The View from Telehealth
By: Merideth C. Norris
Tags: Telehealth, Classism, Pandemic Diaries, Addiction, Medicine

Merideth C Norris, DO

When I was in residency, there was a lady who was 102 and always looked immaculate at her visits. She made sure to clean out her ears in case we looked in them. She set her hair. She had a hat. She had on pure white ankle socks and sturdy pumps and her best dress. Going to the doctor was a special occasion.

It is several months into a pandemic and I am seeing a lot of my patients online. People do not dress up for these doctor’s appointments. If they are wearing a hat, it is to cover their bedhead and it probably carries a logo from an energy drink or Fox News. Sometimes a cannabis leaf.

To be fair, I am wearing the t-shirt that I have worn through two heavy workouts and three nights’ sleep so it’s not as though I am living in other than a glass house. In fact this all feels like a glass house. Patients I would normally meet in my office are seeing the walls of my home and occasionally a fleeting glimpse of a dog or a child or whatever I hang on the fridge. They have more information about me than I would normally provide, even though I am a pretty self-disclosing kind of gal.

For the most part, they are either too narcissistic, too unobservant, or too sedated to pick up any details that could be potentially damaging to me or my privacy. The few who do make comments are bothersome in a different way — the same way it is when they say “and are and your kids doing ok?” It very rarely feels kind — for one thing I’m on a tight schedule and we are not here to yak about my side of the two way mirror, and talking about anything we don’t need to discuss is taking up minutes I don’t have. But it also rarely feels benign. It’s a way of leveling, of creating the impression that we are both just folks hanging out, chatting about our day. And talking about my kids.

It tends to be the same people who call me “Merideth” uninvited. Some of the time it’s just because they are socially clumsy and don’t understand about titles, but it’s more usually a maneuver. It’s a way of putting me in my place, just like how telling me “how young I look to be a doctor” was never really the compliment it pretended to be.

For the record, my medical assistant has been asked over and over to call me by my first name and she is unable to do it, after about 10 years of working together. I have thrown up in a trash can in front of her and ugly-cried about my dead dog to her and she never calls me Merideth, not even when I’m nowhere in the building. When speaking of me to my friends or my mom, I remain “Dr. Norris” in her world. Even after I spent a whole day in the office walking around with a huge hole in the seat of my yoga pants.

So yeah, it’s uncomfortable. For me. It does not seem to bring the same level of stress to the patients, and in some ways that’s a shame. It seems not to occur to people that if they can see me, I can see them, and that means that I can see them blowing smoke into my virtual face, I can see them spitting out of the corner of their mouths, and I can see that they are lying in bed, showing some side boob around the blanket they are holding up with one hand. Sometimes they park the phone and keep talking while they roll smokes, giving me a good view up their nose.

The homes I see over their shoulders are heaped with assortments of empty bleach bottles, boxes of sugary cereal, and soiled laundry. Disposable diapers teetering over the edge of the trash can. Ashtrays which do not appear to have been emptied for days. I can almost smell the mixed aroma of sour milk, moldy sponges and stale nicotine.

I have also been told “oh sorry I was just going to the bathroom.” By which they mean literally that they picked up while on the toilet, and their way of maintaining privacy is to simply tilt the phone to the ceiling so I can count tiles while they finish up.

There is a dishevelment. About their environment, about their presentation, about the fact that about a third of them miss my call the first time and then frantically message me back during someone else’s appointment time saying “sorry I was having a butt, lol”. If I don’t pick up they keep calling back like a rat hitting a lever to get cocaine. I could see a few hiccups when we were first learning this process but it’s been months now and still they don’t have it together.

I am scheduled to use 10 minutes of their time. And most do not have jobs or school or children. Their time is not of a premium. Yet when I call them I have to try a few times. Or I wake them up. Sometimes they just don’t feel like waiting, and they take off from their location and have the secretary “tell Merideth to call me on the phone.”

Again with the “Merideth”.

Everything about them is a mess. These are people who have tattoos on their face. Not artful, deliberate ones like you might see on a Maori. These look as though a first grader was trying to draw something with charcoal and then couldn’t wipe it off all the way.

