英文讀書會

January 7, 2010

Doctor and Patient

Are Doctors Ready for Virtual Visits?

By PAULINE W. CHEN, M.D.

For over a decade now, health care experts have been promoting telemedicine, or the use of satellite technology, video conferencing and data transfer through phones and the Internet, to connect doctors to patients in far-flung locales. But are doctors ready for this form of technology?

Telemedicine has the potential to improve quality of care by allowing clinicians in one “control center” to monitor, consult and even care for and perform procedures on patients in multiple locations. A rural primary care practitioner who sees a patient with a rare skin lesion, for example, can get expert consultation from a dermatologist at a center hundreds of miles away. A hospital unable to staff its intensive care unit with a single critical care specialist can have several experts monitoring their patients remotely 24 hours a day.

But despite its promise, telemedicine has failed to take hold in the same way that other, newer, technologies have. Not because of technical challenges, expense or insufficient need. On the contrary, the most daunting obstacle to date has been a deeply entrenched resistance on the part of providers.

New technologies in health care always require a reassessment of how patients and doctors best relate to one another, a judgment call on whether the relationship, and care, is helped or harmed by e-mailing instead of calling, updating Web sites instead of mailing out notifications, blogging and posting updates to Twitter instead of publishing in medical journals. And while most doctors believe that technology can help to strengthen the doctor-patient bond, that’s not the case for telemedicine. Indeed, for many doctors, telemedicine seems to depersonalize the relationship and sabotage trust.

But are doctors resisting telemedicine based on truth or on fear? And if we are afraid, how can we address or adjust those fears in a way that might better help patients?

A recent study by researchers at the University of Texas Medical School in Houston looked at the impact of telemedicine on patients in the intensive care unit. Although the researchers had initially set out to study telemedicine’s effect on mortality, complications and the length of stay of patients in five different hospitals, they inadvertently discovered the extent to which clinicians were reluctant to incorporate this technological change.

Every I.C.U. patient in the study received the usual on-site care throughout the study, as well as all the additional audiovisual and vital signs monitoring offered by a remote critical care specialist 24 hours a day. In addition, each patient’s physician could choose the degree to which the remote specialists would be involved in delivering direct care — that is, giving orders and intervening from afar.

If the patient’s physician wanted only minimal remote direct involvement, the remote clinicians would offer care only during unexpected life-threatening emergencies, like sudden drops in blood pressure or acute bleeding. If the regular physicians wanted maximum involvement, the remote clinicians would work together with the on-site doctors and give routine orders and change treatment plans.

Clearly for an I.C.U. patient there are potential advantages to having an “extra set of eyes” at all times, eyes that might notice a disconnected monitor or an errant passing, but potentially recurrent, lethal heart rhythm. And at least anecdotally, many patients seemed to welcome the additional monitoring. “Families seemed to be very accepting of the technology because they felt that someone was always looking in on the patient,” said Dr. Bela Patel, the senior author of the study and executive medical director of critical care at the Memorial Hermann Hospital-Texas Medical Center.

Despite the seemingly obvious advantages and patient willingness, however, the majority of doctors in the study chose to have as little remote involvement for their patients as possible. Many were worried about telemedicine’s effect on their relationships with patients and that it might adversely affect care.

“Certainly some of the doctors were just skeptical,” said Dr. Eric J. Thomas, a lead author of the study and director of the University of Texas-Memorial Hermann Center for Health Care Quality and Safety, “but others were hesitant because of how they felt about their relationship with their patients.”

“Some physicians felt we were being too intrusive,” Dr. Patel added. “We would recommend changing the ventilator settings, for example, but it wouldn’t be how they practiced. The doctors would respond, ‘It’s my patient; leave me alone.’ They did not want 20 people looking in on their patient and seeing if anything else could be done.”

And doctors were not the only ones who resisted this technology; nurses did, too. “Some of the nurses felt that somebody was looking over their shoulder all the time,” Dr. Patel commented. “And someone was. In the right context that would have been helpful; but if all that the nurses were hearing from the remote clinicians was that their patient’s EKG leads were disconnected or that a certain monitor had fallen off again, they ended up frustrated.” While the nurses acknowledged that reminders like these were important, “we were also bothering their workflow. The nurses would say, ‘Stop calling me. I don’t want to hear that again.’ ”

This lack of acceptance made it difficult for the study investigators to assess the impact of telemedicine on patients who were less sick but who had much to gain. “Early recognition of changes in a patient’s status is what really helps in critical care,” Dr. Patel said. “When a patient’s heart stops or a patient is clinically crashing, everyone knows about it. But when a patient’s heart rate goes up slightly, not everyone catches that. If you notice and act upon these kinds of changes early, you can rescue the patient early.”

While the researchers ultimately found that telemedicine could significantly improve survival among the sickest of I.C.U. patients, the resistance of on-site clinicians made it nearly impossible to assess the broad impact of such technology on quality of care. “Perhaps we never reached telemedicine’s full potential in this study because we did not have adequate acceptance,” Dr. Patel reflected. “You can’t just randomly assert some technology. You need a significant infrastructure to use it effectively, and that includes widespread acceptance.”

That acceptance will first require redefining the patient-doctor relationship in light of this new use of technology. Telemedicine and the idea of unseen clinicians in a remote “control room” doling out care is scary. But with dire predictions of physician shortages, particularly in rural regions, and insufficient numbers of critical care specialists even in large metropolitan areas, telemedicine likely has an important role in improving the quality of patient care.

But it will only work if all of us, doctors and patients, accept care from a clinician working in conjunction with a team of providers, each of whom is deeply engaged and committed to the patient, and some of whom, on occasion, may not be anywhere near that patient’s bedside, city or state.

“My view is that we want to provide the highest quality care possible for our patients,” Dr. Thomas said. “In some situations that might be with a remotely located physician; in others, not. I think that as long as we keep our eye on the ball — that ball being the patient — we will be okay in the end.”

“We can divide our work up in new ways and still do what is best.”

Q: If you were a patient, would you like that your doctor diagnoses you by using telemedicine?