Roy Benaroch MD (a pediatrician who blogs at the Pediatric Insider and is the author of A Guide to Getting the Best Health Care for Your Child and the creator of The Great Courses’ Medical School for Everyone: Grand Rounds Cases) has written this interesting KevinMD article after getting promo brochures in the post from his families Health insurer (Aetna) pushing him to try Teladoc’s telemedicine app and asking himself if a quick phone call can substitute for a Doctor visit.
“One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?” it says in big friendly letters. Holly, presumably the child’s mom, is quoted, “One night, my child was running a high fever. I called Teladoc and the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER”
It stuns me that the more Doctors aren’t calling out the harm that is resulting from the way regulators are allowing prescription drugs to be promoted like this by marketeers. Doctors should never be promoted as a means to get a medication as it’s dangerously undermining efforts the Profession is making to put a stop to inappropriate prescriptions, have antibiotics used prudently, etc.
“I realize taking your children to see their doc is a pain. So is taking your car into the mechanic, waiting for the cable guy or going out for groceries. There are other things you’d rather be doing with your time. Can a quick phone call substitute for a doctor visit?”
I think this is a commonly held but rather patronising and short sighted view amongst medics and it’s alienating Patients because it’s reinforcing the failure to adopt the tools of our time in the Sickcare industry.
Believe it or not there are people who don’t take their car into the mechanic everytime something goes wrong (many cars can now be updated over the air, many manufacturers offer courtesy cars, my garage picks up and I leave the key at reception, etc), last time I had to wait for a ‘cable guy’ I got a SMS from him the evening before in which he told me when he’d be with me (he was on time but if he had been late I would’ve just called him on his mobile phone to ask what’s up), many people shop for groceries on their mobile, etc.
In 2016 instead of asking “Can a quick phone call substitute for a doctor visit?” we should be asking “Does the problem we’ve helped you share require you to visit me in my office?”.
“What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history and symptoms, it would have been appropriate to either: Stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor. Or if there was a chance of a genuinely serious medical issue, get evaluated right away”
I think it’s unfair to blame Patients because family Doctors have failed to make themselves accessible because we all know that the very affluent and executives working at $multibillion firms don’t run to ER’s everytime their child has a fever, and if Holly’s mom was in the UK and her NHS GP was Dr Rupert Bankart or Dr Amir Hannan the idea of straight away going to sit in an busy A&E with fever symptoms would probably not have even crossed their mind.
“The child could have had meningitis, pneumonia, a viral infection or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever means “call in a prescription”? That is completely and utterly wrong”
I think you shouldn’t be allowed to work as a Doctor without a supercomputer in your pocket so we should try and think like the born mobile and have more imagination than just risk assessments because triaging clearly isn’t the easy bit where it makes sense to try and do things cheaply.
In this presentation I gave at the Doctors2.0 event in Paris in 2014 you can hear me explain how Patients can share their medical history (using the clinically validated Instant Medical History questionnaire that we have embedded within the 3G Doctor website) and have the output reviewed by an experienced Doctor who can make a decision and support their Patient to make the right choice (eg. message or video call them with some considered advice, make them an office appointment with the most appropriate informed Carer).
“So why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?”
I think it’s a bit more complex than this as cheapness isn’t the only opportunity for insurers. Here are a few reasons I think we’re seeing big corporates like insurers the world over promoting Doctor calls over the telephone (and increasingly Facetime):
> Video consulting startups are getting debt financed by tech investors which is making it possible for them to offer the service at no cost (or massively subsidised price points) to the insurers (and retail Pharmacies etc). With next round investors accepting evidence of ‘market traction’ instead of revenue/profits there are countless accounting tricks that these startups are being encouraged partake in. The need to market and get users for their services is driving these startups to compete to be the most deceptive eg. we were approached by Bupa (an International Health insurance giant that generates about £10B in annual revenues) several years ago and laughed them out of the room when they suggested we offer their paying members a ‘free trial’ that we’d pick up the bill for. In the land of tech VCs this would be regarded as a “partnership with a global health insurer” and the startup would simply agree to any terms the insurer puts to them, put the press release out/add the logo to their website, and then use this relationship as validation of a market need for what they’re doing so that they could go and raise lots more money from gullible investors.
> Everytime an insurer surveys their target audience ‘Facetiming a Doctor’ tops the polls because it’s the most obvious pain point for any Patient who has ever sat in a waiting room unnecessarily. Fortunately for the marketing team it also looks great on a color brochure and is preferable to the usual ‘generate fear’ marketing materials they like to post to customers.
