Thursday, February 02, 2006
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 1:26 PM, at
By 3:25 PM, at
Heck, they keep trying to computerize medicine...
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
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."
By 4:44 PM, at
Anonymous, the Last,
Boinky raises a valid issue of trust. But his statement that telemedicine undermines trust is misleading at best. Consider the real causes:
By 12:01 AM, at
By 4:46 PM, at
Anonymous, the Latest:
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