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 in their offices can look into aching ears while the child remains in his or her living room . . . sort of.
All of this is a far cry from the Norman Rockwell image of a doctor from decades ago. But while there was an undeniable charm to the physician with the black leather bag, modern technology has improved medical care in ways we never dreamed possible. When used inappropriately, though, it can cause substantial harm.
One recent innovation is telemedicine — essentially, an office visit without the office . . . or the visit. Exactly how this works can vary greatly from provider to provider. Some primary-care doctors or specialists offer virtual visits (with the assistance of a nurse who is physically with the patient), interacting with the patient on a video screen and using advanced equipment to listen to the heart and lungs, look into the ears and throat, and perform other aspects of the physical exam remotely. On the other end of the spectrum are urgent-care services that deliver care to patients in their homes using nothing more than a smartphone.
Parents may use these services to seek after-hours care for their children, often hoping to get started on medicine as quickly as possible. And many insurance companies have been pushing these services because, well, they’re cheaper. Thanks to the low overhead costs, insurers pay only a fraction of what they would pay for an office visit. Telemedicine visits are also quick and available 24 hours per day.
But while the convenience of a 2 a.m. virtual visit for a child with a fever might be tempting, sometimes a face-to-face visit is clearly superior — and less risky.
Strep throat, for instance, should never be diagnosed in children without first doing a rapid strep test or culture. Urinary tract infections in children also require sending a sample to a laboratory for diagnosis. If a child is thought to have pneumonia that requires antibiotics, it’s probably a good idea to examine the patient in person to ensure that hospitalization isn’t needed.
And while there are devices that allow parents to peer into a child’s ears and transmit an image of what they find to a physician, this approach isn’t perfect. Examining a child’s ears is a skill that takes practice: 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. These devices can be useful if an in-person visit is available as a backup, but they do require some equipment on the patient side.
Nearly any infection that requires treatment with antibiotics demands a more thorough evaluation than a smartphone video can provide. But I’ve seen and heard of numerous cases of infections being treated without an appropriate evaluation.
A fellow pediatrician told me about a young patient whose parents wanted him to explain why she was having recurrent urinary tract infections — four of which a large telemedicine service had diagnosed with no urinalysis or culture to support the findings. Not only had she been treated unnecessarily on multiple occasions, but the parents were also convinced that she needed expensive and invasive testing to look for a surgically correctable problem.
After doing an urinalysis and culture, my colleague concluded that the child had most likely had a local irritation caused by bubble baths, a failure to wipe after urinating or some other relatively minor issue.
Misdiagnoses such as this are not unique 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 get it right.
So while it may seem as though I’m bashing telemedicine, I’m really not. It just needs to be use appropriately.
For instance, telemedicine would be compatible with good doctoring for such things as follow-up visits for attention-deficit hyperactivity disorder, 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 without the need for specialized equipment.
It’s seductive to use telemedicine when your pediatrician’s office can’t be reached and a child is sick. Unless a parent has some medical training, it can be hard to know if the advice and care being offered via a virtual visit is low-quality, and it’s only natural to trust that the provider knows what he or she is doing.
So it’s 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. The few truly emergent problems — such as difficulty breathing, traumatic injuries or prolonged seizures — almost certainly require more care than can be provided over an Internet connection.
Unless parents believe that a child’s condition demands immediate emergency room evaluation, it’s almost always better to wait until a pediatrician can see the child in person the next day.
In project management, a principle known as the triple constraint essentially states that you can choose any two of three options: fast, good and cheap. And while that doesn’t entirely apply to telemedicine, we still have to choose among those priorities. Quick, inexpensive care is great — when it’s appropriate. But bad health care provided quickly and cheaply can be worse than no health care at all.
As a pediatrician, I’m obviously biased, but my advice is to find a doctor you trust, hopefully one with some after-hours and weekend availability, and maybe even one who offers some supplementary care by smartphone, text or email.
If, in the middle of the night, you do turn to a telemedicine services to treat your sick child, at least avoid those that offer to treat strep throat, ear infections, urinary tract infections or pneumonia without having the ability to perform the appropriate testing.
Finally, if you believe that your child’s pediatrician is no better than your smartphone, find a new pediatrician.
Hayes is a pediatrician in Charleston, S.C., who regularly blogs about health-care issues.