MIT Review article warns that Mobile Video Calls may encourage Patients to spend too much time talking with Doctors

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In this MIT Review post Christina Farr expresses concerns that mobile access to Doctors could amplify health anxieties.

mHealth Insights

“Your Doctor App Could Amplify Your Health Anxieties…   …People with the kind of health anxiety formerly referred to as hypochondriasis used to have to go to the doctor’s office to quell their concerns. Thanks to a new crop of apps, they can now just take out a smartphone and reach a health professional anytime, from anywhere.”

The start of this article annoyed me as I really hate the idea of calling people hypochondriacs because they have a health anxiety – they’re Patients/Carers first and the most anxious I’ve ever met are normally Doctors or Medical students!

Today I think things are completely different because we can all look things up but I find this is a fascinating point of view as when we launched 3G Doctor in 2006 a Doctor in the audience at the Royal Society of Medicine asked me in front of the whole audience why Patients would ever want to video call a Doctor as though consulting an independent impartial Doctor was something there would never be a demand for.

It reminds me of the classic concept of what happens as a new idea goes through the stages of adoption in Medicine: “First they ignore you, then they laugh at you, then they fight you, then they scream look at what this is doing to the Patients whose needs we had been ignoring all along”…

As we hear technologists hyping the potential of Big Data to transform healthcare outcomes the reality for most Patients with anxiety issues is that they must suffer because their interactions with Doctors follow more of a Zero Data model in which they break down in a Doctors office and try and communicate while being emotionally drained and the Doctor tries to guess why they’re there and what they might need.

“So-called super users might not be a good thing when it comes to on-demand consultations with doctors. People with the kind of health anxiety formerly referred to as hypochondriasis used to have to go to the doctor’s office to quell their concerns. Thanks to a new crop of apps, they can now just take out a smartphone and reach a health professional anytime, from anywhere”

I think it’s quite amusing that in 2017 Doctors who have moved beyond the office visit only model are getting the finger pointed at them for milking Patients. For decades I’ve been listening to Doctors who offer Office Visits Only complaining that Patients are wasting their time but today I can walk into their waiting rooms and either load up the Instant Medical History questionnaire (that we have integrated into the 3G Doctor site since 2006) onto their Patients mobile phone web browser and it has been proven that I will be able to improve the quality of the care and reduce the need for at least 25% of the Patients  to have a consultation with the GP they’re waiting forand yes this could obviously be done before the Patient waited for the appointment and in complex organisations like the NHS where GPs use complex EHRs and workflow tools.

Perhaps Christina Farr has been confused by the work of some VC funded startups that have arrived on the market offering undocumented video chats with random Doctors who prescribe drugs and I agree these are daft, dangerous and hopefully won’t be around long (in my talk at Doctors 2.0 in 2014 I explained how we need to ensure Video Consults with Patients are all supported by tools that help Patients share information before a consult and get documentation of what was said/shared during the consult).

“Studies suggest that health anxiety—more recently termed somatic symptom disorder and illness anxiety disorder—affects anywhere from less than 1 percent to as much as nearly 12 percent of the population. For some of these people, a new array of telemedicine apps like MDLive and Doctor on Demand are appealing because they take insurance and also let you pay up front at cost of about $40 to $50 for a short video or phone consult”

I can’t believe that less than 12% of the population are affected by Health Anxiety and it’s odd that anyone thinks such a group of Patients might be in some way less deserving of high quality care.

The growing numbers of unvaccinated children in the US are a good example to use to make this point as they have Parents who are typically wealthier, have had more formal education, are more likely to have health insurance and the latest iPhone. To change these trends it’s critically important Doctors appreciate that online video (even that produce by quacks) provides such a powerful means of telling a story (eg. a celebrity talking about how his beautiful kid was diagnosed with autism straight after getting vaccinated) and this will very often be more compelling than any statistics that can be produced to support even an area of medicine that has an abundance of high quality evidence (eg. child vaccinations). Ignoring this group because we consider them to be health anxious is not only unethical but it’s putting children’s lives at risk and driving overall trust issues with evidence based medicine (as in order to really believe the story the Parent has to actually be convinced that Healthcare Professionals are all in on an elaborate conspiracy to harm children with harmful medicines) which is in turn fuelling the growing Quack industry.

Dr Roy Benaroch posted an interesting view on these video chat services but it fascinates me that US Patients are using the insurance paid option for talking about a mental health issue when just paying out of pocket for the consult is so inexpensive.  Perhaps the T&Cs aren’t made clear but I can’t think of a quicker way of increasing your insurance premiums. Surely it’s better to pay the $40 for such an interaction and keep this personal information private or perhaps the Patients know the data will get to the insurer anyway?

