The Promise And The Peril Of Virtual Health Care

The Promise And The Peril Of Virtual Health Care

John Seabrook

June 22, 2020

The call came in to the emergency department at Alice Peck Day Memorial Hospital, a twenty-five-bed facility in Lebanon, New Hampshire, around 2 p.m. on a weekday in mid-March. Patient X had arrived by car, and, by the time he reached the hospital, the pain in his legs was so severe that he couldn’t move.

Jesse Webber, a paramedic, donned full personal protective equipment (P.P.E.) before going outside with a wheelchair. Since the onset of the pandemic, almost all sick people who entered the hospital’s E.R. were considered, whatever their symptoms, to be P.U.I.s—persons under investigation for covid-19.

The patient, a heavyset man in middle age, was lucid when Webber wheeled him into the emergency department’s negative-pressure room—a seven-by-eleven-foot windowless space fitted with a noisy exhaust fan that removes contaminated air. Once the man was inside, his mental state deteriorated rapidly. A team made up of Nancy Ferguson, a doctor, and two critical-care nurses, Kacie Boyle and Laura Williams, in full P.P.E., joined Webber and Patient X in the cramped room.

The patient was having difficulty breathing. “Very quickly, his respiratory rate dropped,” Webber later told me. He was “crumping,” as nurses say—not crashing, but failing fast. “His body essentially stopped breathing in front of us,” Webber said.

Ferguson ordered a rapid-sequence intubation, a procedure for swiftly connecting a patient to a ventilator. Ventilating a patient is a complex task that involves not just putting a breathing tube into the trachea but also inserting intravenous lines to deliver sedatives, so that the patient doesn’t fight the tube—known in hospitals as “bucking the vent.”

“As soon as I heard the doctor say that, I reached behind me and hit the emergency-telehealth button,” Webber recalled. Within seconds, the team at Alice Peck Day was connected, through a secure audiovisual link, to the tele-emergency hub at Dartmouth-Hitchcock Medical Center, an academic training institution with more than five thousand employees, affiliated with Dartmouth College’s Geisel School of Medicine. Sadie Smith, a nurse, and Victoria Martin, a doctor, were in the middle of twelve-hour shifts, sitting side by side at one of the hub’s four-screen workstations. The workstations are hardwired into the emergency department at Alice Peck Day, and also into those of ten other community hospitals across the region; the most distant is a hundred and eighty miles away.

Smith’s face popped up on the screen in the Alice Peck Day negative-pressure room. Smith is one of the most experienced tele-emergency nurses on the Dartmouth-Hitchcock staff, and she has an air of unflappable competence that would inspire calm in any crisis.

“How can we help?” she asked.

Smith and Martin had control of a high-resolution camera mounted on the wall of the negative-pressure room. They could zoom in on Patient X, watch his cardiac monitor, and talk to the doctor, nurses, and paramedic on the scene. Electronic-record-sharing allowed them to “chart on” the patient—to have real-time access to his vitals and his medications, just as though they were there. But, unlike the staff attending to him, who were working elbow to elbow in the negative-pressure room, straining to speak over the noise of the exhaust fan, the tele-hub team was unharried and safe from possible covid-19 exposure. The hub personnel could check records and arrange for transport to the medical center, on the other side of town, without the nurses having to leave the room, thereby avoiding the hospital’s P.P.E.-doffing procedure—a two-person, twenty-eight-step job—and the need to put on new P.P.E. on their return.

In the hub, Smith noticed that the hydration fluid the patient was receiving wasn’t compatible with the sedative that he was on; the Alice Peck Day nurses switched fluids. The doctors decided to insert a second I.V. line, using the intraosseous method, which infuses medicine directly into the patient’s bone marrow. Smith told me later that “really large patients are difficult, because it’s really hard to find I.V. access. So I suggested going through the humeral head”—the top of the arm bone. “I’m standing there, with my camera view, going, ‘Bring his arm over, lay it across his belly, then feel here, and right in the middle is where you want to go.’ ”

“Sadie kind of guided us in,” Webber said.

Finally, they got Patient X intubated, and “it turned out his expired CO2 was really quite high,” Smith told me. As the nurses used the ventilator to blow pressurized oxygen into his lungs, his CO2 level started to trend down. The crisis had passed.

Telemedicine and telehealth involve a myriad of remote-health-care technologies and services collectively known as “virtual care.” For years, virtual care played a minor role in the United States’ $3.6-trillion health-care industry; now, with the covid-19 pandemic, millions of people are discovering its benefits and its shortcomings for the first time. If virtual care is the future of health care, is it a future that we want?

In a narrow sense, the word “telemedicine” can mean the type of hardwired hospital-to-clinic setup that allows workers in a large hub hospital to assist in complex emergency procedures in distant spokes. This approach is descended from nasa’s pioneering research, in the nineteen-sixties and seventies, into satellite communications and methods of monitoring astronauts’ well-being in space. One of the first telemedicine projects in a terrestrial setting, which operated between 1973 and 1977, offered remote health care on the Papago—now the Tohono O’odham—reservation in southern Arizona while also testing the technology for use in spaceflight. In the early eighties, NASA began developing a tele-I.C.U. for astronauts on Space Station Freedom. Telemedicine in the Dartmouth-Hitchcock Health system, a network of hospitals and clinics across New Hampshire and Vermont which serves 1.9 million people, is the twenty-first-century embodiment of the fifty-year-old prototype.

Telehealth also comprises virtual interactions between individual doctors and patients, in which the participants rely on an audiovisual hookup instead of an in-person visit. You have a bad sore throat but don’t want to wait to see a doctor—or you are among the thirty per cent of millennials who don’t have one. You could go to the E.R. or to a brick-and-mortar urgent-care center. Or you could download the telehealth app you saw advertised on MSNBC. Before long, you are connected to a physician, who, using your phone to look down your throat and relying on your description of the swollen glands in your neck, can prescribe antibiotics and other noncontrolled substances. You’ve saved yourself a trip to the clinic, and you haven’t made other people sick or caught something else yourself.

Online visits can be enhanced by Internet-connected devices that collect patient data at home and then send it to a doctor. These include fitness trackers, blood-pressure cuffs, pulse oximeters, and gadgets like Kinsa’s smart thermometer and TytoCare’s self-examination kit, which link up with a phone and make it possible to perform at least part of an annual wellness check on yourself.

Telehealth providers typically offer virtual urgent care for non-emergencies. And patients suffering from chronic conditions, such as diabetes and colitis, can conduct routine follow-ups online. Proponents of telehealth have long argued that fifty to seventy per cent of visits to the doctor’s office could be replaced by remote monitoring and checkups. But, until the pandemic, most Americans weren’t interested.

