Empty Promises?

Published in Hopkins Medicine - Winter 2023

In the early days of the COVID-19 pandemic, Jeremy Greene, like other clinicians, turned to telemedicine as a way to keep his patients at an East Baltimore community health center safe from the contagious disease. 

Telemedicine wasn’t new in March 2020, but the pandemic made it ubiquitous. The technology’s grand promise, that it would increase access to care, particularly for disadvantaged people, would be tested in real time. 

Greene, a Johns Hopkins historian and internist, quickly saw that telemedicine was tremendously useful for patients with the technology and skills to log into the electronic system and use home-based equipment like blood pressure cuffs or pulse oximeters. 

But patients without those advantages lost out, he writes in The Doctor Who Wasn’t There, his new book tracing the history of remote care. 

“Telemedicine, a technology that initially promised greater access to care to patients of color in poor urban areas, had in the crisis of the early pandemic come to serve more well-to-do, white patients who needed assistance least,” Greene writes.

Greene, director of the Department of the History of Medicine and the William H. Welch Professor of Medicine and History of Medicine at the school of medicine, has long been fascinated with the powerful and often-overlooked ways that the doctor-patient relationship is mediated by technology. 

“Part of what I do as a historian is I look at the objects we take for granted in daily life and wonder how they came to be that way, who they are designed for and who they leave out,” he says.  

For his latest book, Greene examines how four technologies — the telephones of the 1920s, radios of the 1940s, closed-circuit televisions of the 1950s and connected computers of the 1960s — changed health care. Grand promises to the contrary, they didn’t erase health disparities and often made them worse. 

That historic perspective helps Greene see the promise of the present moment and how easily it can slip away. As his book shows, each innovation was promoted with claims that it would improve access to care, particularly for disadvantaged urban and rural patients.  

However, technology alone can’t bridge the stubbornly persistent divide between medical haves and have-nots, he notes. That requires sustained logistical and financial support from politicians, the medical community and technology companies. 

Greene starts his tale in 1876, the year a new device called a telephone received a U.S. patent. Almost immediately, patients began ringing doctors, often at odd hours, to describe their symptoms, even holding children up to the receivers so doctors could hear their coughs. 

The invention did improve access to care, but only for people wealthy enough to own telephones. And there were downsides: Doctors couldn’t physically examine patients, they resented getting phone calls at all hours, and they feared malpractice suits resulting from missed or misinterpreted calls. 

Each new technology brought trade-offs. Greene shows, for example, how pagers, dubbed “grim beepers” by exhausted physicians, contributed to burnout; how networked computers changed the dynamics of diagnosis; and how wearable devices created vast rivers of medically useless but monetizable data.

“Electronic medicine is nothing new,” he writes. “That would be one way to read this book. But that would not be enough. At its best, this kind of argument helps to puncture the inflated claims of today’s technologists, who promote health applications of new devices as unprecedented without bothering to check for the many precedents that do exist.”

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