Editor’s Spotlight/Take 5: Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status
Seth S. Leopold
Abstract
Telemedicine became a way of life for orthopaedic surgeons and their patients in 2020; as the pandemic bullied its way into 2021, we’ve needed telemedicine to stick around a bit longer. Without question, virtual care provided an option for patients to be “seen” without risk of viral exposure, and it offered a means for orthopaedic surgeons to continue to keep the doors open. File it under “something is better than nothing,” but I’m guessing that I’m not the only person who finds social distancing to be, well, distancing. Part of what I enjoy most about our specialty is connecting in a hands-on way with people in the office, and putting two screens and a coaxial cable between me and the connectee certainly makes that harder. Even so, I do suspect that after the pandemic, telemedicine will continue to play a role in our practices. For quick check-ups—ROM, incisions, and the like—it can give large numbers of patients from geographically dispersed areas a means to access care both conveniently and inexpensively [5]. While I find many claims about patients’ high levels of “satisfaction” with telemedicine to be exuberant, a recent, sober-minded meta-analysis hit me about right on this point: It doesn’t look to be much better or much worse than in-person care [2]. A recent Cochrane review that was abstracted in Clinical Orthopaedics and Related Research® [6] came to a similar conclusion. My two main concerns with telemedicine pertain to safety and medical ethics. The meta-analysis I mentioned correctly points out that most studies on telemedicine have not been able to evaluate its safety in a robust way [2]. Think about what it would take to do so: If we’re concerned that some important diagnosis might be missed, any safety study would have to involve a large number of patients with potentially important, yet subtle, physical findings; those patients would then need to have a telemedicine visit as well as an in-person one to see what was or wasn’t missed in the onscreen visit. Since those kinds of conditions are uncommon, such a study seems impractical in the extreme, and I don’t believe it ever will be done. It’s more likely that we’ll only learn about the safety-related soft spots of telemedicine when plaintiffs’ attorneys point them out to us. For that reason, orthopaedic surgeons need to be selective in terms of which kinds of diagnoses we will (and won’t) evaluate through a computer screen. The ethics of the thing can be similarly complicated. A recent column in CORR® shared the example of a patient receiving an end-of-life diagnosis over a glitchy telemedicine feed, and the columnist thoughtfully covered how to balance efficiency with compassion in better ways than that [3]. This month’s “Editor’s Spotlight” article [7] points to another set of ethical issues, and although it doesn’t talk about them in exactly those terms, the issues it surfaces are no less thorny. A group led by Andrew J. Schoenfeld MD, MSc, from Harvard Medical School in Boston, MA USA, evaluated more than 11,000 patients, including nearly 2000 who received virtual care early in the COVID-19 pandemic at two urban medical centers [7]. After controlling for age, gender, subspecialty, and household income, they found that patients of Asian or Hispanic background, patients who spoke languages other than English or Spanish, and patients insured with Medicaid were less—sometimes much less—likely to access telemedicine care. Not exactly the result we’re shooting for, as we seek to provide care to all who need it. I would hope that we can find ways to use new tools to mitigate, rather than exacerbate, healthcare disparities. My sense is that telemedicine will do a little of both, though the last pages of this story haven’t yet been written. For example, I suspect that virtual care will help large referral centers whose catchment areas cover vast swaths of geography to serve their dispersed, rural populations more conveniently. Obviously, this isn’t something that a study from an urban practice in the crowded New England corridor could ascertain, and future studies will need to do so. And I believe that the important findings Dr. Schoenfeld’s team uncovered in an urban environment are only the beginning, even for that setting. Big-city trauma centers and referral practices serve many different, sometimes difficult-to-reach subpopulations; each may need its own special kind of outreach in order to integrate telemedicine into the delivery of thoughtful, comprehensive care. The risks of getting this wrong are serious. When external pressure—such as a pandemic—causes patients to opt out of care, as seems to be happening for cancer screening [4], we should not be surprised that physicians report observing more-severe initial presentations of potentially lethal diseases [1]. Please join me in exploring those themes and others in the Take 5 interview that follows with Dr. Andrew J. Schoenfeld, senior author of “Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status.” Take 5 Interview with Andrew J. Schoenfeld MD, MSc, senior author of “Telemedicine Use in Orthopaedic Surgery Varies by Race, Ethnicity, Primary Language, and Insurance Status” Seth S. Leopold MD:Congratulations on this important study. To remedy the problem you identified—substantially decreased telemedicine usage among particular groups—we will need to try to find out why those groups are not accessing this kind of care. You offered some speculative explanations in your paper; what would it take to determine the reasons somewhat more definitively for each group in which you observed important differences? Andrew J. Schoenfeld MD, MSc: Thank you for the opportunity to further unpack and discuss these issues. I think the next step in the process would be to conduct a qualitative investigation. In this approach, we would use focus groups and one-on-one structured interviews to understand the issues that confront the types of patients who have difficulty accessing care through virtual platforms. Ideally, this would include sessions with all stakeholders, including the provider and health-system side, to get a holistic appreciation