Tip/Thought of the Day

When Virtual Medicine Isn’t Enough

The current state of the world has resulted in many, if not most, physicians offering telemedicine as an alternative for patients that opt to not come into the office for an in-person check up. This may seem like the ideal solution- offering solutions to individuals who seek them, while providing an avenue that limits physical contact and lingering in an office around other sick patients. But it overlooks many risk factors that occur with the “click and cure” approach. What about things that cannot be seen or measured via a virtual exam or over the phone, like a temperature, heart rhythm, blood pressure, lung function, etc?

Virtual evaluations also doesn’t allow us to evaluate concerns that can be treated and put your mind at rest. In the last two months I’ve had dozens of patients concerned they either had COVID-19 or were exposed to it, adamant their symptoms were proof. This fear extended to family, friends, and co- workers, all worried they too may now be at risk. In all cases they had other illnesses- the flu, bronchitis, sinusitis, ear infection, asthma attack. In other cases they wanted a video evaluation claiming their issues were just stress related and coming into the office would just make them worse. It only took a few minutes on the phone to realize their concerns were potentially much more serious. In person it was quickly evident one was having a stroke, the other a cardiac event- both requiring immediate attention.

This is what happens when the human interaction is eliminated.

Being able to look someone in the eyes, hear the tenor of their voice, perform a hands-on physical is what the practice of medicine is truly about. 

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, 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?

Many of the symptoms purported to be the virus we’re currently combating worldwide could be a whole slew of other issues. A chronic cough could be a result of COVID-19, but more likely is due to a cold, the flu, indigestion, or seasonal allergies. Or, it could be due to more serious etiologies such as pneumonia or heart failure. A thorough physical exam is needed to pinpoint the underlying cause and the origin of the complaints.

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. 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. 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. 

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. 

What about family history or 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, or heart rate are all important to care and only takes 15 minutes to properly input in an office setting. Is this information just ignored? 

A 42 year old lady was treated as a new patient tele-medically for “ indigestion” and told to take tums. While that gave some relief the symptoms persisted so she followed up last week. Hearing her concerns, seeing her face while she spoke and when I examined her told me more than a video chat ever could. But getting the history two close family members had heart attacks in their 40’s clinched it. The EKG showed what I was sure was happening- it was cardiac in origin, not her GI tract. She was seen immediately that day and two heart stents placed. 

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 closest 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 teams, obstetricians or other specialists helped to determine who needed immediate evacuation. But even then we were the specialist’s eyes, ears and exam.

For some, seeing their provider in person is scary during these times. But of all places you may be venturing to we, above all, will always put your health and safety first. In my office, we bring in patients with concerning symptoms for COVID, who are elderly, or just want added precautions, through a side entrance to an exam room.

Seeing a provider in person, who knows medical history, has all records or has the time to review all pertinent information allows patients to speak about concerns that they may not otherwise share with a stranger, or that they might altogether ignore or diminish as not important. Too often, it’s only after that brief pause when I’m asking routine questions such as if they have chest pain, palpitations, belly pain, etc., that their real fears are brought into focus.

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 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.

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 conditions. 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 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: 

On the other hand, telemedicine can be a valuable tool when offering care for quick follow ups to discuss benign labs or studies in stable, well-followed patients. Treating minor symptoms such as rashes, superficial abrasions or lacerations that don’t need to be sutured. And, a new study shows that telemedicine patients score lower for depression, anxiety, and stress, and have 38% fewer hospital admissions. Why? Access to a healthcare professional at almost any hour of the day is crucial in supporting those with mental health concerns, and providing that avenue via telemedicine is an essential preventative measure.

Telemedicine may help an immediate concern, but it can also ignore a whole slew of others. The type that impact us long term.  Telemedicine has its place, and many physicians are using it as an initial triage tool- helping sort through which patients should come in for an additional exam. But in a day and age where the COVID-19 crisis will probably be with us for a while, not maintaining our health and keeping up on all other medical issues could cause so many preventable problems. It also lessens our ability to fight off infections and illnesses. Don’t let fear keep you or your loved ones from getting the care you deserve. As providers we understand the worries and fears impacting our health. Now more than ever our doors are open.

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