SGIM Forum

Perspective: Part II

Being There

Dr. Lu ( is a VA Quality Scholar at the San Francisco VA Medical Center and clinical instructor at the University of California, San Francisco.

(Patient names and specific identifiers were changed or concealed to protect patient privacy. The views and opinions expressed in this article are those of the author and do not reflect the official position of the Department of Veterans Affairs or any agency of the U.S. government. Acknowledgements: Dr. Gaetan Sgro for his encouragement and thoughtful edits on this piece.)

The screen flickered and the clinic room came into view. The nurse adjusted the camera and the image of a thin older gentleman appeared on my computer screen. He was neatly dressed in a worn plaid button-up, seated on the exam table, looking around the room searching for cues for how to act.

I glanced at my own reflection to check my framing on-screen before focusing my gaze into the camera. I had just started my new role as a telemedicine urgent care physician within the VA. This was my first day on the job and the second patient I had ever seen over videoconference. One of the first lessons I learned while shadowing a seasoned telemedicine clinician was the importance of looking directly into the camera lens when speaking to a patient. It mimics the natural eye contact made during in-person interactions that communicates attentiveness and compassion.

Earlier that morning, the charge nurse at this rural Northern California clinic had messaged me about an 81-year-old veteran who had called the clinic about a possible new diagnosis of cancer. His primary care physician had no openings but the patient had seemed so distressed over the phone that she thought scheduling him into telemedicine urgent care clinic was the next best option.

As I reviewed his chart, my heart sank. He had recently undergone a colonoscopy that unearthed a malicious-appearing polyp quickly transforming into a cancerous mass. The rest of his chart was sparse with details about his life or circumstances. Several notes mentioned his long-standing battle with PTSD and mistrust of the medical establishment. Others alluded to his social isolation and lack of family support.

I had been well-trained and well-practiced during residency to have difficult conversations. Gather friends and family that the patient would want near. Find a quiet space. Be gentle but direct. Allow for silence. Sit with the patient. But nothing in my previous experience prepared me for engaging in such a conversation over video. Would it be awkward? Would I be able to gain his trust? How was I supposed to be there without actually being there? I braced myself for the worst.

“Hi Mr. S, I’m Dr. Lu,” I began, “Have you ever seen a doctor over video like this before?”

“No—” he replied, his gaze tentatively landing on the screen in front of him. “This is all new to me.”

“Well, it’s good to meet you and I’m glad you came in today,” I reassured him (though it felt like I was just reassuring myself). I gave a rehearsed spiel about the purpose of our video visit, explaining that this was the quickest way for him to speak with a doctor, and promising that I would do my best to address his concerns the same way that I would if I were seeing him in person. I asked for his verbal consent to proceed and he responded with the slightest nod.

I took a deep breath and continued to look straight into the camera lens. “Tell me what’s been on your mind since the procedure.”

“Well,” he paused, “…they found something in my colon…and they want me to get surgery. Then I would have to get chemo treatments and I would have a bag that I would have to empty. I just don’t know if I want to go through with all that.”

“Tell me more,” I said.

He had seen his primary care physician a few months earlier feeling a bit more tired than usual. It had been their last meeting before his doctor of 40 years formally retired. He was surprised to learn that he had lost about 10 pounds over the course of a few weeks, but he reassured his doctor that it was probably due to the extra work he had been putting into his garden. But his doctor was worried enough to order some blood work which revealed a low red blood cell count. The next thing he knew, he was being wheeled out of the endoscopy suite at the local hospital and the gastroenterologist was yammering away about scheduling him with a surgeon to cut out his colon as soon as possible. He was told with the right combination of therapies, this growth can be treated, even cured. In his post-anesthesia haze, he signed papers and agreed to half a dozen follow-up appointments with various specialists.

But in the last few days, all he could think about was the road ahead. The surgery didn’t scare him, the life after it, did. He thought about how exhausted chemo treatments could make him, what adjustments he would have to make for the ostomy, and the time he would be spending at the hospital instead of the woods. He couldn’t help but wonder if the extra time promised by the treatments would bring him more loss than gain.

As we talked, everything else seemed to fall away—the clinic, the screens, the awkwardness. I was right there with him in that quiet room—sitting, being silent, listening to his story.

He had served in the Army during Vietnam. He was lucky to have gotten out alive and was awarded the Purple Heart for doing what he thought was just a part of his job. He went on to travel the world, marry his childhood sweetheart, and raise a family together. When she suddenly passed away from a stroke a decade ago, he moved into a modest cabin surrounded by redwoods, where he found solace from his PTSD in nature. Now he spent most of his days working in the garden. He’d even grown enough squash to sell at the farmer’s market this year. Each day was a blessing.

“Doc, I’m 81 years old and I’ve had a good life,” he concluded, “I know I don’t have too much time left and I don’t have any regrets. I just want to be able to live like this however much longer I am able. Is that ok?” He looked straight into the camera as he uttered those last three words, his eyes pleading for my permission.

The worries and preconceived notions I once held, vanished. I understood what he needed from me as a doctor. I understood that we had both come to the right place despite the 400 miles that separated us.

We discussed his goals and made some plans. He was going to exchange the appointments with the surgeon for time with a palliative care physician. He resolved to reach out to his estranged family. As our conversation winded down, I assured him that I was only a phone call away should he want to talk again.

“This was really something,” he remarked. “I didn’t know what to think when I came in today or how this was going to work. But I’m glad I’m here. Thank you for everything, doc.”

Much has been written about the disruption of the doctor-patient relationship by the encroachment of technology. Nobody goes into medicine to stare at a computer screen. But what if, instead of a barrier, that screen becomes a window. You inch closer, and on the other side, the rich expanse of a human life draws you in until the frame melts away


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