During the pandemic, I was forced to see patients in a virtual setting. I say forced because I prefer to see my patients in person so I can perform a physical exam and use my best clinical judgment to get to their underlying ailments.
However, when the world shut down, and people were getting sick, we had to rely on technology to see our patients in an outpatient setting.
The fear of misdiagnosis
One of my patients during this time was a 2-year-old boy. During his virtual visit, his mother told me he was extremely fussy, not sleeping through the night, he was pulling at his ear, and he had a mild fever. I was not comfortable formulating a diagnosis and plan at the time, because I was unable to physically examine the toddler, but I was suspicious he had an ear infection.
Still, it was against everything I learned in school and training to prescribe antibiotics for an undiagnosed ear infection, because the only way to be sure of an accurate diagnosis is to look in the ear.
I explained to the mom that she needed to bring him to his pediatrician or urgent care so he could be properly examined. She refused, saying she was too nervous about contracting COVID-19. I understood her trepidation, but at the same time, I knew the boy needed a physical exam.
I ended up writing a prescription for antibiotics to cover otitis media. I then gave the boy’s mother very specific instructions to go to urgent care if she did not see any improvement after 48 hours of antibiotics. I was beyond frustrated, but I also understood where she was coming from.
I have had many frustrating encounters like this with patients over telehealth. Physical exams are obviously a necessity in medical care, and body language is easier to read in person than over a computer screen. Virtually, I can’t tell how sick a patient is, nor can I gather accurate vital signs. I also find patients to be very distracted when talking through a screen.
However, insurance companies still push telehealth visits because it’s cheap. Insurance payouts to telemedicine companies are far lower than what they’d pay for an urgent care or emergency room visit. It is also convenient for patients.
"Nobody wants to go to the doctor, much like they don't want to take their car to the mechanic or the DMV, yet we still do these tasks."
— Kristen Fuller, MD
There have been quite a few studies done to prove my point about why telemedicine can be incredibly dangerous for patients.
Potential for misdiagnosis
A study published in JAMA Dermatology contacted 16 telemedicine companies about rashes.
They uploaded photos of skin diseases to "pose" as patients and found that the physicians, via telehealth platforms, misdiagnosed skin cancers, herpes, and syphilis.
Many of the physicians failed to ask basic questions and then prescribed medications without taking a proper history. Two telehealth sites hosted doctors overseas who were not licensed to practice in that particular state, and very few telehealth services asked for the patient's PCP information to send a copy of the records.
Patient and provider dissatisfaction
Studies show that telehealth visits are often billed lower than comparable in-office visits, patients have a higher satisfaction rate for telemedicine visits vs in-office visits, and patients are less likely to schedule follow-up appointments if they have a telemedicine appointment rather than an in-office appointment.
Although patients and insurance companies may be happier due to telemedicine, physician satisfaction and patient safety may be compromised.
(Not) comprehensive care
A study in the Journal of the American Geriatric Society found that telehealth services can be convenient and safe for the geriatric population because they do not have to rely on transportation or worry about spreading infectious diseases.
However, many of these patients felt that telehealth visits were more superficial than seeing their PCP in person. Of those surveyed, 22% felt their PCP was less likely to ask about multiple health problems, but “focus primarily on the chief complaint in a telehealth visit than an office visit,” the study authors wrote. The authors also noted that many respondents said they were less likely to share worries or concerns during telehealth appointments compared with in-office visits.
"I don’t think telehealth is all bad, as there are some benefits when used appropriately. However, I do think we need to tread carefully and slowly."
— Kristen Fuller, MD
Supplementing with telehealth
Until at-home affordable and accurate tests (for things like strep and UTIs) are more readily available, it is difficult to adopt a full-fledged supportive view on telehealth, not to mention the clunky software and touch-and-go internet connections I often experience.
In my opinion, we still need to go to see a doctor in person, and maybe telehealth can be a supplemental way to follow up with your healthcare provider for very specific visits, such as follow-ups for behavioral health or psychiatric medicine.
It can also be a convenient way for doctors in rural areas to receive help from a specialist on complex cases and to allow expert-level interpretation of objective tests (such as EKGs and echocardiograms). Trying to diagnose a rash, look in an ear, or even assess whether vital signs are normal is impossible during a telehealth visit. As a result, we cannot determine whether a patient is just a little sick or genuinely ill.
Each week in our "Real Talk" series, mental health advocate Kristen Fuller, MD, shares straight talk about situations that affect the mental and emotional health of today's healthcare providers. Each column offers key insights to help you navigate these challenging experiences. We invite you to submit a topic you'd like to see covered.