> Health insurers will also inevitably be looking to find ways to save and/or make money. In addition to making Insurers look good (they are now associating their services with instant access to the advice of caring Doctors) read the T&Cs on these services and you’ll see that the insurers (or worse still the debt financed tech startups) are all storing the information shared in the calls and will be no doubt be using it to decline claims, readjust their risk profiles and perhaps even increase premiums, sell additional services, etc. In comparison to a largely undocumented face to face office visit where the Doctor is prioritising their Patient’s needs and billing the insurer with telephone services run under the insurers new terms and conditions they are now getting an avalanche of information by essentially becoming the owners of a recording of the consultation that can be retrospectively investigated and data mined.
> Patient data trading: It should be obvious that a business could give away cheap or free (eg. subsidised by adverts or by selling on your personal information to corporations) to Patients a service like a short Doctor advice call if in exchange the Patient agreed to a ‘Terms & Conditions’ sheet that let them sell on all the private personal information they can scrape from the exchange. This is why a lot of remote consulting startups claim they are tech companies and the Doctors providing the advice are ‘third party contractors’ along with rather bizarre disclaimers eg. that the service is ‘limited to providing a information for entertainment purposes’, ‘not for medical care’, ‘is to be used solely at your own risk’, etc.
“I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis and prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.”
I think the lack of evidence is because any claims made against Doctors who are providing such undocumented (or poorly documented) telephone call consults are typically being settled to stop them going to court (as that’s so much more expensive and time consuming and the lack of good records makes the Doctors pretty much indefensible).
The easiest way for a Doctor to measure the ‘quality’ of this type of care is to call their medical liability insurer. Most will want to charge you huge premium increases if you want to provide care in such a potentially dangerous way and the extent of the increase in cover you will need will give you an idea if the data shows what they are doing is anywhere close to good/safe care.
If your insurer doesn’t want an increase in premiums from you it might be wise to look for another insurer or ask for a discount because you probably shouldn’t be subsidising colleagues who are consulting over the phone with random Patients they know next to nothing about.
“Though there are zero pediatric studies, I found one good study in adults, reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses. Many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record”
I think it’s unfair to refer to this very poor quality NIH study from 2013. I’ve reviewed it here in some detail.
Interestingly I recently attended a GP training day and during the dermatology session led by a leading Consultant Dermatologist the GPs were all over the place in the multiple choice questions (the consultant asked the GPs to raise hands in response to a multiple choice). If there is an area where telemedicine is a no brainer dermatology is it as the skills and experience make it much safer with a Consultant reviewing a history and picture and the capacity to message & video call a Patient if there are any uncertainties.
“I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just two copies of telemedicine records in the last few years. They’re frankly embarrassing. One was about an 8-year-old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s what’s called the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone. The other telemedicine record I have was nearly identical, a 15-month-old also diagnosed with strep — amoxicillin called in. (More Krap Kare for Kids.)”
I think Dr Benaroch makes a great point here but I don’t think medical records aren’t being provided because “they’re frankly embarrassing” but rather because the ‘providers’ are all too often ‘get rich quick Doctors’ who are happy to chance their arm and play a numbers game to earn some easy cash while the sun shines.
I think you shouldn’t be allowed to practice remote care without proper documentation of Patient history before a Doctor is allowed to consult eg. a best practice you described by Prof John Bachman MD (Prof of Primary Care at the Mayo Clinic) and like we offer at 3G Doctor and as described in this presentation I gave at Doctors2.0Paris a couple of years ago.
“There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be an excellent way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms”
I hear this a lot from Doctors. The odd thing about this is that ‘telemedicine’ is how most Doctors get their own care (even if it’s mostly conducted unofficially eg. calling friendly colleagues, old class mates, etc) and want to get care for a wide range of things (see the BMA’s Doctors for Doctors service).
“But current available technology — like this Teladoc service — doesn’t allow a clinician to really examine a patient, look in their ears or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick — and that is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy. But it’s no substitute for genuine medical care”
I think Dr Benaroch is wrong to conclude that the Teladoc service is somehow ‘current available technology’ eg. in the UK I know NHS GPs who have provided the majority of their consults (to Patients he already knew) over the plain old telephone line BACK in 2009!
Today more than 100 million people in America can use a secure website to share their medical history (and in most cases they’d do it more honestly than they’d do it in person, plus they wouldn’t feel the pressures of time constraints, etc) and Facetime a Doctor who has had the time to review their history and make any necessary research to prepare them for the consult that they can choose to manage in a variety of documented ways.