Dartmouth and its affiliated think tank, the Dartmouth Institute for Health Policy and Clinical Practice, have been on the vanguard of health-care reform for decades. Twenty-four years ago, they began publishing the Dartmouth Atlas of Health Care, an annual survey of medical spending and patient outcomes in communities across the United States which was credited as an important influence on the 2010 Affordable Care Act. In 1999, Dartmouth-Hitchcock opened the Center for Shared Decision Making, with the aim of giving patients the tools to engage in their own health-care decisions. The Connected Care center, which was launched in 2012 and today includes the tele-emergency and tele-I.C.U. hubs, was an extension of its founders’ belief in patient empowerment and data-based medicine.

Title Walt's Nightmare. A man stands in front of a museum called the American Museum of Walt's Browser History.

Cartoon by Joe Dator

Among Dartmouth-Hitchcock’s patient base are members of a number of medically underserved communities, as defined by the Department of Health and Human Services: poor, elderly, and special-needs populations who lack easy access to primary-care physicians and medical specialists. Patients who routinely drive two hours to visit a cardiologist or a gastroenterologist can “see the doctor” through a secure smartphone app. Dartmouth-Hitchcock offers a diverse menu of services for distant patients, including tele-psychiatry, tele-neurology, and tele-urgent care.

But even in rural northern New England telemedicine has been a hard sell. “We have been struggling in some areas, to be perfectly honest,” Mary Oseid, the medical center’s senior vice-president for connected care, told me. Many rural clinics and community hospitals in small American towns fear that their already meagre medical staffing, and the revenues generated from procedures that can be performed on-site, will be further hollowed out by remote medicine. And often the patients who need care the most—the old and the poor—don’t have smartphones or broadband connectivity, or can’t afford extra minutes on their wireless plans, placing one of telehealth’s greatest promises, of allowing old people to “age in place,” out of reach. Before the pandemic, outpatient telehealth across the entire Dartmouth-Hitchcock Health network averaged only thirty visits a week.

This is representative of virtual care throughout the country. Telehealth totalled just 0.1 per cent of all medical claims filed in 2018, according to fair Health, a nonprofit that analyzes data on insurance claims. The National Business Group on Health, which publishes an annual survey of employee health benefits offered by large firms, found that in 2016 seventy per cent of companies included telehealth as part of their plans, but only three per cent of their workers used it. Some employees weren’t aware that the service existed; others didn’t trust an anonymous doctor. According to a 2019 survey conducted by J.D. Power, forty-nine per cent of patients believed the quality of virtual care to be inferior to that of an old-fashioned in-person doctor’s visit.

Reimbursement has been another issue. Until recently, Medicare covered telehealth only in rural areas, and required patients to conduct visits in a clinical setting. And, in spite of the time-and-money-saving advantages of telehealth, a lot of people clearly want to be in the physical presence of their physician, undergoing the familiar rituals of a checkup—the doctor’s scrubbed hands emerging from the crisp cuffs of a white lab jacket—that no screen can yet provide.

Doctors haven’t been sold on telehealth, either. In a 2019 survey conducted by the American Medical Association, only one in three specialists expressed full confidence that virtual care would benefit their practice, and only two in five primary-care doctors did. In addition to the diagnostic and therapeutic limitations of seeing patients on a screen, there are economic considerations, too: virtual doctors’ visits can actually take longer than in-person ones, owing in part to the widely varying ability of patients to operate the necessary technology. Local regulations present another barrier. Last December, a team of legal analysts determined that only ten states required private insurers to reimburse virtual visits at the same rate and with the same freedom from restrictions as in-person visits. Tele-doctors could spend more time with fewer patients for less money. What’s the appeal in that?

Then “lo and behold, a pandemic, right?” Oseid said. On Friday, February 28th, a Dartmouth-Hitchcock employee, recently back from a trip to Italy, reported flulike symptoms to medical staff at the hospital. He was told to self-isolate, but instead went to a party, hosted by Dartmouth’s Tuck School of Business, at the Engine Room, a music venue in nearby White River Junction. Three days later, he tested positive for covid-19—the first known case in New Hampshire. By the following Tuesday, a second Dartmouth-Hitchcock employee had tested positive. The story made national headlines. Thirty beds were allocated for the treatment of covid-19 in the Dartmouth-Hitchcock Medical Center.

On an average day before the pandemic, Dartmouth-Hitchcock and its outpatient clinics scheduled forty-five hundred ambulatory visits and almost a hundred elective surgeries. The economic foundation of the medical center—like that of health-care facilities everywhere—rests on in-person visits and procedures. “Let’s be clear,” Mary Dale Peterson, the president of the American Society of Anesthesiologists, told Politico in March, “elective surgeries are the lifeblood of many hospitals, if not all hospitals.”

By mid-March, Dartmouth-Hitchcock had all but shut down its ambulatory business and reduced its elective surgeries to only the most essential ones, in order to conserve supplies of P.P.E., and to protect both doctors and patients from covid-19. By April 1st, the Dartmouth-Hitchcock Health system was managing two thousand outpatient telehealth visits a week. “Now everyone wants to do telehealth,” Oseid said. Still, Joanne Conroy, the C.E.O. of Dartmouth-Hitchcock, told me, “the chief financial officer and I exchange e-mails all the time at night.” The two discuss how they’ll make up for the shortfall in the hospital’s budget.

As the country went into lockdown, its health care went virtual. In-person primary care, which is responsible for nearly fifty per cent of medical visits, effectively ended. Some elective surgeries, like hip replacements, were postponed; patients who needed such procedures as a kidney-stone removal or a heart-valve replacement got sicker.

The regulations governing telehealth changed. On March 6th, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which, in part, cleared the way for fifty million seniors to use their Medicare benefits for telemedicine, including physical therapy and psychotherapy, without the former restrictions. Medicare claims for telemedicine jumped from ten thousand a week in March to well over a million a week in April. The government also temporarily waived privacy rules set by the Health Insurance Portability and Accountability Act (hipaa), allowing doctors and patients to connect over FaceTime and Zoom. With White House encouragement, state governments suspended rules that limit doctors’ practices to the states they are licensed in; similar injunctions against writing prescriptions for out-of-state patients were also lifted.

These are boom times for businesses that offer telehealth infrastructure to hospitals and to health-care providers and make direct-to-consumer telehealth apps. In the states that were hit first by the pandemic, telehealth companies became “forward triage” centers, allowing doctors to prescreen patients who exhibited covid-like symptoms, in the hope of preventing all but the sickest from going to an emergency department. Teladoc, the largest such company in the U.S., saw a hundred-per-cent increase in virtual doctor’s visits from the first week of March to the first week of April. Its C.E.O., Jason Gorevic, told me that within that approximate time span the company doubled its roster of doctors from three thousand to six thousand. It includes internists, dermatologists, dieticians, pediatricians, and psychiatrists, all of whom are turning to telehealth to keep their practices afloat. The platform now handles twenty thousand visits a day.

Both Teladoc and Amwell, a major competitor, also offer online doctor’s appointments, starting at about eighty dollars, to people without insurance. Other companies sell yearly memberships that offer access to a particular virtual specialist, rather than billing per visit. Among the advantages of virtual health care is that patients can talk to a doctor outside office hours—by secure chat, for example. You can request a doctor you’ve had before, or you can take the first one who’s available. The ability to text your physician or therapist whenever you need enables “less structured interactions,” Gorevic said—a convenience for patients, if not always for doctors.

