The Rise of Telehealth

Well down the path of protecting health care workers with vaccines and masks, it remains for insurance companies to decide whether to still cover virtual visits.

Just a few years ago most people who studied health communication expressed doubts about the value of remote health “visits.” A phone or video appointment with a professional might be fine for a patient or client isolated in a remote location. But more recently, the more typical telehealth “visit” has gone local, with patients talking to a provider just a few miles away, usuallly via some version of Zoom.  Indeed, no person with symptoms of COVID was really welcome in a typical medical office, especially when vaccines were still months away.  Rates of virtual visits for all types of care are now at about 35 percent.

I certainly was among the skeptics, believing that a live face to face encounter is far preferable. And health professionals note that if they take time to notice, they may learn more about a patient’s condition in the small ways they present themselves during an in-office examination. But COVID obviously made telehealth “visits” a safer alternative.

Now, well down the path of protecting health care workers with vaccines and masks, the question remains for insurance companies whether to continue to fully reimburse health providers for virtual visits. And since states pitch in for federal insurance, many are grappling with what they will reimburse. Some state leaders have expressed concern that virtual visits are easy to abuse, and maybe little more than a glorified phone call. Then, too, it takes some planning and skill  to do exams remotely.

The behavioral health therapists I know bridle at the suggestion that they do any less for a virtual visit. Some argue that they often achieve more because they have to listen closely to a patient’s or client’s descriptions of their world and concerns. Not surprisingly, a face on a flat screen sometimes gives away very little. With video, the work and the payoffs are ironically in the process of active hearing and listening: something we are less apt to do in the presence of a lot of visual stimulation.


The Human Glitch of Required Video

There’s also an unexpected glitch with a mandate that specifically requires video visits. Many older patients  and clients are hardly in the position to use a computer or smart phone to connect with a professional. What is second nature to most of us is often awkward for a senior with limited abilities. They may not be able to pull off a video chat, with all the normal prerequisites of finger dexterity, access codes, Wi-Fi connections, and basic management of the software. And, to be frank, there aren’t enough staff around these folks to stand by and help.

For these seniors, phone visits are often adequate and preferred. They’ve grown up with telephones. So far, through much of the pandemic insurers have usually allowed calls to be counted as full “visits.” But those who pay our healthcare bills have a hard time imagining that seniors would be challenged to manage Zoom calls. Most surely need a more active imagination to understand why what is essentially video conferencing is poorly suited to an assisted living or nursing home situation.

There is also an additional advantage to audio-only visits. They allow a person to give up the natural anxiousness that comes with the offering of oneself to the gaze of others. This is no small matter, as anyone with a teen in the house knows. Almost all of us worry about how we will look to others. It’s part of the human condition. Face to face meetings require, in sociologist Erving Goffman’s perfect phrase, “the presentation of self.” Our presence in the same space with others carries the double burden of trying to meet perceived expectations, and implicitly inviting others to judge the-outer most shell of the self.

To some extent that still happens with voice-only messages.  But the so-called “white coat syndrome” is probably reduced. We can retain more of our personal “front,” making it easier to focus on what we are saying. For now, it remains to be determined how routine medical visits will look in the coming years.

America’s Recurring Cycles of Forced Relocation

What are the historical moments that illustrate the canon of American values still worth celebrating?

Whether it was the Presidency of Donald Trump, the world-altering effects of COVID, or the continuing interest in America’s ethnic and tribal identities, the nation is now looking back on its history with an especially critical eye. What narratives have been blindly passed on that were wholly or partially false? What are the historical moments that illustrate the canon of American values that are still worth celebrating? Is every monument to national greatness now burdened with back stories and alternate narratives that give pause?

Of the many layers of this onion of shared national experience, we could just consider diasporas and forced relocations within our borders. Most raise troubling questions of just how much freedom the American “melting pot” has allowed some of its members.

There is, of course, the depressing and decades-long relocation of indigenous groups, with many unhappily resettled on the arid lands of Oklahoma and the southwest. There is also an entire literature devoted to African Americans fleeing their own southern roots for a better life in the industrial Midwest and northern cities like Chicago: perhaps the biggest internal diaspora of any. And there is the ongoing effort to cleanse the population of foreign nationals—many who are hard workers—who are non-citizens. Even Mormons went through their own diaspora, moving because of persecution first in New York State and, later, in Missouri, before finally settling in the empty spaces of Utah.

Claiming membership in a cultural community now often produces more pride than claiming American citizenship.

More recent attention has been paid to the thousands of Chinese who were brought in during the 19th Century to build the railroads and mines. They and their heirs have faced discrimination from the beginning. The national disease of nativism that was turned against Asian Americans has also played out against the Irish, or Jews and Muslims—legal citizens after their own diasporas—who settled in communities as servants, shopkeepers, mill workers or domestics.

Not every story about ethnic separation comes with stories of overt discrimination. And seemingly endless accounts of forced removal or denial of entry include most cultures on every continent.  Daily headlines currently focus on in-migration to southern Europe and North America. Even so, it is all the more ironic that American citizenship per se may now mean less to many than membership in a specific cultural community.

Recent comments from actor/writer George Takei of Star Trek fame raises a representative moment. Takei was a Japanese American aged five when his family was swept up in yet another diaspora: this one initiated by F.D.R. at the beginning of World War II. A federal order called for the round up Japanese Americans—men, women and children—to be held in camps far removed from their homes. The government seemed to favor one-story barracks in the desert, like Dalton Wells in Utah.  Camps were typically surrounded by guards and barbed wire. By chance, Takei’s family was moved from California to a small camp in Arkansas. The official argument then was as weak as it is now: Japanese Americans might be disloyal in the war against Germany and Japan.

His account is chilling as it is simple. At gunpoint they were ordered out of their home by two military guards and held in a prison camp from 1942-1946.

We were loaded onto trucks that morning and we were driven down to Little Tokyo, the  Japanese American community in downtown Los Angeles. We were let out at the Buddhist temple there, and the area was crowded with other Japanese Americans who had been picked up. There was a row of buses, and we were tagged and loaded onto those buses, and the buses took us to the Santa Anita racetrack and there we were unloaded and     herded over to the stable area. Each family was assigned a horse stall, still pungent with the stink of fresh horse manure. That’s where we would sleep temporarily while the camps were being built. For my parents, going from a two-bedroom home with a front yard and a backyard, to taking their children into a horse stall to sleep was devastating. My father told me about it when I was a teenager, and said it was absolutely horrific, humiliating, and degrading. The government at that time called it a Japanese neighborhood, or relocation center, but it was really a prison camp.

When we wonder how so many Americans and more than a few presidents could stray so far from the nation’s professed beliefs, we should remember that an unearned form of nativism seems woven deep into the nation’s fabric. It’s clearest manifestation is in the nation’s original sin of slavery. And it’s all the more ironic when the country was built up by immigrants and their heirs who fled their own states, only to appropriate lands of the indigenous population already present.