Four months into the coronavirus pandemic, my mother did something I had thought was impossible. She decreased her sugar intake and lost enough weight to safely get off insulin, effectively putting her Type 2 diabetes into remission. And she did it the way nearly everything has been done in the last year: online.
After reading several reports that people with diabetes are at a higher risk of complications from covid-19, my mom signed up for a virtual diabetes reversal program. A few days later, she received a recipe book and multiple connected devices to automatically transmit her weight and sugar readings to her care team. She downloaded an app that gave her 24/7 access to a health coach and doctors via text messaging and video visits. It also let her connect with peers, like a fellow Indian American based in Chicago. He, like my mom, followed a strict vegetarian diet and shared several recipes with her early on. This extra support empowered her to make dramatic changes to her lifestyle, and within weeks, she was off insulin for the first time in more than a decade.
Much of our focus over the past year has rightly been on the widespread failures related to the pandemic. But we’ve taken for granted just how flexible the American health-care system showed it can be in a crisis. Before the coronavirus, doctors, patients and policymakers had largely grown cynical about the prospect of bringing real changes to the front lines of care. But over the last year, we finally learned that the right role for innovation and technology should simply be to increase the care in health care. In many respects, my mom’s story mirrors the fundamental shifts that have occurred — shifts that are not yet available to everyone but that point to a future when health care finally works for us.
Like my mom, many patients have realized that their health is in their hands. We’re now aware of how our health is linked to our behaviors: how far apart we should stand to socially distance, how often we should wash our hands and how face coverings can protect us from viral particles. For many, this realization also extended to the way they accessed care. Faced with an overtaxed health-care system that was scrambling to adjust, patients learned that they couldn’t always rely on their medical providers. They often couldn’t see their regular doctors — either because of temporary pauses or permanent closures due to the financial impact of the pandemic on clinics — or didn’t feel safe going in person.
While the resulting decrease in medical care led to precipitous drops in cancer screenings and chronic-care visits, these circumstances also forced a greater sense of self-reliance in my patients. Many came to appointments more organized, with questions written down or medication bottles with them. Others took this a step further: One of my patients with long-standing, uncontrolled hypertension came back to the clinic after six months with his blood pressure finally managed. The difference? Because he hadn’t felt comfortable coming to the clinic, he bought a blood pressure machine and, with regular feedback at home, learned how to keep his condition in check.
That my mother found the diabetes reversal program herself is also indicative of a wider trend. Before the last year, most patients relied on their medical providers to navigate the byzantine health-care system. Now, many have had to find their own coronavirus tests and, more recently, their own vaccines — a frustrating experience, to be sure, but one that proved patients are their own best advocates.
Even so, patients weren’t entirely on their own. With the shift to virtual, home-based and community care, doctors finally began fulfilling the promise of “meeting patients where they are.” According to many observers, the coronavirus accelerated the shift toward virtual care by seven to 10 years. Nationally, we saw 46 percent of consumers use telehealth in the first months of 2020, up from a mere 11 percent in 2019. I consider myself a tech-savvy physician, but even I had never done a single virtual visit before the pandemic. Now I’ve done hundreds.
While telemedicine is traditionally used for urgent care, the pandemic pushed primary, specialty, mental health and even ancillary care into virtual spaces. My mom’s online diabetes program is just one example. But providers have our work cut out for us to ensure that new technologies for additional types of care don’t continue to leave our most vulnerable patients behind.
Beyond technology, we realized that drive-through testing for acute viral illnesses is safe and efficient. It turns out it’s just as easy, if not easier, to vaccinate large numbers of people at football stadiums or churches as it is in clinics or hospitals. Faced with overflowing hospitals, doctors also expanded the idea of hospitalizing patients at home — providing around-the-clock nursing support, a hospital bed and equipment, and IV medications — which is safer, cheaper and more humane for many patients who need hospital-level attention.
Physicians finally embraced the impact that social determinants — like socioeconomic status, neighborhood and physical environment, education, food, and housing — have on health. When I meet with patients now, I ask about their lives, who lives with them, how they get groceries, etc. These things of course drove the health of my patients before the pandemic, but I never routinely asked about them until I started trying to assess their risk of covid-19. In one case, I learned that a patient of mine was homeless, and I was able to get her a hotel room through a local organization — and her first restful night in months.
Care also became more continuous during the pandemic. Part of the reason my mom’s diabetes didn’t get better for so many years is that she’d leave the doctor’s office with a long list of lifestyle changes to make, but little or no support or communication from her providers in between visits. Now, she sends data daily on her weight, blood sugar and ketones and receives immediate feedback from her health coach.
Although my mom’s program is far more advanced than what most patients have access to, many components of continuous-care models have been implemented in my clinic, which serves low-income and uninsured patients. Once I was issued an iPhone and permitted to text and FaceTime with my patients, I found myself keeping up with them more, checking in after visits to confirm that they picked up the medication I had prescribed or just to see how they were doing. While this did create new burdens on me as a doctor, it also created new efficiencies — a quick text often saves a great deal of downstream communication. It was also a way for me to more deeply connect with my patients, something that had been wanting in my medical practice for years.
As we improvised solutions for hospital bed shortages and restrictions on in-person visits, continuity with patients increased. High-risk patients who came through our drive-through testing site were sent home with pulse oximeters. In one case, the family of a covid patient with shortness of breath was too scared to go to the emergency room — but also too scared to go home. By giving him a pulse oximeter to track his oxygen levels, we were able to help him stay home.
Perhaps the biggest change is that doctors and patients have come to believe that better is possible. Our deeply held assumptions about where and how health care happens have been upended, offering us a glimpse of the future.
Months into her program, my mother remains off insulin. She doesn’t have everything figured out and still needs support, or she risks backsliding. The health-care system is no different. While there are reasons to be hopeful, health care is still too inaccessible, too costly, too inequitable. We can’t stop now.
When I recently asked my mom if she’s glad she joined the program, she replied: “Beta, I’m now living the life I want and finally getting the care I need.” This future is what all of us should hope for.