She had been alone in the electronic waiting room for a long time. Yet the face that appeared in the two-dimensional window was composed and thoughtful as she tilted her head to show the angle of her right jaw. ‘It’s my ear,’ she said. ‘It’s hurting something fierce.’ She brought the smartphone closer to her ear canal, so that its camera might show what lay within. But without lighting and an otoscope, all I could see from where I sat was a dark, blurry hole that filled the computer monitor.
Welcome to the hybrid clinic. In my case, it’s part of the East Baltimore Medical Center, about a mile from Johns Hopkins University Medical School where I teach, and even closer to the city jail and juvenile detention building. The waiting room is packed today. A row of exam rooms bear signal flags coloured red, yellow, blue, green. The signal flags let me know if a patient is waiting; if a patient has been seen; if a lab result is waiting; or if a patient is ready to go. Urgent-care doctors can easily fall behind schedule, so I’m used to keeping an eye on the hallways to see how many people are waiting for me. For those beaming in for a telemedical encounter – now roughly a quarter to a third of the patients on my schedule – it’s harder. There are no coloured flags in the hallway. While I had been scanning the clinic, she had been waiting a half-hour in the ether, and I hadn’t noticed. Telepresence is not the same thing as presence.
She accepted my apologies with an easy wave and moved on. ‘I don’t know what happened, but this ear pain just won’t go away,’ she said. ‘It’s like the time when I was cleaning out my ear with a bobby pin and my daughter jumped out and surprised me and I pushed the bobby pin all the way into my ear.’ She paused. ‘Except this time there was no bobby pin.’ Was any bloody discharge coming from her ear? No. Was there fever or chills, nausea or vomiting? No. Was her hearing affected at all? No. Was there anything meaningful I could do through this link connecting my clinic to her smartphone? No.
The physician Clarence John Blake would have sympathised. In 1880, this founding faculty member of the Massachusetts Eye and Ear Infirmary struggled with the limits of medical care by telephone. He recalled with some humour how quickly he and his colleagues had conjured new, far-reaching applications for the new phone, immediately after the first demonstration by Alexander Graham Bell in 1876. They envisioned a new specialty of telephone consultants who ‘would each settle themselves down in the centre of a web of wires’ and listen to ‘the heart-beats of a nation’, diagnosing and treating patients at a distance. But four years later the promise had not come to pass. Of the many new gadgets proposed to help make telephones into long-distance stethoscopes, Blake sighed, ‘none have as yet, even in a slight degree, answered this purpose.’
Blake had been one of the first to see the medical potential of the telephone. His predictions spread along with sensational stories of ‘tele’-medicine, like the 1879 report of a teledoctor in Cincinnati that appeared both in the Journal of the American Medical Association and in The British Medical Journal. Late one night, a physician in Ohio was summoned by a caller who feared his coughing child had a bad case of the croup: a true emergency. Instead of making a midnight ride to the house of the caller, the technologically savvy physician asked the father to simply ‘hold his child for a few moments before his telephone’. Using the phone as a long-distance stethoscope, the ‘practised ear of the physician’ determined the cough was not croup; there was no emergency. Father, child and physician were all able to go back to sleep, and by the time the physician saw the patient in the morning ‘all symptoms of laryngismus stridulus had disappeared, and the child was apparently quite well.’ The fortuitous story of the careful and clever Cincinnati paediatrician and his fortunate little patient was not how most telemedicine encounters went, however.
In his audiological research and clinical practice, Blake simply could not translate the theoretical abilities of the telephone into the practical demands of everyday care. His attempts to use the telephone as a stethoscope reported no positive results, except ‘in one instance only, of the suspicion of a barely perceptible “thud”, no sound which could be referred to the heart as its source was heard.’ Instead, he heard all sorts of artefacts. These ambient and distorted sounds came from the electrical grounding of the device: ‘the snapping and crackling noises indicative of earth currents, the clicking of the Morse instruments, and the sound of a “fast speed transmitter” on the Western Union lines running along the Providence railroad, and the ticking of the clock connected with the Observatory in Cambridge.’ The ‘web of wires’, as Blake put it, failed to create a specialty of telephone medicine, in part because of ‘the very delicacy of the telephone … and its almost fatal propensity – if such an expression may be used – to pick up sounds that did not belong to it.’ Sometimes, the telephone brought too little information, sometimes it brought too much.
