During the pandemic, I engaged in telemedicine with my patients out of necessity. This platform was already destined to become part of the medical landscape even prior to the pandemic. COVID-19 accelerated the process. The appeal is obvious. Patients can have medical visits from their own homes without driving to the office, parking, checking in, finding their way to the office, biding time in the waiting room and then driving out afterwards. And patients could consult physicians from far distances, even across state lines. Most of the time invested in traditional office visits occurs before and after the actual visits. So much time wasted! Indeed, telemedicine has answered the prayers of time management enthusiasts.
At first, I was also intoxicated treating patients via
cyberspace, or telemedically, if I may invent a term. I could comfortably sink into my own couch in
sweatpants as I guided patients through the heartbreak of hemorrhoids and the distress
of diarrhea. Clearly, there was not much
of a physical exam that could be performed virtually, but as I have opined
elsewhere on this blog, in most cases the physical exam is not essential. I felt that the quality of my virtual care
approached the level that I performed in my traditional office visits. There were instances, however, when a virtual
visit was inappropriate and I advised a face-to-face meeting with me.
But the novelty of the experience wore off after a few months. Many of my patients are chronologically
advanced but technically limited. A
recurrent frustration for many participants was when they couldn’t connect to
the platform or activate the audio.
Those lucky enough to have a 12-year-old grandchild nearby could be
easily rescued. For the rest, my staff
would be calling the patients to try to guide them toward cyber success, an
exercise that burned up staff time and burned out my patients. This demographic rapidly became disenchanted
with this experience. And so did I.
Remember this?
From my standpoint, telemedicine was simply less fun. I realize that the work of doctoring is
serious business, but the personal rapport and interactions I have with
patients contributes greatly to the reward of what I do. I found that this could not be replicated
with two of us staring into our computer screens. Virtual visits are transactional
experiences. Similarly, much of America
soon tired of zoom meetings recognizing that efficiency has costs. Ever heard of the term ‘zoom fatigue’?
But telemedicine won’t be deterred as the forces favoring it
are overpowering.
Wonder what the patient experience will be when conventional
medical care is replaced by artificial intelligence? How important will the human physician be
then?
There is already too much technology separating patients
from medical professionals. How much
time do patients watch us pecking on our keyboards during their visits? Do you think that telemedicine and the next
technological frontiers will bring patients and physicians closer
together? As technology advances, our health
may be much better and we will reminisce about doctors of yore as we do today about
typewriters, pay phones and the Kodak Instamatic camera.
Thank you. I have to agree. While I will continue to do an occasional televisit due to inability to actually see the patient, the personal contact, ability to assess nuance, and physical exam make me value the in person visit, as my patients seem to.
ReplyDelete@anonymous, glad you have added your voice to the chorus. So much in medicine and beyond has been sacrificed in favor of efficiency.
DeleteI have to agree-- I went into medicine not to cure disease but to help people and be part of their lives. And I think that now that I am mostly retired, when I run into old patients they consistently say how much they miss the human interaction I provided, and that doctors now are too busy to listen. And touching the patient, whether listening to the heart and lungs or putting my hand on the arm or shoulder of someone talking about their spouse's death or illness, really meant something. One problem with the internet is that it gives you what you are looking for, but makes it hard to find the unexpected (I love book stores for that reason) and telemedicine will never let you find an unexpected murmur or a mole on someone's back.
ReplyDelete@anonymous, I fear that we are anachronisms. The sacrifice of humanity to technology is ubiquitous and i fear we are outmatched. Yes, the advantages of a cyberworld are mind boggling, but there is a cost to this that is simply not valued or understood by those who came of age in the digital era. Thx for your thoughts.
ReplyDeletePerhaps in pediatrics where our patients and parents are younger the tech gap is not as much of a burden if you are lucky and privileged enough to own the tech. I personally experienced the opposite as far as personal connection, especially with my teen patients. By being able to see each others faces on the screen vs being under N95s and goggles in person it felt more like the in person encounters we had in the past.
ReplyDeleteGood points. The pandemic disrupted and distorted medical practice as it did throughout society. In my workplace, masks remain required for all employees and patients and I'm uncertain if this will be relaxed.