It has been a season of exploration for many flavors of online gathering. The medical school recently had a graduation which was conducted entirely by Zoom. It was strange and somehow spooky. The pageantry was maintained by the Dean of the school delivering her speech from a podium, in front of the school crest.

It was then diminished somewhat as she concluded her address and swiftly put a mask back over her face. This entire moment of memorable transition had clearly been recorded at some time other than the actual ceremony. The student president followed suit with her own parting words, also masking up right after she finished speaking, followed by silence instead of applause.

This process underlined the fact that the Dean and the student president were clearly giving their speeches to an empty room. It felt haunted but also deeply holy and momentous.

A number of us did “well wishes class of 2020!” videos. I did mine from my living room, holding a chicken in my lap.. I was doing this for flair and whimsy, because I recognized that people could see me and that they might get some joy out of the tableau. I had made sure to be sitting in a room that was tidy. I had on a fleece with our organizational logo and I had done my makeup.

The entire graduating class also participated in the ceremony from living rooms or patios. As each newly minted physician received their doctorate, rather than crossing a stage, the camera would cut to the diplomate as their name was read, and they would be hooded by a friend or a family member, whoever was close enough to be allowed within their germ zone. For some it was a spouse. For some it was a roommate. One man sat by himself on a couch in a dimly lit apartment, there in his graduation gown alone in the world and putting the hood over his own head.

Many were surrounded by beaming parents. As the name of their graduate was read and they realized it was their turn on camera, the whole family would straighten up, arrange themselves and square their shoulders to represent the hooding. Many blew kisses. One woman held up a sign that said “We Did It!” Another, a student who had been class president, waved a message board, “Miss U Guys”.

For the most part, they had not been in personal contact with any of their classmates for about two months.

Virtually all of them were carefully coiffed, well made up, and surrounded by cheering sections who were similarly attired. One group was assembled in what was clearly an impressive library with a grand piano in the background. Another was in a beautifully maintained backyard garden.

It was a stark contrast to the other people I usually viewed on screen.

I had already been resenting my patients, seething that they could not pull on some clothes or get it together for the 10 minute meeting I had with them. This juxtaposition put me over the edge from a simmer into a full burn.

Look at these graduates! They are all upright. Is that so goddamn hard? They are at home but there is no trash behind them. No one is smoking. If their kids are in the background, someone is keeping track of them so they don’t take their clothes off or throw food at the screen.

They are considering the experience of the people watching them undergo this transition, putting on a good show and in so doing, sending a message about their own worth. “Look at me! I’m a special occasion!’ They worked hard to get where they are and they needed to be acting that way.

I was getting up a good head of steam and indignation when the penny dropped that I was being ridiculous and unreasonable.

Both groups are deviant and neither is any kind of yardstick. The patients are not a lesser version of the students. No one is failing at being the other one, any more than a lantern fish is superior to a sockeye salmon. One can survive at very deep oceanic pressure and one can jump upstream. Very different talents but both pretty incredible.

The medical students.are people who have such extreme skills at delaying gratification that at age 18, they embarked on an educational journey that would not end until they had completed a 4 year degree followed by another extremely arduous four year degree which would be followed by at the minimum three more years of training in hospitals.

You cannot survive medical school without knowing how to present well, to follow the ever changing scheme of what “presentable” looks like. You have to hold your urine for hours, to stay awake for days, and to recite arcana when prompted. You have to be inordinately concerned with how people perceive you. Sometimes you won’t even be told what people want from you, but you will figure it out via the finely honed radar that years of approval seeking have provided.

No one normal would do this. And whatever drives someone to follow this path is atypical. If you want to show that you are smart, get a PhD. If you want to be a do-gooder, become a social worker. If you want to make a lot of money, be a bond trader. If you go to medical school, you have something else going on, and it’s not any of the things you claimed it was on your application.

It’s because you have always suspected that no matter how hard you work, you will never be good enough.

It’s because appearances are everything and it’s titles that count.

It is because you are a bottomless pit of social justice rage and maybe if you reach the apex of your educational field someone will give you a voice.

