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Health See other Health Articles Title: Remote Patient Visits by Phone or Email: Yes or No? Prescribing by Phone Is Like Playing With Scorpions Can you practice medicine over the phone? What is an appropriate way to use communication technology to help treat patients? Recently on Medscape Connect, an all-physician discussion group, members discussed how they had used the phone and other devices to diagnose, prescribe, or otherwise deal remotely with medical issues. A primary care physician started things off: "Given my experiences with my own patients, I always insist they come into the office before I prescribe antibiotics if I haven't just seen them. Have you had experiences where you were glad you made your patient come in to your office before treating them based on what they told you over the phone, or a time when you wish you had?" A dermatologist jumped right in, taking an emphatic stand against offering any kind of diagnosis over the phone: "People tend to lie more on the phone, when it is not documented. They will lie to get what they want. The first time [that] I got screwed by a patient was [when] a military wife...insisted that I prescribe a topical ophthalmic antibiotic for her kid over the phone. Despite my reluctance...I did so, as she said it always worked for her kid. She claimed that owing to schedules, she couldn't come in. Two days later, I heard her in the clinic saying [that I] misdiagnosed.... From then on, I never let a patient convince me to prescribe and diagnose over the phone." A primary care physician agreed with this line of thinking and warned that giving in to patient pressure can have dire consequences: "The one time you yield and call in eye drops, it'll be Stevens-Johnson or mucocutaneous lymph node syndrome." Another primary care physician offered a critique of patients who want to be treated over the phone: "Basically, most of these people are lazy. They can click their phones to see movies on demand, send texts instead of letters, and order pizza from a cell phone for home delivery." "[My] rule is: If you need to order or prescribe, or if the conversation lasts a minute or more, [the patient] needs to be examined. Most patients cooperate; the few that don't and have no time to see you often have trivial issues," wrote an internist. And a primary care physician summed it up with an ominous metaphor: "Phone triage is playing with bark scorpions." Most physicians agreed that it was wrong to do too much over the phone, but some saw a tiny bit of wiggle room. "I routinely tell everyone who calls that my malpractice insurance doesn't allow me to make treatment decisions on the phone. It took a while, but there is rarely a weeknight call and on the weekend, maybe 2 calls. During office hours, I may call a prescription in and not demand a visit, but those folks are chosen carefully," wrote one primary care physician. "I will treat one and only one condition over the phone with antibiotics: conjunctivitis, with lids stuck closed in the morning and green or yellow discharge. Otherwise, no go. My job on the phone is to offer advice and figure out: clinic later, clinic tomorrow, or ER now, or 'I need you to hang up and call 911,' which I've only had to use once," wrote another primary care physician. A pediatrician agreed and offered a similar system for approaching phone conversations: "I really think the only purpose of phone triage is determining the time frame within which the patient needs to be seen in person: (1) emergency department now; (2) office today; (3) office this week." What About e-Visits? Others saw the increasing use of new technologies on remote diagnosis as worthy of discussion. "Note that a hot new marketing technique with many [insurance companies] is the e-visit, offering a patient the capability to contact the physician for advice and prescription by the Internet (at least they can upload pictures.) Give a credit card number and presto -- for about 25-30 bucks," wrote one pediatrician. But a neurologist felt this approach was severely limited: "I am not sure how good a neurologic assessment I could do with only visual and auditory interaction with a patient -- no palpation, no direct testing of motor resistance, no direct stimulation to assess sensory thresholds, no direct reflex testing. How can you possibly detect a subtle reflex asymmetry if you don't have the limb right in your hand when you're tapping? At best, it is a way of making an initial contact...and deciding whether the patient should go to the ER, come in to the office right away, or can wait until the next available appointment for a real exam." An internist, though, was significantly more optimistic towards the potential for remote diagnoses: "Cybervisits can thrive. I've diagnosed acute appendicitis by instructing a patient where to press and [taking a] history, but took 10 to 15 minutes of my time. With built-in cameras in most PCs, a myriad of lesions can be diagnosed. Nowadays, [some] technology...can transmit heart and lung sounds in addition to a graph. Now it can be networked." Finally, some physicians used comparisons with other professions to bolster their outrage at patients who wanted full service over the phone. "Can you call your lawyer and accountant without getting a bill? Do you call your mechanic, plumber, or electrician to manage your issues?" asked an internist. If those other professions are not asked to do real work over the phone, why should a physician? The full discussion of this topic is available at: http://boards.medscape.com/forums/.2a589039/16. Please note that this is open to physicians only. Poster Comment: I say yes to e-Visits, especially if BP data can be supplied by patient or pharmacist where patient may be going anyway. Post Comment Private Reply Ignore Thread
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