The web of wires that extended into hospital, clinic and home brought about new understandings of an electronic network as both an abstract concept and a material thing. In the early 20th century, hospitals modernised and grew more and more specialised, and telephone wires formed its rapidly branching nervous system. As telephones became a common feature of the middle-class home, and patients increasingly used them to call their doctors, a new form of telephone triage soon became part of medical practice. When was it OK to give medical advice over the phone? And when was it dangerous to do so? What kind of ailments, like the ear complaint I was being called to see, required the presence of the doctor or the body of the patient? When was telepresence ‘good enough’ for medical practice – and when was it just a form of substandard care?
There are vast differences in the social norms of technology and the political economy of care that separate the medical use of the 19th-century telephone from the health apps of the 21st-century smartphone. As a physician, however, in my hybrid clinic every week of the ongoing COVID-19 pandemic, I have found some similarities too. Some limitations of practising medicine through electronic media link the frustrated 19th-century ear doctor and the frustrated 21st-century ear patient. They are not solvable by better tech. The promise of telemedicine may be much closer at hand now than it was a century or so ago – as close as the smartphones found in the pockets or purses of more than 85 per cent of the US population. Yet the fact remains that some forms of care require more physical presence than others.
The platform we now call telemedicine or telehealth was born of frustration with the limits of the technology of the telephone. Kenneth Bird, the Boston-based physician who coined the term ‘telemedicine’ a half-century ago, thought that television could solve the shortcomings of telephone medicine. At the time, Bird staffed his own hybrid urgent-care clinic at Boston Logan International Airport. The doctor was in person during peak commuting hours, and on call by telephone and pager for the nurses who staffed the clinic 24 hours a day. One of his first telephone patients had a hip injury too tricky to understand over the phone, and had to be sent to the hospital. ‘If only I could see the patient,’ Bird thought, he could have saved her that ambulance ride. ‘If I could see a space launch 1,000 miles away in Florida, and hear an astronaut’s heartbeat 1,000 miles up in space,’ he continued, ‘then there was no reason why a patient a few miles away couldn’t be seen and his vital signs checked, while a nurse led him through a physical examination.’
A grant from the US Public Health Service, a collaboration with local TV engineers, a set of specialised cameras, microwave towers and a lot of coaxial cable allowed Bird to transform the tiny airport clinic into a ‘wired clinic’. Its cameras patched directly to a special multimedia room in the Massachusetts General Hospital.
Telepresence, to Bird, permitted a ‘dynamic interaction which allows interpersonal communication across distance to recreate, and even enhance [my emphasis], face-to-face communication.’ Bird drew heavily on the media theorist Marshall McLuhan, especially his observations that, in the electronically interconnected society of postwar America, ‘ours is a brand-new world of allatonceness’, as he and his co-author Quentin Fiore put it in The Medium Is the Massage (1967): ‘“Time” has ceased, “space” has vanished.’ So too with the clinic: the teledoctor defined ‘telemedicine’ as ‘the practice of medicine without the usual physician-patient physical confrontation’. Interactive television created new possibilities of being together, even when apart.
Telepresence brought peril as well as promise. How could a doctor or patient know whether the video quality was good enough to simulate the face-to-face presence of a direct physical examination? Artefacts or poor focus might lead to a missed diagnosis. Measures of parity obsessed Bird and the TV engineers who set up the clinic. They assembled archives of visual data to establish where, exactly, to set the threshold of ‘good enough’ diagnostic image quality. If a doctor could see a lesion in the blood vessels of the conjunctivae in person – that is, the red streaks in the ‘whites’ of your eyes – would that same lesion be visible to another doctor looking at that eye on a TV screen several miles away? Consider the photographic prints pasted onto the page in the figure below, depicting three television screens, which themselves depict images of the eye exams of a model patient at three different camera settings. In hundreds of images like these, testing the influence of different permutations of cameras, lenses and video-enhancement algorithms on the ability to distinguish key features on microscopic, radiological and physical examinations, Bird launched a new science of similarity, documenting the equivalence of telepresence and physical presence.
