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    Thursday, February 02, 2006

    Future of Medicine: Hippocrates at The Medical Blog Network, thinks perhaps the answer to retail clinics may be internet medicine:

    Aside from locating your office in a mall (bad joke huh?), support for telemedicine may be the answer. Consider the issues:

    * Costs: Online consults for routine matters could cost less than full office visits, but cannot compete with co-pays. Still the lower cost per incidence could actually net more per hour, because of less time and interruption required. 
    * Scope: No doubt, you cannot do everything without seeing patient face to face. Physical exam is still required by law to diagnose and prescribe in many jurisdictions. Getting to know your patients personally has no substitute too.
    * Availability: Telemedicine does not have to be real-time. A busy professional can submit a request before or after work hours and the doctor can answer... whenever he or she feels like, perhaps within a certain time window.
    * Location: Flexibility can be increased not only for time but place of care. Travel is a big issue for many people, especially in rural areas. For physicians this could mean being able to increase the "service radius" and attract more patients.
    * Reimbursement: In most places, telemedicine still means "cash-only-please". But some health plans (e.g. in California) are starting to catch up and include coverage. Yet, it still may be too early to count on this in your planning.

    Maybe in another generation, telemedicine will be the answer, but I don't expect it to be widely adopted any time soon. For one thing, the majority of the population still is not internet connected. It might seem that way for those of us who spend most of our time on the internet, but that's only from within the bubble. Most baby boomers do not use the internet regularly. Many of them assign the internet tasks for their jobs to someone else - a secretary to print out the email for them, a grown child to buy their airline tickets for them.

    Two years ago, the American Board of Family Medicine decided to create an internet-based ongoing certification program for family physicians. Once a year, doctors are expected to complete an exam on their website. If any group would be expected to have a high internet use rate, you think it would be physicians, but the outcry was great. In fact, the second year they modified it so the test could be printed out and taken on paper, then later entered into the website. (A task that could conceivably be delegated to a trusted internet-savvy employee or spouse or child.) I suspect the under-35 population (or maybe even under 40) are much more intensive users of internet services, and when they need more medical care, perhaps telemedicine will fly.

    The other problem is technological. There is no substitute for experiencing something in person in 3-D with the added senses of touch and smell. It might be possible to send a photograph or digital video of a patient, or to even use a realtime webcam to view needed parts of the physical, but it's still inferior to being there. Anyone who's ever taken a written medical test with photographs of rashs knows what I mean. And never underestimate the importance of smell:

    Still, I have come to appreciate one part of the physical exam that cannot be replaced by blood draws and x-rays, a part in which I have actually improved since first donning a long white coat. This part often doesn't make it into my official histories or daily progress notes, but its prognostic implications can be as important as those of the white-cell count or costophrenic angles. I am referring to a patient's smell.

    In a closed hospital room, odors are often much easier to appreciate than carotid bruits. I have been greeted by enough stenches on removing dressings from the feet of diabetic patients to know whether someone is going to need intravenous or oral antibiotics. I have sniffed sufficient foul-scented tracheostomy sites that I'm no longer surprised when sputum cultures grow out a mixture of oral flora. I have done morning rounds for so many patients who are being prepped for colonoscopy that I now know who has and who has not received a full dose of GoLytely. When a nephrologist asked whether my new patient's confusion was due to her age or her renal function, I felt confident choosing uremia on the basis of her fetid breath.

    Smells also indicate in which direction a patient is headed. A patient who has showered and brushed his teeth before 6:30 a.m. is obviously getting ready to go home, no matter what his laboratory values might say. More than once, just a few sniffs have let me know that I can advance a patient's diet without embarrassing her by asking whether she's been passing gas. When I admit a new patient from the emergency room who reeks of cigarette smoke, I make a mental note to watch his oxygen requirements closely and to keep cancer in my differential diagnosis no matter what the reason for his presentation.

    I'm not convinced that telemedicine will ever be as good as real time medicine.

    posted by Sydney on 2/02/2006 09:22:00 AM 10 comments


    Telemedicine is not the answer for the future of medical care for patients. It may be one answer for mid-career doctors looking to augment their progressively shrinking income secondary to rising expenses, decreasing reimbursements, and competition from "quick clinics." As far as I am concerned, the basis of medicine is the face to face, hands-on history and physical examination. E-medicine is not medicine. Let's invent another word for it so that the public doesn't confuse it for the real deal.

    By Anonymous Anonymous, at 1:26 PM  


    You are absolutely right. Telemedicine will never *replace* real-time medicine. The point is not to replace wholesale, but to use it as a supplement for routine things. Some of which could bring retail-clinic-goers back to you.

    To consider your specific comments:

    1) I think the problem at American Board of Family Medicine might have been with the fact that this was a required program. A vocal minority can always raise enough objections to kill anything new. Consider a voluntary approach where the early adopters self-select one-by-one.

