Introducing IBX: The Cover Story Podcast

Full podcast episode transcription

Peter Panageas:

If you’re looking for timely, relevant conversations about the most important topics in health coverage, you’ve come to the right pod. This is IBX: The Cover Story from Independence Blue Cross hosted by me, Peter Panageas. So by day, I oversee all of our national commercial business here at IBX. I’m also a caregiver and a patient. We always say that healthcare is personal and it is, so my guests and I are exploring how the big picture and the big issues affect our everyday lives and the well-being of those we all care about. Together, we’ve got this covered. So let’s get started.

Peter Panageas:

Hello, everyone. This is Peter Panageas, and welcome to episode one of IBX: The Cover Story. Today, we’re talking about telemedicine. It’s a subject I first encountered with my own cancer experience. About three years ago, I was diagnosed with a very rare form of cancer called Merkel cell. I’ll never forget the day I got that call from Penn sharing with me I had a very rare form of cancer. So rare that they rarely even had any patients that they’ve really treated. Their suggestion to me was to meet with a world-class physician who specializes in Merkel cell, Dr. Nghiem. And the challenge however for me living in New Jersey was Dr. Nghiem is based out of Seattle, specifically the Seattle Cancer Clinic. It wasn’t as simple as just driving an hour over the bridge to Penn and seeing the oncologist. Certainly a lot of stress associated with learning of cancer and knowing that the only individual that really had a level of expertise in treating this form of cancer was literally across the country, rose my level of anxiety.

Peter Panageas:

When I reached out to Dr. Nghiem through his recommendation, his initial consult with me was via telemedicine. The first time I’d ever done that. And in full transparency, it was incredible experience for me. It eased my mind. It allowed me the opportunity to get a lot of my questions answered by Dr. Nghiem. But obviously, he had to see me and I got on a plane and I went out and visited with him. And as my journey continued and I started to beat and ultimately did beat my cancer, I was able to limit my visits to Dr. Nghiem to once a year. I continued to get scans and get blood work, and I have, on a quarterly basis, a telemed visit with him. The experience has been an incredible one and one that frankly, Dr. Nghiem is doing more and more with his patients, not only domestically, but globally.

Peter Panageas:

The cancer that I had is a very, very rare form of cancer and there was only a handful of physicians globally who actually treat it. Dr. Nghiem being one of them. He’s shared with me that he’s doing a lot more telemed not only domestically, but globally. So it’s been an incredible experience for me and one that I highly recommend.

Peter Panageas:

During my journey, we learned my mother and father both came down with cancer as well. My mother with pancreatic cancer and my father with prostate cancer. Last year, as we all experienced, we came down with a pandemic and the way that we were experiencing treatment for my mom and dad changed dramatically. April of last year, we started telemed for both my mother and father with their respective oncologists. And I will offer to you that it was a challenge at first. It was something that, for my mom and dad, was very, very scary. They’re not used to having telemed. They’re not used to talking to a physician via their computer. My mom and dad in their mid to late 70s. My father was an immigrant from Greece. I would say that in addition to some language barriers, there’s also some technology barriers. They’re not necessarily tech savvy.

Peter Panageas:

And I remember setting my mom up for her initial visit with Dr. Teitelbaum, her oncologist from Penn, and literally setting up her computer and walking her through as a tutorial from basically outside the house. This is when COVID first hit back in April. A lot of credit to my mom. She grasped it, she did it. And she subsequently have had a number of televisits with her doctors and it has been a great experience.

Peter Panageas:

Aside from that, the element of having to drive down to the shore, I live in Southern New Jersey, but having to drive down to the shore where my parents live, which is about an hour from where I live and then drive them into Philadelphia, go through that whole process, then drive them back and then come back to my house was, as a caregiver for my sister and for myself, was a long day. And the beauty of the telemed was it allowed us the opportunity to cut that time in half, have a quality visit, and making sure that the level of care that was needed was there.

Peter Panageas:

And another little wrinkle here for us is as we were caring for my mother, my sister lives in Florida. And the idea of being able to bridge that gap, where my sister could be part of care literally from her home in Florida, my mother in Jersey and obviously, my mother’s physician in Philadelphia allowed for peace of mind for my sister who wasn’t necessarily right here in New Jersey.

Peter Panageas:

So I can’t talk highly enough about the experience of telemed, what it’s meant to me personally, in my journey, but also what it’s meant to my family as we’ve been caring for both our parents, our mother and father, my sister, Dorothy.

