Speaking on a landline, the patient complained of an itchy eye. On the call’s other end, physician Carla Harwell considered the possibilities, from seasonal allergies to vision-damaging herpes. Luckily, the elderly patient’s daughter was visiting during the phone consultation, so Harwell asked her to text a picture of her mom’s eye. The photo shocked Harwell. It was the worst case of bacterial conjunctivitis the doctor had ever seen.
Without the picture, Harwell would have told the octogenarian patient to call back in a few days or come to her office, risking an in-patient visit during the Covid-19 pandemic. She certainly wouldn’t have prescribed the antibacterial eye drops needed to treat the infection. “I probably would not have prescribed anything,” Harwell says. “That’s a scary thought.”
Amid the coronavirus pandemic, more of the nation’s medical care is being delivered by telephone or videoconference, as in-person care becomes a last resort for both doctors and patients. That’s a problem for tens of millions of Americans without smartphones or speedy home internet connections. For them, the digital divide is exacerbating preexisting disparities in access to health care.
Harwell, a primary care doctor, is based in Cleveland, where nearly one-fourth of households lack broadband. Her patients are predominantly black and older, and many are lower income with chronic conditions like hypertension, asthma, diabetes, or obesity. “All things that place them at the top of the list for dying from Covid,” Harwell says. “It also means my patient population is at the bottom of the list for access to the technology that’s needed to effectively do telemedicine.”
Harwell and other clinicians worry that patients without reliable devices or internet service are receiving inferior care—or none at all. In some cases, doctors are asking patients on the wrong side of the digital divide to come in for visits, despite the safety risks. “When you need telemedicine everywhere, you see a vulnerable population that doesn’t have the means to use it,” Harwell says. “It’s revealed these inequities and the disparities that we’ve been sweeping up under the rug.”
Patients unfamiliar with or lacking access to technology already tend not to use online tools that can improve health outcomes and allow them to request appointments and prescription refills, as well as message their doctors directly. Telemedicine was supposed to increase access to health care during a national medical emergency, says Jorge Rodriguez, a physician at Boston’s Brigham and Women’s Hospital who also studies health care technology disparities. But for some, it’s just another barrier. “It’s become a lifeline,” he says, “but not across the board.”
Since March, doctors—from infectious wound specialists to psychiatrists and pulmonologists—have reshuffled their hierarchy of care. In-person appointments, the bread and butter of medicine, are a last resort. Instead, to avoid full waiting rooms that expose both doctors and patients to the novel coronavirus, videoconferencing has become the preferred alternative. Telephone consults are the next best option, often described to me by physicians as “better than nothing.”
Overall, as many as 157.3 million people in the US only have access to substandard download speeds. During the pandemic, roughly half of low-income American say they’re concerned about affording to pay their broadband and smartphone bills, according to April Pew Research data. In rural areas (where Pew figures suggest only 63 percent of residents have home broadband subscriptions), phone calls might be patients’ best option.
Kim Templeton, an orthopedic surgeon with an oncology subspecialty in Kansas City, Kansas, routinely tries to connect with patients over videoconferencing after biopsies or reconstructive surgeries. But her rural patients often didn’t have the technology or home internet for virtual check-ins. Instead, many drove five or six hours to office visits. “It’s inconvenient, but it’s worth it,” Templeton says.
Now, she can’t ask them to travel to her. In some cases, Templeton says, she can’t even receive their x-rays, MRIs, or CAT scans from rural hospitals or doctor’s offices that don’t have the bandwidth to upload image files to the cloud. Those patients are left to describe healing incisions and lingering pain over the phone. “It can be almost impossible to figure out what’s going on,” Templeton says.
With cancer patients, Templeton is also discussing hospice and end-of-life care over the phone or through a screen—a career first, she says. “I’m so used to having those face to face,” Templeton says. “As a physician, I’m uncomfortable doing that over the phone.”
She’s not alone. Across the board, clinicians cite the subtle limitations of phone consults and video visits. Medical training, early on, emphasizes demeanor as a key signal of a person’s condition. Without sitting across from a patient, it’s that much harder for a doctor to tell how they’re doing. Are they leaning over, nostrils flaring, panicked, or can they speak in full sentences and make eye contact? Are they pale or flushed? Swollen or haggard? Even details like whether a patient has been clipping their toenails or washing their hair can hint at cognitive decline or potential self-neglect.
During the lockdown, patients without reliable internet access are forced to make a difficult choice: Is it better to put off necessary care or expose yourself to infection when your health may already be compromised?
“We’re worried they’re so afraid of coming in that they’ll stay at home,” even if they’re having a heart attack or a stroke, says Julia Loewenthal, a geriatrician at Brigham and Women's. “That’s my number one concern: patients we can’t reach.” Loewenthal says some of her older patients don’t have at-home internet or even a landline phone. When one patient didn’t answer phone calls, Loewenthal grew concerned enough to ask police to do a welfare check. The patient was fine. “She was just trying to save her minutes,” Loewenthal says.
Pediatric kidney specialist Ray Bignall typically looks forward to appointments with immigrant families.
Located in Columbus, Ohio, Bignall sees a variety of patients: the city’s underserved communities of color, the country’s second largest Somali population, and rural patients who drive several hours from the foothills of Appalachia for care. When Bignall meets with immigrant families, he shares that his own parents came to the US from Jamaica. There’s a particular joy, he says, in overcoming language barriers, sometimes through an interpreter, and expressing warmth through eye contact and hand-holding. “I can connect with them on some level, and the interaction is so organic,” Bignall says. Today, with most of his practice conducted over the phone or videoconference, it can be a struggle to connect at all. “All of those things that I do that help add richness to my encounters, I can’t do anymore.”
Since Covid-19 upended his practice, he’s watched patients—in particular minority, low-income, and rural patients—struggle to download apps or loop interpreters onto phone consults. He’s canceled visits because of inadequate Wi-Fi; on some calls he spends as much time guiding families through the technology as he does helping with their medical concerns. “When I call my suburban families, it’s no problem. It’s a fun Zoom visit,” Bignall says. But for the others, tech issues consume appointment slots.
At night, he and his wife, a pediatric psychologist, bemoan the challenges of reaching patients with obstacles to care, such as transportation access, food insecurity, or language barriers. “We see these things clustering together,” he says. “These families are already getting the short end of the stick.” Now they’re being asked to devote limited resources to bridge the digital divide between them and medical care. “It’s daunting for a lot of families, and they just don’t have the time or means to navigate the change,” Bignall says.
Since the pandemic forced Bignall to shift toward telemedicine, he says, his patient volume has “precipitously dropped.” He hopes patients will return once the virus recedes. “The internet is no longer a luxury. It’s now a necessity,” Bignall says. “I don’t think anybody in 2020 would claim not having internet in their home would be OK. We’ve got to start thinking about access to internet as a utility, just like power and water and sewer.”
To that end, Rodriguez suggests clinics should routinely screen for connectivity when patients reach the front desk. That’s not yet standard practice—meaning many health care systems don’t know which families can easily videoconference, and which are sharing a limited number of monthly minutes on a smartphone. “Let’s just get a sense of where our patients are,” he says. “Most places are not even doing that.”
Harwell has also been thinking about her clinic’s post-pandemic future. In April, she applied for a Cleveland Foundation grant for 200 tablets for patients in her practice who don’t have smartphones or home computers. This month, she hopes to ramp up her in-person visits. But she knows telemedicine, in some shape or form, is here to stay—especially if we see another wave of Covid-19, as predicted by public health experts. “We will get through this pandemic,” she says. “But what will we do about what it’s highlighted?”
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