Don’t replace your pediatrician with a smartphone

There’s no doubt that technology is changing the face of medicine. Today, surgeons can perform minimally-invasive procedures with the assistance of a robot or replace missing limbs with bionic ones. Radiologists can read imaging studies from halfway around the world. There are specialists providing remote services to patients with strokes, women with high-risk pregnancies, and critically ill neonates. Mental health professionals are now able to offer life-changing care to patients who would otherwise be unable to access these services. And pediatricians can look into a child’s ears from their living rooms … sort of.

All of this is a far cry from the idealized Norman Rockwell image of a doctor from the early 20th century. But while there was an undeniable charm to the physician with the black leather bag, modern technology has the potential to improve our medical care in ways we never dreamed possible. When used incorrectly, though, it can cause substantial harm.

One recent medical innovation is telemedicine — which is essentially an office visit without the office … or the visit. Exactly how this looks can vary greatly from provider to provider. Some offer virtual visits using advanced equipment that allows doctors to listen to the heart and lungs, look into the ears and throat, and perform other aspects of the physical exam remotely, often with the assistance of a nurse who is physically with the patient. Other services enable patients to receive medical care from the comfort of their living rooms using nothing more than a smartphone.

Many parents have been using these services to seek after-hours care for their children, often hoping to get started on antibiotic therapy and knock out an infection a little sooner. And many insurance companies have been pushing encouraging telemedicine services because, well … they’re cheap. Due to the low overhead costs, insurers pay only a fraction of what they would pay for an office visit. The visits are quick, inexpensive, and available 24 hours per day.

But while the convenience of a 2 a.m. virtual visit for a child with a fever might seem tempting, it isn’t without its risks. Despite all of our technological advances, there are some times when a face-to-face visit is clearly superior.

Strep throat, for instance, should never be diagnosed in children without a rapid strep test or culture. Urinary tract infections also require sending a sample to a laboratory for accurate diagnosis (a standard that is different from adult women). If a child is thought to have pneumonia that requires antibiotics, it’s probably a good idea to examine them in person to ensure that they don’t need to be hospitalized. And while there are devices that allow parents to peer into a child’s ears and transmit this image remotely to a physician, examining a child’s ears is a skill that takes practice to develop — there’s often wax in the way, kids don’t tend to hold still, and it’s not hard to cause trauma to the eardrum.  In fact, nearly any infection that requires treatment with antibiotics also demands a more thorough evaluation than a smartphone video can provide.

But I’ve seen and heard of numerous cases of these infections being treated without any appropriate evaluation — placing children at risk for severe side effects from unnecessary medications and contributing to the very real problem of antibiotic resistance. One of the more impressive examples I’ve heard of was a young girl whose parents wanted to know why she was having recurrent urinary tract infections — all four of which had been diagnosed by a telemedicine service with no urinalysis or culture to suggest that any of these infections actually existed. Not only had she been treated unnecessarily on multiple occasions, but the parents were now convinced that she needed expensive and invasive testing to look for a surgically correctable problem.

Problems like this are not isolated to telemedicine; it’s certainly possible to practice medicine poorly in person. But when the doctor doesn’t have access to the required tests, a relationship of trust with the parents, or access to the child’s medical records, it’s much harder to do it right. So while it may seem like I’m bashing telemedicine, I’m really not. Just like any other technology, telemedicine is neither good nor bad. My issue isn’t with telemedicine itself, but with the providers and insurance companies that capitalize on parents’ concerns while putting children’s health at risk by practicing poor medicine.

The reality is that this technology could be used effectively for many situations — things like ADHD follow-up visits, routine visits for management of asthma or allergies, behavioral concerns or potty training issues. Discussions about healthy eating and exercise could easily be handled with a video visit. And many rashes could be diagnosed by without the need for specialized equipment.

So why are poor-quality telemedicine services thriving? Well, they are filling an enormous void of accessibility and convenience that traditional practices are failing to address. If a pediatrician’s office can’t be reached when children are sick, parents will turn to more convenient options. Unless a parent has some medical training, it’s hard to recognize low-quality care; it’s only natural to trust that the provider knows what he’s doing. And if parents don’t realize that their children are receiving poor care, they’ll come back again and again.

In addition to recognizing poor quality, it’s also important for parents to remember that the vast majority of pediatric illnesses–even those that require antibiotics — do not require evaluation and treatment in the middle of the night. And the few truly emergent problems — things like difficulty breathing, traumatic injuries, or prolonged seizures — almost always require more care than can be provided over an internet connection. Unless a child is truly emergency-room-sick, it’s almost always better to wait until his pediatrician can see him the next day.

There is a principle known as the “triple constraint,” which essentially states that you can choose any two of three options: fast, good, and cheap. And while innovations like telemedicine can change this balance to a degree, we still have to choose which of these priorities are most important. Quick, convenient care is great — when it’s appropriate. But bad health care provided quickly and cheaply could be worse than no health care at all.

In summary, here are a few suggestions for ensuring the best health care for your child:

  1. Find a pediatrician that you trust, preferably in a practice with some sort of after-hours or weekend availability–or maybe even one that offers telemedicine appointments when they are appropriate.
  2. Realize that most pediatric illnesses, while unpleasant and inconvenient, do not require diagnosis or treatment in the middle of the night.
  3. Recognize that fast and cheap services are unlikely to provide good care for your child, and that waiting until the next day to see your pediatrician is almost always a better idea.
  4. If you choose to use telemedicine services, avoid those that offer to treat strep throat, ear infections, urinary tract infections, or pneumonia without the ability to perform the appropriate testing.
  5. And if your child’s pediatrician is no better than your smartphone, find a new pediatrician.

Chad Hayes is a pediatrician who blogs at his self-titled site, Chad Hayes, MD.

Image credit: Chad Hayes

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