As more Americans are turning to telehealth to receive care during the country's coronavirus epidemic, they're discovering a new type of home visit that is "less intimate than having a doctor sitting at your bedside, but more personal than sitting on your doctor's exam table"—and finding that location always shapes quality of care, "for better or worse," Marion Renault reports for The Atlantic.

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For some patients, telehealth means better care

Although some patients may find virtual visits with doctors awkward, telehealth allows physicians to observe patients in the context of their everyday life, which sometimes can lead to patients receiving better care, Renault repots.

For instance, Mark Fendrick, a primary care doctor with Michigan Medicine, said some patients find doctors' offices "stressful" and, as a result "some things we look for that are more artificial in a doctor's office [are] more real-world at home."

Measuring a patient's blood pressure could result in a more accurate reading when they're in their homes than when they're at a doctor's office, for example. That's because some patients experience what's known as "white-coat hypertension," meaning they "regularly [have] higher blood pressure in clinical settings as a result of anxiety or fear" even though their blood pressure may be at a normal level when they're at home, Renault reports.

In addition, Julia Loewenthal, a geriatrician at Brigham and Women's Hospital, said some patients perform better on cognitive tests for dementia when they take the tests during a telehealth visit in the comfort of their own homes. While in-office exams can induce unease, being at home "reduces test anxiety," which can allow patients to think more clearly, Loewenthal explained.

Susan Kressly, a pediatrician, said she's also observed that patients are more relaxed during telehealth visits at home than they are during in-person visits in her office. "When you move the playing field to the patient's home base," she said, "some of that power imbalance and discomfort with the setting goes away."

Christina Dierkes, a 37-year-old who lives in Ohio, can serve as an example of Kressly's theory. Dierkes told Renault that sessions with her therapist have improved since they've started holding sessions over the phone instead of in her therapist's office.

"You bare your soul to this person and then you're running into somebody in the elevator and sitting in the car crying and driving home," Dierkes said. But, at home, Dierkes is in her "own space," which "made it easier to imagine [she] was talking to [her]self or someone [she] felt really safe with," she said.

Further, some clinicians have noted that virtual visits allow them to observe patients' symptoms and habits in real time and in their typical surroundings. "Whatever might be missing from the patient's descriptions, doctors can glean information through telemedicine that they wouldn't otherwise have access to. And this might be the true magic of the virtual house call," Renault reports.

For instance, Kressly said video visits allow her to learn more about her patients, like the toys they play with and whether they have siblings. "We get a glimpse inside the reality of where patients spend a lot of time—with [Covid-19], a majority of the time," she said.

Carman Ciervo, a family doctor for Jefferson Health, said telehealth visits allow him to observe the prescriptions patients have in their medicine cabinets and the food they have in their refrigerators. Sometimes, Ciervo even asks to see patient's thermostats to make sure they're working and observes the patients' houses for tripping hazards if they have limited mobility. 

"Just observing how they climb the stairs can give you a wealth of information," Ciervo said. "These are all safety problems they might not be aware of, and that might not come up in an office visit."

Sometimes, telehealth can be challenging

But it's not always the case that telehealth visits result in better care, Renault reports.

For example, David Bober, a 51-year-old who lives in Maryland, said having therapy sessions at home increases the risk of him being interrupted. Instead, he'd be "happy" to have in-person visits and "sit 12 feet away, on the other side of the room, wearing a mask," he said.

And Jon Johns, a 54-year-old who lives in Ohio, said virtual visits make him nervous that a symptom may be overlooked. "What if I was in pain or something was wrong?" he asked. "I would be anxious about how well I was describing my symptoms."

In addition, Kirby Randolph, a medical historian at Kansas City University, said virtual visits can make it difficult for some patients who liked to keep their lives private. "A lot of patients don't want the doctor to see their home environment, because they're self-conscious," Randolph said. "The idea of meeting the person where they're at, that's not a preference for everyone."

For instance, Renault reports that video visits may reveal some low-income patients' housing to clinicians who often have higher incomes, and patients could be concerned that they will be blamed for their health conditions based on the condition of their homes.

Jeremy Greene, a medical historian at Johns Hopkins, said, "The very deep social determinants of health and illness seem so intractable that finding a technological solution that might short-circuit them is enormously appealing." However, he noted, "technology can be liberating and oppressing" (Renault, The Atlantic, 8/6).