    2) The population of people who go to the Internet for health information is growing rapidly. Manhattan Research did a recent study that we blogged about (Top 4 Consumer eHealth Trends, Consumer-Generated Health Content on the Rise). The people whose health decisions are affected by what they find online may never show up in your office to begin with. But if you catch them on the Internet it is a pure incremental for a small practice.

    3) Technology IS a big problem. You are right that there is no ready-to-go solution for you to use today. Telemedicine just had not been simplified enough to be easy to use for real physicians and patients. As far as I understand most action has been with vendors trying to sell it as a mandate to institutions, running into the roadblocks, per item #1.

    So to net it out. Significant promise. Not ready today. Until someone addresses the real challenges. For real physicians and patients.

    I second the motion to come up with better naming. The word "telemedicine" may have been tainted by failures past.

    By Anonymous Anonymous, at 3:25 PM  

    Heck, they keep trying to computerize medicine...
    But people want "hand on" medicine, and if we don't give it to them, they will go to quacks, chiropracters, and herbalists...
    And will telemedicine pick up the REAL reason behind the visit? I wish I had saved the NYTimes essay about the "oh just one more thing doctor" moment, where the real problem (which can be anything from rectal bleeding to an alcoholic abusive husband) is revealed...

    By Blogger Nancy Reyes, at 1:07 AM  

    oh, NYTimes has an article on people taking natural herbs etc...http://www.nytimes.com/2006/02/03/health/03patient.html?incamp=article_popular&pagewanted=print
    "I don't hate doctors or anything," Ms. Newman said. "I just know they can make mistakes, and so often they refer you on to see another doctor, and another."

    Seeing a naturopath, she said, "I feel I'm known, they see me as a whole person, they listen to what I say."

    By Blogger Nancy Reyes, at 6:35 AM  

    Medpundit wrote: "Most baby boomers do not use the internet regularly. Many of them assign the internet tasks for their jobs to someone else - a secretary to print out the email for them, a grown child to buy their airline tickets for them."

    What planet are you living on? Have you ever spent time in an average corporation, small business or government office? A good portion of the business world operates by email or by the exchanging info on the Internet. And damn few people have secretaries, let alone someone who can print out an email for them. The oldest of the baby boomers has just turned sixty. YOu can bet that 90% of these persons and younger use email or the Internet regularly. Just because doctors have staff that can print out emails, or look stuff up on the Internet, doesn't mean everyone else does, either at work or at home.

    No wonder people think their doctors are out of touch.

    By Anonymous Anonymous, at 4:44 PM  

    Anonymous, the Last,

    This may come as a shock to you, but not everyone in this country works in an office. Some people work in factories, some wait tables, some spend their time caring for the sick in their homes, or at nursing homes, or at hospitals, some work in construction - actually building things instead of designing them. These jobs don't require the use of email. And some of them don't even require the use of computers.

    When I started using email to communicate with my patients, I thought that most of them would embrace it. They haven't. A consistent ten percent of my patient population has decided to use it. And most of those who don't, say they don't use email or they don't trust the internet. What's more, a large percentage of people who use computers/email at work only have access to them at work, and not at home.

    So, what world do I live in? The real one.

    By Blogger Sydney, at 10:14 PM  

    Boinky raises a valid issue of trust. But his statement that telemedicine undermines trust is misleading at best. Consider the real causes:

    Trust: Traditional or Electronic, A Doctor-Patient Relationship Starts There

    By Anonymous Anonymous, at 12:01 AM  

    DearDr. Medpundit,

    I work in the chemical industry as a chemist. Every plant worker, clerk, delivery person, technician, and so on uses email. The majority of company communications are done by email, and no longer by paper. Even the union communicates by email. The company has an Intranet for posting all information about company policies and benefits. Don't comment about what work in corporations or factories is like, if you haven't ever worked in one.

    By Anonymous Anonymous, at 4:46 PM  

    Anonymous, the Latest:

    "Don't comment about what work in corporations or factories is like, if you haven't ever worked in one."

    I would hazard to guess that working in a chemistry plant is much different than working on an auto assembly line or a packaging plant. I would also hazard to guess that I'm in daily intimate communication with a wider variety of people than someone who works in the chemistry industry.

    Do you really think that GM and Ford supply all of their autoworkers with computers and email? Do you honestly think a restaurant owner sets up email accounts for all of his waitresses and waiters? Get real.

    As someone who has been actively promoting email communication with a diverse group of people, I can tell you, there a lot of people who simply don't have - or don't use - email on a daily basis. And there are a whole heck of a lot of them who don't have to use it on their jobs.

    By Blogger Sydney, at 9:15 PM  

    Hi, good idea for a blog you have here, thought i'd leave a comment. Keep up your good blogging.

    low cost health insurance quote

    By Blogger Rob, at 11:50 PM  

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