“Technology is a useful servant but a dangerous master.”
Christian Louis Lange, Historian
We need to define Telemedicine first and foremost. Telemedicine or Distance Medicine is the art of evaluating, diagnosing, and treating a patient outside one’s clinic during the consultation. The modern Indian medical practitioner’s most accepted definition is transferring electronic medical data (i.e., high-resolution images, sounds, live video, and patient records) from one location to another.
Telemedicine has come to the fore in India after the lockdown started. It was physically impossible for most patients to seek much needed non-emergency medical care for their various ailments. Doctors could not offer routine consults and were forced to keep their clinics closed, and the patients could not travel to any open clinics.
Most of the population suffered terribly. The Government of India realized the problem quickly and came up with telemedicine guidelines way back on March 25, 2020, through the MOHFW.
Human beings had been practicing Telemedicine since times immemorial.
At times, Galen (129-200 AD) chose to prescribe to patients without ever seeing them. Galen was so skilled in understanding symptomatology that there were times when he preferred to diagnose without questioning the patient. He then went on to prescribe by mail with confidence. His elevated status permitted him to offer consultations by letter. He would receive generous rewards for his postal consultations: in one instance, it is said that he had received 400 gold pieces for curing a woman in this fashion.
In its early manifestations, African villagers used smoke signals to warn people to stay away from the village when serious disease rampaged through the village.
We have all practiced telemedicine earlier. When we prescribed a headache pill over the phone, when we advised the patient to undergo specific investigations on the phone, when we recommended preventive measures on the phone or through radio/TV broadcasts, when we discussed cases with our colleagues, we were indulging in Telemedicine.
Society, law, and the health system accepted the necessity of informal teleconsultations. Doctors never charged for them; the patients knew that they were just a preliminary step towards a physical consult and did show up at the doctor’s clinic the next day. The doctor now took a detailed history and physical exam. She advised many investigations as she deemed necessary and prescribed medications or recommended procedures or treatment.
The system chugged along fine, and it suited all parties. A few rotten apples on all sides always spoil what has been good. Some patients decided to game the system, seek free telephonic advice, and never turn up for a consultation the next day. A few doctors, on their part, would be very perfunctory or curt on the phone and go through the motions very desultorily. This led to dissatisfaction. Doctors start demanding compensation for their time and effort. The patients, taken aback, started demanding perfection in diagnosis and treatment, forgetting that a teleconsult is always a compromise to the real McCoy.
Where there is trouble, the government steps in. There was a phase about five years back when the government was practically on the warpath with doctors. They started finding fault with the doctors where it was an unwritten rule that it was impossible to be precise and accurate. The system so far had been working simply fine. There were a few instances where doctors were disproportionately punished for telephonic advice gone awry. Medical professionals were scared to offer any advice at all on the phone, and their associations issued strict guidelines about what was permitted and what was not.
The loser, in the end, was the whole system. Patients were put to many inconveniences; the doctor-patient relationship eroded very severely.
COVID quickly changed that. Not only was it convenient, but Telemedicine offered the only way out for both doctors and patients alike.
The government, on its part, as already noted, set out guidelines and made teleconsultations legal again.
So, should you go in for a teleconsult? Let us look at the various advantages and disadvantages of teleconsultations.
There is no traveling involved (the cost, the hassles, and the time involved in commuting can be significant). Some persons cannot travel – orthopedic issues, the geriatric population, the immunocompromised, or the home-bound patients cannot travel. House visits are expensive and a waste of the doctor’s time (one can finish off at least five teleconsults in the time taken to visit one patient at home).
Doctors can no longer keep their patients waiting for hours on end to be seen on a first-come-first-served basis. The patients cannot just drop into the doctor’s clinic and take a chance that the doctor will see them. Appointments result in a far more efficient time management system.
The doctor must take pains to record the whole patient encounter in the minimum prescribed format by the MOHFW to not run afoul of medico-legal requirements. She must issue a proper consult note after getting the patient to accept a disclaimer about the limitations of the teleconsult. Most of these consult notes are usually generated electronically, and the dreaded “doctor’s scrawl’ gets eliminated and with-it prescription errors of all kinds.
If you cannot make them better, do not sicken them, at least!