Prior to the pandemic, virtual doctors had to be licensed in the state that the patient called from. Mia Finkelston, an Amwell family doctor I spoke with who works from a basement office in her home, in Leonardtown, near Chesapeake Bay, is licensed in twenty-nine states. She used to work in a practice nearby, but she “just got tired of the commute,” she said. Lindsay Henderson, an Amwell psychotherapist, told me that she switched to telehealth in 2016, after the birth of her second child; it allowed her to continue seeing patients without having to be away from her kids all day.

For many years, I have lived part time in rural Vermont, and I have a long and painful relationship with Dartmouth-Hitchcock’s E.R. Most recently, my wife and my daughter drove me to the E.R. with a deep wound in my shin, the result of my aspirational belief in the health benefits of chopping firewood. (I now have a gas-powered log splitter.)

On a snowy day in early April, I visited the hospital’s Connected Care center remotely. Mary Oseid FaceTimed with me while standing in the center, which is divided by a glassed-in corridor, with the tele-emergency room on one side and the tele-I.C.U. on the other. Through the glass, I could see Sadie Smith at work in the tele-emergency hub, with Kevin Curtis, an E.R. doctor and the center’s medical director, next to her at a four-screen workstation. They were in the final stages of treating a patient who had suffered a cardiac arrest and been taken to one of their connected regional hospitals. Local staff had hit the emergency-telehealth button when the ambulance was on the way, and Smith and Curtis had been waiting in the hub when the patient arrived at the hospital, in Claremont, New Hampshire.

Both Oseid and Curtis have master’s degrees in health-care-delivery science from Dartmouth College. In their view, Dartmouth-Hitchcock’s advanced telemedicine infrastructure is an example of “reverse innovation”—technologies devised in the developing world that are later adopted by wealthier nations—a concept that was popularized by the Tuck School management theorists Vijay Govindarajan and Chris Trimble. In a U.S. setting, Oseid told me, “we think of our work as something we’ve developed in a rural market that can go to an urban market and be just as successful.”

Oseid turned around so that I could see into the tele-I.C.U., where Robert Westlake, a critical-care physician, was monitoring patients. The tele-I.C.U. is connected remotely to eighty-five I.C.U. beds—sixty in the main hospital, where the hub is situated, and twenty-five in the regional hospitals.

Oseid told me, “We have created a system where a patient who is potentially covid-19-positive can be seen by a provider without going into the room. That’s a huge benefit for us. We save P.P.E., and we save exposing the health-care worker to covid.”

The tele-I.C.U. uses a software platform designed for Dartmouth-Hitchcock by Philips, the Dutch technology company. It runs predictive algorithms powered by artificial intelligence to monitor patients’ prognoses. The system constantly updates each patient’s “acuity score,” a grade that reflects remotely gathered patient data—such as blood pressure, oxygen level, heart rhythm, and pulse—to evaluate the risk of a sudden deterioration. When Westlake, in hospital scrubs, came out into the corridor, he told me that, because of data analytics, “we here in the tele-hub often know what’s going on with the patients before the people who are ten feet away from them do.” One recent analysis suggested a correlation between equipping an I.C.U. room with telemedicine technology and a reduction in patient mortality.

The Dartmouth-Hitchcock hub closely reflects the founding idea of telemedicine. It’s space medicine, brought to a rural setting on Earth. According to some estimates, an I.C.U. can consume a quarter of a hospital’s budget. And covid-19 patients are likely to remain in intensive care for longer than the average stay, of four days. Studies have shown that telemedicine can reduce the expense of intensive care, but the cost of equipping and running a single hardwired I.C.U. room can be as high as a hundred thousand dollars a year—prohibitive for many smaller hospitals.

At Dartmouth-Hitchcock, Oseid told me, there are also tele-I.C.U. carts, which cost about twelve thousand dollars each. The carts carry audiovisual equipment and can connect directly to the tele-I.C.U. software from any hospital room. Another critical-care doctor I met at the hub observed, nodding at one of the carts, “We can just look at the patient and ask, ‘How are you doing, sir? How is your breathing?’ ”

In theory, portable units of this kind could be used to deliver care at home. But that would also undercut the prevailing business model at many hospitals, which is to get as many “heads in beds” as possible.

Corey Siegel, a Dartmouth-Hitchcock doctor who is one of the top specialists in inflammatory-bowel diseases in the country, was an early adopter of telehealth. Many of his patients, such as Jessica Caron, a young mother of two from Manchester, New Hampshire, who has Crohn’s disease, were driving an hour or more to see him at his office, in Lebanon, often with kids in tow. Siegel started to offer virtual visits in 2015. “It was a big win for me,” Caron told me. “It doesn’t replace the brick-and-mortar visit, but it complements it.” Using the telehealth option, “Corey and I can get together and talk about what makes sense, and when we need to see each other in person.”

When Caron heard about covid-19, she panicked. “Managing chronic illness never really stops,” she said. “I thought, Oh, gosh, I’m on immunosuppressant medication, is that going to be a problem for me?” Telehealth offered Caron a way to keep in touch with Siegel and manage her condition until she felt safe enough to visit the office again.

“I won’t say anything good has come out of covid-19,” Siegel told me, in April. “But we’ve done almost seven hundred telemedicine visits since it hit. Already, my colleagues are saying, ‘This is great, let’s do this after the pandemic ends.’ We might have learned in a very scary way that this is a great way to deliver care to patients.”

But it’s one thing to offer tele-care to a patient you know; it’s another to try to distinguish a bowel disease from indigestion during a virtual first visit. A tele-doctor who misdiagnoses a stomach ache that turns out to be stomach cancer has the same liability that a traditional doctor does. For that reason, virtual doctors are supposed to tell patients whose symptoms suggest a more complicated underlying condition to make an in-person visit to an office, for lab tests and a hands-on physical exam.

Internists I spoke with in New York City were quick to point out the diagnostic limitations of telemedicine. “You can’t have a belly exam” via a screen, my New York doctor, Martin Beitler, said. He was doing virtual visits from home as a necessity, but he wasn’t a fan. He says that telehealth, at its worst, promotes a kind of “knee-jerk, ‘give them antibiotics for every cold that they get’ attitude. That’s the kind of medicine you are going to get if you switch to all telehealth.”

Thomas Nash, an internist whose practice is on the Upper East Side, said, “Is it doable? Of course it’s doable. I’m doing it now.” But, he added, “I worry that it’s going to delay a good exam, and get in the way of deeper interactions between people and their doctors.” David Avram, a dermatologist in Brooklyn, told me that telemedicine works well for checking moles, because you can look at a mole with a smartphone. But he’s postponing full-body exams until he can return to the office.

