Emily Gibson, a family physician who blogs at Barnstorming, has provided a guest post on MedPageToday’s KevinMD that provides some fascinating insights into the changes of in person consultations with Doctors. Read the full text here or watch this little cartoon video to get the general idea:

Criticism of Dr Gibson

It’s interesting (but not a very big surprise) to see that there have already been comments criticising this Doctor:

saraeanderson: I’m a frequent patient who reads this blog to see what is going on with doctors, and all I find is that they hate their patients. Of course you know about more cold remedies than the average patient. You’re a trained physician and they’re not. That’s no reason to exhibit this kind of contempt

Eleanorofcastile: What a smarmy, judgemental doctor! There is no mention of the last time this particular patient had an antibiotic and occasional antibiotic use is not harmful. The doctor has made a judgement without asking any questions. The doctor has assumed the “important events” of the patient’s coming week are arbitrary. It may be a student facing final exams, a patient facing a vital job interview in this economic crisis, a daughter’s wedding – This doctor asked no questions at all and in not listening to the patient, but in using a “one size fits all” knee jerk response and dismissing the patient’s concerns out of hand, has caused harm to the patient whether offering an antibiotic or not. Not clever and not good medicine. Not cute at all

I personally don’t think it’s helpful or particularly fair to be critical of Dr Gibson. Not only is this a very intelligent and generous Doctor, but clearly the whole patient history taking process hasn’t been shared with the reader and obviously the Doctor also has access to the patients EHR (detailing exactly when they last had a course of antibiotics etc) and all those important non verbal signals that Doctor are trained to make sense of. I also think there is something very important taking place when a Doctor shares so openly their first hand experience with everyone and I think we should all be very grateful for this candid contribution.

Of course (as you can also see in the comments) Dr Gibson is also perfectly capable of defending herself:

Eleanor, I did expect some reaction like yours from patients on this one. There is a frequent expectation that for a patient a clinical encounter is like a fast food order and that if the clinician doesn’t deliver the desired treatment in a timely way, with a smile, that we have failed the customer. I’m the smarmy judgmental doctor who wrote this and in my real practice, I do ask what kind of “hard week” the patient is facing but it won’t change whether or not an antibiotic is prescribed in this particular scenario. It usually results in a discussion about how to reorder priorities, listen to what your body needs, and finding ways to minimize symptoms to be able to tolerate the activities that can’t be rescheduled. And just so you know, I’ve very recently been ill wishing for that miracle cure for a viral infection that will take time and self care to resolve, and without antibiotics it took two weeks to get over the “green stuff”, painful facial pressure, low grade fevers and gagging cough from the post nasal drainage. I resisted the very strong temptation to find an urgent care (my “hard week” was indeed stressful, delivering our youngest child to her first year of college 3000 miles away from home and we were on the road and attending orientation activities while I was sick) because I knew antibiotics would make me better in, oh, about two weeks or so. And the antibiotics would have gotten all the credit if I’d taken them. Instead, my immune system did what it was created to do. So in this case it was “Physician, heal thyself” –I’ve had to heed my own smarmy advice and lived to tell about it…

Gender issues?

I’ve chosen to illustrate this encounter in the cartoon depiction using a male patient and although Dr Gibson doesn’t suggest this I’m quite confident that this assumption of mine is correct. Since I enrolled at Medical School in 1995 there have been more female candidates entering and finishing medical school in UK than their male counterparts. This is having a massive impact on the profession and there are various opinions on this that are well documented but I think this article highlights an all too common negative and aggressive attitude expressed toward female Doctors by male patients. It continues to amaze me how widely overlooked and silently these issues are suffered.

Here are some “general” things I’ve noticed happening:

1 Patients prefer opening up to female GPs
2 Female Doctors are better listeners and communicators
3 Male patients are much less familiar with health issues (in this instance I think this has been highlighted by the antibiotic ignorance eg. most women understand the need to avoid the administration of unneccessary medication) and so the informational imbalance is greater between a male patient and Doctor than a female patient and Doctor.
4 Insulting the Doctor. I don’t think we’d see this dialogue if the patient was more familiar with the work of a Doctor. Men (who typically attend Doctors less) are likely to presume things because of this lack of familiarity with the stresses and emotional challenges that their Doctor faces on a daily basis
5 Male patients are much less likely to question male Doctors and male Doctors are less likely to want to argue with a male patient who is adamant about receiving an antibiotic (eg. “give him the advice and a script and then put the ball in his court and let him make the decision”). It wouldn’t be a big surprise to learn that the walk in clinic this patient was experienced with was staffed by a male Doctor.
6 Macho male patients often find themselves challenged by female Doctors who are more knowledgeable than them. This is a persistent problem because there is always going to be an informational assymetry in the Doctor/Patient relationship
7 Women are more familiar with managing their own health and reading up on health information, as such they present to Doctors after having tried to manage the condition themselves so the value of basic info is less with women than with male patients
8 Except in the instance of stay at home fathers etc, these issues are amplified in the situation of male parents bringing their children to the Doctor

