The patient-physician relationship has traditionally been centered around face-to-face contact, be it at a house-call, an outpatient visit, or during a hospitalization. This relationship cemented by the image of the careful assessment of the pulse by a physician or a thoughtful physical examination has been immortalized in countless books and movies. Historically, while the applicability, convenience and cost-effectiveness of telemedicine has been recognized and supported by a scattering of evidence, telemedicine has not gained widespread popularity for a number of reasons 1, 2 . Both patients and providers have remained unconvinced that it can replace the value of a face-to-face encounter, and importantly, reimbursement for telephone or videobased appointments have been a fraction of in-person care, thereby limiting the adoption of this technology. However, the unprecedented challenges thrust upon the healthcare system by the ongoing COVID-19 pandemic has brought telemedicine to the forefront on a broad scale as never before. In an attempt to minimize healthcare-associated transmission of the SARS-CoV2 infection and protect patients and providers, most major healthcare systems in the United States have shut down routine outpatient clinical care. Instead, and almost overnight, the traditional face-to-face care has been widely replaced by telephone-or video-based visits. While the initial impetus for this was to minimize disruption to patient care rather than a financial incentive, an important step legitimizing this as an acceptable and equivalent mechanism for care delivery were steps such as those announced by the Centers for Medicare and Medicaid services whereby video-based telemedicine visits would be reimbursed at parity with office-based appointments on a temporary and emergency basis. Hence, it is highly plausible that telemedicine is here to stay.
There is a growing body of evidence that has examined the value added by telemedicine.
This study by de Jong et al. 3 that suggest to the provider that one party may be underplaying their symptoms or overemphasizing their treatment adherence. How the patient carries themselves, whether they are comfortable or in distress, are important components of the overall assessment of the clinical status of the patient but cannot be inferred remotely with both parties seated at their video screens from the beginning to the end of the visit. Anecdotally in our personal experience, telemedicine visits have been significantly shorter than face-to-face encounters with the same patient. Whether the shortening of the fifteen-minute in person visit to a five-minute video call just distills out the extraneous without meaningfully impacting patient care or whether the gap represents questions that were unasked and unanswered can be debated, but will likely include parts of both. Indeed, the 'meaningless' chatter at the beginning and end of in-person visits may strengthen the patient-provider relationship, encouraging adherence to therapy and demonstrating openness to engagement; and this relationship-building may end up being sacrificed at the altar of telemedicine. Though the population as a whole is more technologically-savvy than a couple of decades ago, certain patient populations including the elderly and socio-economically or developmentally disadvantaged may not be in a position to participate or benefit optimally from telemedicine consultations, and thus this system has the potential to unintentionally create bias.
In addition, health discussions may involve sensitive topics that are challenging to conduct at the best of times within the four walls of an office-room, let alone with the physical and technological porousness of telemedicine.
Once (and hopefully sooner rather than later!), the curve has been flattened on this pandemic and things are ready to move back to the regular order of business, should telemedicine be abandoned once again in favor of face-to-face office visits? To do so, would be an enormous disservice. As the study in this issue of the journal emphasizes, telemedicine has the potential to be significantly cost-saving to the healthcare system and indeed to society. In regions of the country where specialist centers are few and far between, telemedicine is critical to allow many patients to benefit from remote specialist care, ensuring they have access to the stateof-the art treatment algorithms in spite of the geographic distance. For the stable, well-controlled patient or a general well-visit, an in-person office visit may often mean several hours away from home or work in terms of commute, waiting, and the visit itself. Telemedicine will be an attractive alternative in that setting. Indeed, the efficiency conferred by incorporating telemedicine for such situations may free up office-and provider-time for other patients-in-need.
There are several opportunities to enhance a simple video-or telephone-appointment through use of technology incorporating remote vital signs (such as through a smart watch) and point-of-care laboratory assessments that can be done at home. It is important to remember that the more sophisticated the technological platform, the greater the likelihood of introducing inequality in care such that not all will be in a position to equally benefit from and adopt such technology.
From a payor standpoint, it is important to permanently recognize the value of care delivered through telemedicine and make doing so sustainable to health-care systems and providers.
Without the appropriate reimbursement and recognition, widespread adoption will remain unlikely.
In conclusion, an unprecedented pandemic has brought telemedicine to the forefront of medical care. It is important for us to learn from our shared experiences in this situation so that once we return to the regular order of business, we do not make the mistake of either entirely reverting back to the old or abandoning the tried and tested for the new and shiny, but instead appropriately mix the two to concoct a delicious cocktail.