In recent years, a wave of app-driven direct-to-consumer telehealth startups have appeared, offering to be Marcus Welby, e-M.D., for millennials—a virtual doctor who makes tele-house-calls. The idea of having a doctor who makes the equivalent of old-fashioned home visits came up in several of my conversations with people at telehealth companies. Roy Schoenberg, a co-C.E.O. of Amwell, likened the Amwell experience to a visit from Hiram Baker, the fictional physician in “Little House on the Prairie.” In this idyllic view, virtual care is a way of returning the doctor-patient relationship to the pre-insurance days.

Zachariah Reitano is a twenty-nine-year-old co-founder of Ro, a telehealth company that allows consumers to request medications for erectile dysfunction and other sexual-health-related issues, in addition to those for allergies and weight loss, and get them delivered to their door. His father was a doctor. “When I think about what we are trying to build at Ro, I am really trying to re-create my dad in software,” Reitano told me. “The man has saved my life, truly, and he has saved every person in my family. When you have a doctor in the home, when he can solve a problem for you, he’d solve it right then and there.”

Our health-care system is user-unfriendly and wasteful. The average patient has to wait twenty-nine days to get a physician’s appointment, and in most cases you don’t know what the visit and the lab work will cost until you receive a bill. If you need a prescription, you have to make a separate trip to the pharmacy.

Reitano, noting that the annual deductible in employee insurance plans can be more than two thousand dollars, said, “That’s insane. When you turn patients into more traditional consumers, they get to determine what they find valuable. They Google. They compare. They demand price transparency, metrics on the quality and efficacy of care, and the consumer-driven experience they get from Amazon, Apple, or Nike.” He added, “Look at Lasik, cosmetic surgery, breast augmentation. The technology dramatically improves, prices come down, and the patient experience becomes better.”

But what’s to stop Amazon itself from offering health care to its hundred million Prime members? Amazon Care, a pilot program for Amazon employees and their families, was rolled out, in February, as a telehealth supplement to workers’ existing insurance plans. Facebook, Apple, Microsoft, and Alphabet, Google’s parent company, have also made big investments in the health-care field in recent years. Many of the health-care changes spurred by the coronavirus outbreak are in Big Tech’s wheelhouse. At the same time, the economic losses caused by fewer in-person visits are likely to force smaller hospitals into bankruptcy, a trend that began before the pandemic. By one estimate, as many as sixty thousand physicians in family medicine may lose their practices because of the coronavirus crisis.

It’s one thing to make an appointment with a virtual (but real) doctor at Amwell; it’s another thing to list your symptoms on an Amazon or a Google portal and get a diagnosis from an A.I. So far, tech companies have focussed on developing diagnostic tools and sourcing supplies for medical workers during the pandemic. But how long are they likely to let the disaster go to waste?

On Good Friday, I had a Hiram Baker-like virtual house call in my home with Matthew Mackwood, a family doctor with a master’s in public health who is one of the physicians on Dartmouth-Hitchcock’s staff. There was a lump on my foot, and I worried that I might have stepped on a piece of glass, or that a critter had burrowed under my skin. Googling “chigger” only fed my cyberchondria.

Treatment at home offers certain advantages beyond those of keeping quarantine. Benjamin Fogel, a pediatrician at Penn State Children’s Hospital, in Hershey, Pennsylvania, told me about some of his patients. “They are in their room with the door closed, and they feel like it’s private, more than they feel like it’s private in a doctor’s office,” he said. “These kids are sitting at their desks or on their beds. I can tell they are more at ease.”

I’d had some experience with telehealth since the lockdown. My wife and I were having a weekly Zoom session with our therapist. To get some privacy from our kids, we had to sit in the back of our pickup truck, parked close enough to the house to get the Wi-Fi signal. (There’s no cellular service where we live, which is not uncommon in certain parts of Vermont.)

In person, doctors often spend the first ten minutes of an appointment studying records on their computer while you sit across from them, looking at their framed degrees and family photos. But during a virtual visit the doctor meets you face to face, and her gaze mostly stays on you (or on your records on her screen—it can be hard to tell the difference). For fans of telehealth, this is one of its most appealing features. “You’re looking at the physician, and the physician is looking at you,” Schoenberg, the Amwell co-C.E.O., told me. “This is a very intimate encounter. And, once you get exposed to it, at some point you’re going to say, ‘If this is available to me, why should I revert to the laborious, dangerous, hard effort of going into the practice?’ ”

Thomas Nash, in Manhattan, was skeptical. “Eyeball to eyeball is not a normal human interaction, right? A normal human interaction—you shift your body a little, you look to the left for a second, you gather your thoughts, you take a pause, which you really can’t do in this compressed screen-to-screen interaction.”

When my appointment with Dr. Mackwood rolled around, my daughter had the iPad I was planning to use, my son was in a bandwidth-hogging Zoom class, and the cat was howling for food, so I grabbed my phone and retreated to the bathroom.

Mackwood began, “Let me ask you a few questions, and then I’ll take a look at your foot. You said it hurts with pressure. What does that pain feel like? Sharp? Burning? How would you describe it?”

“It’s not a sharp pain,” I responded. “It’s more of a burning, generalized pain. I have my index finger on it. The circumference of it is about the size of a dime, though not as round. It doesn’t feel like there’s a splinter or a piece of glass in there.”

“Any numbness or tingling associated with that? Weakness in the foot or toes? Any drainage?”

“No, but it does have kind of a little dimple right in the middle of it. It’s possible that it’s a little critter that’s burrowed in there. Maybe a chigger?”

“Very uncommon in these parts.”

Using my phone, I showed the doctor my foot. I had to pretzel myself around to give him a good view.

Mackwood diagnosed my lump as an ordinary plantar wart. In normal times, he said, I would be able to come into the clinic, where, over a few visits, he would use liquid nitrogen to freeze it.

“There’s also the duct-tape method,” Mackwood added. You stick a small piece of duct tape to the wart, leave it on for a week, rub the softened wart with a pumice stone, and repeat, for four to six weeks.

I’m waiting for the clinic to reopen.

About a month after Patient X arrived at Alice Peck Day, I had a Zoom call with the team who had assisted him. Kacie Boyle emphatically stressed the benefit of having Sadie Smith there. “Jesse and I had no time to chart on this patient, so Sadie was writing down every medication that was given, every vital sign, reminding us to cycle blood pressures as needed,” Boyle said. “She was just there as an extra set of eyes, and when sometimes we didn’t feel we had enough hands.”

Laura Williams, the other nurse on the scene, said that, in spite of the high-tech nature of their teamwork with Smith and Martin in the hub, telemedicine is “a human connection for me. It can be isolating when you’re in one of those rooms with all your gear on. When I see Sadie pop up on the screen, I feel like she’s right there for me. It’s a reminder we’re all in this together.”

My daughter had made a colorful poster with a drawing of a masked health-care worker and lots of blue sky and rainbows. She asked me to hold it up in front of my laptop’s camera, during my call with the team, to say tele-thanks to everyone who had saved Patient X’s life. But Boyle and Williams were on audio only and couldn’t see the poster, so I did my best to describe it.