In a well-designed telemedical interface, argued Bird in a 1970 paper co-authored with the lead nurse practitioner Marie Kerrigan, ‘the fundamental doctor-patient relationship is not only preserved, but often it is actually augmented, enhanced, and seemingly more critically focused.’ Let’s consider the terms more closely, as Bird and Kerrigan did. Bird’s microwave transmitters ‘augmented’ the signal to travel long distances; he developed image ‘enhanced’ filters for TV signal processing; and the ability to shift between wide-angle and long-lens cameras allowed his teleclinic to be ‘critically focused’. In his more expansive moments, Bird hoped the TV frame could engineer more than ‘good enough’ medicine; it could deliver better medicine. ‘Telemedicine can provide as much or more [my emphasis],’ he insisted, ‘than the actual physical presence and direct interviewing of the physician.’ Despite these hopes, in fact many doctors and patients found telepresence to be a poor substitute for physical presence.
Television medicine provided more modes of contact than telephone medicine, but was still limited to sight and sound and the constraints of the camera frame. The absence of touch, of smell and of the sensibility we use to navigate interpersonal interactions persisted. The sociologist Joel Reich, in a 1974 report on telemedicine that took Bird’s clinic as its principal model, tried to catalogue all the things not present in telemedical encounters. Reich’s account of telemedicine is a history of the senses: visual and aural were present, yes, but olfactory, gustatory, thermal and haptic channels were not. They were all missing, and their absence was crucial.
‘Until such a time as Smell-o-Vision became a reality,’ Reich half-joked, ‘with contemporary interactive television the loss of the olfactory channel is complete.’ Reich compiled a list of roughly 50 diseases for which the use of smell might still play a part in routine diagnosis. The clinical significance of losing smell (and taste, for that matter) was minuscule, but they were losses all the same. Nor was it clear that a nurse practitioner, standing in the same room as the patient, could develop an adequate language for describing odours verbally to a physician on the other end of a telemedical circuit. A similar concern related to the relevance of colour. Bird’s studies of visual thresholds for telemedical parity assumed black-and-white television was more practical for telediagnosis. When colour was relevant, for example, when diagnosing a skin rash, practitioners on both ends could refer to numbered codebooks (analogous to the Pantone Color chart) to convey the right colour. Colour could be standardised and rendered legible at both ends of the black-and-white television circuit in ways that smell could not.
These losses paled in comparison with losing touch, or the ‘haptic channel’. Some elements of touch, like the sensation of hot and cold, could be captured using thermometric sensors and transmitted electronically as graphs, charts or raw numerical data. Yet the single quantum of temperature could not contain all the qualitative information captured by a physician’s hand on a clammy brow. The haptic channel also works two-ways: the hand of the physician is both a sense organ and a means of providing communication, reassurance, a form of therapy in its own right. Another hand, perhaps that of a nurse practitioner in the same room with the patient and the television camera, might act as a limited prosthesis for some of these functions, but not all.
Bird suggested that other technologically mediated senses and agreed-upon codes of interaction would compensate for the loss of touch. ‘There are several uses of telemedicine circuitry,’ he noted, ‘in which a modification of the normal co-presence ritual may have to be considered eventually.’ After all, wasn’t our own presence in the three-dimensional world in part a construct of our shared social reality, a set of etiquettes and protocols that had evolved over millennia but could be re-engineered to work, perhaps better, in electronic forms? Just as deep-sea divers learned to communicate with coded hand gestures in a benthic environment that did not permit oral communication, doctors and patients could figure out new codes for telemedicine.
Bird focused on proofs of parity, and since then much of the scientific literature on telemedicine has likewise been concerned with demonstrating that the services provided by medicine at a distance are equivalent, even if not identical, to those provided by flesh-and-blood encounters. This evidence is uneven: well-developed in the highly visualised fields of radiology and pathology, or in tele-vanguard fields of psychiatry, neurology and cardiology. It is harder to document in more generalist fields, including primary care internal medicine, obstetrics and gynaecology, and paediatrics, and especially difficult in procedure-based surgical fields. The difference between these fields is not absolute but relative. It is a difference of stakes and proof, and who faces the risks and costs if something is lost along the way.
TO BE CONTINUED