I read an article that said we’re moving towards “telemedical” care. I find this strange and hard to understand. Is this what years of training have come down to? Someone going into a cubicle or picking up their phone or computer and receiving a diagnosis and treatment after just a few minutes?
What happened to the human interaction? Being able to look someone in the eyes, hear the tenor of their voice, perform a hands-on physical? The physical exam is an art where you actually touch a patient, and it tells volumes about their medical status and needs. I remember training with a doctor who could anticipate through his physical exam alone, the lab results such as anemia, elevated liver enzymes, and electrolyte deficiencies, that we now get by blood draws. Factors like where someone hurts, how much pressure causes pain, if certain organs are enlarged (i.e. liver, lymph nodes), their heartbeat, the sound of their breathing, skin texture, color, extremity pulses, and swelling are all important to a comprehensive evaluation. Are we supposed to glean this from a quick video chat? Is this really the way you want someone you love treated? Have we gotten to the point where the expedient path is taken, regardless of the consequences?
A chronic cough could be a viral upper respiratory infection that does not require antibiotics, pneumonia, allergies, indigestion, or heart failure. . . How does it get distinguished in a booth or over a computer?
We’ve been giving out antibiotic‘s like candy for so long in cases where they weren’t appropriate, we now have what are called “super bugs” like MRSA. Super bugs are infections so resistant that our normal array of antibiotic‘s won’t take care of them. This is what happens when expedience is more important than quality of care, especially when the majority of concerns should not be treated with an antibiotic because it’s not due to a bacterial infection. I learned early on that one of the hardest thing a provider can do is not give an antibiotic when necessary. So often a patient will complain that they took off work, have been sick for days and all they were told was to rest and drink fluids. Hearing as they leave frustrated statements like-
“I could have stayed home for that advice.”
Instead of seeing that they gained knowledge. They learned they did not have anything serious and it would run its course.
Chronic cough and “cold“ symptoms often are neither, as I previously shared. A recent patient had been seen online repeatedly over several weeks for this complaint and was treated for an infection and allergies each time. When I finally saw her she had a stricture in her esophagus requiring a procedure to dilate, as well as a stomach ulcer. We knew her history and took the time to learn she’d been consuming large quantities of Motrin for a back ache she hadn’t discussed in her video chat. It resulted she also had signs of anemia. After a careful exam, a far different diagnosis was seen.
An 80 year-old lady had chosen her insurances option for “video conferences” and was handed multiple antibiotics when she had persistent urinary complaints; instead of getting a specimen and learning the exact bug involved. By the time I saw her, nothing but intravenous medications could help due to the scatter gun treatment she’d received.
Another was treated unnecessarily for a “sinus infection” when it was an abscessed tooth that mimicked pain in his maxillary sinuses. A thorough exam would have distinguished between the two and he wouldn’t have lost the tooth.
Another needed admission after an inhaler was given for “asthma” when it was really congestive heart failure.
A 60 year old truck driver had neck pain into his left shoulder treated as merely a muscle ache. In reality it was cardiac, leading to the massive heart attack months later. The same oversight can also happen when indigestion is the symptom.
Another was treated for low back pain when it was due to a kidney stone instead, but could easily have been prostatitis, hip, an ovarian cyst. . .or other issue not recognized in a video encounter.
And what about the personal and family history, medication list, allergies, or even something as simple as vitals? A change in weight could imply water retention from heart failure or other issues. That’s why it’s required every visit. A change in temperature, blood pressure, heart rate are all important to care and only takes 15 minutes to properly input in an office setting. Is this information just ignored?
Are all diagnoses to be based on the patient perspective? Just because they’re sure it’s one thing, doesn’t mean it is. As with the examples above, it took the careful expertise of a practitioner evaluating all aspects of care, to better understand the concerns and make sense of them.
When I was a resident, we joked about becoming a doc in the box when the powers above tried to introduce logarithms that would allow those not trained in medicine to provide care, or “help us find the proper diagnosis faster.” It was a complex set of circumstances that guided us down different paths, depending on symptoms and observations. It was like a map; if the patient had a fever go down one path. A sore throat would lead to another route. Symptoms concerning tonsils would result in yet another detour that might point towards strep throat. The problem was patients don’t always follow set pathways. Some don’t have discharge or fevers but still have strep throat. Nuances often appeared that had to be differentiated to discern the final diagnosis. It took a human exam AND interpretation to work.
I can understand when you’re in the boonies, hundreds of miles from the closet medical facility. Then it can be a life saver. As residents my ex and I used to take shifts on weekends working in Morenci, a mining town, where we were the only doctors for miles. Then our input on the phone to trauma, obstetricians or other specialists helped to determine who needed immediate evacuation. But even then we were the specialist’s eyes, ears and exam.
Nobody likes to wait. Its upsetting, especially when you have other places to go. I don’t like it either. But consider, most people, including me, would take the time for their pets, why would a human being deserve less? That’s the price we all pay for the face to face encounter. Knowing there will be times when a visit represented as something simple devolves quickly into far more. I became a physician, not to cut someone off because the appointment ran over, but to honor each patient’s needs as best I can.
Like the lady who came in for “a toenail fungus” who really wanted to discuss the possibility of exposure to a sexually transmitted disease.
Or the 40 year-old man who took 20 minutes to ask his real question,
“Can I get get Viagra?”
To the 50 year-old in for “a physical” who finally volunteered at the end of a 20 minute encounter that the real reason he came in was chest pain while jogging.
And the 22 year-old presenting as a lingering “cold” who only admits well into the visit when asked mental health questions that she’s been anxious and not sleeping to the point of considering suicide.
In-office visits track that mole you can’t see on your back, gives the opportunity to examine your prostrate, breasts, and follow chronic conditions and family histories that may make you more prone to certain issues. They monitor pressures, weights and encourage discussions on hard to hear realities as to how they impact your health. We are the hub of the wheel- following along with any other specialists to make sure all the data is shared and you’re treated as a whole person, not just parts. Primary care isn’t just acute care. It’s
interceding when necessary and guiding when appropriate to a longer, healthier life. We aren’t one dimensional and treating us as such in quick video visits that attend to only one issue ignores all our other needs. In a day and age where:
- two thirds of the population are obese
- one half have cardiovascular disease
- colon cancer detection is higher in those under 50
Telemedicine may help an immediate concern, but it is an easy way to ignore a whole slew of others. The type that impact us long term.
Human beings are complicated, making that one on one interaction invaluable. Even if the cost is time. It’s what my loved ones and I deserve. Don’t you and yours?
Main image provided courtesy of: physicianlicensing.com