of the various issues, challenges, and opportunities to implement change. The results of these qualitative studies could then lead to a demonstration project that could ultimately be scaled to the health system as a whole if it proves to be successful.Andrew J. Schoenfeld MD, MScMy team is working on several qualitative efforts where we are trying to understand how the advantages of telemedicine can be leveraged to the benefit of patients and the community. We have completed a relatively large mixed-methods investigation evaluating patient preferences for telemedicine—anticipating that the attractive features of telemedicine will mean that health systems and clinicians will want to offer this service even when the pandemic is over, and certain patients still will want to avail themselves of this technology as well. A sneak peek on the findings: Patients prefer initial visits to be in person as they find it helps develop rapport and a working relationship with their orthopaedic surgeons. On subsequent visits, such as follow-up visits for imaging, tests, or evaluations following an intervention, patients enjoy the ability to avoid traffic, parking hassles, and associated costs. Dr. Leopold:I was intrigued by your finding that patients of Hispanic ethnicity were less likely to use telemedicine than were white patients, but Spanish speakers were not less likely than patients whose mother tongue was English. You cautioned that people in the Hispanic community should not be treated as a Spanish-speaking monolith in terms of thinking about pathways to care access, and that we need to recognize that challenges for native Spanish speakers may be different from those experienced by other Hispanic-Americans. Can you take us a little deeper on this? Dr. Schoenfeld: I would be happy to speak to this directly, especially since both my maternal grandparents moved from Puerto Rico to the United States in the first half of the 20th century. My maternal ancestral roots on the island can be traced back to 1500, in fact, and I have an avocational interest in the ethno-cultural history and folk religions of the Caribbean. The Hispanic community in the United States is heterogeneous, and there are numerous intersections that influence how an individual may view the healthcare system, how much they trust the system, and what they would consider appropriate access to care. These intersections occur at the racial, cultural, socioeconomic, community, and language-based levels, among others. The outlook for a first-generation Spanish speaker from El Salvador in this regard may be different from that of a Mayan speaker from Central America, a Mexican-American from Texas, and a third-generation native English speaker with African-Caribbean ancestry from New York. All of these individuals likely would have different takes on the challenges to accessing the healthcare system in general, as well as obstacles to participating in telemedicine visits. The field of healthcare in general, as well as orthopaedic surgeons more specifically, should understand there is not a one-size-fits-all approach that can satisfy the needs of the Hispanic community in the United States. Dr. Leopold:Some of your proposed solutions—community telemedicine kiosks, in particular—struck me as potentially expensive; to motivate those types of commitments, I think city or regional governments are going to need to be convinced telemedicine is going to be with us in a big way for the long haul. How important is all of this going to be following the pandemic, and if the answer is “pretty important,” what will it take to inspire the civic investments you suggested? Dr. Schoenfeld: I think there is a lot about telemedicine that is attractive to patients and also creates “economies of access” for orthopaedic surgeons and the health systems they support. As a result, I don’t think the interest in and desire to utilize telemedicine is going to go away completely (on either the provider or consumer side) once the pandemic is over. That being said, I think the onus is on the healthcare organizations, not civic government. Community telemedicine kiosks do not have to be some type of large capital investment as you might be imagining. This could be as simple as a secure laptop with video capability that is located at a local health center, community hall, or other accessible facility at the heart of an underserved community. The funding, advertising, and infrastructure to support this would ideally come from the healthcare organization itself, which could partner with leaders, grassroots organizations, and community stakeholders to ensure members of the community are aware of telemedicine and have the ability to access the technology. Dr. Leopold:What specialties or healthcare settings have you seen—either through experience or through what you read in the course of performing and writing up this study—that are doing better than orthopaedic practices in terms of delivering virtual care, and what are they doing differently? Dr. Schoenfeld: To be frank, I think that the orthopaedic field really was out front in developing numerous avenues of research in the last year regarding telemedicine and how it can safely and effectively be applied in clinical practice. The efforts of several orthopaedic journals, including CORR, in moving to make this work available expeditiously has allowed many to incorporate telemedicine best practices on an accelerated timeline that one rarely sees in translational research. I am not aware of other disciplines that I would say are utilizing this technology more efficiently or effectively than the orthopaedic field at present. Dr. Leopold:Let’s end with a personal question: What are you most looking forward to once life returns to normal? Dr. Schoenfeld: I would say without question that I am most looking forward to reuniting with friends and family, whom I have not been able to see in more than a year. In line with this, I really miss connecting with colleagues at national and international meetings. I very much look forward to being able to travel again in general, and specifically to get to in-person meetings, to meaningfully engage in exchange of ideas with scholars, coinvestigators, and peers.