The COVID-19 pandemic ushered in many insidious handmaidens among its foul equipage. From Zoom meetings and school closures to masks and lockdowns, our world was torn asunder and, eventually, rendered anew into a place where almost everything has been changed, by large degrees and small, perceptibly and imperceptibly. It will come as no surprise that medicine is foremost among the more obviously perceptible areas of life that have been irrevocably changed. One such area in medicine specifically that appears drastically different from the B.C. era (before COVID) is the concept of telemedicine.

With the lockdowns of 2020, people became far more open to the possibility of virtual visits with their physicians, and the market took notice. Here was, and still is, a burgeoning market indeed. The telemedicine industry was estimated to be valued at roughly 90 billion dollars in 2021, and there are predictions of growth well-exceeding 600 billion dollars by 2028. There are clearly a lot of motivated actors hoping to capitalize on the emerging gold rush. While I recognize the futility of standing between such a lucrative market and its profits, I think it important that someone pauses for a moment, not to ask, “Can I participate?” but rather to ask, “Should I?”

It would be unfair not to steel man the counterargument as robustly as I am able in a short amount of space. Telemedicine has potential opportunities, especially for patients in remote locations who cannot easily see a primary care physician or are bound to certain aspects of specialties such as psychiatry. There has been some success in using telemedicine in acute stroke patients when the patient is far from a stroke center, and medications like tPA can potentially make a profound difference in a patient’s ultimate outcome. The ability to consult with a neurologist from afar has been salutary for many stroke patients around the country.

And yet, while it is one thing to use new technology to fill in some gaps of care, it is quite another to create an entirely new side industry. Telemedicine looks set to reimagine the world of medicine for both patients and physicians alike. It would appear, therefore, that one should ask a vital question. Is this good medicine? And, perhaps as a corollary, cui bono?

The answer to the latter question of who benefits will help answer the former, for if it is not the patients, it is not good medicine. One must argue further that if that is the case, it cannot, mutatis mutandis, be in the physician’s interest either. The problem is not corporate greed, medical expediency, or the allure of a new(ish) technology, though all three may be contributory. The problem lies rather in the technology itself-the feature is the bug. Medicine, in general, cannot be practiced through a screen between a doctor and a patient. This is representational medicine. Rather than being present to each other, the patient is represented to the physician, and while it is obvious that this would preclude any procedures to be carried out or any significant physical exam to be performed, it is less obvious how antithetical this is to the practice of medicine. A decent analogy might be that if medicine is sexual intimacy with a loving partner, then telemedicine is mere pornography — a representational encounter that mimics a higher good to the detriment of those who would partake in it.

Medicine requires a patient and a physician in a room together because real medicine requires the interaction of two people present to each other. This is not merely so that a physical exam may be performed, although this is critical, but rather because there is so much nuance and context that goes into every unique interaction between a patient and a physician. How a patient speaks, the clothes they wear, their gait, the shimmy in their hands, the condition of their feet, the behavior and comportment of those accompanying them to the ER, their posture, their eye contact, and their overall affect to name just a small sampling of what the wise physician considers, all contribute heavily to both the explicit and implicit reasoning of the astute physician. The tacit art of intuition and the necessary role of the imagination are both crippled when presence is forced across a screen that merely represents a patient but can never adequately convey that spark of humanity that medicine must catch a glimpse of to function properly. The flow of a life is somehow cut up and minimized through the screen, and that intangible wholeness that is somehow greater than the sum of its parts is unable to be observed and understood by the attentive physician. Everything important is lost, and doctors become mechanics as patients become machines.

This is, of course, a philosophical argument and will not likely convince many, but it is, in my opinion, the best reason to resist the current trend toward the isolated and remote reality of telemedicine. After all, this is a kind of half-medicine removed from any real physician-patient interaction and isolated from medicine’s true purpose of trying to heal a human being who may be filled with terrifying anxiety, hopeless anguish, indescribable pain, tortured heartbreak, bleak malaise, or the grey despondency of modernity. It is, after all, most often a kind eye, the perfect word at the right moment, or a gentle touch that is the most therapeutic weapon in a physician’s armamentarium.

In truth, if we are to keep our beautiful art intact, physicians should avoid the siren song of more technology inserting itself between them and their patients. Patients should avoid the easy allure of a quick video chat if they think something may be wrong with them (not to mention the second bill once they are almost invariably counseled to come to the ER to be seen anyway). Hospital administration should resist the profits that might accrue to their benefit at the expense of the local citizens whom they ostensibly serve and reserve this technology for certain niche areas as needed (rural medicine, acute stroke, psychiatry, etc.)  While this scenario seems quite unrealistic, the benefits it would accrue to our health care system if taken relative to the almost certain lack of faith that will be engendered by telemedicine upon medicine as a whole if not taken would be salutary indeed.

Perhaps we might take the sage advice of Cornelius, the Queen’s physician in Shakespeare’s Cymbeline, who, upon hearing of the Queen’s disingenuous plan to test poison on small animals in order to “gather their several virtues and effects,” replies, “your highness shall by this practice but make hard your heart.” If the advent of social media has taught us anything, it’s that it is much harder to become a cynic when confronted with another human being and much easier when there is a screen to hide behind. To pretend to care for our fellow man remotely is to invite cynicism into our souls and hardness into our hearts, for it isn’t a “real” encounter at all but rather a virtual representation of one. It is, in short, not medicine but the representation of medicine; not a calling founded on a love of humanity but a job predicated on the need for a paycheck. Let us keep cynicism at bay and softness in our hearts. Let us keep telemedicine within its limited and proper scope. Let us be physicians, not technicians, and always, first and foremost, human beings.

Andrew Ross is an emergency physician and author of The Sweet and Bitter Taste of Moonshine.

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