ReplyDeleteI don’t know if you experienced this as well, but insurance reimbursement for telemedicine visits dropped substantially over the past two years. We were getting less than a 99213 visit for nearly all of them…I can barely pay my staff with this low rate!
ReplyDeleteI retired in 2016, prior to the era of TM, so I have no direct experience with it. I have read the comments with interest. I can understand all of them. However I am surprised that none of them shared that seeing the patient in an exam room WILL always be the most accurate form of medical endeavor. The chances for medical error-and with that increased litigation & patient harm-likely has already raised its evil head! I’m surprised that none of you practicing folks were courageous or smart enough to bring it up.
ReplyDeleteTelemedicine is very similar to Zoom. It does not replace the richness of a face-to-face encounter. However, it allows for many very worthwhile interactions in an inexpensive and incredibly convenient manner.
ReplyDeleteFull disclosure on my own bias, I am a pediatrician who has been practicing and advocating telemedicine for well over a decade My practice has been comprised of busy parents from most of the economic spectrum. The never met a parent that didn’t appreciate these visits.
Like any technology it has its place. For triage of children who may or may not be “sick” It is wonderful. For many rechecks it is quite adequate, and for behavioral issues you get to see the patient in their natural environment. Telemedicine certainly can’t replace everything, but it is a very worthwhile technology when used appropriately. I do understand in other fields that may be challenging. However as our population ages and our tech savvy 20, 30, 40, and let’s face it 50 and 60 somethings age, this will be not only more easily accomplished, but expected. I think of myself in 20-30 years and unless my cognition decreases more than my mobility, I will certainly be appreciative of the convenience of telemedicine for needs that require only that.
Telemedicine is most useful when the patient is fully known (have all medical records) and the diagnosis is known. Short of that, EDs are seeing many significant errors and misses from Telemedicine, e.g. diabetic foot treated with keflex only, nearly lost leg. There are 100s of example of poor care.
ReplyDeleteMedicine is based on the History and Physical. We do a physical to corroborate the History. Many times in my practice what patients say and what I've found are two different things, even when a medical complaint seems simple. The same goes for medicine over the telephone. Telemedicine is in it's infancy and we have yet to hear about all that can go wrong or has gone wrong. But since much of medicine is controlled by large corporations that have to meet the bottom line, they choose to ignore the dangers in a rush to scoop up all the profits they can wrangle before it's too late. I'll admit during most of the pandemic that there was no other way, but everything has it's risk/benefit ratio, and for Telemedicine, the future will tell.
ReplyDeleteExcellent comments! Some antagonists to telemedicine argue that the absence of a meaningful physical examination substantially limits its value. While I have largely abandoned telehealth, limits on the exam was not among my reasons. Indeed, I have argued elsewhere that the worth of the physical exam may be overvalued. I understand that many of my colleagues may regard this as heresy. https://mdwhistleblower.blogspot.com/2020/11/is-physical-examination-still-useful.html
ReplyDeleteBeing paralyzed I need it. it takes me two days to prep, four days ahead to schedule appointments (which I had to leave a few times because the Doctor was behind. Well he was was a behind after that.) pay $8. for the ride and once spent 5 hours on the cripple bus to get home. Telemed is a Godsend for me. Thankfully my Doctors are considerate and sane.
ReplyDeleteThat is why I do house calls.
Delete@anonymous, your point is excellent. In fact, I wonder if telemedicine should be required under the Americans with Disability Act?
ReplyDeleteI don't like telemedicine either. I prefer regular personal visits in the office to evaluate and treat my patients, especially in our specialty of rheumatology where the physical examination is important.
ReplyDeleteTelevisits received support from administration because it justified them changing “hospital” fee if your employed doc. However when your doing telemedicine visit to reduce risk of infection from Covid only to find the patient was walking isle of Walmart that was my last straw. Homebound due to true medical issues are good example of appropriate use of telemedicine visits but the patient who saw their healthcare visits as an inconvenience became ridiculous.