John Seabrook

June 22, 2020

The call came in to the emergency department at Alice Peck Day Memorial Hospital, a twenty-five-bed facility in Lebanon, New Hampshire, around 2 p.m. on a weekday in mid-March. Patient X had arrived by car, and, by the time he reached the hospital, the pain in his legs was so severe that he couldn’t move.

Jesse Webber, a paramedic, donned full personal protective equipment (P.P.E.) before going outside with a wheelchair. Since the onset of the pandemic, almost all sick people who entered the hospital’s E.R. were considered, whatever their symptoms, to be P.U.I.s—persons under investigation for covid-19.

The patient, a heavyset man in middle age, was lucid when Webber wheeled him into the emergency department’s negative-pressure room—a seven-by-eleven-foot windowless space fitted with a noisy exhaust fan that removes contaminated air. Once the man was inside, his mental state deteriorated rapidly. A team made up of Nancy Ferguson, a doctor, and two critical-care nurses, Kacie Boyle and Laura Williams, in full P.P.E., joined Webber and Patient X in the cramped room.

The patient was having difficulty breathing. “Very quickly, his respiratory rate dropped,” Webber later told me. He was “crumping,” as nurses say—not crashing, but failing fast. “His body essentially stopped breathing in front of us,” Webber said.

Ferguson ordered a rapid-sequence intubation, a procedure for swiftly connecting a patient to a ventilator. Ventilating a patient is a complex task that involves not just putting a breathing tube into the trachea but also inserting intravenous lines to deliver sedatives, so that the patient doesn’t fight the tube—known in hospitals as “bucking the vent.”

“As soon as I heard the doctor say that, I reached behind me and hit the emergency-telehealth button,” Webber recalled. Within seconds, the team at Alice Peck Day was connected, through a secure audiovisual link, to the tele-emergency hub at Dartmouth-Hitchcock Medical Center, an academic training institution with more than five thousand employees, affiliated with Dartmouth College’s Geisel School of Medicine. Sadie Smith, a nurse, and Victoria Martin, a doctor, were in the middle of twelve-hour shifts, sitting side by side at one of the hub’s four-screen workstations. The workstations are hardwired into the emergency department at Alice Peck Day, and also into those of ten other community hospitals across the region; the most distant is a hundred and eighty miles away.

Smith’s face popped up on the screen in the Alice Peck Day negative-pressure room. Smith is one of the most experienced tele-emergency nurses on the Dartmouth-Hitchcock staff, and she has an air of unflappable competence that would inspire calm in any crisis.

“How can we help?” she asked.

Smith and Martin had control of a high-resolution camera mounted on the wall of the negative-pressure room. They could zoom in on Patient X, watch his cardiac monitor, and talk to the doctor, nurses, and paramedic on the scene. Electronic-record-sharing allowed them to “chart on” the patient—to have real-time access to his vitals and his medications, just as though they were there. But, unlike the staff attending to him, who were working elbow to elbow in the negative-pressure room, straining to speak over the noise of the exhaust fan, the tele-hub team was unharried and safe from possible covid-19 exposure. The hub personnel could check records and arrange for transport to the medical center, on the other side of town, without the nurses having to leave the room, thereby avoiding the hospital’s P.P.E.-doffing procedure—a two-person, twenty-eight-step job—and the need to put on new P.P.E. on their return.

In the hub, Smith noticed that the hydration fluid the patient was receiving wasn’t compatible with the sedative that he was on; the Alice Peck Day nurses switched fluids. The doctors decided to insert a second I.V. line, using the intraosseous method, which infuses medicine directly into the patient’s bone marrow. Smith told me later that “really large patients are difficult, because it’s really hard to find I.V. access. So I suggested going through the humeral head”—the top of the arm bone. “I’m standing there, with my camera view, going, ‘Bring his arm over, lay it across his belly, then feel here, and right in the middle is where you want to go.’ ”

“Sadie kind of guided us in,” Webber said.

Finally, they got Patient X intubated, and “it turned out his expired CO2 was really quite high,” Smith told me. As the nurses used the ventilator to blow pressurized oxygen into his lungs, his CO2 level started to trend down. The crisis had passed.

Telemedicine and telehealth involve a myriad of remote-health-care technologies and services collectively known as “virtual care.” For years, virtual care played a minor role in the United States’ $3.6-trillion health-care industry; now, with the covid-19 pandemic, millions of people are discovering its benefits and its shortcomings for the first time. If virtual care is the future of health care, is it a future that we want?

In a narrow sense, the word “telemedicine” can mean the type of hardwired hospital-to-clinic setup that allows workers in a large hub hospital to assist in complex emergency procedures in distant spokes. This approach is descended from nasa’s pioneering research, in the nineteen-sixties and seventies, into satellite communications and methods of monitoring astronauts’ well-being in space. One of the first telemedicine projects in a terrestrial setting, which operated between 1973 and 1977, offered remote health care on the Papago—now the Tohono O’odham—reservation in southern Arizona while also testing the technology for use in spaceflight. In the early eighties, NASA began developing a tele-I.C.U. for astronauts on Space Station Freedom. Telemedicine in the Dartmouth-Hitchcock Health system, a network of hospitals and clinics across New Hampshire and Vermont which serves 1.9 million people, is the twenty-first-century embodiment of the fifty-year-old prototype.

Telehealth also comprises virtual interactions between individual doctors and patients, in which the participants rely on an audiovisual hookup instead of an in-person visit. You have a bad sore throat but don’t want to wait to see a doctor—or you are among the thirty per cent of millennials who don’t have one. You could go to the E.R. or to a brick-and-mortar urgent-care center. Or you could download the telehealth app you saw advertised on MSNBC. Before long, you are connected to a physician, who, using your phone to look down your throat and relying on your description of the swollen glands in your neck, can prescribe antibiotics and other noncontrolled substances. You’ve saved yourself a trip to the clinic, and you haven’t made other people sick or caught something else yourself.

Online visits can be enhanced by Internet-connected devices that collect patient data at home and then send it to a doctor. These include fitness trackers, blood-pressure cuffs, pulse oximeters, and gadgets like Kinsa’s smart thermometer and TytoCare’s self-examination kit, which link up with a phone and make it possible to perform at least part of an annual wellness check on yourself.

Telehealth providers typically offer virtual urgent care for non-emergencies. And patients suffering from chronic conditions, such as diabetes and colitis, can conduct routine follow-ups online. Proponents of telehealth have long argued that fifty to seventy per cent of visits to the doctor’s office could be replaced by remote monitoring and checkups. But, until the pandemic, most Americans weren’t interested.

Dartmouth and its affiliated think tank, the Dartmouth Institute for Health Policy and Clinical Practice, have been on the vanguard of health-care reform for decades. Twenty-four years ago, they began publishing the Dartmouth Atlas of Health Care, an annual survey of medical spending and patient outcomes in communities across the United States which was credited as an important influence on the 2010 Affordable Care Act. In 1999, Dartmouth-Hitchcock opened the Center for Shared Decision Making, with the aim of giving patients the tools to engage in their own health-care decisions. The Connected Care center, which was launched in 2012 and today includes the tele-emergency and tele-I.C.U. hubs, was an extension of its founders’ belief in patient empowerment and data-based medicine.