Although it would be nice if this situation didn’t exist (and male patients could all be polite and unbiased in their dealings with Doctors) I think it’s fair to accept that it’s not going away as men still aren’t on the whole properly engaged with their health needs, and when they do come forward it’s all too often as soon as they notice any symptom at all, or conversely after much delay, and all too often loaded with a good helping of preconceived expectations or denial of the related issues.

With asynchronous communications I think there is a much better way to manage male patients who behave in this way because the male patient then doesn’t:

1 feel the same need to wait until things develop before going to the Doctor
2 have to be reminded in a face to face encounter that there is a woman who is more qualified and knowledgeable
3 doesn’t have to admit to anyone that their knowledge base is lacking (they can view the information provided when/if they choose to and receiving something doesn’t mean they don’t know it).

Highlights the importance of recognising the increasingly informational role of the Doctor

I’ve lost count of the number of men who genuinely ask me “What can a Doctor possibly do over a mobile video call?” and in some cases actually argue with me about the existence of the need (“no one would ever want to video consult with a Doctor”). I’ve even had this happen at mHealth events in front of a room full of paying delegates (eg. Saadi Hussain, Head of Commercial Propositions, BT) yet I’ve never been asked this by a woman. I think the experience Dr Gibson shares highlights the importance of gathering a patient history and sharing information in a typical modern Doctor consultation.

Highlights the Patient Doctor informational assymtery

It’s clear that the decisions that take place as a result of a Doctor consultation are arrived at from a situation in which one party has more or better information than the other. Sometimes it’s the Doctor (they’ve got all the diagnostic machines, tests, drug information etc) and sometimes it’s the patient (only they really know how they feel, only they know that they lost/threw-away/stopped-taking their last meds, only they know they’ve started drinking excessively, only they know …., etc, etc…) but one thing that’s consistent is that less honesty and openness increases the chance of the relationship not working optimally. Here’s a few ways I think informational assymetry is challenging the relationship between this Doctor and Patient:

1 Because of information asymmetry the patient here might be feeling he’s just being fobbed off with advice instead of the medications he deserves.
2 Because of the inforamtion assymetry the Doctor here might be feeling the patient is being unreasonable (after all everyone knows antibiotics don’t fix viral infections, right?)
3 Because of the assymetry of power and accountability the Doctor (who is regulated by their professional body) is being insulted by a patient who probably knows that they can remain unaccountable for their actions in the exchange (at worse the Doctor might refuse to be their Doctor)

Why we need to plan for and accept new ways of dealing with healthcare needs

I could write a book on this but I think it’s rather obvious when you think back to the notices that were being posted on the doors of medical centers across the UK/Ireland during the H1N1 Swine Flu pandemic:

How mHealth can help

I think it’s easy to see how mHealth adoption will ultimately improve the Doctor Patient relationship in the following ways:

Lower cost: Without the need to have an inperson consultation the patient doesn’t need to take time out or travel. Likewise the Doctor doesn’t need to spend their valuable time meeting in person with people who can be treated with advice. Dr John Bachman, Prof Primary Care at the Mayo Clinic, has published a detailed paper on how he has been able to safely manage 70% of his patient needs without them having to come into his consulting room. Check out this video to learn more about this.

More timely: With 24/7 access, lower costs and greater ease of access (only need to visit a website) patients can be encouraged to present earlier and only come in when there is something that can’t be managed remotely.

Data Centered: A lot of the problem commenters had with this consultation process was that it appeared to be thin on history taking. What may or may not have been asked/recorded is uncertain and as we all know most of what we’re told in an inperson consultation often goes in one ear and out the other. The ability for properly designed mHealth consultations to give a patient a detailed medical report documenting the entire history given by the patient, advice of the Doctor and an action plan for next steps is a million miles away from a patient perspective to a goodbye.