We are all too familiar with chock-a-block waiting rooms of ‘successful’ doctors. Most visitors to doctor’s clinics are sick patients, and if they are crammed into a small waiting room, it is a recipe for disaster. Crowded waiting rooms become a scoring board for the doctor and act as a confirmation for the patient that he has indeed chosen a successful and good doctor. Their ego is fed, but so are the germs that are delighted to spread ever so quickly between already weakened patients.
If you find yourself in a shared waiting room of your doctor with other patients, you will inevitably meet a few of your friends or relatives there. Inevitably, it leads to probing (delicate or otherwise) about the purpose of the visit, which can prove very embarrassing. You may be very reluctant to share details of your illness with your neighbors or friends. In the case of the psychiatrist or the sexual disorders specialist, a common waiting area is inexcusable.
While waiting for a teleconsult, you have no exposure at all to your fellow patients, thereby eliminating health risks and privacy concerns.
Only in real estate and mortar and brick structures is it all about “location, location, location!”. Patients from across the globe can benefit from your expertise and the socio-economically disadvantaged in remote villages. You can benefit by tapping the expertise of the top experts in the world using the different digital modalities that are available.
Education is widely and freely available.
Both patients and medical professionals have access to top-quality resources and educators, thanks to Telemedicine.
Better Follow up and Long-term care.
Humans have significant inertia and tend to procrastinate, mainly when a medical office visit entails inconvenience, expense, and effort. By bringing the medical office to a location of your patient’s choice, you eliminate most of these barriers. Patients are more likely to continue with the suggested therapies and care, leading to better outcomes.
Gung-ho about Telemedicine? Do not sell your clinic yet!
Like everything else, there are downsides, and some of them are significant ones.
A significant investment, both financially, time, and the desire to learn new technologies, is required. At the very least, you need a high-speed internet connection, a home/office computer with a large screen, a subscription to a cloud-based telemedicine service, and the technical know-how to run a successful telemedicine service. You can go the extra mile and add bells and whistles to this basic package to further embellish what you have to offer.
My number one reason not to recommend teleconsults for all consultations! There are so many subtle cues that you pick up during an on-site consult. The way they enter the clinic, how they start the encounter, the inter-personal relationship between the patient and the accompanying persons all help in the full evaluation of the patient and her family. For genuinely holistic care, this is vital. Patients are not numbers, and they do not add up. It also emphasizes the importance of conscious consultations in our routine practice. Most of us acquire this art subconsciously over a few years in practice. The process is faster if one trains oneself into consciously acquiring these skills.
Despite the declining importance of a physical exam in modern practice, there are many situations where a physical consult is a necessity. I submit that you must insist on a physical consult if you are seeing the patient for the first time. An X-ray chest cannot substitute for a chest examination; you will miss many cases of pneumonia. Another example, how can one examine a child with undescended testis without trying to palpate the testis? A USG locates the testis accurately in about 50% of cases! Will you do an MRI for all your undescended testes patients?
The best-laid schemes o’ Mice an’ Men
Gang aft agley,
An’ lea’e us nought but grief an’ pain,
For promis’d joy!
To a mouse
– Robert Burns
We may plan, check, cross-check and double-check; machines and men will breakdown and result in frustration and wastage of time due to failed computers, failed connections, low usage of technology. There is no getting around this, and the best is to anticipate that these things will happen. Just reschedule the teleconsult.
The basic cost of setting up a teleconsult restricts its use to a certain class of patients and doctors only. A lot of illiterate, semi-illiterate, and the voluntarily illiterate (computer variety) are excluded. You must account for them and make provisions and have a safety net for this subset of your patient population.
To summarize, one may rail against the concept of Telemedicine, but it is here to stay. If you do not dive into it, then rest assured that you will lose at least some of your practice to a friendly practitioner halfway across the world!
A slight twist on an adage: “To the well-prepared, go the spoils of war”. If you spend some time planning out and preparing adequately for your online strategy, you will be much better prepared to get into the brave new world of Telemedicine.
Furthermore, I leave you with a quote as a caution:
“It has become appallingly obvious that our technology has exceeded our humanity.”
— Albert Einstein
I am sure that I have missed out on some more advantages and disadvantages of teleconsults. Please feel free to add to our collective knowledge about what you think are the most significant pros and cons of Telemedicine in the comments section below.