Alone, lonely, and missed
Authors: James Kahn
Journal: The Lancet Respiratory Medicine (2021)

The COVID-19 epidemic changed my practice, transforming patient flow from what were mostly face-to-face encounters into telephone and video interactive experiences. I was concerned when these new modes of patient care were first rolled out and we substituted technology-based interactions for in-person visits. I was worried that patients without access to computers or without high-speed internet connections, or cell phones, or lacking the knowledge and experience to use their computer and phones for health-care visits would be marginalised and left out of the health-care enterprise. Although the technology facilitated encounters were initially presented as an option intended to improve care, it soon became an enterprise-wide necessity in response to the spreading epidemic. Patients were initially sceptical, and physicians were not gung-ho either, and yet, once the epidemic broadened and threatened our patients and ourselves, we had to respond and mitigate risky activities and still provide the needed health care. The technology was necessary. Nevertheless, I was concerned. Would the new connections support our interactions and provide a platform for effective health care? Would our empathetic bonds deteriorate and worsen clinical outcomes? I was apprehensive; however, these new modalities might have improved the experience for the patients. I viewed patients in their home setting and that provided me with new insights into their life. If we are connected through a mobile source, patients could walk around their home and simulate a house call. It turned out that patients enjoyed showing me where and how they live. In one day, I was able to see into a patient's bedroom, another showed me his kitchen, and a third his patio! It also became easier to understand medication adherence because patients showed me their medication bottles and pill boxes and they revealed their daily rituals to consume them. When I ask patients if they have guns, they now could show me their gun safe. For fragile, weak or neurologically impaired patients, I can potentially see if their home is clean and if it is safe from tripping hazards. Many older patients included their adult children in these visits. The children were necessary for their technical expertise, but they were also important for helping me and their parent manage the visit's information and provide context to our discussions. Even the telephone appointments improved my workflow. It is easier to be on time for telephone visits, and my compliance with reminders flagged in the electronic medical record improved without worrying about missing eye contact and losing an empathetic connection. Health-care costs are reduced for patients because there is frequently no co-pay or reduced co-pay compared with in-person visits. There are savings in travel expenses and reduced problems associated with driving to and parking at the clinic. Difficult long walks from the parking lot to the clinic are eliinated as are delays in checking in, avoiding crowded waiting rooms, hold ups in being allocated to a room, and the time lost waiting in the examination room. The reverse problems are either eliminated or at least reduced, including check-out delays, waits at the pharmacy or phlebotomy, walking back to the car or catching the bus back home, and the challenges of understanding and then explaining what happened at the visit to family members or friends. Thinking back, it is no wonder that patients would be unhappy with many aspects of their past health-care experience and why they might like these new arrangements. Much to my surprise, and although it did take some effort, the empathetic connections could be nurtured too. Talking about our shared and our unique experiences dealing with COVID naturally leads us to discuss the importance of behavioural therapies to help mitigate infection with the virus. This conversation opens a channel for other healthy behaviour-based activities such as completing stool immunochemistry tests, implementing nicotine abatement strategies, and working to complete and update immunisations. Despite these improvements for patients and for physicians, recently, patients seem less happy with these new experiences. They were usually pleased with one, maybe two visits facilitated by the technology; however, something has changed. They missed the intimacy of speaking face to face. They are lonely. The COVID epidemic isolated them from others and I came to understand that for many patients the health-care visit is a critical social interaction. This is true for many of our patients, but seems especially true for our older patients and our Veterans. Many Veterans rely on our Veterans Affairs (VA) health-care system for their health-care needs. They live alone. They might be elderly, less connected with family members, have fewer resources, and are less technically savvy. The VA provided them with pleasant social interactions that are meaningful and interacting with other Veterans is the highlight of their day, even if their interactions spanned generations of Veterans. Veterans are on campus longer than simply for their health visits. They like the canteen, the cafeteria's low cost and familiar food, and simply seeing other Veterans. Their caps, reflecting their service, are worn with pride and it is a source of great joy when another Veteran recognises the cap and their common history. They form a tribe and I can understand missing one's tribe members and the resulting isolation when you do not socialise and cannot find or count on others in your tribe. That is sad. Patients also miss the professional staff. The administrative staff, phlebotomists, nursing staff, pharmacy staff, chiropractors, and the physicians represent an important source of social interactions for patients. They enjoy speaking with people who are dedicated to their health. They are appreciative too. Of course, missing some social interactions, even important ones, does not lead to loneliness. However, many of these patients do not have other support structures to help them fight off their feelings of loneliness. Eliminating face-to-face encounters might only slightly impact a day's activities, but it can have a disproportionate effect on patients' feelings of isolation and might exacerbate their loneliness. The staff miss the patients too. They sense the patients' loneliness and they notice how patients extend telephone conversations, not wanting to disconnect from a common bonding activity. We all notice their social isolation. Their hardship adds to our sorrow. I miss seeing the patients too. I miss seeing their reactions to new clinical information like controlled blood pressure or a lowered haemoglobin A1c. I worry when I use the new technology compared to in-person visits when I communicate upsetting information such as a positive faecal immunochemistry test or a rising serum creatinine. I am concerned as we strategise next steps and develop complex treatment plans. I realise that telephone and video conferencing is a practical and necessary compromise during the pandemic. The technology offers clinicians the opportunity to diagnose, treat, and support our patients, but it is not as satisfying as face-to-face encounters and can minimise important social connections. The epidemic nearly eliminated the option of face-to-face encounters and I can hardly wait until we return to in-person visits. I think our patients want that too. In the meantime, I schedule telephone or video visits more frequently than I would in-person visits with the primary purpose to connect with patients and limit their feelings of loneliness and support their health-care needs. Once the pandemic is tamed, how will the telephone visits and video visits integrate into the more traditional face-to-face visits? For some patients, telephone or video visits will be the preferred type of encounters because of the convenience, lower costs, and relative ease for integrating family members. For other more isolated patients, they will want the social interactions and the support they receive from face-to-face clinic-based encounters. Patients repeatedly ask me, "When can I see you in person?". "Soon", I tell them, "I hope real soon." I declare no competing interests.