Peter Panageas:

Today, I’ll be talking with my special guest, Dr. Ursina Teitelbaum of the Perelman Center for Advanced Medicine at the university of Pennsylvania. Dr. Teitelbaum is my mother’s oncologist. And Dr. Teitelbaum, I cannot thank you enough for being with us here today.

Dr. Ursina Teitelbaum:

I feel so privileged to be here.

Peter Panageas:

Well, first and foremost, Dr. Teitelbaum, my mother made me promise, so I did, that she sends her biggest love and admiration to you, and she’s thinking and praying for you. And she just wanted me to say she loves you and she says hello.

Dr. Ursina Teitelbaum:

I really miss her. Thank you. That means a lot to me.

Peter Panageas:

And you mean a lot to us. Dr. Teitelbaum is the clinical director of Penn Pancreatic Cancer Research Center. In addition to pancreatic cancer, she’s a specialist in all GI cancers. And before the pandemic, she saw patients like my mom at the Perelman Center for Advanced Medicine on the campus of the hospital of the University of Pennsylvania. Dr. Teitelbaum, did you have any experience with virtual appointments before the pandemic hit?

Dr. Ursina Teitelbaum:

We had none at all, which actually seems kind of shocking now that we hadn’t incorporated it earlier into our practice of medicine. I have to say that on our end, we adjusted remarkably quickly to the new reality. We all really jumped in. I’m really impressed actually how my colleagues, including the older ones embraced the technology. Physicians and advanced practice providers have really learned how to incorporate telehealth into our practice. I actually can’t imagine clinical life anymore without telehealth. And I actually think in the end, it will be a COVID silver lining, a really meaningful innovation in the care of our patients.

Peter Panageas:

Dr. Teitelbaum, I couldn’t agree with you more. I think that we’re all trying to figure out what would be a silver lining in this pandemic we’re all facing. And this for me is one of them. I know for one, firsthand, when we learned in April that all appointments with you for my mom were going to be done virtual until the foreseeable future, it was a scary proposition for my mom. She’s in her 70s as you know, and she’s never had any type of experience like that before. And I think the work that Penn did and you all as physicians was an incredible experience for us, but it was scary for us as we went down that path.

Peter Panageas:

I think I even shared this story with you. I literally drove down to her house and had to tutorialize her on how to sign onto an iPad and do all that. And we have to do that from a distance. So I was really proud of her and she navigated through it. And I remember the first time and I was standing outside, looking from the outside in, and she was live with you.

Peter Panageas:

So I know for my mom, it was a unique and frankly, a little bit of a scary experience. From your lens, how did you all feel about that? How did you and your colleagues feel about the whole telemedicine thing?

Dr. Ursina Teitelbaum:

It was actually super scary in the beginning for us too. I was really nervous, but I can tell you thatpatients and the docs are actually really relaxing into it now. My fundamental initial concern was howthe audio visual experience would be, the technology. Would we be able to connect? And actually it’s getting better and better and better.

Dr. Ursina Teitelbaum:

The other outstanding fear for me was, would I be able to accurately assess how my patient was doing? Would I miss something critical without vital signs and the physical exam and the ability to lay hands on?

But I’m actually amazed at how much I can pick up clinically from a virtual visit and I’m much less worried now. I even learned how to do a neurologic exam virtually. In truth, it’s all about patient selection. I’m an oncologist, so it’s great for surveillance visit if you have an imaging review or a survivorship visit. We use it now for patients that are on oral treatments, oral chemotherapies. Sometimes we really need to follow their symptoms very often, and this makes it much less cumbersome to do so. They don’t really need to come in for that.

Dr. Ursina Teitelbaum:

We’re actually even using it on the day before a patient’s IB chemotherapy treatment. The whole name of the game for us now is spacing out the waiting room and shortening the visit, really limiting the time the patient is on site to limit their exposure. So we may have a visit the day before and that way, when the patient comes in, they don’t have to come to the lab and the clinic, they go right back to the chemotherapy suite. So it’s much more efficient. And then I like it for confirmatory consultations. Patients that may be coming from afar or might be too sick to come. This is particularly relevant when they’re interested in the clinical trial. It is really nice to be able to spare them the physical trip.