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“Because they are so easy to use, some medical experts wonder whether, over time, telemedicine apps will encounter a disproportionate number of users with health anxiety disorders. Already, app makers are encountering the ethical question of whether they should encourage such users to seek mental help”

So clearly I’ve got a vested interest in that I developed a course for medics seeking to move beyond the office visit only model of healthcare but why is anyone surprised that office visit only model Doctors really don’t like the idea that care can be made convenient for Patients?

Now that your iPhone has a faster CPU than the computer in a £10Million Surgical Robot I think it’s time we realised it’s unethical for the big mobile device manufacturers to not encourage their customers to seek help from a registered Healthcare Professional  considering the quantity and quality of data they are gathering on us (eg. tracking our eyeballs with high quality cameras).

“MDLive’s chief medical affairs officer, Deborah Mulligan, says that the company’s app has 28 million registered users, and it’s likely that about 6 percent have this condition, which mirrors the proportion found in the general population. What makes matters more complex is that with any other type of mobile technology, these people would be considered “super users” who drive revenue—the kinds of folks you want to stick around and keep using the app all the time”

I think this is another reason why Doctor Video Consulting services should be owned and operated by Doctors and Patients/Carers should be wary of those that aren’t – especially those who are heavily debt funded (eg. MDLive has raised $73.6M from Venture investors who in all likelihood are expecting a 10X return on their investment and has a T&C page that clearly states ‘MDLIVE does not provide any physicians’ or other providers’ services itself’ disclaiming the company from providing and being responsible for Patient Care)  as unlike registered Physicians they could be forced to exploit Patients mental health needs to get more revenue, trade Patient data, etc, etc.

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“Mulligan spent much of her career working in emergency rooms and was trained to recognize the symptoms of health-related anxiety disorders, which include worrying about a disease when there are no symptoms, experiencing high anxiety about minor aches and pains, and not feeling reassured by negative test results. She recalls one MDLive patient who exhibited all of these symptoms, and who suggested setting up regular consults to discuss a specific health condition that the patient didn’t have. After several sessions to build up trust, Mulligan recommended that the patient try MDLive’s cognitive behavioral therapy service. “They contacted me to thank me,” she says. “It was like a weight off their shoulders.”

I wonder what’s going to happen when this unfortunate Patient tries to renew their Health Insurance?

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I think the idea of using Video Chats to establish trust with a Doctor is quite odd. Perhaps MDLive should also copy the phrase we use at 3G Doctor where we inform Patients that the best place they can get care is with a Family Doctor. We would on the first Consult inform a Patient reporting concerns like this with us to go and register with a Family Doctor and provide them with a written consult report so that their first consult with that Family Doctor would be a productive one.

“Doctor on Demand board member Bob Kocher says that the majority of people who use the app are calling up about routine symptoms, like colds and the flu. He isn’t aware of patients with health-related anxiety regularly using the app to discuss their symptoms. However, he thinks it’s possible that more such patients will discover the app as it gains mainstream recognition. “Frankly, I think there are some of these patients in the health system who haven’t found us yet,” he says. “I’m sure we’ll have board meetings someday about a patient who used us 20 times that week.” Kocher says that app makers might make a “lot of money” through these interactions but will have a responsibility to investigate whether the cases were handled well”

I think this is an important distinction between how a business (that disclaims itself from providing the Care of a registered Healthcare Professional) and an actual Doctor can operate. Every single Doctor deals with this on a day to day basis and there are organisations like the GMC who work to protect Patients from Doctors who might want to abuse Patient trust to make a lot of money by repeatedly seeing them for no reason but to take their money.

Try this wheeze as a business that specifically disclaims itself from providing Patient Care (by calling the Doctors providing the advice ‘third party contractors’ and having bizarre disclaimers on your T&C page 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.) and your investors are going to be happy with the financial returns you give them until there’s a class action. But try the same as a Doctor and your career is over quicker than it started.

“One of the challenges of finding these kinds of users, experts say, is the lack of information transparency, particularly as the apps don’t share data with each other. “We don’t really know who the frequent users are,” says John Torous, co-director of the digital psychiatry program at Beth Israel Deaconess Medical Center. “It’s a population that is not well characterized.”

This is a typical reactionary comment about apps. The problem I see with Apps is the opposite eg. that they share data too widely with third parties etc unlike Doctors who rarely get to share at all with colleagues a few miles up the road.

“And Doctor on Demand’s chief medical officer, Ian Tong, points out that excessive health anxiety might be challenging to monitor if patients use an array of different apps. “You might not be able to tell unless the person was being prescribed a lot of medications,” he admits”

Perhaps Cheltenham Week has gripped me but isn’t this a classic case of trying to bolt the shed door once the horse has bolted?

Surely Doctors who are trying to help care for Patients who have excessive health anxieties AFTER they’ve helped to prescribe them too many medications should be struck off the register and retrained?

Key Takeaway

Blaming convenient Doctors for causing Patient Anxiety is like blaming ABS braking systems for causing tailgating motorists…

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