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A Piece of My Mind
June 16, 2020

Socially Distanced Medicine

Author Affiliations
  • 1Department of Infectious Diseases, University of California, San Francisco
JAMA. 2020;323(23):2383. doi:10.1001/jama.2020.8975

I watched her cling to life for weeks on a ventilator, but she never saw my face. As an infectious disease doctor during the coronavirus disease 2019 (COVID-19) pandemic, I was called to evaluate her in the hospital’s intensive care unit. The hours spent poring through her medical record and debating how best to manage this infection took place behind the scenes, without the standard trip to the bedside.

I saw her through the glass doors of the intensive care unit, a woman my mother’s age with dark hair curled on her pillow. Machines and medicines were keeping her alive, and her face was angled towards the window, as though despite her chemical slumber she sought the warmth of the sunlight pouring in. No visitors were permitted, of course, so the only faces she saw in person were masked and goggled; her care team had the disconcerting look of alien invaders.

I can only imagine how frightening it must be as a patient to be sick and dependent on a care team of faceless people—a legion of attendants with eyes, nose, and mouth obscured by masks and eye shields. I too have had the unsettling experience of suddenly being unable to see the expressions I once took for granted on my colleagues’ faces: the gnawing of a lip deep in thought, the slight smile or fleeting frown revealing emotions hidden by well-measured speech. The now ubiquitous personal protective equipment hides these expressions; it is an unpleasant challenge to gauge another’s true emotions, to differentiate between sarcasm or seriousness. Conversations feel stilted. My surgical colleagues—long accustomed to living in a world of masked faces—say you get used to it, that you learn to communicate with your eyes and your body. But we nonsurgeons haven’t had time to master these methods, so we’re all speaking different dialects.

We wear this protective equipment, prohibit visitors, and minimize traffic in and out of patients’ rooms for a reason, of course: to stop the spread of infection. And I know that even from a distance, we are working around the clock to save as many lives as we can. Yet the care I provide feels less real. Without a hand on the shoulder during the lung examination or the reassuring touch of the arm during a difficult conversation, how can I feel like a physician? And will we decide, at the end of this, that moving away from seeing our patients face-to-face was a step in the right direction—that even when it’s safe to go back to the bedside, we need not do so?

Late one recent afternoon, my pager alerted me to a frantic message about a patient struggling to breathe. The primary team told me the cause of this decline wasn’t clear and asked whether it would be prudent to change the antibiotics being given. Because the patient was being evaluated for COVID-19, I made my assessment using the chest radiograph, the blood count, and the oxygen levels. To be fair, whether or not I physically stood in the patient’s room would not likely have changed what I recommended. Yet it seemed antithetical to good doctoring to make a decision without actually laying eyes on the patient and without offering the chance to see me, too.

It was not the first time that week that I had lamented not seeing my patients in person. I help navigate their care from afar, at times so distant and disconnected I may as well be working from outer space. Although I hope that after the pandemic we will return to the bedside, I worry that we will get used to not being there—that we are setting a precedent that carves an enduring chasm between physician and patient and makes it harder to get to know one another and easier to miss important details. These concerns, of course stem from the ability to practice medicine from a safe distance, and it has not escaped me that this is a privilege so many of my colleagues truly on the frontlines do not have.

I wonder whether patients know that we are looking over them and thinking of them, even if from a distance, and how much was lost when visitors were barred. In the days before COVID-19, we knew our patients in part through the friends, family, and even pets that came to visit—loved ones who revealed more about our patients than the medical chart ever could. The loving daughter who brought in home-cooked soups to nudge her ailing mother to eat, for example, demonstrated that my patient was well cared for at home. The prickly partner with scar-studded arms offered a glimpse into the chaotic life that made it difficult for my patient to take life-saving antivirals to treat HIV.

Now we are left to care for patients in the hospital as if in a vacuum; we wonder who they and their loved ones truly are. I never got to meet the partner of the patient who was pregnant and sick with COVID-19, a recent immigrant who had sought medical care when she could no longer bear the sensation of impending suffocation. She lived with 7 other people in a small apartment, and I found myself wondering about her partner in particular. Had he discouraged her from going to the hospital, or had he called the ambulance? Was he supportive, neglectful, or even abusive? We were left guessing about details that had important implications for her care. I fear that if enough time passes, we might forget how important visitors are not only to patients but also to the care we provide. Worse, we may decide it’s more convenient to do without them.

We navigate these uncharted waters together, my colleagues, patients, and I, yet we are unable to truly see each other. It has been a surreal trip into a parallel dimension in which we may be together, but too often feel utterly alone. I’m not sure it will ever be the same again. In fact, I worry that it won’t be.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Allison Bond, MD, MA, Department of Infectious Diseases, University of California, San Francisco, 513 Parnassus Ave, Ste S380, San Francisco, CA 94143 (allison.bond@ucsf.edu).

Conflict of Interest Disclosures: None reported.

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