Peter Panageas:

Yeah, and firsthand, I’ll offer … I live in Southern New Jersey. My mom and dad do too. They’re down at the Jersey Shore. And from where I live in Jersey, it’s about an hour to get down to them. And I can remember when we were doing face-to-face visits and consultations with you, I would leave my home to go drive down to pick my mom and dad up, bring them up to your facility, we’d go through the appointment with you, drive them back, and then I’d come back to my house. It was a long day. It’s a long day for me as a caregiver, it’s a long day for my mom and dad as they were going through it. We just felt it was, from a time perspective, it really did help us navigate it. And it was a lot less stressful for my mom and dad as they were navigating through it.

Peter Panageas:

Now I will tell you, as much as my mom does love the element of the simplicity and the … She really, at times, does miss the touchy-feely being face-to-face with you. And I would imagine some of your other patients probably feel the same way.

Dr. Ursina Teitelbaum:

I am having an interesting situation where some patients that are perfect for telehealth actually are starting to try and transition their appointment back. I think it’s exactly what you’re saying. They miss being with me and I really miss being with them. Right now, it’s not that the right time. Later on, I think we could alternate visits and make it easier. To your point, patients come in super stressed after they’ve coped with the traffic and the parking and all that it takes to come into a visit. So I do think that the stress level is lowered right now, which is really important given what we’re all going through.

Peter Panageas:

I couldn’t agree with you more. So let me ask you I had this offer, what would you think the pros and the cons of virtual appointments are?

Dr. Ursina Teitelbaum:

The obvious pros, you don’t have to worry about the travel and parking. This is especially relevant for an older patient. Virtual completely mitigates the risk of COVID exposure. This is for the patients. This is for the … You know, it just decreases the context, the front desk, the medical assistants from start to finish. And so that takes out a tremendous fear factor. And again, it decompresses those waiting rooms so everyone is safer.

Dr. Ursina Teitelbaum:

I actually surveyed a lot of my colleagues to get some input on these pros and cons. I will say to your point, one of the things it does is it permits out-of-town family members to participate in the visits, which has been amazing. There’s nothing more stressful, I think, than being a loved one from afar when your parent or sibling or spouse is sick. For example, I think in one of our meetings, your mother was in New Jersey, I was in Pennsylvania and your sister was in Florida. I mean, that’s extraordinary to have everyone participate in the visit.

Dr. Ursina Teitelbaum:

The other thing that I never anticipated is it turns out I rely more on lip reading than I realized, all of us do. And so for anyone hard of hearing or not even hard of hearing, there’s a real communication barrier with the masks. So one of the things I love when I’m on a telehealth is I can see them and they can see me. And it’s not just the improved understanding of the conversation, it’s being able to see the patient’s face. I really like that.

Dr. Ursina Teitelbaum:

It’s also, this is kind of funny, it’s an intriguing personal window into a patient’s home and their life. I get to see what’s really important to them. And so I see pets, I see their kitchen. I have had patients have a visit with me when they’re in the grocery store, which is sort of humorous, but it tells me that they’re fit and functional and feeling well enough to be out and about.

Dr. Ursina Teitelbaum:

I can’t tell you how many patients have their visit with me in the car. That happens more than you’d know. And then I have a subset, this is sort of amusing too, of patients that actually will have their visit in bed in their pajamas. They don’t need to be in bed. They’re totally fine. I think it’s sort of a quarantine thing. But it’s just really interesting to get this peek into their lives and kind of creates a wholer picture of the person that I’m caring for.

Dr. Ursina Teitelbaum:

It’s really good for survivorship since we have patients that we see infrequently, and we’re not even getting a lot of tests or studies on them. It’s really just a check-in. And so that really spares them the visit. It’s surprisingly good for palliative care visits. If you’re doing symptom management, you can really manage pain or side effects of treatments or symptoms of cancer virtually very effectively.

Dr. Ursina Teitelbaum:

We like the video, my colleagues and I also like, you can pick up body language on the video. I prefer video, audio visual to telephone alone. Although sometimes if patients are having trouble with the technology, I can actually get a lot from the phone. And again, I’m a big believer in the better you feel, the longer you live. So I can do a tighter management of patients on therapy and manage their symptoms. And I suspect that might lead to a better outcome actually. Sometimes I feel guilty having patients come in a lot, because it is so cumbersome. But now I can say, “Let’s change the dose a little. Touch base in two weeks and make a quick modification that makes a big impact.” And I do wonder if that improves their outcome.

