The old-fashioned house call.
Those good old days, when the family doc brought his little black bag to your house. Patients stayed at home. Doctors visited their patients. Norman Rockwell captured these images beautifully.
I’ve made a few house calls over the years, but I have spent most of professional life in the office.
Then COVID-19 came and everything changed. I started doing “house calls.” My patients stayed home and I started to visit them. Instead of using the tools in my little black bag, I started using the app on my little black iPhone.
Telehealth has been a life saver, literally.
What is telehealth?
Telehealth allows patients to visit their doctors through a video platform. The technology has been around for years, primarily used by patients in rural areas to access medical care remotely.
Until March of 2020, I was NOT a fan of telehealth. Telehealth was evolving, marketed to patients as a convenient alternative to visits with their primary doctors. I was concerned that my patients might get the wrong advice from a healthcare provider that did not know them, their health history or have access to their medical records.
What happened in March 2020?
As things started to close down, primary care doctors wondered how they would continue to care for their patients.
IT directors stepped in to save the day. As soon as we got the green light to start telehealth visits, I found a Britney Spears-style mic and headset and I started doing “house calls” from my iPhone.
Video medicine felt awkward at first, reminiscent of my first job in the McDonald’s drive-thru. I felt the urge to ask patients if they “wanted fries with that.”
But telehealth allowed our patients to continue to access their doctors.
That “special moment”
If you have already done a telehealth appointment, there is that special moment at the start of every visit when the video connects and everyone’s eyes light up. Whether we are happy to see a familiar face or just grateful that the internet connection worked, it is reassuring that our doctor-patient connection is still strong through a screen.
Successful telehealth requires creativity
Initially, I ran into difficulties with tracking newborn baby weights. Not every family had access to a baby scale at home. Then one of my families creatively solved the issue with a $10 kitchen scale.
They set the kitchen scale on the floor, placed a cookie sheet on the scale and pressed the tare button. Then they put the baby on the cookie sheet and we instantly had a precise weight in ounces. It was a brilliant solution.
I realized that with a little creativity we could make telehealth work well for pediatrics. I now use my Angels’ baseball “Rally Monkey” as a prop to demonstrate my 20 years of finely-tuned baby burping and calming techniques.
When I need to examine a sore knee, I walk parents through the exam. I’ve taught numerous medical students to do physical exams and teaching parents hasn’t been a stretch. It is not the same as doing it myself, but so far it has been effective to determine if an injury warrants a visit to the urgent care, an X-ray or a couple of days of rest. If there are still concerns at the end of a telehealth visit, we jump back into another visit the following day for a recheck.
After office hours, you’d normally find me at a ball field. These days, I am on-call from home and able to offer after-hours telehealth visits. It’s convenient for patients (and satisfying for me) to diagnose and treat poison oak without having to refer someone to an urgent care or wait until Monday.
Fun with custom Zoom backgrounds
As a pediatrician, I try to make my visits as fun as possible. Using custom backgrounds has been huge success. Every now and then I post some backgrounds on social media and ask friends to vote for their favorites.
My favorite background allows me to “sit” in the dugout at Angel Stadium. I’ve fooled a few tired parents and my patients are impressed that their doctor “plays catch” with Mike Trout between appointments. This background also fits well with my Rally Monkey burping demonstrations.
How can you get the most out of your telehealth visit?
First, try to understand the workflow at your doctor’s office. Practice using the Zoom app or whichever telehealth platform your office is using.
Gather together relevant vital signs before the appointment.
For pediatric patients, it’s helpful to have a current weight and a temperature (if you have a scale and a thermometer). If you want to discuss growth, use a tape measure to estimate height or head circumference.
For an adult patient who regularly checks blood pressure or blood sugar at home, have those values ready to share.
Prepare a list of questions ahead of time.
Know your pharmacy preference, in case a prescription needs to be sent in.
If your doctor uses an electronic health record, look to see if you can upload relevant medical/vaccine records ahead of time. If you are able to upload an image of a rash, the resolution of a photo can be better than a video.
Choose a room in your house with good lighting. Have a flashlight available to help shed some light on a rash or to have a peek inside the mouth.
From the comfort of your living room
Walking into an exam room with my white coat has triggered some tears over the years. Now imagine that toddler’s response if I had to walk into the same room wearing full PPE (mask, goggles, face shield, gloves and gown)?
An unexpected benefit of telehealth is that my patients are much more comfortable in their own living rooms. They wave, laugh and show me their favorite toys. This allows me to observe developmental milestones in a way I have never been able to do in my office.
What are the limitations of telehealth?
Not all appointment types are ideal for telehealth, but when patients can see their own doctor (who has full access to their electronic health records), much more can be accomplished than you might think.
My job is deeply rooted in listening and observing. Telehealth is well-suited for this. In medical school, we are taught to ask open-ended questions and take detailed medical histories. If I do my job well, I can narrow down the list of likely diagnoses before we ever get to the exam.
Drive-in/drive-out vaccines
As a pediatrician, I have the responsibility to keep my patients up to date on their vaccines. Virtual vaccines don’t really work.
I have read about doctors on the East Coast packing soft-sided coolers full of vaccines, getting on their bikes and riding over to their patients’ houses to give shots out on the front porch. I have colleagues in Northern California who offer car-based vaccines in their parking structures.
Practices like mine are fortunate to have a large parking lot, and a team of amazing nurses, making it possible for patients to drive-in after their telehealth visits, get their vaccines and then drive back home.
I sleep much better at night knowing that we are keeping our patients up-to-date on their vaccines.
Most of the illness has disappeared
One of the most remarkable effects of our physical distancing experiment is that almost all illness has disappeared. Not only have we kept COVID-19 in-check locally, but we are seeing very few colds, asthma flare-ups, hand-foot-mouth disease or seasonal stomach “flu.”
As day care centers and schools reopen, it will be interesting to see how and when seasonal illness returns. I wonder how we will be able to sort out cases of COVID-19 from common colds and what documentation schools will require in order to have students return safely to the classroom. With some COVID-19 tests having a false-negative result up to 30% of the time, it may be impossible for someone like me to determine when a patient is recovered and no longer contagious to their classmates.
Telehealth is here to stay
Telehealth was here before all this craziness started. In a matter of weeks, telehealth evolved into an invaluable tool to keep patients connected to their medical homes.
Now I have the ability to see my own patients, in the comfort and safety of their own homes, with their personal electronic medical records at my fingertips.
I can do just about every type of medical appointment as a telehealth visit, including well visits, sick visits and behavioral consultations. I have done many consults to answer questions that parents and “quaranTeens” have about COVID-19. I hope to use telehealth as a tool to keep all of my patients up to date on their annual appointments and vaccines.
As medical offices reopen, some visits will return to the office. As long as insurance companies continue to allow patients to use telehealth, I suspect that a video visit from the living room will continue to be a preference for many families.
For now, I am content with using my little black iPhone and a little creativity to offer modern “house calls” to all of my patients.
—Dr. Dan Brennan is a board-certified Pediatrician at Sansum Clinic, who thanks you for staying home to protect your Tribe and help prevent the spread of COVID-19. Please contact Dr. Dan at 805.563.6211, drb@sbpediatrics.com or visit www.sbpediatrics.com.