The practice of medicine is a sacred event between a doctor and a patient – two individuals who have met each other in the flesh. This is the sentiment of many, and soon to be the law in the great state of Texas. It was also a popular topic of conversation at the American Telemedicine Association meeting in Los Angeles.
As a physician, I’m passionate about the profession of medicine, and as a soon-to-be MBA, I’m passionate about the practice of medicine. In this case, these ideals are pulling in opposite directions. I’m writing this dialectic as much to help me form my opinion as to help you with yours.
Should the practice of medicine be reserved only for those patients whom you have met in person? This is, after all, our history. All of us who practice medicine know the laying on of hands heals. It is a core human interaction that conveys care and concern, warmth and protection. It is the most powerful tool we have as clinicians to diagnose and heal. Touching patients can only be done in the flesh, and any interaction between a doctor and a patient that lacks this is, in one way, inferior. Not only does seeing a patient in person ensure that we won’t miss the obvious melanoma not visualized in the photo or video, but it also enables us to better connect this visit with every other visit and with the entirety of the patient’s record.
Having access to a patient’s medical record improves the quality and efficiency of care, a value conspicuously missing from one-off-dial-a-doc interactions from an online doctor who cares nothing of patient history or future.
Dr. Jack Resneck, a plenary presenter at ATA this year, told a cautionary tale of an acne patient who was treated online with an antibiotic that caused him to develop Stevens-Johnson syndrome, a life-threatening condition requiring extreme medicine and extraordinary costs. Clearly, digital medicine has shortcomings.
On the other hand, should we yield to the demands of our patients who want convenient care? Leaving work (or family) to endure traffic, to find a parking space, to sit in your waiting room, then your exam room, to have a chance to touch you once and see you for 10 minutes is not convenient. Given the option to receive care by the phone, online, or in person, patients increasingly are choosing the more convenient channels. And if you wrote a prescription for trimethoprim-sulfamethoxazole for an acne patient with no history of medication allergy and he developed Stevens-Johnson syndrome, would seeing him in person have helped? Perhaps, but probably not.
We are reluctant to call our patients “customers” for good reasons. I respect that, and I caution us to consider the truth that the trade of service for a fee is a business transaction. No matter how much patients love and respect us as doctors, if the price of our services grew exorbitantly high, or if it became impossible to see us, then they would abandon us. They would do so with remorse, yet they would do so.
Ideally, a person with a rash makes an appointment to see a dermatologist. In reality, patients turn to many services and products for this need. They choose primary care doctors, physician assistants, nurses, naturopaths, moisturizers, coconut oil, pharmacists, Dr. Oz, WebMD, customer care agents at WalMart, Google, and even God (see Book of Job). Our patients have many choices, and they choose us because we are the best value for their money. This could change.
I’m concerned that in a digital world where customers can book a trip to Italy, buy a house, and even get married without ever having to leave their phone, (yes, the last is legal in some states, but not in Texas), we risk irrelevance. By forcing our patients to use an inconvenient channel, we risk losing our one and only customer, our patient.
Dr. William Osler said, “In seeking the truth, we aim at the unattainable, and must be content with finding broken portions.” Telemedicine may not offer the warmth of our hand, but it does offer the service our modern patients desire. The question is not whether or not we practice medicine digitally, but rather how we will maintain the quality, trust and convenience that our patients ask of us.
Please discuss.
Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.