stethescope on laptopIf I’ve said it once, I’ve said it a thousand times. “The best medicine is always done face to face.”

Telemedicine is all the rage these days. Companies are furiously buying subscriptions for their staff in the hopes that team members won’t have to take a day off work to see the doctor or that management won’t have to pay higher insurance premiums in the coming years if staff were to utilize more costly resources like urgent treatment centers. Legislators have embraced the idea as the salvation for the looming physician shortage even though for years medical examiners boards and malpractice insurance companies have cautioned physicians against prescribing medications to patients that have not been properly (ie, physically) examined.  Yet the telemedicine boom continues.  A recent report cited that more than 90% of companies plan on having telemedicine services for their employees.  Even the insurance companies are directly soliciting their members to use their own telemedicine services (which is pretty ironic since most insurance companies have yet to offer reimbursement for telemedicine within their own plans).

In this article, the author points out at least one of the most important flaws I see for telemedicine.

“The problem is that healthcare is much more complicated — patients may overreact to minor symptoms or not be clear enough in describing their situation and that leads to doctors feeling obligated to schedule an office visit,” he said.  “Further, providers can also get insufficient or ambiguous information that makes it tough to adequately diagnose the issue, resulting in an additional office visit.”

I was on call one night during residency. It was the standard adult inpatient service and I was early in my career so all the patient concerns came to me first. About 10pm one night I received a page from the step down unit on the sixth floor. This unit was where patients would come who were not sick enough to stay in the ICU but too sick to be on the regular floor by themselves. It was staffed with some really awesome nurses who I felt could handle just about anything.  During my training, these experienced nurses taught me many things.

So when I received the page that Mr. Patient was having some irregular heart beats followed with a request for a change in his medication, it initially sounded very reasonable.  However, I didn’t agree to it.

I had this personal habit, really more like a personal code, that I vigorously stuck to throughout medical school and residency.  I never treated a patient over the phone for anything, no matter how small it seemed, if I was able to personally go to the bedside and evaluate the patient. I wanted to see the patient for myself every time. Often, merely walking in the room gave me more information than a thousand phone calls could.  Sometimes, I would be tied up in a procedure and unable to visit personally.  I would make the best decision available and then follow up in personal when I was free.  However, when I was able, I met with the patient face to face to address their concern.

This night when I went to the bedside of Mr. Patient on the sixth floor, my evaluation led me to a different conclusion. It wasn’t drastically different, just nuanced.  I ordered the therapy I thought best and he got better.  Would the nurse’s request have worked? Probably,  but if I was going to order it, if I was going to put my name on the line and say ‘I take responsibility for this treatment plan,’ then I was going to make up my own mind before I ordered anything.

What did a learn or, rather, what was reinforced by this?  It showed me that if one of the most experienced nurses on one of the most well monitored floors in the hospital wasn’t able to adequately describe the clinical situation over the phone without leaving out what I felt were important details, then the further I was from evaluating a patient in person, the less complete the information necessarily had to be.

This is why I don’t believe telemedicine will be the answer to any of our current healthcare concerns.  I think it can be a helpful adjunct but certainly not a replacement.  As the article points out, many times physicians utilizing telemedicine needed patients to follow up in the office to make sure they were on the right track and receiving appropriate care.  For this reason I don’t believe telemedicine can ever replace the in person physician-patient evaluation.

I do believe that it can be a help to patients and physicians in the context of a well established professional relationship such as that found in Direct Primary Care programs.  I see my patients frequently, sometimes even multiple times in one week.  I routinely communicate via email and phone with my patients before or after their visit when they have further questions or information they need to relay to me.  All these alternative means of communication, apart from the face to face encounter, are added bits of information I use to enhance my ability to diagnose and treat their concern.

For example, I recently started corresponding with a mother a young boy who was struggling with some abdominal complaints.  She’s a great historian and provided a well written account of his symptoms.  We exchanged a series of emails making sure there weren’t any alarm symptoms that demanded an urgent evaluation, then I offered up a few suggestions based on this information.  Our emails continued over about 7-10 days attempting to isolate the cause so as to offer an appropriate therapy with the last exchange ending with an adjustment to the over the counter treatment regimen and a scheduled appointment after the coming weekend.  By the appointment time, his symptoms had dramatically improved and the physical exam confirmed my final diagnosis.  We discussed plans for what to do in the future if similar symptoms occur.

I believe telemedicine, apart from a trusted and knowledgeable relationship with a personal physician, may ultimately only cause missed opportunities for care.

If you’re one of the multitudes of patients who feel like they don’t get enough time with a physician to really get started on solving some of your concerns, then give us a call at 244-1800.  Trinity Direct Primary Care is the region’s largest Direct Primary Care program with offices in Hardin Valley and Maryville.  We offer unlimited contact via email, phone, and office visits with no per contact or visit fees.  All our memberships are month to month and include most common labs and testing necessary to take care of you.  Anything else is offered at steep discounts up to 90% of the retail price offered around town.  Our goal is to offer you the best quality primary care experience with less out of pocket costs.

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