Is telemedicine dumbing down the standard of care?

Telemedicine is the new rage in medicine and a very needed service. It is vital in areas that are underserved and doctors hard to come by. Additionally, it can be a great convenience for patients who may not actually need to physically go to the doctor. But, is telemedicine dumbing down the standard of care?

Doctors are held to a certain standard in the way they treat patients. If they fail that standard, they can be held liable. However, there is no set standard of telemedicine care yet established. We are learning as we go along.

Patients often utilize these services as a convenience but is this always a proper way to receive medical care? A woman may call with symptoms of a urinary tract infection and want a prescription for an antibiotic. It is easy enough to prescribe an appropriate medication and most of the time it works. But, I practiced medicine long enough to know that sexually transmitted diseases can sometimes look like urinary tract symptoms and without an appropriate exam and urinalysis, these can be missed. It may not happen often, but anyone can imagine the consequences of misdiagnosing a sexually transmitted disease.

On the other hand, if it is a patient I know that often suffers from urinary tract infections and she is suffering the same symptoms, maybe a prescription for antibiotics without a visit is the best medicine. The same may be said of the little boy with the throat infection. The standard of care is to do a rapid strep test to decide the need for antibiotics. This cannot be done over the phone. Is prescribing the medication without a rapid strep test now the new standard of care?

Antibiotic stewardship is of utmost importance in our current times. If we head down the path we are following, resistance will be the rule of the day, and we will not have any weapons against bacterial infections. Superbugs already are on the rise which will only continue through the inappropriate use of antibiotics. Sure, this happens even when the patient comes to the office. But, deciding to prescribe an antibiotic over the phone must be done with much less clinical information.

Clues to disease are often observed on clinical exam. A patient may be coming for a refill of their hypertensive medication and have a large goiter. The patient may not be concerned about it, but it may represent a serious underlying problem that needs further evaluation. This would have been missed without a visit.

What are the downsides of telemedicine?

It can contribute to antibiotic resistance through inappropriate prescribing of antibiotics. Patients often feel an antibiotic is warranted whether it is or not. A physician may prescribe because they do not want to miss any serious bacterial infections. But, in clinical practice, this is not the standard of car. Antibiotics are for bacterial infections only, and often the only way to know is with a careful physical exam.

Diagnoses can be missed. Not everything can be discussed in a 5 minute or more phone call. Telemedicine calls tend to focus on one problem while, in fact, many conditions can be happening at one time. These will not be uncovered over the phone.

Wrong diagnoses can be made. A suspected strep throat may actually be mononucleosis or hand-foot-mouth diseases.

Patients may rely on telemedicine as their primary care provider. While many acute problems and questions can be addressed, it should not take the place of having a real doctor. Having a regular doctor ensures that your preventive health needs are being addressed as well, such as the need for vaccines and screening tests.

The human touch is lost. Sometimes a patient just needs their doctor to talk to. They may not be suffering a physical ailment but trust their doctor as someone they can turn to in times of stress. Telemedicine can never give a hug.

That being said, there is a big need for telemedicine services in the U.S. The physician shortage is growing, and patients in remote areas find it difficult to see doctors. Also, as the health care system reforms, many patients are left without doctors through third-party complications. No one should be left without medical care.

Additionally, there are many medical problems and concerns that can be addressed through telemedicine. A new mother with a colicky baby probably has many such questions. A patient may need advice about their strained muscle or some minor in jury. Patients with chronic diseases may find some benefit in doing telemedicine visits in between their regular visit, such as diabetics to discuss their blood sugar readings.

The potential for telemedicine is huge, but it must be used judiciously. As the prescribers of treatments, doctors and other health care workers hold the responsibility to make sure that happens. Patients may think they need a certain medication, but we are liable to follow the standard of care. Without more appropriate triage, we are dumbing down the standard of telemedicine care. Prescribing antibiotics to everyone who calls with a fever is dangerous. We need to delineate the standards and then raise the bar. Patients deserve the best medical care, in a real office setting, over the phone or in the virtual world.

Linda Girgis is a family physician who blogs at Dr. Linda.

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