Title Walt's Nightmare. A man stands in front of a museum called the American Museum of Walt's Browser History.

Cartoon by Joe Dator

Among Dartmouth-Hitchcock’s patient base are members of a number of medically underserved communities, as defined by the Department of Health and Human Services: poor, elderly, and special-needs populations who lack easy access to primary-care physicians and medical specialists. Patients who routinely drive two hours to visit a cardiologist or a gastroenterologist can “see the doctor” through a secure smartphone app. Dartmouth-Hitchcock offers a diverse menu of services for distant patients, including tele-psychiatry, tele-neurology, and tele-urgent care.

But even in rural northern New England telemedicine has been a hard sell. “We have been struggling in some areas, to be perfectly honest,” Mary Oseid, the medical center’s senior vice-president for connected care, told me. Many rural clinics and community hospitals in small American towns fear that their already meagre medical staffing, and the revenues generated from procedures that can be performed on-site, will be further hollowed out by remote medicine. And often the patients who need care the most—the old and the poor—don’t have smartphones or broadband connectivity, or can’t afford extra minutes on their wireless plans, placing one of telehealth’s greatest promises, of allowing old people to “age in place,” out of reach. Before the pandemic, outpatient telehealth across the entire Dartmouth-Hitchcock Health network averaged only thirty visits a week.

This is representative of virtual care throughout the country. Telehealth totalled just 0.1 per cent of all medical claims filed in 2018, according to fair Health, a nonprofit that analyzes data on insurance claims. The National Business Group on Health, which publishes an annual survey of employee health benefits offered by large firms, found that in 2016 seventy per cent of companies included telehealth as part of their plans, but only three per cent of their workers used it. Some employees weren’t aware that the service existed; others didn’t trust an anonymous doctor. According to a 2019 survey conducted by J.D. Power, forty-nine per cent of patients believed the quality of virtual care to be inferior to that of an old-fashioned in-person doctor’s visit.

Reimbursement has been another issue. Until recently, Medicare covered telehealth only in rural areas, and required patients to conduct visits in a clinical setting. And, in spite of the time-and-money-saving advantages of telehealth, a lot of people clearly want to be in the physical presence of their physician, undergoing the familiar rituals of a checkup—the doctor’s scrubbed hands emerging from the crisp cuffs of a white lab jacket—that no screen can yet provide.

Doctors haven’t been sold on telehealth, either. In a 2019 survey conducted by the American Medical Association, only one in three specialists expressed full confidence that virtual care would benefit their practice, and only two in five primary-care doctors did. In addition to the diagnostic and therapeutic limitations of seeing patients on a screen, there are economic considerations, too: virtual doctors’ visits can actually take longer than in-person ones, owing in part to the widely varying ability of patients to operate the necessary technology. Local regulations present another barrier. Last December, a team of legal analysts determined that only ten states required private insurers to reimburse virtual visits at the same rate and with the same freedom from restrictions as in-person visits. Tele-doctors could spend more time with fewer patients for less money. What’s the appeal in that?

Then “lo and behold, a pandemic, right?” Oseid said. On Friday, February 28th, a Dartmouth-Hitchcock employee, recently back from a trip to Italy, reported flulike symptoms to medical staff at the hospital. He was told to self-isolate, but instead went to a party, hosted by Dartmouth’s Tuck School of Business, at the Engine Room, a music venue in nearby White River Junction. Three days later, he tested positive for covid-19—the first known case in New Hampshire. By the following Tuesday, a second Dartmouth-Hitchcock employee had tested positive. The story made national headlines. Thirty beds were allocated for the treatment of covid-19 in the Dartmouth-Hitchcock Medical Center.

On an average day before the pandemic, Dartmouth-Hitchcock and its outpatient clinics scheduled forty-five hundred ambulatory visits and almost a hundred elective surgeries. The economic foundation of the medical center—like that of health-care facilities everywhere—rests on in-person visits and procedures. “Let’s be clear,” Mary Dale Peterson, the president of the American Society of Anesthesiologists, told Politico in March, “elective surgeries are the lifeblood of many hospitals, if not all hospitals.”

By mid-March, Dartmouth-Hitchcock had all but shut down its ambulatory business and reduced its elective surgeries to only the most essential ones, in order to conserve supplies of P.P.E., and to protect both doctors and patients from covid-19. By April 1st, the Dartmouth-Hitchcock Health system was managing two thousand outpatient telehealth visits a week. “Now everyone wants to do telehealth,” Oseid said. Still, Joanne Conroy, the C.E.O. of Dartmouth-Hitchcock, told me, “the chief financial officer and I exchange e-mails all the time at night.” The two discuss how they’ll make up for the shortfall in the hospital’s budget.

As the country went into lockdown, its health care went virtual. In-person primary care, which is responsible for nearly fifty per cent of medical visits, effectively ended. Some elective surgeries, like hip replacements, were postponed; patients who needed such procedures as a kidney-stone removal or a heart-valve replacement got sicker.

The regulations governing telehealth changed. On March 6th, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which, in part, cleared the way for fifty million seniors to use their Medicare benefits for telemedicine, including physical therapy and psychotherapy, without the former restrictions. Medicare claims for telemedicine jumped from ten thousand a week in March to well over a million a week in April. The government also temporarily waived privacy rules set by the Health Insurance Portability and Accountability Act (hipaa), allowing doctors and patients to connect over FaceTime and Zoom. With White House encouragement, state governments suspended rules that limit doctors’ practices to the states they are licensed in; similar injunctions against writing prescriptions for out-of-state patients were also lifted.

These are boom times for businesses that offer telehealth infrastructure to hospitals and to health-care providers and make direct-to-consumer telehealth apps. In the states that were hit first by the pandemic, telehealth companies became “forward triage” centers, allowing doctors to prescreen patients who exhibited covid-like symptoms, in the hope of preventing all but the sickest from going to an emergency department. Teladoc, the largest such company in the U.S., saw a hundred-per-cent increase in virtual doctor’s visits from the first week of March to the first week of April. Its C.E.O., Jason Gorevic, told me that within that approximate time span the company doubled its roster of doctors from three thousand to six thousand. It includes internists, dermatologists, dieticians, pediatricians, and psychiatrists, all of whom are turning to telehealth to keep their practices afloat. The platform now handles twenty thousand visits a day.

Both Teladoc and Amwell, a major competitor, also offer online doctor’s appointments, starting at about eighty dollars, to people without insurance. Other companies sell yearly memberships that offer access to a particular virtual specialist, rather than billing per visit. Among the advantages of virtual health care is that patients can talk to a doctor outside office hours—by secure chat, for example. You can request a doctor you’ve had before, or you can take the first one who’s available. The ability to text your physician or therapist whenever you need enables “less structured interactions,” Gorevic said—a convenience for patients, if not always for doctors.