Dr. Ursina Teitelbaum:

So you said cons, right? There are some cons. I miss them. I miss my patients and I miss their loved ones. You know, you’re not just taking care of a person, you’re taking care of a village. And so I miss seeing their people. It is not a substitute for human contact and human touch. I mentioned, I think that’s why some of the patients are trying to switch back in-person because they really miss it. But now again, while we’re trying to keep everybody safe, it’s really important to leave that for later. The technology glitches that can happen can affect the flow of the conversation. It makes it a little stressful. That’s usually easily remedied. Sometimes if I can’t get the video and the audio to connect, I’ll just call them. And then I have the videos, so I have the combination and that works. It’s certainly, as you mentioned with your mother, sometimes harder for an older person to manage the technology. Although, they’re getting really good at those iPhones. If you have a screen, there is a way. So that really helps.

Dr. Ursina Teitelbaum:

In theory, the virtual physical assessment isn’t perfect so we could miss something. That’s always what I worry about the most. It hasn’t really happened, but I’m very cognizant of that. The hardest thing on the provider, besides the audio visual, the tech stuff is in our practice, sometimes we have a mix of in-person and virtual visits, and it’s much harder for us to manage the flow of the clinic and be on time to the minute to that virtual waiting room for that visit. And what I find is patients and their families get very nervous because I think they think they haven’t managed that virtual waiting room properly. They’re not logged in, something’s wrong. And really and truly, it’s just trying to manage our time.

Dr. Ursina Teitelbaum:

Thankfully, they have this new thing where in our switchboard we can send a signal that we’re running late. And for my less savvy patients, I’ll call them and say, “I’m running behind. Can I call you when we’re ready so that I can have this dedicated visit?” But they get really anxious about it. And so figuring out how to manage that has been really one of the trickiest parts. And then I would also say the con is you really need to make sure you’ve picked the right patient for the telehealth experience. It’s not great for a severely ill patient or a critical discussion, a difficult scan, a change of therapy, an end-of-life discussion. I need that in-person experience as much as I can to sort of nurture people through it.

Dr. Ursina Teitelbaum:

In clinic right now, you can’t use touch to comfort, which is really hard. It’s also hard because we can’t reliably have a companion, but there’s some situations where it just has to be in person.

Peter Panageas:

For those listening here today, I will tell you firsthand and anecdotally, a couple of points that Dr. Teitelbaum brought forward were definitely very relevant, certainly with the care with my mom. I remember when we had our appointment and we were all wearing masks very early on. I remember when we had the virtual appointment, one of the things that my mother had said to me was, “It felt as if I was right there with Dr. Teitelbaum. I didn’t have the mask on. We could see each other.” And she felt as if you were right next to her, Dr. Teitelbaum. Now, a big part of that was you. You were very genuine in the approach. You were very warm and forthcoming. And I would imagine that’s a very natural thing for you. I see that in you from the moment we’ve met, but I also imagine maybe a con for some either caregivers or even physicians where this type of interaction via virtual might be not necessarily comfortable for some folks.

Peter Panageas:

The other point you brought up was in regards to the level of anxiousness about waiting in the virtual waiting room. Your technology was incredible. I told my mom at the, I think it was the third time she had met with you and you were a little bit backed up and we did get a message that came through. And I was telling my mom like, “Ma, you’re going to be okay. She’s just probably running a little late.” And she started to think, “Did I do something wrong? Did I log in wrong? Did I hang up now?” Now luckily for her, I was here and then your technology actually showed it, but I could see where that would be somewhat of a challenge for somebody who doesn’t necessarily have somebody there with them physically, or the provider or the facility doesn’t have necessarily the technology that you do. But all wonderful points, and thanks for that insight.

Peter Panageas:

So let me ask you this, if you could give any advice that you have for your patients and or caregivers, what to expect? How to prepare to make the most of a virtual appointment?

Dr. Ursina Teitelbaum:

I just want to say one point to what you just said. I think even when we are more vaccinated as a population, I think masks are going to be around for a long time. And so I actually think that telehealth option is going to be even more important going forward. Again, to the COVID silver lining, I’m really glad that I have this technology now. It really rounds out my practice. So I would just say again, be patient with us, especially if we’re late. We see you’re on our schedule. We’re excited to meet with you and find out how things are going, but on our end, it can be incredibly unpredictable. So again, to your point, we’ll use the technology with a running late text, or I’ll call you if I’m running behind. But if we are 15 to 20 minutes late, and there is no alert and no phone call, it is really reasonable to call. When I’m behind and I get the message that the patient called in worried that I forgot them, I actually really appreciate it. In that way, I have the opportunity to let them know what’s going on.

