The way we work now: Pregnancy in the time of telehealth

A bonus benefit of Taylor Clancy’s first online appointment with her obstetrician in October of 2020 — besides maintaining safe distance, avoiding a drive to office, and being able to wait on her own couch — was finally getting to see her doctor’s smiling face. Clancy, 34, an emergency room nurse in Boston, had entered the third trimester of her pregnancy, and as a first-time parent, she had all the usual worries and concerns. But a pregnancy during a global health crisis heightened those fears. 

Although she had seen her obstetrician, Katherine Matta, in person for ultrasounds and physical exams, COVID precautions meant that each appointment was conducted as quickly as possible (not much chit-chat), with as few people as possible (Clancy’s partner, Peter, could only join via FaceTime), and through the protective filters of face masks and shields. Despite the physical distance, online appointments offered a chance for a more personal connection as Clancy’s pregnancy progressed.

“A lot of prenatal care is talking about what to expect, how the mother is feeling, and any concerns they have,” says Matta, part of the Steward Health Care Team with an office at St. Elizabeth’s Medical Center in Boston. “Video has been great for that, and you can tell patients are happy to be able to talk face to face.”

The dawn of a new era in healthcare

Telemedicine or telehealth — delivering medical care and advice via video, phone, or messaging through a patient portal — isn’t new, but it hadn’t been widely adopted before the pandemic. Matta, for example, had never conducted a video appointment with a patient before the pandemic — only 12% of obstetricians in the US had. But by March 2020, the number of virtual appointments rose by 4,000% in some parts of the US, as patients and their doctors recognized its value in making healthcare possible from a distance. By June 2020, 84% of obstetricians had added telemedicine, offering a mix of in-person and virtual prenatal care for the dozen or so appointments a woman can expect during a typical pregnancy.

Beyond providing a temporary fix amid COVID concerns, telemedicine has emerged as an option that could reshape the way doctors and patients interact. Joseph Kvedar, professor of dermatology at Harvard Medical School and chair of the board of the American Telemedicine Association says that, as doctors learn more about what they can do via telemedicine and patients grow accustomed to the convenience, we’re all moving forward on a learning curve toward better, more accessible, more patient-centered care.

“Right now, we’re using it to keep people safe at home, but that’s just the beginning,” Kvedar says. “Telemedicine is the gateway to reimagining what healthcare could be like.”

Webside manner 101

Standard prenatal care follows an established cadence: a first appointment about six weeks after a positive pregnancy test, and then monthly visits for routine ultrasounds and check-ins. At 28 weeks, appointments become more frequent, with check-ins every two weeks to monitor blood pressure, weight, and belly growth. And at 34 weeks, pregnant mothers start seeing their doctors weekly.

Many of those appointments don’t require diagnostic equipment or physical exams, but they do require attentiveness, reassurance, and empathy — all of which can be difficult to communicate on screen. Part of the learning curve for physicians is moving the personal experience of talking one-on-one in a private exam room to the screen, or as Kvedar puts it, developing a good “webside manner.”

“So much of what makes us effective communicators in person is nonverbal,” says Neel Naik, director of simulation education at the Center for Virtual Care in New York City. Facial expressions, eye contact, hand gestures, posture — all of these often unconscious actions send important cues that doctors must learn to communicate through a screen. For Matta, that means looking directly into her camera whenever possible to show her attentiveness, pausing if a patient looks upset during a difficult discussion, and smiling to project calm and reassurance.

“I always tell my patients I’ll tell them the truth, without sugarcoating,” she says. “But how you say something matters. People can tell by your face whether you’re really concerned about something or not so concerned.” 

Naik has developed a training program to help medical students and practicing physicians learn how to cultivate webside manner. Students conduct simulated virtual appointments with actors playing the patients and then watch the recordings to see how they show up on screen.

“You can see what your body language and facial expressions are like, where the lighting or camera angle makes a difference, whether you’re fidgeting, and how all of that looks from the patient’s perspective,” Naik says.

The new doctor-patient partnership

Naik says part of learning how to build doctor-patient relationships on screen requires accepting that the care experience is no longer 100% under the doctor’s control. The steps that typically set the scene for an appointment — traveling to the doctor’s office, being welcomed by staff, changing into a hospital gown — aren’t factors when patients are sitting in their homes and the appointment begins with the click of a button.

This includes helping patients set up what Naik calls a “virtual exam room,” with members of the healthcare team or the provider themselves possibly calling patients in advance to be sure they know how to access the right platform, their webcam and microphone are working, and they can be in a private space without distractions.

It can also mean relying on patients to gather data that would have normally been taken care of by a healthcare professional. Clancy, for example, would document her own weight and blood pressure before her online appointments with Matta, but that’s just the tip of the iceberg of what’s possible as at-home diagnostic devices become more widely used.

Surgeons are sending patients home with high-resolution cameras to track wounds as they heal, ophthalmologists are lending them retinal cameras to monitor eye health, and the market for home health technology for everything from glucose monitoring to diagnostic testing is exploding, setting the stage for a future in which patients are the ones providing the crucial data doctors use to inform care.

Finding opportunity in the distance

After Clancy delivered a baby girl after a little over 12 hours of labor in December 2020,  she went in person for her daughter’s first pediatrician visit but also had virtual appointments from home with a specialist and a lactation consultant. “It’s nice to be able to keep her here in a controlled environment and still feel like I’m getting good quality medical attention and care,” she says of those early days. 

That kind of positive experience is leading more physicians to think bigger about what they can do for patients when proximity isn’t a requirement.

At the Northwest Regional Telehealth Resource Center (NRTRC), which provides telehealth education, training, and support to physicians and patients and is part of the National Consortium of Telehealth Resource Centers, program director Nicki Perisho says telemedicine represents a paradigm shift for healthcare providers.

She says she’s seen a burst of enthusiasm from doctors who see the potential for reaching patients that they couldn’t before to provide remote care across a range of specialties, such as increasing access in rural and urban communities, real-time translation services, and removing the stigma for patients who may not want to be seen visiting a mental health provider or clinic for STD services. 

“It took a pandemic to show the real value that telehealth offers, but providers who didn’t use it before are telling us they love to have this option,” Perisho says.

Kvedar says the hybrid model of care that emerged out of necessity during the pandemic, with patients seeing doctors both in person and remotely, has been a bright spot for doctors — a stopgap that could end up reinventing patient care.        

 “We’re in this field because we want to take care of people,” he says. “The fact that we can achieve convenience, access, and quality at the same time, without making patients leave their homes — that’s exciting and fulfilling for all of us.”

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