Telemedicine: Heart and Physical Exam Play

* The remote diagnosis and treatment of patients by means of telecommunications technology is referred to as Telemedicine. This technology enables medical providers to share data and images using video or wireless technology, and make treatment decisions without in-person examinations. * There are many issues that arise from not seeing a patient face to face such as the lack of a proper physical exam and communication barriers. * Physical exam

Even when doctors go through the motions of doing a physical, their diagnostic skills aren’t what they used to be. One recent study in the Journal of the American Medical Association examined stethoscope skills of various kinds among 453 practicing physicians and 88 medical students. Whatever their age or experience, the doctors correctly recognized only 20 percent of heart problems.

Can you imagine how that percent drops if they aren’t even in the room?

I found this audio clip from the morning edition of NPR (national public radio) news to be a bit bleak but informative. It is entitled the “Fading Art of the Physical Exam”

Kinda makes you think a bit about the care you’re already receiving doesn’t it?

At Stanford, they’re trying to reverse the trend. The school’s graduates and trainees have to master 25 different bedside exam skills that it considers essential to good doctoring. These include:

Stanford 25 (chart)

1. Examine the back of the eye
2. Examine the pupil of the eye and its response to light
3. Examine the thyroid gland
4. Examine the neck veins for abnormal size and pulses
5. Examine the lung’s surface, lung sounds and borders
6. Evaluate the heart’s motion
7. Examine the liver’s size and shape
8. Evaluate the spleen’s size and density
9. Evaluate gait (walking movements)

10. Test ankle reflexes for nerve abnormalities
11. Identify markers of liver disease throughout the body
12. Identify signs of stroke caused by blockage of a deep brain artery
13. Examine the knee
14. Identify abnormal heart sounds
15. Evaluate tremors and other involuntary movements
16. Recognize markers of disease in the hands and fingernails
17. Examine the tongue
18. Examine the shoulder for injuries and joint abnormalities
19. Assess blood pressure and abnormal pulses

20. Assess lymph nodes in the neck
21. Detect fluid in the abdomen and abdominal blood flow
22. Perform a rectal exam
23. Evaluate a mass in the scrotum
24. Test balance and ability to perceive the body’s position in space
25. Use a pocket ultrasound device. **This item is not yet standard practice in most U.S. medical settings, but Dr. Abraham Verghese of Stanford says it’s valuable in detecting abnormal fluids, quickly evaluating heart function and assessing organ abnormalities** * Ask yourself, how many of these can really be done effectively over a phone, email, or internet connection? 10? 8? Less than 5? * Communication

* Simple and effective communication is another benefit of having a doctor physically in the room with you. Language barriers & the varying communication levels of some children, elderly, mentally impaired, or just uneducated are easier to navigate in person where they could point, make faces, or otherwise guide a doctor through their health related problems. Also it’s easier to work in person rather than over the phone, through instant messenger, or over email. An issue that may take a dozen emails back and forth to sort out can probably be resolved through one short conversation in person. An hour-long phone call to describe a few symptoms may be resolved with a fifteen-minute face to face appointment. Also with telephone or over the internet it may be difficult to visualize ideas and concepts. Collaborating and discussing in the same location allows for you to pick up on details that may not have been shared otherwise, or offers the option to ask about symptoms patients may have just shrugged off if not there in person

Summary

I hope everything I’ve discussed here helps to inform you of some of the sacrifices being made for telemedicine. When you consider all the risks from the lack of a proper physical exam or adequate communication you have to ask yourself…. Is it worth my life?

Counter
(AKA Yes it can save time and money…. BUT)

While telemedicine can save time and money, its reliance on continuous, real-time transmission of data over computer networks also creates risk. At every step of the process, problems may occur, including diagnostic errors, technical glitches, and patient privacy and security violations. Add in that most insurance carriers will not cover telemedicine expenses and it can end up costing the patient more in the long run.