It is because your advisor in 11th grade told you to go to a tech school because he didn’t think academia was in your future.

It is because you want to get back at all the mean kids who made fun of you for waiting in line, doing your homework, and not running in the halls. They are probably washing cars somewhere and here you are, Dr. Somebody.

This is not to say that people who go to medical school are at some kind of superior end of the curve. We are just dysfunctional in a different way than the people who become my patients. We wear our mess more adaptively

The students have great skills at delayed gratification. The patients are extremely talented at delaying threat, at survival. Which runs on a different clock.

While the students are good at presenting on screen, they have the luxury of having a choice when to be on camera and when to be off. My patients do not have the expectation of privacy. Child protective workers, probation officers, all have felt free to walk into their homes and their lives, many for several generations. Some were very small the first time a stranger showed up at the door, and unlike the med students would have done in childhood, they let the stranger in.

Even if they had wanted to present as put together, as camera-ready, who would have told them how? Some of them had parents who would not have kept track of picture day, much less found them a nice outfit to wear or given them a comb. Sometimes they will smile for a mug shot but rarely have they fixed their hair first.

Some of them were children who had been traded by their mother in lieu of drug money. Some had learned early that sexy was the way to safety, and that keeping secrets from one adult protected them from the wrath of another adult.

I met these children while on clinical rotations in med school: they were the 8 year olds who didn’t understand questions about “when you go poop” and instead had to be asked about “when you take a shit.” You couldn’t use the euphemism “private parts” because they didn’t know they had any.

They grow up to be the people who show a lot of cleavage at the doctor’s office or don’t even get dressed for telehealth.

Sure they call me Merideth. There were probably a whole series of men they were expected to call “Daddy”, how important are titles to them?

Some of them have worked hard their whole lives, as hard as the med students do but with a very different set of rewards. They ran drugs for their uncle who made them carry the baggies in their bicycle seat because no one searches a 9 year old. One of them started doing badly at school by age 10 because she was trying to make sure her siblings got dinner even though her mother was out on a bender. They were not lazy: they just were not acquainted with labor that was linked to a goal: it was just labor because life is a chore and if you don’t get it done, and cover for the adult who is supposed to get it done, someone will show up and take you from your home. They were also good at suffering without appearing to do so. Until they learned how to medicate the pain.

People who go to med school self medicate with achievement, with success, with parental approval. The other folks just self medicate with what’s around.

I have changed the way I talk to med students and make it a point to ask them what they enjoy, who they love, what makes them happy. I try to start there and then move on to their clinical interests and previous work experience. I tell them out loud that they are enough today just as they are.

And I have changed the way I look at my view of the computer screen. Do I still get irritated when I have to chase my telehealth patients down despite them having nowhere else they need to be? Sure, I do. Is it aggravating when they smoke during our visit, or take the opportunity to brush their teeth while we are talking? Yes, it is. And it helps them for me to redirect them, and it helps them to be reminded to be on time.

Because if they are not on time for me, that means they also will forget when the child protective worker was supposed to inspect their home so they can get their kids back. It means they also won’t be dressed correctly when they interview for a job. It means they will forget to show up when the probation officer wants them in for a random tox test. So I do try and teach them. But I also bear in mind they had no way of knowing another way to be. They raised themselves or simply were not raised at all.

No one read to them at bedtime. No one got them up in time for the bus the next morning or even let them know that school was important. No one stood behind them and braided their hair and put little bows on the ends. If they had a learning disability, no one cared enough to be their advocate, and the teachers assumed they were “acting out” because of a “difficult home situation” and left it at that. When the boys were becoming young men, they learned to shave by trial and error and no one was interested in showing them how to tie an Oxford knot.

And yet here they are, still trying to do better.

“Is that Captain Crunch?” I ask my current patient about the bowl they are slurping out of at 2 in the afternoon.

“Yes,” they reply warily, recoiling in preparation for the inevitable nag about their poor nutrition, their just getting out of bed, the noises they make when they eat.

And I remember to show them a big smile, infused with the love they should have always seen in the face of the grown-ups. And I lean in to the computer screen and beam,

“I love Captain Crunch.”