Telemedicine in COVID-19: Disparities still exist [PODCAST]

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“An increasing number of institutions are relying on telemedicine to continue delivering care to patients in lieu of typical outpatient visits in response to the COVID-19 pandemic. Telemedicine has been lauded as a potential equalizer in health care access. Indeed, it allows for safe and easy access to medical professionals. It especially benefits patients with transportation issues or those seeking specialty care from far away. Some pitfalls such as reimbursement issues and lack of physical exam notwithstanding, telemedicine overall is a helpful service at a time like this. However, telemedicine does not benefit all patients equally. In fact, it exposes and amplifies the existing health care disparity in a subgroup of patients.”

Wenjing Zong is a pediatric gastroenterology fellow.

She shares her story and discusses her KevinMD article, “Telemedicine in COVID-19: Disparities still exist.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Wenjing Zong. She is a pediatric gastroenterology fellow, and she wrote the KevinMD article “Telemedicine in COVID-19: Disparities still exist.” Wenjing, welcome to the show.

Wenjing Zong: Thank you for having me, Kevin.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you just share your story and your journey to where you are today?

Wenjing Zong: So I grew up in China, and I immigrated to the U.S. when I was in middle school. I went to college and did my postgraduate training in Chicago, and four years ago, I moved back home to the East Coast, and now I’m based out of Philadelphia. I am working as a pediatric gastroenterology fellow at the Children’s Hospital of Philadelphia, and this year I’m doing an additional year of advanced training in pediatric nutrition.

Kevin Pho: Wonderful. And from a pandemic standpoint, what are some of the pediatric gastroenterology symptoms that COVID-19 can present as?

Wenjing Zong: That’s a great question. COVID can present in many different ways, and a lot of times in children, it can present as belly pain, vomiting, and nausea. Some kids even develop pancreatitis. So just because they don’t have the classic symptoms of congestion, cough, and high fever, it doesn’t mean they don’t have COVID-19. So as pediatric doctors, we need to be extra cognizant of these atypical symptoms in our population.

Kevin Pho: So the symptoms that you described are pretty nonspecific. As you know, there are plenty of conditions that can lead to those symptoms as well. So as winter comes up, if we have children who present with these nonspecific gastroenterology symptoms, should they be tested for COVID?

Wenjing Zong: So it depends, and I would recommend talking to your pediatrician about them. It will depend on your risk factors: whether you have any underlying conditions that make you high-risk for developing more severe disease, such as asthma, or if you’re on immunosuppression medicine. It also depends on your exposure risk factors: if you’re close to someone who has contracted COVID-19, or you travel to an area with high prevalence. So your pediatrician should be able to take in all those factors to decide whether you need a test or not.

Kevin Pho: All right. So let’s talk about your KevinMD article, “Telemedicine in COVID-19: Disparities still exist.” Now, for those who haven’t read your article, can you just walk my audience through it and share the story of why you decided to write it?

Wenjing Zong: Yeah, I’ll be happy to. So I wrote the article about three months into the pandemic. At that point, a lot of our outpatient clinics were closed due to the social isolation precautions, and so our division decided to switch our outpatient visits to telemedicine-based visits to ensure that our population could still be served. And as with anyone who’s starting a new thing, we encountered a lot of issues initially, but as time went on, we started to discover ways to troubleshoot those issues.

Along the journey, I realized there are a lot of pitfalls in telemedicine, as great as it is. So I wrote an article to point out some of the things that we need to be cognizant of, especially for people who do not have a stable internet Wi-Fi connection at home, who don’t own a smartphone that would allow them to access the app that hosts telemedicine, and people who have trouble setting up the platform due to, you know, the multiple registration and setup instructions that were sent to them. So there’s definitely a need to improve the technology and access to technology for telemedicine to work.

And then, you know, something that came up after I wrote the article is that there’s actually another population that kind of suffered in the era of telehealth, which is the population that needs medical interpretation. So usually in clinics, we have medical interpreters who can interpret in real time, and as you can imagine, that is pretty hard to do with the telemedicine technology right now. We have found some ways to make that more successful recently, but that has been a population that has been pretty underserved in the initial stages.

