Someday, we may miss the quaint idea of going to see your doctor for your medical concerns.
I realize taking your children to see their doc is a pain. So is taking your car into the mechanic, waiting for the cable guy or going out for groceries. There are other things you’d rather be doing with your time. Can a quick phone call substitute for a doctor visit?
At least one huge insurance company thinks so. My family’s health insurance comes from Aetna Healthcare (the letters of which can be rearranged to spell “At Heartache Lane”.) They’re really pushing me to try “Teladoc” (which, ironically, can be rearranged to spell “late doc” or “eat clod” or “led taco”).
One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?” it says in big friendly letters. Holly, presumably the child’s mom, is quoted, “One night, my child was running a high fever. I called Teladoc and the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER.”
24/7 doctors! What could go wrong?!
What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history and symptoms, it would have been appropriate to either: Stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor. Or if there was a chance of a genuinely serious medical issue, get evaluated right away. The child could have had meningitis, pneumonia, a viral infection or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever means “call in a prescription”? That is completely and utterly wrong.
So why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?
I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis and prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.
Though there are zero pediatric studies, I found one good study in adults, reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses. Many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record.
I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just two copies of telemedicine records in the last few years. They’re frankly embarrassing. One was about an 8-year-old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s what’s called the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone. The other telemedicine record I have was nearly identical, a 15-month-old also diagnosed with strep — amoxicillin called in. (More Krap Kare for Kids.)
There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be an excellent way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms.
But current available technology — like this Teladoc service — doesn’t allow a clinician to really examine a patient, look in their ears or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick — and that is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy. But it’s no substitute for genuine medical care.
Roy Benaroch is a pediatrician who blogs at the Pediatric Insider. He is also the author of A Guide to Getting the Best Health Care for Your Child and the creator of The Great Courses’ Medical School for Everyone: Grand Rounds Cases.
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