The COVID-19 pandemic, and the adjustments the medical world has had to make to accommodate it, have thrown into sharp relief some professional, legal, and ethical questions that have scarcely been raised in the long history of medicine.

Let us remind ourselves how we got here. The COVID-19 virus, during the early and optimistic months when the fog of war prevailed, was largely seen as something that could be easily dealt with. We were wrong. It prompted escalations in public health policies the likes of which we have not seen for generations: lockdowns, social distancing, mask mandates, restricted travel, etc. 

People and businesses struggled to keep up, and uncertainty became the new normal. The modern world is built, to some degree or another, on the assumption that certain aspects of life would always continue in a predictable fashion. However, ever-changing pandemic public health guidelines shattered that illusion, wreaking havoc in almost every sphere of life, including health care.

Health care had to pivot very quickly from a model of physical consultation to a remote one. In the International Journal of Medical Informatics, Kaplan listed a number of concerns this has raised: 

  • Informed consent
  • Data protection and confidentiality
  • Malpractice and liability
  • Regulation of telehealth services
  • Equitable access
  • Uniformity of technological standards. 

Poignantly, Kaplan wrote, “Authors discussing the doctor-patient relationship addressed the importance of human contact, nonverbal cues, touch, expressiveness, and accustomed ways to express empathy and build rapport for diagnosis, treatment, and recovery. They were concerned with the potential for depersonalization and lack of intimacy, prioritizing efficiency and economics over quality care, and for lack of sensitivity to patients’ community, culture and social practices, and language.” 

Using Telehealth in the Treatment of Myasthenia Gravis 

Now let us look specifically at telehealth services offered during the pandemic in the context of myasthenia gravis. 

The management of myasthenia gravis includes clinical surveillance, continuous care (given that it is a chronic, progressive disease), and personalized/precision medicine. 

In Neurological Sciences, Ricciardi and colleagues wrote, “Patients should continue ongoing treatment monitoring blood markers and it is advised not to discontinue existing medications or initiate new treatments unless specifically discussed and approved by the healthcare providers, to reduce hospitalization and avoid the potential risk of increased disease activity and/or of [myasthenia gravis] crisis.” 

Read more about myasthenia gravis etiology

Physicians treating patients with myasthenia gravis during COVID-19 are caught between a rock and a hard place: on one hand, the treatment regime of myasthenia gravis cannot be let up given the severity of the disease; on the other hand, if precautions are not taken against the virus and the patient becomes ill, the rise of respiratory failure is high, given that myasthenia gravis predisposes a patient to respiratory weakness. 

The general consensus forged by neurologists during the pandemic was that a shift towards telemedicine (more specifically, “tele-neurology”) was worth exploring. The belief was that it was a safe means of conducting follow-ups, especially when dealing with stable patients. Many neurological examinations can be conducted virtually, in addition to the many helpful clinical scales that allow patients to indicate the extent of their symptoms remotely.

Ricciardi and colleagues conducted a literature analysis on the use of telemedicine during COVID-19 for the care of patients with myasthenia gravis, and proposed a 4-item test to detect signs and symptoms of bulbar and respiratory involvement: 

  • Counting aloud, ie, asking patients to take a deep breath and count as high as they can out loud. This test is a simple tool to help physicians approximate the patient’s vital capacity based on how soon they run out of breath. 
  • Hoarseness test, ie, asking patients to make a high-pitched sound. This allows physicians to assess the weakness of the laryngeal muscles, especially if hoarseness is heard. 
  • Head up test, ie, asking the patient to flex the head and keep that posture for as long as possible while supine. This exercise is helpful because neck muscle weakness is often related to fatigability of muscles with bulbar innervation; hence, the dropping of the head typically signifies a worsening of the patient’s condition. 
  • Swallowing test, ie, asking the patient to swallow a small amount of water. If the patient displays symptoms such as coughing or experiencing a change in voice, it is a clear sign the disease has worsened.

These items demonstrate that, even with all the restrictions of the COVID-19 pandemic, innovative solutions can be found to make the most of an unfortunate situation. All of these tests can be conducted remotely, and most importantly, effectively. Should the physician suspect that the patient requires further in-person investigations, the physician may then request the patient to come in physically.

Read more about myasthenia gravis patient education 

It would be a wonderful thing if some of the innovative practices created out of necessity during the COVID-19 pandemic continue to live on in medical practice, even after the pandemic has dissipated. The pandemic has forced a rethink in health care; if we can continue to conduct health care remotely when indicated, saving time and money for both the patient and the medical institution, while conducting in-person consultations when necessary, we may already be in the throes of the next great evolution in medicine. 


Kaplan B. Revisiting health information technology ethical, legal, and social issues and evaluation: telehealth/telemedicine and COVID-19Int J Med Inform. 2020;143:104239. doi:10.1016/j.ijmedinf.2020.104239

Ricciardi D, Casagrande S, Iodice F, et al. Myasthenia gravis and telemedicine: a lesson from COVID-19 pandemicNeurol Sci. 2021;42(12):4889-4892. doi:10.1007/s10072-021-05566-8