Medicine at a Distance

“all new media deal in futures” -Jeremy Greene

“automation is the dream of autonomy” -Hannah Zeavin

It was at once an odd experience and an exhilarating one. Sitting at the edge of the sofa, I leaned over towards the coffee table to turn on my laptop and open the required application. I waited, intermittently checking my phone for a text notification announcing that the link for my appointed time was sent.  An iPad was propped up on the table as well, picking up snippets of conversations between me and my partner; hopefully it would be effective in transcribing the audio through the laptop speaker into comprehensible captions.

This was the set-up for a surgical consultation during the COVID-19 shutdown.

I’m accustomed to lip-reading and assessing people’s body language and gestures to fully understand conversations. Without the extra set-up—captions on the laptop, back-up captions on the iPad, my partner to elaborate or clarify mishearing—telemedicine would not have been accessible for me, as a deaf person who wears hearing aids and does not sign fluently.

But there’s also something profound about being able to use technology to access medical care and information within the privacy of one’s home. The process was strictly managed: we had to fill out a virtual form (similar to filling out paperwork on a clipboard), wait for a link to be sent (similar to waiting in the lobby to be called in), then we waited in the virtual room (similar to waiting in the examination room), until a doctor appeared (after some time, as usual).

The tech setup was certainly a privilege for me. I had the devices I needed, the stable internet connection, and was part of a healthcare system (and insurance, because I live in America) that provided patients with access to their health portal—which included opting for telemedicine during a pandemic. As advantageous as the system could be, telehealth is not accessible for all people. Socio-economic disparities, lack of insurance, and unfamiliarity with the technology all shape and limit the kinds of healthcare and treatment patients could receive through a screen—or telephone, radio, advice column, or letter.

The history of telemedicine and telehealth (they are not interchangeable terms!) is a history of technological advancement to improve medical access as much as it is a history of new media extended towards the healthcare sector. Two recent books emphasize this history in complementary perspectives: Hannah Zeavin’s The Distance Cure and Jeremy Greene’s The Doctor Who Wasn’t There. I read Zeavin’s book when it was first published and Greene’s several months later and couldn’t help but highlight similar messages about media and technology. And more importantly, about the status of American healthcare system and the cultural obsession with the new and the innovative rather than the need to maintain the system (side note: do read The Innovation Delusion by Andrew Russell and Lee Vinsel on the history of maintenance). As Greene aptly puts it: “The history of healthcare information technology is full of revolutionary promises that did not come to pass, and more mundane ones that did” (4).

The first message is about access through the promise of providing better healthcare for all, by creating new platforms for “practicing medicine at a distance…with the intention of flattening disparities” (Greene, 3) and positioning technology to create a “state of intimate communication” (Zeavin, 2). This recalls Thomas Misa’s compelling tangle of modernity and technology that craft a legend of progress to supposedly take us closer to futurity, or at least, a system of efficiency that dismantles structural inequality (the cynic says: ha! not possible). Greene argues that each new evolutionary stage of telemedicine coalesced around a new technology, or new use of old technology—telephone, radio, pager, computer—that provide a promise of access to the modern doctor, “without needing to engage with the messier roots of structural racism” that create and maintain socio-economic divisions (143). The telephone is an especially prevalent technology, not only as a “symbol of the constant availability of the modern doctor” (30)—or in many instances, as deaf people know all too well, the constant inaccessibility—but also a form of conductive distance that offer help through hotlines and other forms of teletherapy. The phone—in both text and calling—is a form of access, Zeavin writes, “when and where no one else is: any time, on demand, whenever the caller is on their phone” (2). And if it doesn’t feel right, you can simply hang up or ghost the texter. What makes the process good, what makes the teletherapy accessible is not the communication itself, but the offering of “the right combination of presence, distance, intimacy, and control” (Zeavin, 2) (indeed, this is the hallmark of the para-therapeutic call-in radio show of the 1970s and 1980s that even made its way to sitcoms: I’m Doctor Frasier Crane, and I’m listening).

But can this combination be recreated outside of telemedicine? Or are we all, like the physician’s pager, tied by an electronic leash (Greene, 101)? Are we dependent on technology for governing our health, and if so, to what extent?

Greene and Zeavin’s books chronicle the development of technology as promises: to “annihilate time and distance,” to improve intimate social relationships, and to present the possibility of unlimited potential. Yet despite the grandeur of such schemes, they all seem to fall short—perhaps merely mirroring human fallibility. The radio pill developed by Vladimir Zworykin ended up being a mere prototype (which reminds me of nanobots for nanomedicine), designed not for manufacture, but for encouraging “future speculations.” Joseph Weizenbaum’s ELIZA, a forerunner chatterbot to today’s (annoying) messenger bots, was useful for computer-program-based therapy, but despite the anthropomorphism, ELIZA could hardly replace the essential human-to-human interaction necessary for successful therapy.

It’s not that these technologies aren’t useful. They certainly are, and many of them encouraged further rethinking and innovation of telehealth. The problem, as Greene points out, is that their “usefulness had been oversold and misplaced” (209). However they were imagined to redesign the experience of healthcare—in all sectors, from patient to administration—they fell short. Yet we still come to expect innovation (I love Greene’s term of these as “thought-saving devices”) as a driving force for improvement in healthcare and to solve structural inequities and bureaucratic drudgery in ways we haven’t been able to thus far. The next iteration is certainly a version of chatGPT…that is, if it hasn’t already been implemented.

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