Disparities in Telehealth and COVID-19: Lessons in Empathic Leadership

By John R. Freedy, MD, PhD, Professor of Family Medicine, Medical University of South Carolina

Professionals who focus on Family Medicine/Community Health seek work that is consistent with deeply held beliefs. Our clinical, education, research and policy work is an extension of ourselves — our most deeply held values. To remain professionally and personally well, we require that our work reflects meaning, purpose, and value. What we do must be ethical and moral at its bedrock.

Is the Covid-19 public health pandemic bringing out the best, the worst, or some mixture of both regarding ourselves, individually and collectively?

While it is still early in this crisis, my candid assessment is that while we strive for our best, our actual efforts and results (at least in the coming weeks to months) will be a mixture of good, middling, and sometimes worse (tragically so) efforts and outcomes.

Note the massive health disparities illuminated in recent weeks/months related to Covid-19 impact. In talking with professional colleagues in Charleston and elsewhere in the country, many have noticed that our most vulnerable patients struggle to use telehealth for a variety of reasons. And drive-through Covid-19 testing centers require you to have a car or to know someone who does.

The recent shift to video and telephone virtual visits illustrates an ethical dilemma: Are we being forced to choose financial viability over caring for our most vulnerable patients?

In the past three weeks, I have found myself thinking things like:

• Is this charge necessary for this patient’s well-being or is it necessary for this organization’s well-being?
• Is this charge creating a barrier to care for our more vulnerable patients and community members (i.e. potential patients)?

Covid-19 has brought me face-to-face with an uncomfortable realization. Namely, at least a third of my patients simply cannot use telehealth technology for a variety of reasons, like being older, having multiple medical comorbidities, having less education, experiencing poverty, having chronic mental health issues.

It hurts like hell to see our most vulnerable patients and community members hurting most in this insidious and deadly community health crisis. I did not become a family physician to contribute to such problems.

Being an experienced family physician with interest in behavioral health issues, I see many patients with complex medical and comorbid mental health issues. With the remaining two-thirds of my patients, telehealth is working beautifully, save a technical glitch here and there.

Due to current Covid-19 CMS regulations and SC Medicaid rules, I cannot get paid adequately for virtual telephone-based consultations which is really what my most vulnerable patients need. But to do my part to keep my organization afloat, I strongly favor using telehealth.

As a result, beyond my scheduled clinic hours, I find myself calling my more vulnerable patients by phone to meet to their needs while still accepting the substantially reduced reimbursement rate for phone consultation. It is the only temporary solution I can see to this systemic issue.

We at the federal and state governmental levels have chosen to fully fund the use of telehealth, defined as technology that includes both video and audio simultaneously, that seems possibly to be worsening health disparities in this instance.

Collectively, we are being asked to work in a rapidly changing, still imperfect system that is both helping and hurting members of our society, including ourselves. Professional pride in being treated as important health center team members should not dissuade us from the moral obligation to do better by the most vulnerable of our patients and community members. Expressions of gratitude, encouragement, and being pointed towards resources is appreciated.

I also try to offer leadership both private and public praise, encouragement, and assistance. Hard work and trying to do good does have its rewards, but we are all also being exposed to high doses of vexing societal problems during this pandemic. Such experiences are painful and should not be borne alone.

I suspect that the societal ideal of physicians and other health professionals as “heroes” is a well-intended collective balm for the terrible suffering that we are witnessing with proximity. The public needs heroes and physicians need sufficient courage to believe that what we are tasked with doing will turn out okay. Still, we should not let such mutual desperation in the service of hope distract us from what is true.

People are frightened and some are dying — especially the most vulnerable among us. What does effective leadership look like in these circumstances?

Tangible resources alone are insufficient. Leaders must express genuine empathy, concern, and realistic hope: “I hear you. I’m with you. This is difficult. You and I will continue to do our best in these difficult times. Please take care of yourself.”

These are powerful words coming from a respected leader. For me, this is the most fundamental task of leadership during this crisis: To let our colleagues know that we share their fundamental human vulnerability. Kind words and gestures coupled with patient, compassionate listening to support the humanity of the people sitting right in front of you.

Some quotes that have helped me to cope with the cruelty of the disparities exposed by Covid-19:

“We are not rich by what we possess, but by what we can do without.” — Immanuel Kant

“Listening to and understanding our inner sufferings will resolve most of the problems we encounter.” — Thich Nhat Hanh

By John R. Freedy, MD, PhD, Professor of Family Medicine, Medical University of South Carolina, Charleston, South Carolina