“M” was diagnosed with a rare skull-based cancer. A one-in-a-million diagnosis, he was given little information about his diagnosis and told he must seek care outside his home state. “M” worked full time, was the primary caretaker for two young kids, and could not fathom how he could travel to another state for treatment. He did not come to his scheduled out-of-state appointment. It was just too difficult. “M” was fortunate to have an older daughter who became involved in his healthcare, but she worked full time, had three young kids, and lived in a state far from her dad. Flying to join her father to help coordinate health care in person would have meant time away from work, obtaining childcare, and the expense of a flight and hotel.
Fortunately, after the missed appointment, I was able to conduct a telemedicine consultation via Zoom with “M,” who joined from the comfort of his own home, with his daughter logging on from her home. I gently conveyed the course of treatment needed, which included more surgery and proton radiation, and a favorable prognosis if he completed this treatment. “M” came for treatment and is doing well four years later. His consultation was possible during the pandemic, but it is now illegal. While I initially followed him via telemedicine visits, this is also now illegal.
The explosion of telemedicine during the pandemic enabled encounters like this. As doctors treating rare cancers during the pandemic, we were initially skeptical that a tiny camera in a patient’s home could replace a clinic visit but found the benefits monumental for our out-of-state patients seeking an opinion or a continued connection with their treating physician. We envisioned this silver lining of the horrific COVID-19 crisis as the way of medicine in the future. The lifting of state licensure restrictions allowed widespread access to care, eased financial toxicity, and allowed continuity of care for patients who had traveled for treatment unavailable in their state. It also reduced disparities, and COVID-19 taught us in a very poignant way how health inequity impacts us all. Telemedicine across the U.S. also reduced carbon emissions—from a long drive for some to a private jet for others. Perhaps the most immense benefit was that telemedicine across state lines allowed for a visit when there would have been no visit, such as in “M’s” case.
For some patients, telemedicine resulted in treatment at a specialized center. Others achieved peace of mind by knowing they had explored all options and that the best treatment was at home with their local doctor. While we initially thought of telemedicine as colder and disconnected, we can now see unmasked faces, express emotion through more than just eye contact, get a glimpse of who our patients are by seeing their art, meeting pets and children, and sometimes detecting a need that would have never been vocalized. Children could join aging parents without taking time off from work. Pediatric patients could play in other rooms during serious conversations rather than being removed from a clinic room and knowing their parents were about to discuss the “bad stuff” they were being shielded from. We found many of our patients at greater ease in their homes. With reduced anxiety came better comprehension of medical information. The pandemic shined a spotlight on the definition of “practicing medicine.” We are now made aware that the location of practice is where the patient is.
So, it seems cruel that this ability has been stripped away at a time when burnout for health care workers is at an all-time high. With state licensure being enforced again, even if the encounter is by video or phone, the patient must be in the state where the physician is licensed. The change has caught physicians and our patients off guard. We are left asking our general council, “Is returning a phone call to my patient, who is now out of state, that I delivered treatment to ‘practicing medicine’ if I give advice?” In the strictest interpretation of the law, the answer is “yes,” and bill or no bill, note or no note, we put our licenses at risk by doing so. Patients who are ill drive across state lines and sit in “telemedicine parking lots” just for visits. They use their phones and sit in their cars rather than using a computer from the comfort of their home so that they follow the rules. I have a patient who received her diagnosis of a brain tumor from a coffee shop on public Wi-Fi surrounded by other customers while she looked out at her kids sitting in her car. We are torn between following the law versus doing the right thing for our patients, while risking our licenses. This is added stress for doctors and bad care for patients; it makes no sense in the modern era when distance disappears over the internet and phone.
Shannon MacDonald, MD is a Radiation Oncologist at Mass General Brigham and Associate Professor at Harvard Medical School.
