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Editor's Corner: The Zoombie Apocalypse

December 30, 2021
David Steensma, MD
Edward P. Evans Chair in MDS Research and Institute Physician at the Dana-Farber Cancer Institute; Associate Professor of Medicine at Harvard Medical School; Editor-in-chief of ASH Clinical News

Last Thursday, due to a calendar snafu, I found myself scheduled for videoconferences continuously from 8 a.m. until after 10 p.m. That meant 14 hours sitting in the same office chair and staring at the identical glowing rectangle, wiggling my legs periodically to avoid blood clots.

It turned out that all of these meetings required continued attention. There was no break – no chance to switch off the video feed and make a quick phone call, no time to rest between sessions. My wife, who subscribes to the Duchess of Windsor's axiom, "I married him for better or for worse, but not for lunch," made an exception to our usual practice of separate midday meals and mercifully dropped something edible on my desk in the early afternoon. At 7 p.m., I pretended I was having connectivity problems, turned off the webcam, and snuck away for 90 seconds to microwave a slice of pizza. By the time I finally shut down the computer for the night and dragged myself off to bed, my eyes were burning and as red as eosinophils, and I had been rendered nearly senseless by Zoom. I had become a Zoombie.

I used six videoconferencing platforms in addition to Zoom during that pixel marathon: Skype, Microsoft Teams, GoToMeeting, Cisco Webex, RingCentral, and Adobe Connect. Switching between them was a nuisance, but I felt the same exhilaration about that roster as when I finally "collected them all" as a kid and acquired the last baseball card in the Topps 1978 series – the Pete Rose Record Breaker. Then a tech-savvy colleague burst my bubble by pointing out that I hadn't used ezTalks, StarLeaf, BigBlueButton, and a few more exotic programs that I had never heard of.

While most days are not that extreme, lately life has become exhausting in a new way. All of this videoconferencing is helping us stay safe, remain connected, and get things done during the pandemic. The only infection you can catch by computer is the kind for which Norton, McAfee, and Kaspersky antivirus software already have a treatment. Still, endless videoconferencing messes with our brains.

There are many reasons why videoconferencing is so tiring. Sitting in the same position and using the identical tool all day is a recipe for fatigue. Our eyes can get irritated and dry with too much screen-staring. There is less downtime now than in a typical day. Really, I don't understand why all these videoconference meetings are exactly 1 or 2 hours long; 50 minutes or 110 minutes would give us a chance to rehab or take a bio break in between. In a normal conversation, we do not make eye contact 100% of the time – that would be creepy – yet doing so is common in videoconferences, and seems to trigger something intense in the deep, reptilian part of our brains.

The boundaries between work time and personal time, and between home and office, are now blurred to the point of nonexistence. The degree of connection with conference participants may be greater by video than via the telephone – we're visual creatures, after all – but seeing people on a small screen confined to a gallery of boxes like actors from The Brady Bunch or contestants on Hollywood Squares is not the same as sitting together in a room, and senior vice presidents and biostatisticians are only rarely as hilarious as Alice the housekeeper or Paul Lynde. People seem to have forgotten that it is OK to use the phone (or not to meet at all), so the number of videoconferences has proliferated faster than an FLT3-mutant myeloblast. Finally, for many of us, there are background distractions that we have to work around: traffic noise, jackhammers (the forest next door to my home was bulldozed into oblivion in January to build 40 poorly timed townhomes), antics of small children, intrusions of pets, or sounds of partners on similar videoconferences.

We are still learning how to do medical meetings remotely. While it is helpful to be able to replay an online presentation if you missed or don't understand something – or stop watching a talk that is boring or irrelevant without making a scene by leaving a crowded conference hall – there is no ability to meet up with friends and colleagues for dinner after a long day of sessions. Also, all the recent major conferences have had intermittent problems with slow servers or dropped connections (ASH has taken precautions to minimize the risk of that happening during this year's annual meeting in December). Our trainees and young investigators have consumed a steady diet of remote meetings, leaving them with less opportunity to network with colleagues and with senior physicians and scientists. We as mentors need to find ways to help them make those connections anyway.

The biggest videoconferencing change for clinical hematologists has been the rapid switch to telemedicine. In January, telemedicine accounted for less than 3% of health care in the U.S. At the peak of the pandemic in Boston in mid-April (hopefully that will remain "The Peak" and not become "The First Peak" in the way "The Great War" eventually became "World War I"), my colleagues and I at Dana-Farber were seeing almost 70% of outpatients via telemedicine. Many patients have since returned to the clinic, but I am still connecting with about 30% by video or telephone.

This issue of ASH Clinical News includes a feature on telemedicine. In just a few weeks in March, we saw dramatic changes to how medical care is delivered – changes that otherwise might have taken decades of committee meetings, debates, and periods of public commentary. The biggest obstacle to expansion of telemedicine in the past has been reimbursement, but at the end of March, the Centers for Medicare and Medicaid Services (CMS) was paying for 100 additional services through telehealth compared to the status quo in February. CMS also relaxed regulations on cybersecurity and no longer restricts telemedicine to patients in underserved areas, nor does it require them to go to local health facilities to link up with a distant specialist. There is a chance these changes may become permanent.

Telemedicine has much to recommend it. Patients want it. It is more convenient for them than driving to a distant medical center, struggling to find parking, and filling out forms in a lobby for 15 minutes before waiting to see the doctor. For physicians, there is the chance to expand our geographic reach. My new patients before the pandemic were mostly from New England and the mid-Atlantic region, but now I can just as easily advise patients in Sacramento, Traverse City, or Baton Rouge about myelodysplastic syndromes and clonal hematopoiesis, without them having to get on an overcrowded airplane to fly to Boston. I also find it informative and fascinating to look inside patients' homes – I have met many of my patients' pets and learned that a surprising number keep birds. One man, a sculptor, even gave me a brief video tour of his studio and showed me some projects he was working on.

But telemedicine also has its limitations. You can't feel a spleen remotely or examine the swollen lymph node that a patient is concerned about. There is no opportunity to touch the patient; physical contact is a big part of human connection and of the art of medicine. Also, it isn't easy to answer a page from a worried nurse in the middle of an intense video consultation. If you are tied up talking to a webcam, you can't quickly run over to the clinic's infusion unit to assess the patient who is bleeding a little more than expected or looks unstable. Much is lost when we can't see subtle nonverbal cues, like change in posture or fleeting expressions. Some patients struggle with technical aspects of video platforms or do not have broadband access. Telemedicine also doesn't pay as well as in-person visits – no "facility fees" – and institutions that are already on the brink of insolvency due to months of postponement of elective procedures may not be keen to continue it.

Regardless of what happens with telehealth, videoconferencing seem here to stay as a major part of modern work life. This can lead to some amusing moments. Yesterday I saw a patient in clinic for a follow-up visit after an initial video consultation. She said I looked much taller in person than on the laptop screen.


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Mid-January 2023


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