Through the Looking Glass

As I press the Accept button in the Zoom meeting on my computer to start a patient visit, I feel like Alice in Wonderland stepping through the looking glass. Starting my encounter, I make my electronic way through the maze of the internet and emerge on a smartphone screen, not knowing what to expect. The stated reason for the appointment on my schedule often differs from what the patient wants; things are not always as they seem.

I click on the video icon and she appears on the screen. We are face to face, I am in her world. I see her sitting on a couch with her leg propped up with cushions. As the pixels on the camera adjust themselves, she comes into focus with the sun shining on her face through the window. The room behind her is bright with sunshine, but the counters are scattered with coffee cups, colored pencils, and children’s toys. There is a family photograph behind her, parents and four children.

“I need my asthma medications refilled,” she says. I note that she is a ‘same day telehealth appointment with medication refills only’.  A neat, young woman with her full leg in a cast, with names signed and pictures drawn on it in brightly colored markers. “I am just here for refills,” she emphasizes.

I am more interested in her broken thigh. How did she get injured? Is her pain under control? Is she in physical therapy? Does she have any support at home? These are the questions that arise in my mind, but she appears to have a fixed agenda. My goal is to ensure she is taken care of, but just like Alice, I feel as though I am on a chess board, bound by the rules of the game. I attempt to assert some control, asking her casually, “What happened to your leg and how can I help you?”

She looks at me, almost wills me to take my eyes off the keyboard and look at her directly through the camera lens on the computer screen. “He kicked me,” she says in a flat emotionless voice. A silence follows her statement. In the background, a child’s voice calls out to her, asks her a question, and she responds with an answer, all without moving the camera. This is not the answer I expected and I consciously will myself not to flinch.

In an attempt to know her more, I try to look behind her into the background; and see the photograph again. “Are those your children?”.

“Yes, I have four,” she says, and I can hear the pride in her voice. The family looks content, together, but I wonder if the person standing beside her is the perpetrator.

I have conflicting thoughts on how to continue this visit. While I want to know more about her injury and how it happened, the patient clearly does not want to share. She gives short precise answers to my questions. Thus, guided by the predetermined framework of the chess game, like Alice, I allow the larger forces to guide this visit. I scrutinize her chart, review the emergency room visit and check her problem list, her referrals, and her specialist appointments.

Everything appears to be in place. She is compliant with all her appointments and has a social worker helping her. I understand that my initial assumptions of a stable and safe environment were incorrect, and I have a new inverted perspective regarding my patient.

“Are you safe now?” I ask.

“Yes, he is dead. We are safe; my parents live with me now.” This admission makes me want to know more. However, before I ask additional questions, she speaks up again in an anxious voice, “I need to carry on with my day, can I get a 90-day supply on my refills?” She moves the camera to show only her face, and I cannot see the splinted leg any more. The sun continues to shine on her, but she does not allow any further glimpses into her surroundings.

Her medical record has reassured me about her care and her connections. “Let’s make sure you have a follow up so that we can see you again.” She agrees, schedules a follow up, and signs off.

As I emerge from the visit, I wonder about how she’s doing. I realize that there was a lot left unsaid, but she got her refills, and I have tried my best to assure myself that she’s safe.

My time of 20 minutes for my patient is up; I am not sure if I am fully satisfied. I would like to reflect and ensure I have not missed anything, but a blinking light on my computer alerts me that my next patient has joined their Zoom meeting room. Reality is sobering, but time is moving, so I send a note to her primary care provider and her case worker before I hit the Accept button again. I jump into the electronic maze and emerge into the next visit, through the looking glass.