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Telemedicine - ethical, realistic, forced on us? Let's talk.............


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I left the behemoth corporate monster from the original post.

 

They have pushed and pushed and pushed telemedicine.

 

In my lovely little private family practice - I saw one of their victims.

 

She works for the corp monster in non-medical role.

 

She was "strongly encouraged" to use the tele app on her phone rather than leave work for an appt.

 

She "saw" a doc in another state on her phone with her UTI symptoms. NO VITALS. NO EXAM. NO UA. NO CULTURE.

 

Given Macrobid for 7 days. Symptoms still bad on day 5.

 

Comes to my office. We actually examine the patient. What is the world coming to.

 

Starting to have flank pain. Low grade temp. Feels rotten. Urine +LE, +nitrite, +blood - ON MACROBID.

 

Start her on Cipro - run culture - and ---- voila - she feels better.

 

She has now paid TWO COPAYS AND TWO RX FEES and suffered in my opinion about 4-5 days longer than needed.

 

Not sure the doc in the other state is licensed in our state.

 

A doctor in Idaho lost her license earlier this year for basic telemedicine due to this.

 

This patient was risked for pyelonephritis, NO VITALS, no one actually touched the freaking patient. 

 

NOT TOUCHING A PATIENT ALONE IS CAUSE FOR MALPRACTICE IN MY MIND. 

 

Medicine is an art - not an app on a phone.

 

This patient deserved better.

 

I WILL NEVER DO TELEMEDICINE AS A PRACTITIONER OR PATIENT. I will flip burgers before that day.

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I left the behemoth corporate monster from the original post.

 

They have pushed and pushed and pushed telemedicine.

 

In my lovely little private family practice - I saw one of their victims.

 

She works for the corp monster in non-medical role.

 

She was "strongly encouraged" to use the tele app on her phone rather than leave work for an appt.

 

She "saw" a doc in another state on her phone with her UTI symptoms. NO VITALS. NO EXAM. NO UA. NO CULTURE.

 

Given Macrobid for 7 days. Symptoms still bad on day 5.

 

Comes to my office. We actually examine the patient. What is the world coming to.

 

Starting to have flank pain. Low grade temp. Feels rotten. Urine +LE, +nitrite, +blood - ON MACROBID.

 

Start her on Cipro - run culture - and ---- voila - she feels better.

 

She has now paid TWO COPAYS AND TWO RX FEES and suffered in my opinion about 4-5 days longer than needed.

 

Not sure the doc in the other state is licensed in our state.

 

A doctor in Idaho lost her license earlier this year for basic telemedicine due to this.

 

This patient was risked for pyelonephritis, NO VITALS, no one actually touched the freaking patient. 

 

NOT TOUCHING A PATIENT ALONE IS CAUSE FOR MALPRACTICE IN MY MIND. 

 

Medicine is an art - not an app on a phone.

 

This patient deserved better.

 

I WILL NEVER DO TELEMEDICINE AS A PRACTITIONER OR PATIENT. I will flip burgers before that day.

While I agree with you in that I want no part of telemedicine, the basis of your rant is a little suspect IMO.

 

The risk of choosing an incorrect abx can happen anywhere, unless you are advocating withholding treatment until you have the culture back...

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Okay. I've been holding my tongue, for a few reasons, but this categorical, black and white thinking is silly.

 

Assuming this is one of your primary care patients, and this isn't her first UTI ever, I would argue that it's ridiculous to ask a patient to take time off from work to get this treated. I also agree that treating a UTI without so much as a UA is bad medicine, and very easily becomes malpractice.

 

So instead, why not do it this way:

 

- talk on the phone, or over secure patient email to get the basics of history, pertinent positives and negatives, etc.

 

- (even better, have an RN you know and trust do it, and have standing orders agreed upon up-front)

 

- let the patient drop by any of the affiliated lab locations/ come in for a lab-only appointment to give the sample. You put in the lab order ahead of time.

 

- meanwhile, once the labs are cooking, if the story sounds good for UTI and you have no concerns about pyelo, you release the Rx for Bactrim.

 

- you set yourself (or your rockstar RN) a reminder to check in with the patient in 48 hours, and discuss what's up with lab results, and how she's feeling.

 

At any point if you feel like it's important to put your hands on the patient, by all means have them come in for a "real" visit. But don't throw out the baby with the bath water here. Plenty of stuff (including a lot of follow up on chronic issues) can be done in newer ways. You save time and money, both yours and the patient's. If you insist everyone who thinks they might have a UTI has to schedule a visit with you, I guarantee a non-trivial proportion will just go elsewhere.

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My biggest point was that she was pressured by her employer - who profits from this - to use this service - even though I am her PCP and in town not far away.

 

NO UA was done. No vitals were taken. No exam of her flanks was performed. No follow up was scheduled or even discussed. 

 

No, I do not wait for a culture to treat.

 

BUT, I have access to her old records and any previous cultures. I have insight to her and her overall health.

 

Yes, sometimes we let patients drop off urine and NO, I don't have an RN - see other threads.......

