Recently there has been increased concern about telemedicine. Some see it as a new opportunity for business.
More worry about the potential problems
it creates. Can doctors “see” patients using
WhatsApp aided by photos and voice recordings? How about live chats via computers? Is physical examination dispensable in some
cases? How about spot diagnosis? Can doctors prescribe without meeting the
patients physically?
Actually, telemedicine is nothing new. I read in novels that in the old days patients
wrote long letters describing their symptoms to doctors. And I think every doctor has answered
telephone calls from patients. Most of
us would have given advice via the phone. Some have placed phone orders to nurses. While there are some features unique to
telemedicine, I do not regard it a standalone process. Rather, it is part of consultation. Thus, rules for the normal consultation
process apply.
It must be clear to both the doctor and the patient that it is, or
it is not, a medical consultation. This
is very important but can easily be overlooked. A patient might just send you some photos or questions.
While you consider them casual chats, he
might take your answers seriously and rely totally on you. In such cases, a doctor-patient relation is
established. The doctor is said to owe a
duty of care to the patient.
Whether the doctor has discharged his duty of care to the patient
would be judged by the standard of care, with reference to the standard of his
peers. Telemedicine is just part of the
consultation process. It is up to the
doctor to justify how much he relies on the information he collected through
telemedicine. The doctor can always
request the patient for a face to face history taking, followed by physical
examination and investigations. However,
with the real-time live-chat technologies, there might not be much difference
in the history taking part. Telemedicine
might even serve better as the patient is in his familiar environment and can
be more at ease. Sometimes, the patient
might be able to show you some paroxysmal physical signs which can never be
witnessed at the consultation room.
The aim of consultation is to arrive at a diagnosis, or to derive a
management plan. Some doctors regard
telemedicine dangerous as it is difficult to adequately examine the patient
physically. However, it all depends on
the condition of the patient. Physical
examination might not be necessary. Or,
telemedicine might serve as a temporary measure to handle the patient. It is the clinical decision that matters. Even during a normal face to face
consultation, similar argument can apply. Do we need to investigate every patient? Physical examination has its limitations. But obviously we would not say that a
consultation is not complete without investigation. Most consultations end with history taking and
physical examination. This applies to
telemedicine also. We need to know the
limitations and the merits of telemedicine. In rare occasions, it can stand alone. In most occasions, it can help to diagnose and
to manage.
It is prudent to build a safety net for yourself and for your
patient. Apart from the most probable
diagnosis, we always need to rule out some differential diagnoses with serious
implications, especially treatable ones. I remember when I was working in the A&E
Department, I always ran through the 10 treatable causes of sudden loss of
consciousness, and I always carried a wide bore needle, just in case I
encountered a patient with bilateral tension pneumothorax. In telemedicine, it might be possible to send
a from-the-lawyer disclaimer to every patient you see if you really love
defensive medicine. It is up-to-standard
practice to alert patient on any red flags, explain the natural course of the
illness, warn about the limitations of the consultation, and arrange for follow-ups.
Thus, telemedicine is not a new topic for doctors. There are existing codes and laws governing
its practice. However, the real threat
to patients is the lack of clear laws, and the failure in enforcing such laws,
for non-medical parties. They might sell
health food, sell drugs, solicit patients to non-orthodox treatments through
engaging with patients via telecommunication and advertisements. We do not want to repeat the history of
untrained “beauticians” doing whatever they choose to while doctors’ hands are
tied.
(Source: HKMA News April 2018)
