They’re actually really upset,” she added, “they kept taking their masks off to talk to me,” she said. “They’d say, ‘I can’t see your smile, I can’t see your smile. I come here once a year, I want to see your smile.’”

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