Kevin Pho: Now, for people who need interpreter services during a virtual visit, how does that work? Do you have an interpreter also come online as well?

Wenjing Zong: Yes, so that’s what made it hard. The platform we use, unlike Zoom, usually accommodates two screens very well, but once you start adding people into the visit, there are sometimes audio issues and video issues. Sometimes one other party is unable to hear for whatever reason. So there was some technologic stuff that needed to be worked out for the medical interpretation piece to work.

Kevin Pho: So you mentioned that there is a subset of the population that doesn’t have access to the internet. So what are some demographic characteristics of patients who may not be the best candidates for virtual medicine?

Wenjing Zong: Yeah, that’s a great question, and the funny thing is, the population that’s typically underserved, those who we feel like, “Ah, they won’t make it to their appointment today,” is actually pretty similar to the population that is underserved by telehealth. You know, we think that telehealth is great because it bridges the gap. You don’t have to travel to the hospital; you save on transportation time and money. But often these are the same families who do not have a stable connection at home, so they would not be able to do telehealth.

You know, at the beginning of the pandemic, we had families who called into the visit from the parking lot of McDonald’s to catch the Wi-Fi. They’ve gone to cafes to try to catch the Wi-Fi, and sometimes those places are not stable either. So it’s just very hard, and we as providers need to know that and be able to help them, and not lose them due to the issues accessing this platform.

Kevin Pho: Now, there’s a very real possibility that the number of COVID-19 cases will go up, especially during the winter, and that practices will have to shut down again and go back to virtual visits. Now, what are some of the lessons that we can learn from the first attempt at telemedicine that we could apply to this potential new wave of virtual visits that may come up?

Wenjing Zong: So one thing that has been really helpful, that our division set up in the beginning stages, is that we set up extra time and resources. You know, our coordinators are trained to help families troubleshoot the technology issues before their visit. You know, it’s not helpful to have them struggle for the first 10 minutes of the visit when each visit is only 30 minutes long, so this needs to be addressed beforehand. If we notice someone did not sign up for MyCHOP, which is the platform that our hospital uses to host telehealth, then likely they will not be able to join. So, you know, usually the day before, our coordinators will call the family to ensure they have everything they need, and if they need extra help, we can walk them through how to set up MyCHOP.

Kevin Pho: Right. We’re talking to Wenjing Zong. She’s a pediatric gastroenterology fellow, and she wrote the KevinMD article “Telemedicine in COVID-19: Disparities still exist.” Now, no matter how much we try alleviating those disparities, they are still always going to be present. There are always going to be people who are going to have trouble having access to broadband internet. Now, what’s the answer to care for these patients?

Wenjing Zong: The answer is not easy, and I think there are multiple reasons that these disparities still exist today, and we’re trying our best to address them. And like I said, we have to put in the resources beforehand, before we expect the winter wave to come, to accommodate a volume that’s going to be switching to telehealth, likely needing more help and more time for setup, and for it to run smoothly.

And for those families who cannot access telehealth, we need to make special accommodations to see them in person, but also ensure that both the patient family and the providers are safe. It may mean that we just have to distribute the patients differently throughout our clinic area, and that we try to have better PPE for all providers as well as the families.

Kevin Pho: So we are now speaking in the middle of October. We’re 10 months into the pandemic. Are there any lessons that you’ve learned over the past 10 months that you want to share with the clinicians who may be listening to this podcast?

Wenjing Zong: So the one thing I learned is to not be afraid to ask for help. As providers, we are always, you know, seen as strong human beings who are hardworking, and we’re expected to do that throughout every stage of our training. But this pandemic is hard on everyone in every aspect of their lives, and I think as human beings, we’re not special in any way, and we should not be afraid to ask our colleagues, our family, and friends for help if we need to. And I think only if we can rely on each other can we actually fight against the pandemic.

Kevin Pho: And my final question: What is your take-home message that you want to leave with the KevinMD audience?

Wenjing Zong: The take-home message is, telehealth is great. It has a lot of potential to help, but we need to place the resources there early to take care of the underserved population.

Kevin Pho: Wenjing, thank you so much for sharing your insight, and thanks again for being on the show.

Wenjing Zong: Thank you for having me.

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