 

So, she was pressured to use a service that didn't actually help her and might have been illegal altogether with a doc in another state who might not be licensed in our state. She was discouraged from seeing her long time PCP. 

 

THAT is bad medicine. 

 

And, NO I will never be a part of telemedicine. EVER.

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It's funny - I can't say too much about my current employer (they have a really smart social media policy that says I can basically talk about whatever, but I need to take care not to identify them or my work site) but I showed up to interview for two positions: the one I eventually got, and one in an onsite, corporate-medicine clinic. The kind of thing where the clinic is right there at the work site - I get why these are convenient, and why the employer and the health system like them, but I'm with RC2. They kind of creep me out. It's bad enough that health coverage is still very closely tied to a person's employment, and I feel like it's a step too far when the employer gets to exert influence about where the patient gets seen. So I said a big NO to that opportunity, and I think that probably contributed to my getting the gig I have now. We want people who are committed and passionate. 

 

I still say the issue isn't that telemedicine was used, it was used badly. Back in the day, people were opposed to xrays and CT scans ("physical exam skills are going to atrophy if you can just look inside the patient!"). People were opposed to the EMR ("documentation is going to get worse!" - as if scrawled, too-brief notes in paper charts you can never find are better in any way). Shoot, there was a time when people were opposed to the stethoscope, hand-washing, or anything else that was new at the time. 

 

Like any tool, it's all about how well it's used. But of course, we are all entitled to our own comfort level, and even our own biases. 

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And yes, if it's a patient you have seen in the office previously, video can be a very useful tool for assessing derm issues and rashes. Along with the ability to ask questions in real-time, if you can just get your eyeballs on a rash, you can rule zoster in or out, you can tell impetigo from contact dermatitis, you can decide if the patient needs to come in for an in-person visit. 

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It's funny - I can't say too much about my current employer (they have a really smart social media policy that says I can basically talk about whatever, but I need to take care not to identify them or my work site) but I showed up to interview for two positions: the one I eventually got, and one in an onsite, corporate-medicine clinic. The kind of thing where the clinic is right there at the work site - I get why these are convenient, and why the employer and the health system like them, but I'm with RC2. They kind of creep me out. It's bad enough that health coverage is still very closely tied to a person's employment, and I feel like it's a step too far when the employer gets to exert influence about where the patient gets seen. So I said a big NO to that opportunity, and I think that probably contributed to my getting the gig I have now. We want people who are committed and passionate. 

 

I still say the issue isn't that telemedicine was used, it was used badly. Back in the day, people were opposed to xrays and CT scans ("physical exam skills are going to atrophy if you can just look inside the patient!"). People were opposed to the EMR ("documentation is going to get worse!" - as if scrawled, too-brief notes in paper charts you can never find are better in any way). Shoot, there was a time when people were opposed to the stethoscope, hand-washing, or anything else that was new at the time. 

 

Like any tool, it's all about how well it's used. But of course, we are all entitled to our own comfort level, and even our own biases. 

In all fairness, I doubt any of the those opposed to stethoscopes, hand-washing, XRs, or CTs were worried about being sued out of a job by blood-sucking attorneys...

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 In all fairness, I doubt any of the those opposed to stethoscopes, hand-washing, XRs, or CTs were worried about being sued out of a job by blood-sucking attorneys... 

 

True enough. But it does seem like the push-back against telemedicine is at least a little bit about the same old uneasiness with technology changing the way we've always done things. It's a healthy and necessary discussion to have, but it works way better if more people participate in the discussion, and bring more experience to it. 

 

I feel pretty strongly that as long as we get out in front of a new technology, and create protocols and rules about how to use it that are based on evidence, we can prevent the lawyers or the administrators or the corporate overlords telling us how to practice.

 

I understand finding the change to be uncomfortable, or having philosophical reasons for being against something. Patient satisfaction surveys are a decent example, if we want to get away from clinical tools. But the end result is the same. If we just refuse to participate, we run the risk of setting ourselves up for a future where someone else tells us we have to use a tool, and we have no basis for arguing for using it in a better way.  

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I find it curious that legislation in Washington passed through the legislature without much resistance. However, we are told that approving independence for PAs is too difficult to get passed. This demonstrates the gross difference in power and influence that physicians enjoy with legislators that PAs do not. We need to focus our efforts on winning independence in state legislatures and abandoning retesting. I know I'm hijacking the thread but underlying this telemedicine advance is a move that reveals the weakness of the AAPA to generate parity with NPs. 

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I can pretty much guarantee that physicians had little to absolutely NOTHING to do with telemedicine getting approved in Washington.

 

Pretty sure some lobbyists from the big insurance companies and corporate medicine pushed on that one with one and only one thought process - the almighty profit margin.

 

No one really looks at the medical impact or ethics - trust me - no one medical was involved in writing 99% of the EMRs or designing exam rooms or purchasing equipment.

 

So, nice hijack but moving back to telemedicine - not something a medical provider probably came up with - at least in the mutation it has become.

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