BMJ: “The doctor won’t see you now: online consulting and prescribing”

In the BMJ (2012;345:e7238) Glasgow GP and Blogger Margaret McCartney looks at the UK’s leading online prescribing services Dr Fox and DrThom (now operating as Lloyds Pharmacy’s Online Doctor since their takeover by Celesio AG – Europe’s biggest pharmaceutical wholesaler) and asks “is the proliferation of private consultation and prescription services on the internet good for patients?”

My thoughts

More clarity needed on how NHS services are being provided by private companies

Although this is probably more a symptom of the competing interests and lack of best practice sharing within the NHS I’m surprised that a report in the BMJ hasn’t recognised that many of the “private companies” that are providing “the whole consultation and prescription process online” are actually doing it for NHS patients and being paid by the NHS for doing it eg. there are some NHS Primary Care clinics that will not only offer this but will even provide consultations over Skype video calls to their patients.

I think this article would benefit from an attempt to recognise this as it goes on to suggest that as more conditions can be managed online for the benefit of patients “then surely this shouldn’t be limited only to those people able to pay?”.

When you appreciate that the entire NHS website is outsourced to a private sector company, the NHS is wasting £100 million/annum running NHS reDirect (despite the lack of evidence base and the fact that it’s a very profitable premium rate service) I think there’s no reason why the NHS shouldn’t be more open to doing business with efficient private care providers or at least trying to emulate services that they are creating to improve patient outcomes.

Distinction needed between online consulting and online prescription sales

I think the article would benefit from not confusing these two different services. To my mind consulting a registered Doctor and going to a website to get a prescription drug are very different things and both have important (but somewhat distinct) roles.

“many routine face to face consultations with GPs could be done safely online”

The article quotes Dr Tony Steele, the GP who set up Dr Fox 2 years ago – a service that has so far provided 70,000 prescriptions, and I think readers of this article could benefit greatly from being pointed to some of the growing evidence base that supports this claim (eg. Safety of Prescribing PDE-5 Inhibitors via e-Medicine vs Traditional Medicine, 2008, Mayo Clinic Proceedings) and the value of providing patients with documentation.

Are T&C’s “fair sharing of risk between doctor and patient”?

Margaret points to the potential to “dehumanise medical interactions” as we move “more consultations into the realm of the tickbox based protocol” and asks if the DrThom website (which has so far provided 500,000 prescriptions – mostly in the area of sexual health) being used in the treatment of depression (although the DrThom website does not prescribe antidepressants) is providing a “fair sharing of risk between doctor and patient” through the use of a tick box that has patients pledging “I understand that in an emergency or if I feel a risk to myself or others I will contact my GP or voluntary service such as the Samaritans”.

I think it’s important to accept that while there are of course new challenges as we increasingly try to serve care needs in online environments the alternatives we have in place already aren’t anywhere near perfect eg. the UK’s biggest mental health charity accepts that it ignored 16,000 calls for help to it’s 9-5 Mon-Fri helpline last year.

“But could patients answer questions minimally or miss out important information to get a prescription more quickly or easily?”

I think Dr Van Every has answered this very well (“The range of services – we offer – is not so catastrophically risky that patients would come to grief, we have processes in place that minimise that risk, but ultimately, like any part of medicine and history taking, a great deal relies on trust”), but again it reminds me of the lack of comparison with the alternatives eg. patients who aren’t registered with a family Doctor, patients who are subject to rushed 3 minute “one patient, one complaint” in-person office appointments at which they get little/no documentation, etc.

It surprises me that Dr Van Every’s point that the online systems can be made “hyperefficient” even needs to be made in 2012 when the vast majority of us now enjoy the benefits of things like mobile phones, electronic banking, etc.

“clear evaluations of the limitations of entire consultations moving online are needed”

Claiming that “GPs are trained in the value of face to face consultation, of cues, the facility of silence, open questions, and the “door handle moment” (when a patient voices concerns when seemingly also about to leave)” is all well and good but what about the value of other talents that specific GPs have eg. I know a GP who is visually impaired and has telephone consulting talents that are in many cases a whole lot better than their in-office consulting skills.

Everyday the news reports on isolated individuals who are taking their lives. So what’s so wrong if we have Doctors who want to specialise in this important and growing area of medicine and make themselves accessible anytime/anywhere? What’s so wrong if we have Doctors who would prefer or need to work (through disability perhaps) in a home office environment rather than in a clinic?

“Moving more consultations into the realm of the tickbox based protocol has the potential to dehumanise medical interactions… …Additionally, the value of personal relationships and interaction is lost”

What about the other side of the coin? You might think of Facebook as a dehumanised means of communicating but it’s definitely not for some of us eg. patients like the Super Amit Gupta who used it so effectively to educate/encourage others about the opportunity we all have to register as organ donors.

Of course many Doctors still feel the idea of a patient sharing their history through use of an interactive questionnaire tool (like the one we’ve adapted as part of the consultation we offer at 3G Doctor) is dehumanising the Doctor/Patient encounter but it’s in reality the opposite.

Not only can the talents of more than one Doctor be immortalised into a questionnaire but with the mobile internet it also doesn’t place any constraints of time/location on a patient.

Every single patient who uses 3G Doctor is automatically screened for depression and gets an opportunity to share their important (sometimes very sensitive) information at a time and place that they feel most comfortable. Contrast this to the experience in a rushed in-office consultation (when your primary concern may be another ailment) and is it really any surprise that patients communicate more and Doctors use their time more effectively?

My conclusion

So the original question was “is the proliferation of private consultation and prescription services on the internet good for patients?” and I think the answer is that we don’t have a choice: it’s going to happen. Access to healthcare is so fundamentally important to patients that they will make it happen. The opportunity we have today is that this future is going to be shaped by us.

Just as online shopping started with static copies of bricks and mortar stores and evolved into customer service masterclasses and product recommendation engine powerhouses, I’m pretty sure we’re going to see the way Doctors interact online with patients evolving from these early drug/prescription retail experiences and I have no doubt that the many innovative medical technologies we’re seeing converging to the newest mass media will have a huge bearing on this future landscape.

What do you think?

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