Video: Read more about the challenges of functional health literacy and the mobile video opportunity here

Connected: Sometimes things don’t go away, they get worse or symptoms change altogether. The problem this presents to patients is they face having to repeat the entire process over again eg book an urgent appointment, come in, wait, wait, see Doctor (and recount from memory what was said before), pay again. A connected service is distinctly different from this. Not only is it a case of the Doctor reaching out to you (you don’t have to always take time off and drive to the Doctors office) but that Doctor is always informed and can see what you’ve reported and what advice you’ve been given.

How it would look at 3G Doctor

All too often critics of the status quo dismiss current approaches but don’t share how they think it should be done, so I’ve made a go at this to give you the general idea of the transformation we’re talking about:

The process starts with a visit to the 3G Doctor website. Sign in, pay £35 for a consultation and then select or enter your complaint:

Complete the interactive patient history questionnaire.

Complete the free text box at the end with any information you feel is relevant (eg. can i have a prescription for antibiotics?).

A Doctor reviews the information shared by the patient and sends a message to the patient. Patient gets a SMS notifying them that there is a new message waiting for them in the secure 3G Doctor portal:

Patient log’s into the secure website and clicks on “New Message” to read the following:

Dear David,

Thank you for requesting a consultation and completing an interactive patient history questionnaire.

I have read through the answers you gave to the questionnaire and the information you added (you can view, download, print off and share this at anytime by simply clicking where it says “past consultations”) and sympathise with the urgency you’ve expressed in your additional comments to get this cleared up as you have an important business meeting next Monday, and your wish to receive a course of antibiotics.

It is very clear to me from X years practicing family medicine that you have a bout of VIRAL SINUSITIS which is a common UPPER RESPIARATORY TRACT INFECTION that gives rise to the exactly the symptoms you have described.

In the following video Dr David Hill makes a great job of explaining the types of sinusitis that commonly effect adults like you. I hope it reassures you that it would be inappropriate to prescribe a course of Antibiotics as they aren’t effective in treating this medical condition, they can do more harm than good and studies show there is no difference in symptoms between patients who are treated with antibiotics and those who did self-care only.

Here is a quick guide that you should find will give you the best chance of recovering quickly:

1) Use salt water rinses and try applying a warm towel to your face. Breathing water vapour (put boiled water into a boil, place your head over it and a towel over your head) will also help keep your lungs clear of congestion as will be propping yourself up with an extra pillow. Here is an online video that you may find useful:

2) Pick up some decongestant nose spray, cough mixture and ibuprofen over the counter from the pharmacy

3) To keep your fever and high temperatures down be sure to drink lots of fluids and you may find some ibuprofen will help. A cough mixture can also help alleviate some of the discomfort associated with the coughing.

How we charge you for this advice:

A video consultation with an informed Doctor is included in the £35 you have already paid, but you might like to try the above first before making use of your video consultation.

> If you would still like a video consultation now please simply reply to this message OR send a SMS to +353876745287 requesting a video consult and we will have a registered Doctor make a Video Call to you within a hour to consult on this problem.

> If things aren’t starting to resolve in the next 48 hours please send us a SMS requesting a video consult and we will have a registered Doctor make a Video Call to you within a hour.

> If this advice helps and things do start to improve (as we’d expect) you’ll notice that you’ll still have £35 credit in your account that you can spend next time you’d like to consult with 3G Doctor.

Hope you’ll start getting better soon,

Dr NAME NAME
3G Doctor

Did you notice?

> There’s no reason for the patient to feel disappointed because they “just waited an hour” or had to take off work to attend the clinic?

> The Doctor didn’t have to say “I really am sorry about the wait; there are a lot of sick people with this viral thing going around”.

> The patient didn’t have to subject the other visitors to the busy clinic with a hour in the presence of someone with a viral URT infection?

> The “but I paid $20 co-pay today for this visit” isn’t necessary because the patient receives a service that doesn’t require them to take time out visiting a Doctor?

> The Doctor doesn’t need to spend time criticising the approach taken by the “walk in clinic”.

> The “So you spent all that time in school just to tell people they don’t need medicine?” becomes unnecessary because the patient can see that the Doctor isn’t just passing them off with a treatment but explaining that they have reviewed the patient’s history and the detail of their concerns, provided advice (backed up by written documentation of this advice), included some links to helpful and reassuring videos, and offered to be readily accessible should the patient still feel the need to consult with the Doctor.

> The Doctor doesn’t have to charge for everything and can act with a little more discretion. Sometimes there’s more value to be had by being on your patients side helping them with quick things when and if you can.