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Why In-Person Visits Will Always Be The Foundation Of Quality Healthcare

In a recent Forbes editorial, conservative commentator John Goodman argues that the Texas Medical Board is sending the state back to “the middle ages” because they are trying to limit the practice of medicine in the absence of a face-to-face, doctor-patient relationship. He believes that telemedicine should have an unfettered role in healthcare – diagnosis and treatment should be available to anyone who wishes to share their medical record with a physician via phone. This improves access, saves money, and is the way of the future, he argues.

He is right that it costs less to call a stranger and receive a prescription via phone than it does to be examined by a physician in an office setting. But he is wrong that this represents quality healthcare. As I wrote in my last blog post, much is learned during the physical exam that you simply cannot ascertain without an in-person encounter. Moreover, if you’ve never met the patient before, it is even more likely that you do not understand the full context of a patient’s complaint. Access to their medical records can be helpful, but only so much as the records are thorough and easy to navigate. As the saying goes: garbage in, garbage out. And with EMRs these days, auto-populated data and carry-forward errors may form the bulk of the “narrative.”

Telemedicine works beautifully as an extension of a previously established relationship. Expanding a physician’s ability to connect with his/her patients remotely, saves money and improves access. But bypassing the personal knowledge piece assures lower quality care.

I currently see patients in the hospital setting. I run a busy consult service in several hospital systems, and I have access to a large number of medical records, test results, and expert analyses for each patient I meet. Out of curiosity, I’ve been tracking how my treatment plans change before and after I meet the patient. I read as much as possible in the medical record prior to my encounter, and ask myself what I expect to find and what I plan to do. When medical students are with me, we discuss this together – so that our time with the patient is focused on filling in our knowledge gaps.

After years of pre and post meeting analysis, I would say that 25% of my encounters result in a major treatment plan change, and 33% result in small but significant changes. Nearly 100% result in record clarifications or tweaks to my orders. That means that in roughly 1 in 4 cases, the patient’s chief complaint or diagnosis wasn’t what I expected, based on the medical record and consult request that I received from my peers.

If my educated presumptions (in an ideal setting for minimizing error) are wrong 25% of the time, what does this mean for telemedicine? The patient may believe that they need a simple renewal of their dizziness medicine, for example, but in reality they may be having heart problems, internal bleeding, or a dangerous infection. Let’s say for the sake of argument that the patient is correct about their needs up to 75% of the time. Are we comfortable with a >25% error rate in healthcare practiced between strangers?

Goodman’s cynical view of the Texas Medical Board’s blocking of telemedicine businesses for the sake of preserving member income does not tell the whole story. I myself have no dog in this fight, but would side with Texas on this one – because patients’ lives matter. We must find ways to expand physician reach without eroding the personal relationship that makes diagnosis and treatment more customized and accurate. Texas is not returning healthcare “to the middle ages” but bringing it forward to the modern age of personalized medicine. Telemedicine is the right platform for connecting known parties, but if the two are strangers – it’s like using Facebook without access to friends and family. An unsatisfying, and occasionally dangerous, proposition.

The Problem With Dermal Fillers

From Forbes:

But today, a range of dermal fillers can be injected into those crow’s feet, marionette lines, thinning lips and furrows between the brows, taking years off the face–and all can be done during your lunch hour, with no invasive surgery and little recovery time.
Source: forbes.com/2009/05/26/dermal-filler-cosmetic-forbes-woman-well-being-facelift.html

I love how the press tends to make it seem like Dermal Fillers are the solution for which we have all been waiting. They make it an issue of just “choosing the right one.”

The issue here is that dermal fillers Read more »

*This blog post was originally published at Truth in Cosmetic Surgery*

Are Doctors Using Their iPads Too Much In The Work Setting?

Great blog piece in Forbes by Tom Gillis — VP of Cisco’s Security Technology Business Unit — on how hospital Chief Security Officers (CSOs) are having issues with managing physician use of mobile devices at work.  He had dinner with the CSOs of five major healthcare providers, who stated their biggest headache is how Doctors love their iPads and want to use them for work.

Gillis is in the business of enterprise security, and he gives an insider’s perspective on mobile device use in the hospital setting.  He writes about the fundamental shift in how physicians are consuming content.  Before the proliferation of mobile devices, hospitals had complete control of managing the “endpoint” — how the content was consumed.  This is no longer the case, and since these personal devices have created a new paradigm, IT teams are left playing catchup.

It was refreshing to hear Gillis talk about how the solution Read more »

*This blog post was originally published at iMedicalApps*

A TV Physician Is Not Your “Doctor” Or “Coach”

A German physician wrote me about this, so while CNN may have an international reach, it’s not always with an adoring audience.

The physician was reacting to the weekend “Paging Dr. Gupta” program, which Dr. Gupta referred to once as “SG, MD.” The first thing that struck me was his introduction, in which he said:

“I’m your doctor. I’m also your coach.”

Later in the program he said:

“Think of this as your appointment. No waiting. No insurance necessary.”

I find this very troubling. He’s not my doctor. He’s not my coach. When I watch a “news” program, it’s NOT my medical appointment. It’s supposed to be news, not medical advice.

But that’s not what the German physician wrote to me about, so I kept watching (the segment in question appears about 5 minutes and 30 seconds deep, and after the 30-second commercial you have to watch to get there):

Gupta reacted to a viewer’s message on Twitter in which the tweep asked: “Does anyone know a ‘miracle’ treatment for ovarian cancer?” Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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