Dr. Ursina Teitelbaum:

The other thing is if I can’t see you in person, I need you to communicate with me how you’re feeling. and any physical concern. I actually rely a little bit more on the patient since I don’t have my eyes directly on, or my hands directly on. I can actually get a lot of a physical examination with the camera, but I need to know what I’m looking for. So if you can write out a list of symptoms or physical concerns before you get on the call, that’s enormously helpful.

Dr. Ursina Teitelbaum:

Another thing, I still really miss vital signs: weight, pulse. So if you could weigh yourself that day, great. If you could take your temperature and give me that data, love it. If you could measure your pulse, amazing. And some of you have a home blood pressure cuff, I’d love that vital sign. That data would help me tremendously in my physical assessment. And it would really be very reassuring to me to have that. I don’t want to miss anything vital. So having a vital sign is something I can hold on to.

Dr. Ursina Teitelbaum:

Having your family there is great so they can hear everything. And also, so they can give me an important update. It’s really good to have an extra ear or to be they right next to you, or logged into the call on that virtual visit. I would say also, if you’re feeling extremely ill, it is better to come in person because there’s a lot of things I can’t do in a virtual visit. I can’t give you fluids. I can’t draw labs and cultures. I can’t do any other workup or intervention to figure out what’s going on and how to make you feel better when you’re not in front of me. I personally am always trying to keep my cancer patients out of the emergency room and out of the hospital. So if you’re really sick, it is actually better to come in person.

Dr. Ursina Teitelbaum:

And I guess fundamentally, I think tele-health is here to stay. We may not rely on it as much as we’re doing now, but it’s absolutely a great innovation in addition to traditional visits. And again, we’re all looking for the COVID silver lining, and I certainly think this is one in medicine. It is really tremendous addition to our practice.

Peter Panageas:

Dr. Teitelbaum, let me offer this to you. My sister and I, predominantly my sister, has been the one really helping and caring for my mother a lot more than I have been. And I give a lot of credit to my sister for taking a lot of that on living in Florida. And as you had recalled, there was one time where you were in Pennsylvania, my sister’s in Florida, my mother’s in New Jersey, and what you’ve done and what Penn has done to help us navigate this journey. My mother has been fighting, as you know, her pancreatic cancer now for going on three and a half years, right? She is a walking miracle. I’ve said that to her many times and I think you’ve actually said those words to me as well. And her spirit and her fight is a direct derivative of who she is as an individual. And I couldn’t be more proud of my mom’s fight and her zest for life. But there’s no question in my mind that you had a huge part to play in her.

Dr. Ursina Teitelbaum:

Thank you. She is a miracle.

Peter Panageas:

So for that, thank you. Thank you for everything that you’ve done for my mother, for my father, for my sister and I, and thank you for being such an incredible physician. And we are so blessed to have had you come into our lives to help us with this really incredible journey of telemed. It has worked so incredibly well for the Panageas family. I can’t thank you enough for being with us today. So thank you.

Dr. Ursina Teitelbaum:

Thank you, Peter. Could you tell your mother also, I’m thinking about her. I miss her. She is a medical miracle. I think she’s a combination of great medicine meets great faith meets great family, and it’s really a pleasure to care for her. And I do feel really privileged that you have entrusted me with her care.

Peter Panageas:

Thank you, Dr. Teitelbaum. Thank you, God bless you. Thank you.

Peter Panageas:

COVID hasn’t just been challenging for patients. It’s also been tough on us as caregivers. The Health of America Report recently investigated the health of caregivers. The study has found that the pandemic has escalated the need for caregiving and also intensified the caregiving that’s required. Caregivers are also reporting increased stress, isolation, and loneliness. So for those of us who are caregivers, we need to ask for help wherever and whenever we can. Telemedicine is one way health plans and employers can support their employees who are trying to balance their jobs with their roles as caregivers.

Peter Panageas:

I want to thank Dr. Teitelbaum again for her incredible insight. And I also want to thank all of our listeners today. Hopefully you found today’s podcast informative and helpful. Please check out the episode notes for more information about my family story, a recent study on our caregiver health, and also details about Dr. Teitelbaum’s practice.

Peter Panageas:

Our next podcast is going to be about tragedies around return to work. We’ll be releasing new episodes the last week of each month. So thank you so much. We appreciate you listening.