Prior to the pandemic, virtual doctors had to be licensed in the state that the patient called from. Mia Finkelston, an Amwell family doctor I spoke with who works from a basement office in her home, in Leonardtown, near Chesapeake Bay, is licensed in twenty-nine states. She used to work in a practice nearby, but she “just got tired of the commute,” she said. Lindsay Henderson, an Amwell psychotherapist, told me that she switched to telehealth in 2016, after the birth of her second child; it allowed her to continue seeing patients without having to be away from her kids all day.

For many years, I have lived part time in rural Vermont, and I have a long and painful relationship with Dartmouth-Hitchcock’s E.R. Most recently, my wife and my daughter drove me to the E.R. with a deep wound in my shin, the result of my aspirational belief in the health benefits of chopping firewood. (I now have a gas-powered log splitter.)

On a snowy day in early April, I visited the hospital’s Connected Care center remotely. Mary Oseid FaceTimed with me while standing in the center, which is divided by a glassed-in corridor, with the tele-emergency room on one side and the tele-I.C.U. on the other. Through the glass, I could see Sadie Smith at work in the tele-emergency hub, with Kevin Curtis, an E.R. doctor and the center’s medical director, next to her at a four-screen workstation. They were in the final stages of treating a patient who had suffered a cardiac arrest and been taken to one of their connected regional hospitals. Local staff had hit the emergency-telehealth button when the ambulance was on the way, and Smith and Curtis had been waiting in the hub when the patient arrived at the hospital, in Claremont, New Hampshire.

Both Oseid and Curtis have master’s degrees in health-care-delivery science from Dartmouth College. In their view, Dartmouth-Hitchcock’s advanced telemedicine infrastructure is an example of “reverse innovation”—technologies devised in the developing world that are later adopted by wealthier nations—a concept that was popularized by the Tuck School management theorists Vijay Govindarajan and Chris Trimble. In a U.S. setting, Oseid told me, “we think of our work as something we’ve developed in a rural market that can go to an urban market and be just as successful.”

Oseid turned around so that I could see into the tele-I.C.U., where Robert Westlake, a critical-care physician, was monitoring patients. The tele-I.C.U. is connected remotely to eighty-five I.C.U. beds—sixty in the main hospital, where the hub is situated, and twenty-five in the regional hospitals.

Oseid told me, “We have created a system where a patient who is potentially covid-19-positive can be seen by a provider without going into the room. That’s a huge benefit for us. We save P.P.E., and we save exposing the health-care worker to covid.”

The tele-I.C.U. uses a software platform designed for Dartmouth-Hitchcock by Philips, the Dutch technology company. It runs predictive algorithms powered by artificial intelligence to monitor patients’ prognoses. The system constantly updates each patient’s “acuity score,” a grade that reflects remotely gathered patient data—such as blood pressure, oxygen level, heart rhythm, and pulse—to evaluate the risk of a sudden deterioration. When Westlake, in hospital scrubs, came out into the corridor, he told me that, because of data analytics, “we here in the tele-hub often know what’s going on with the patients before the people who are ten feet away from them do.” One recent analysis suggested a correlation between equipping an I.C.U. room with telemedicine technology and a reduction in patient mortality.

The Dartmouth-Hitchcock hub closely reflects the founding idea of telemedicine. It’s space medicine, brought to a rural setting on Earth. According to some estimates, an I.C.U. can consume a quarter of a hospital’s budget. And covid-19 patients are likely to remain in intensive care for longer than the average stay, of four days. Studies have shown that telemedicine can reduce the expense of intensive care, but the cost of equipping and running a single hardwired I.C.U. room can be as high as a hundred thousand dollars a year—prohibitive for many smaller hospitals.

At Dartmouth-Hitchcock, Oseid told me, there are also tele-I.C.U. carts, which cost about twelve thousand dollars each. The carts carry audiovisual equipment and can connect directly to the tele-I.C.U. software from any hospital room. Another critical-care doctor I met at the hub observed, nodding at one of the carts, “We can just look at the patient and ask, ‘How are you doing, sir? How is your breathing?’ ”

In theory, portable units of this kind could be used to deliver care at home. But that would also undercut the prevailing business model at many hospitals, which is to get as many “heads in beds” as possible.

Corey Siegel, a Dartmouth-Hitchcock doctor who is one of the top specialists in inflammatory-bowel diseases in the country, was an early adopter of telehealth. Many of his patients, such as Jessica Caron, a young mother of two from Manchester, New Hampshire, who has Crohn’s disease, were driving an hour or more to see him at his office, in Lebanon, often with kids in tow. Siegel started to offer virtual visits in 2015. “It was a big win for me,” Caron told me. “It doesn’t replace the brick-and-mortar visit, but it complements it.” Using the telehealth option, “Corey and I can get together and talk about what makes sense, and when we need to see each other in person.”

When Caron heard about covid-19, she panicked. “Managing chronic illness never really stops,” she said. “I thought, Oh, gosh, I’m on immunosuppressant medication, is that going to be a problem for me?” Telehealth offered Caron a way to keep in touch with Siegel and manage her condition until she felt safe enough to visit the office again.

“I won’t say anything good has come out of covid-19,” Siegel told me, in April. “But we’ve done almost seven hundred telemedicine visits since it hit. Already, my colleagues are saying, ‘This is great, let’s do this after the pandemic ends.’ We might have learned in a very scary way that this is a great way to deliver care to patients.”

But it’s one thing to offer tele-care to a patient you know; it’s another to try to distinguish a bowel disease from indigestion during a virtual first visit. A tele-doctor who misdiagnoses a stomach ache that turns out to be stomach cancer has the same liability that a traditional doctor does. For that reason, virtual doctors are supposed to tell patients whose symptoms suggest a more complicated underlying condition to make an in-person visit to an office, for lab tests and a hands-on physical exam.

Internists I spoke with in New York City were quick to point out the diagnostic limitations of telemedicine. “You can’t have a belly exam” via a screen, my New York doctor, Martin Beitler, said. He was doing virtual visits from home as a necessity, but he wasn’t a fan. He says that telehealth, at its worst, promotes a kind of “knee-jerk, ‘give them antibiotics for every cold that they get’ attitude. That’s the kind of medicine you are going to get if you switch to all telehealth.”

Thomas Nash, an internist whose practice is on the Upper East Side, said, “Is it doable? Of course it’s doable. I’m doing it now.” But, he added, “I worry that it’s going to delay a good exam, and get in the way of deeper interactions between people and their doctors.” David Avram, a dermatologist in Brooklyn, told me that telemedicine works well for checking moles, because you can look at a mole with a smartphone. But he’s postponing full-body exams until he can return to the office.

