By Dr. Michael Szabo
There’s no question that virtual health care is on the rise. It’s seen as the wave of the future, a way to make our health care system more efficient and convenient. There are now many providers of this service in Canada.
Virtual care allows you to “see” a doctor in minutes over your mobile phone or on your desktop computer. Typically, the service functions essentially as a virtual walk-in clinic. You won’t see your regular family doctor. It’s more like an “Uber”-ization of health care, as you’ll be connected with any doctor employed by the service provider who happens to be available at the time that you request the virtual visit.
Our modern lives are busy. Access to health care, quite frankly, can be difficult and time consuming. Who wants to take the entire afternoon off work for a doctor’s appointment, just to check blood pressure and renew a prescription? Many people with high blood pressure can monitor themselves with reliable home devices. You may not feel you need a doctor to physically take the reading; you just want medical advice as to what to do about it. As another example, who wants to visit a crowded emergency room at two in the morning for a urinary tract infection, when you already know exactly what it is because you’ve had it before? You may believe you can do without an examination, and that you just need a prescription for antibiotics.
Virtual care solves a lot of issues like these. It allows you to see a doctor quickly and conveniently. This can be good for patients, doctors, employers and the health care system in general.
When Virtual Medicine Fails the Patient
I don’t think, however, that most medical problems can be managed effectively with virtual care from a random medical provider – an “Uber doctor,” if you will.
Imagine you’re a healthy, 28-year-old female investment banker who has been troubled by lower abdominal pain for several months, and has already seen several different doctors about it. You’ve been examined, had blood work done and been given an ultrasound in the emergency room. Everything is normal. You follow up with your family doctor in her office, as instructed, and are examined again. She feels it isn’t a concern, and instructs you to observe your symptoms and return for follow-up in two weeks.
Your family doctor does wonder about stress in your life as a possible cause of the pain. However, she’s treated you for 15 years, and she knows you haven’t had a lot of anxiety-related complaints. Thus, while she feels your symptoms are not immediately concerning, she does want to see you again.
You’re very busy at work, though, and don’t want to take an afternoon off to see your doctor for the follow-up. Instead, you decide to use the virtual medicine app your friend at work raves about.
After you discuss your pain with the virtual doctor, describe the tests you’ve had done, and tell him you’ve already been physically examined, he reassures you that it is likely just irritable bowel syndrome. The doctor does ask you a few more questions over the app, but no major red flags are raised. You are a bit stressed out at work, and that would make sense with your symptoms. So you accept the diagnosis, try to increase the fibre in your diet and take up yoga to help you relax, as instructed by the virtual doc.
The pain continues. A month later, you decide to use the virtual app again. This time, you’re connected with a different doctor. This doctor agrees that the likely cause of your discomfort is irritable bowel syndrome. No other red flags have developed. She tells you that perhaps you should see a counsellor about stress and anxiety. She also suggests you do a trial of a gluten-free diet, to see if that helps. You cut out all gluten as instructed and see the counsellor, but feel no better.
After three more weeks of pain, you decide that maybe you should go back to your own regular doctor after all, the one who knows you best. You take the morning off to see her. She’s concerned that you’re still in pain, and isn’t convinced it’s from irritable bowel syndrome or gluten intolerance. Astutely, your family doctor sends you for repeat blood work and refers you to a gastroenterologist for consideration of a colonoscopy.
The results: Your blood count shows a mild drop in your hemoglobin, indicating a small amount of blood loss. Unfortunately, the colonoscopy reveals a mass in your sigmoid colon. The biopsy is positive for colon cancer.
The Importance of Continuity of Care
The American Academy of Family Physicians has issued this statement about continuity of care: “Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review.”
The missed-diagnosis case above illustrates a central problem with much of virtual medicine: There is often a lack of appropriate continuity of care. Virtual care, if it’s going to be effective, should not fragment someone’s care. It should optimize it.
As I often tell my patients, when there are too many cooks stirring the pot, problems develop. I see this constantly in the emergency department (ED) where I practise. Patients come in with all sorts of complaints that have been going on for weeks or months. They aren’t experiencing an emergency when I see them and they don’t require hospital admission, but something clearly is not right. I’m compelled to discharge them home to follow up with a health care provider who can arrive at a proper diagnosis. On further inquiry, however, it becomes apparent that they are currently seeing many different doctors in a wide array of settings, trying to get answers for their complaints.
Access issues in our health system often propel patients to seek care in this manner. Many of these patients actually have their own family doctors, but they find it challenging or awkward to get in to see them, so they turn to walk-in clinics instead. When their symptoms come to a head, they use the ED. They end up being told all sorts of different things by the many doctors they interact with, and they become confused and anxious. What one doctor says, the next doctor disagrees with, and off they go in a different direction. They’ve had multiple investigations ordered by the various practitioners they’ve seen. At this point, it’s difficult to decipher what is actually going on.
I tell these patients that it’s extremely important to stick with one doctor. See that doctor regularly, so he or she has the opportunity to understand you and your symptoms over time. The doctor can take a step-by-step approach to the investigation of your problem, trying different treatment approaches from a lifestyle or a pharmaceutical approach. If tests come back negative, or treatment has no impact on your symptoms, then it is imperative that you circle back to that same doctor to decide on the next approach.
It’s like playing detective. You need to be assessed in a setting that has the best chance of uncovering the truth. Missed diagnoses can happen anywhere, but some factors can increase this risk. I’m not confident that walk-in clinics or virtual care apps, where patients are seen by random doctors, are ideal settings with the best chance of understanding what is really going on with a patient.
Save the Apps for Uncomplicated Cases
Virtual care does appear useful for simple problems that do not require follow-up or ongoing care, such a mild rash, a sinus infection or diarrhea. Perhaps this “wave of the future” truly can help the health care system by skimming off the medical problems that don’t have much complexity around them, and dealing with them more efficiently.
These problems, however, are not the ones that clog up our system. And the more complex the symptoms become, the less helpful virtual care will be. For instance, titrating medications for blood pressure management or blood sugar control are not best accomplished by involving a different physician each time who has his or her own opinion on how best to adjust the medication dosages. Same goes for someone with recurrent urinary tract infections. You need to have urine cultures done and appropriate follow-up to ensure that the infection has cleared. If it’s not clearing, then an astute clinician will take the next step, sending you for further investigations and a consultation with a urologist.
What if virtual medicine could help us to deliver complex, chronic care more efficiently? This is the most exciting potential for this technology. What if you could see your own doctor virtually, when you want? For instance, you might see your regular family doctor physically in the office when you need to, but then interact with him using a virtual care app when that’s more convenient and is a medically appropriate option.
This would truly be the best of both worlds, overcoming the continuity-of-care problem inherent in most virtual medicine models.
The challenge in Canada is getting this service covered by our provincial health plans. Governments are likely concerned that allowing medical services to be delivered virtually will increase utilization – and cost. I expect they are approaching this cautiously.
Until then, we are left with virtual care for only the simplest of medical problems. Using it for anything else is, in my view, not good medicine.
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