Telemedicine and the Tattooed Lady

Abstract

We started with the subjective: The Texas lady appeared in the virtual examination room half-smiling and a bit anxious on the screen of my laptop. I ll HIPAA hop and pretend her name was Mary Kate Kelly. I was assigned to her by software. Doctor, I have these red bumps on my left leg, she said as her only symptom. This was our first video visit; she did not know me, the black doctor in the white coat. She did not smile. I was the telemedicine doctor and she looked at me as strangely, a bit fearfully, as if I were a brown avatar or could be a churlish chatbot. She was calling in from Gun Barrel City, Texas, and I was serving her from afar from that other gun barrel city, Chicago. Here and also there, we shoot straight with you. Her expression said, Do you, a black man on the other side of the country, care about me, a Southern majority lady here in small-town Texas? My thought was, People first need to know you care before they care how much you know. Then she said, I m not sure y all can help me. She did not smile. Would she be like the Southern majority man who had started our video visit smoking; looked at me coldly; said, I m just not sure I want to talk to you; and hung up on me 45 seconds into the video visit? I m here to Make America Kind Again, I wanted to say to him, and to her. What I mean is, my doctors here in Henderson County have been preachy keen up to now, she said. Keen to preach and not taking any time to really listen to anything I m dealin with. She did not smile. My mentor said that the Johari window shows us how we see ourselves and how others see us. I made sure to nod at this with a reassuring smile, careful to let her talk for 2 minutes without my interrupting. The voice in my head said, Don t be preachy. Be kind, and don t hurry this. Another mentor taught that professionalism means rising above our own aggravations of the momentcaring for and serving the patient as if there were no one else in the world. Unlike in my previous brick-and-mortar exam room, this patient and I talked and communicated through one window, bidirectionally. The window on the weary world floated between us, the screen becoming invisible through her cell phone. Here, we shoot straight with you. Balancing urgent care and primary careI had done that for years in brick-and-mortar clinics. But this was different. This was connecting across time zones, connecting across political divides, connecting for her convenience in her living room. She admitted that she had not seen her PCP in many months and was supposed to be taking metformin, 500 mg BID. She confided in a hushed voice, But I don t always take it as I should. I then asked, Have you felt blue, down, or depressed any days in the past 2 weeks? and, Have you had little interest or pleasure in doing fun things? She did not smile. The PHQ-2 score was 2 and would possibly higher be if we did a PHQ-9. Next came the objective: Clad in a T-shirt and shorts, she had many tattoos visible, and this was her proud flesh. She pointed her telephone lens to even more fresh, proud flesh: a recent tattoo that she said she got just last week at a new tattoo parlor in town. This one was of her cat. However, it was now peppered in red polka dots, and her Cheshire Cat was getting sore. It did not smile. The examination was otherwise unremarkable. She was afebrile with a pulse of 80, a normal guided foot examination, and normal capillary refill. She said her blood pressure had always been normal. She checked her current fingerstick glucose for me: 210, fasting this morning. She didn t remember her last A1c but thought it was around 10. My assessment was as follows: First, an infected tattoo. Second, uncontrolled T2DM. Third, nonadherence. Fourth, possible mild depression without suicidality. What would Dr. Marie Brown do here? What did Professor Verghese say in his TED talk about the art of medicine and communication? What did the CME speaker say about shared decision making? Nonadherence. Would she get angry if I called that out? Did she trust me to go there without delivering a sanctimonious sermon? What were her barriers to better self-care? Could there be MRSA in the tattoo parlor ink? Would you tell me, please, which way I ought to go from here? So now, we discussed the plan: First, she said that she had no contraindications or allergies, so we agreed that I would prescribe trimethoprimsulfamethoxazole for furuncles per the popular antimicrobials app. I also asked her to find follow-up in 10 days. I cautioned her to see her PCP in person or visit urgent care sooner if the polka dots persisted or worsened while she was taking the antibiotic. Second, I asked what mattered to her, now that we had agreed on what was the matter with her. The window was more open now. She agreed to see her PCP about comprehensive care for her T2DM control and to talk more about depression. She would call for an appointment on Monday morning. Third, she halfheartedly agreed to start a walking program to help keep her sugars down and brighten her mood. I touched my heart on camera as I spoke now, leaning in a bit. I made sure that she knew she could call back for another video visit if getting in to see her PCP was hard. Finally, I recommended looking at diabetes.org for self-help advice and added the URL to the patient instructions that I e-mailed her at the end of our visit. Technology is the new civil rightsit can bridge the barriers of education, class, race, and geography. To turn a well-known phrase on its head, The arc of history is long, but our technologies can bend us toward genuine connectedness. Connecting across time zones; connecting across political divides; connecting urban, rural, small towns, and big towns; helping to heal holistically. The Cheshire Cat and the tattooed lady looked through the wide-open window, and we all shared smiles. Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads Telemedicine and the Tattooed Lady by Prentiss Taylor, MD