In recent years, a wave of app-driven direct-to-consumer telehealth startups have appeared, offering to be Marcus Welby, e-M.D., for millennials—a virtual doctor who makes tele-house-calls. The idea of having a doctor who makes the equivalent of old-fashioned home visits came up in several of my conversations with people at telehealth companies. Roy Schoenberg, a co-C.E.O. of Amwell, likened the Amwell experience to a visit from Hiram Baker, the fictional physician in “Little House on the Prairie.” In this idyllic view, virtual care is a way of returning the doctor-patient relationship to the pre-insurance days.

Zachariah Reitano is a twenty-nine-year-old co-founder of Ro, a telehealth company that allows consumers to request medications for erectile dysfunction and other sexual-health-related issues, in addition to those for allergies and weight loss, and get them delivered to their door. His father was a doctor. “When I think about what we are trying to build at Ro, I am really trying to re-create my dad in software,” Reitano told me. “The man has saved my life, truly, and he has saved every person in my family. When you have a doctor in the home, when he can solve a problem for you, he’d solve it right then and there.”

Our health-care system is user-unfriendly and wasteful. The average patient has to wait twenty-nine days to get a physician’s appointment, and in most cases you don’t know what the visit and the lab work will cost until you receive a bill. If you need a prescription, you have to make a separate trip to the pharmacy.

Reitano, noting that the annual deductible in employee insurance plans can be more than two thousand dollars, said, “That’s insane. When you turn patients into more traditional consumers, they get to determine what they find valuable. They Google. They compare. They demand price transparency, metrics on the quality and efficacy of care, and the consumer-driven experience they get from Amazon, Apple, or Nike.” He added, “Look at Lasik, cosmetic surgery, breast augmentation. The technology dramatically improves, prices come down, and the patient experience becomes better.”

But what’s to stop Amazon itself from offering health care to its hundred million Prime members? Amazon Care, a pilot program for Amazon employees and their families, was rolled out, in February, as a telehealth supplement to workers’ existing insurance plans. Facebook, Apple, Microsoft, and Alphabet, Google’s parent company, have also made big investments in the health-care field in recent years. Many of the health-care changes spurred by the coronavirus outbreak are in Big Tech’s wheelhouse. At the same time, the economic losses caused by fewer in-person visits are likely to force smaller hospitals into bankruptcy, a trend that began before the pandemic. By one estimate, as many as sixty thousand physicians in family medicine may lose their practices because of the coronavirus crisis.

It’s one thing to make an appointment with a virtual (but real) doctor at Amwell; it’s another thing to list your symptoms on an Amazon or a Google portal and get a diagnosis from an A.I. So far, tech companies have focussed on developing diagnostic tools and sourcing supplies for medical workers during the pandemic. But how long are they likely to let the disaster go to waste?

On Good Friday, I had a Hiram Baker-like virtual house call in my home with Matthew Mackwood, a family doctor with a master’s in public health who is one of the physicians on Dartmouth-Hitchcock’s staff. There was a lump on my foot, and I worried that I might have stepped on a piece of glass, or that a critter had burrowed under my skin. Googling “chigger” only fed my cyberchondria.

Treatment at home offers certain advantages beyond those of keeping quarantine. Benjamin Fogel, a pediatrician at Penn State Children’s Hospital, in Hershey, Pennsylvania, told me about some of his patients. “They are in their room with the door closed, and they feel like it’s private, more than they feel like it’s private in a doctor’s office,” he said. “These kids are sitting at their desks or on their beds. I can tell they are more at ease.”

I’d had some experience with telehealth since the lockdown. My wife and I were having a weekly Zoom session with our therapist. To get some privacy from our kids, we had to sit in the back of our pickup truck, parked close enough to the house to get the Wi-Fi signal. (There’s no cellular service where we live, which is not uncommon in certain parts of Vermont.)

In person, doctors often spend the first ten minutes of an appointment studying records on their computer while you sit across from them, looking at their framed degrees and family photos. But during a virtual visit the doctor meets you face to face, and her gaze mostly stays on you (or on your records on her screen—it can be hard to tell the difference). For fans of telehealth, this is one of its most appealing features. “You’re looking at the physician, and the physician is looking at you,” Schoenberg, the Amwell co-C.E.O., told me. “This is a very intimate encounter. And, once you get exposed to it, at some point you’re going to say, ‘If this is available to me, why should I revert to the laborious, dangerous, hard effort of going into the practice?’ ”

Thomas Nash, in Manhattan, was skeptical. “Eyeball to eyeball is not a normal human interaction, right? A normal human interaction—you shift your body a little, you look to the left for a second, you gather your thoughts, you take a pause, which you really can’t do in this compressed screen-to-screen interaction.”

When my appointment with Dr. Mackwood rolled around, my daughter had the iPad I was planning to use, my son was in a bandwidth-hogging Zoom class, and the cat was howling for food, so I grabbed my phone and retreated to the bathroom.

Mackwood began, “Let me ask you a few questions, and then I’ll take a look at your foot. You said it hurts with pressure. What does that pain feel like? Sharp? Burning? How would you describe it?”

“It’s not a sharp pain,” I responded. “It’s more of a burning, generalized pain. I have my index finger on it. The circumference of it is about the size of a dime, though not as round. It doesn’t feel like there’s a splinter or a piece of glass in there.”

“Any numbness or tingling associated with that? Weakness in the foot or toes? Any drainage?”

“No, but it does have kind of a little dimple right in the middle of it. It’s possible that it’s a little critter that’s burrowed in there. Maybe a chigger?”

“Very uncommon in these parts.”

Using my phone, I showed the doctor my foot. I had to pretzel myself around to give him a good view.

Mackwood diagnosed my lump as an ordinary plantar wart. In normal times, he said, I would be able to come into the clinic, where, over a few visits, he would use liquid nitrogen to freeze it.

“There’s also the duct-tape method,” Mackwood added. You stick a small piece of duct tape to the wart, leave it on for a week, rub the softened wart with a pumice stone, and repeat, for four to six weeks.

I’m waiting for the clinic to reopen.

About a month after Patient X arrived at Alice Peck Day, I had a Zoom call with the team who had assisted him. Kacie Boyle emphatically stressed the benefit of having Sadie Smith there. “Jesse and I had no time to chart on this patient, so Sadie was writing down every medication that was given, every vital sign, reminding us to cycle blood pressures as needed,” Boyle said. “She was just there as an extra set of eyes, and when sometimes we didn’t feel we had enough hands.”

Laura Williams, the other nurse on the scene, said that, in spite of the high-tech nature of their teamwork with Smith and Martin in the hub, telemedicine is “a human connection for me. It can be isolating when you’re in one of those rooms with all your gear on. When I see Sadie pop up on the screen, I feel like she’s right there for me. It’s a reminder we’re all in this together.”

My daughter had made a colorful poster with a drawing of a masked health-care worker and lots of blue sky and rainbows. She asked me to hold it up in front of my laptop’s camera, during my call with the team, to say tele-thanks to everyone who had saved Patient X’s life. But Boyle and Williams were on audio only and couldn’t see the poster, so I did my best to describe it.