ReplyDeleteSince I do not practice medicine in the Alasakan bush, I see almost no need for telemedicine ( there are very rare exceptions). The tech savy populace can rationalize all they want , but there is absolutely nothing better than the personal, hands on, face to face interaction.
ReplyDeleteIt depends on the specialty. I started doing telepsychiatry during the pandemic and have continued doing it. While not perfect, it certainly works almost as well as an in-person encounter. I find it to be more efficient. Our no-show rate is now below 5%. I certainly appreciate the chance to get a glimpse of patients’ home environments.
ReplyDeleteAnother benefit is that we’re able to see patients in remote areas, normally without easy access to a psychiatrist. Think about driving 2 plus hours each way for a 15-20 min “med check.”
I find it to be a very acceptable alternative to in-person visits. Of course, psychiatrists typically don’t do physical examinations, so there’s that.
Telemedicine is horrible for pediatrics. Most of what we do actually requires looking in ears, listening to chests and looking in throats. Not to mention that you cannot reliably diagnose strep over the computer. Behavioral medicine visits are almost worthless with all the distractions of home that interfere. I am glad that they never gained much traction in my practice and I have ceased doing any of them.
ReplyDeleteAgree as a rheumatologist we need the physicial examination. The AMA is trying to get us paid more (finally) which is good too. If we are going to in practice!
ReplyDeleteI knew years ago that the medical world was moving in a direction I wouldn't like when a competing clinic went EMR a year before mine. An elderly lady who had been seeing an MD in that group who I respect came to see me, asking if I would be her PCP. I could see that she had been well cared for, and she spoke well about her MD. l asked why she was making the change. She misted up as she said, "It was bad enough when he didn't have time to touch me, now he doesn't even look at me." His computer was fixed to the wall, and they didn't have voice recognition yet.
ReplyDeleteThere is a place for telemedicine, but much may be lost in the drive for efficiency. I recently saw a senior man in clinic who had been cared for remotely since 2020. He was in for earwax, and didn't seem concerned about anything else. I noticed and asked if he had always had 3+ ankle edema; he said that it just started two months earlier. He had a prominent murmur that had never been noticed before. Physical exam is not always necessary, and is now often neglected in the push to keep numbers up. I hope it gets performed more in the future than it is now.
You are totally correct!
ReplyDeleteFirst, some patients, especially the elderly, find going to the doctor a major outing and like the event. Second, hands on the patient both creates connection and reassurance. Third, while physical exam more often than not is unhelpful, unless you do one you never will find the times when it is. The patient with the new murmur, or a fib, or consolidation in the chest, or the melanoma on the back that the patient isn't aware of, None will be identified and assessed on a televisit for someone who thinks he has a little bronchitis.
ReplyDeleteTotally agree! EHR has increased physician non clinical workload, burnout and doesn’t improve the quality of your work. Excellent comment:”Physical exam is frequently unhelpful. But, unless you perform one, you will not be able to determine if it is unhelpful in a specific case.” AI’s usefulness will be in the “Mechanical Learning” modality. But be aware of biases on the data that the “creators” of the tool feed into it. Also, we must be careful regarding the way we ask a question. We must avoid “yes or no like” type of inquiries. Also references must be provided for us to evaluate them. In summary: EHR, Telemedicine, AI/Mechanical learning are here. But, we physicians have to accept the responsibility to refine them. All of them at this moment ,have more limitations than benefits.
DeleteFor those of us who have concerns about telemedicine, AI is lurking an poised to pounce.
ReplyDeleteDuring the pandemic I watched almost every opera performance transmitted to my computer by the Met in HD program. I enjoyed the voices, the music, the costumes, the action, and the stories. However, I can’t say that I went to the opera. That’s how I feel about telemedicine.
ReplyDelete45 years of medical practice have taught me flexibility in patient care. Video and phone visits to treat visually available conditions saves patient time, physician time and exposure to waiting rooms of infectious disease that can be safely treated remotely. The bigger issue is reimbursement for time spent by the provider. As always administrators time is more valuable than patient care time whether done by video or phone or in person, this is what needs addressing.
ReplyDelete