During the worst phase of the Covid pandemic last year, I received a call for a consultation at my clinic in south Kolkata. During this period mostly emergency patients were being attended to and routine consultations deferred. The person kept insisting on a face-to-face meeting and said any form of teleconsultation, audio or video, would be inadequate.
I had to agree.
The next evening, a young couple, Shekhar and Leena (names changed to protect their identity), both in their late 20s, walked into the clinic. Sadly, Leena had a recently diagnosed locally advanced breast cancer, which needed chemotherapy followed by surgery and further medical treatment.
After the medical discussion, Shekhar requested to discuss some issues in the absence of his wife.
Shekhar and Leena were married just two months before and it was an arranged marriage. However, he was yet to develop any emotional or physical bond with her as they hardly knew each other. The very thought of prolonged cancer therapy and uncertain future was an enormous burden for him. Shekhar agreed to take the economic liability but after prolonged thought decided to separate as such a relationship would hamper his professional progress.
He always dreamt to be successful, rich and famous. He asked: “Doctor, how can I achieve my dreams with such liabilities?” To my peril, he kept demanding an opinion regarding his decision to separate.
Intimate conversation or clinical examination is not feasible in tele-consultations, especially in cases which involve intricate medical, social, economic or such emotional dilemmas. Clinical medicine cannot fully replace telemedicine as it has many limitations.
However, delivery of healthcare services at a distance through the use of technology is useful in some situations. This forms the basis of telemedicine. The common modes are video, online, audio and text-based communication.
The VOCAL study led by the Nuffield Department of Primary Care Healthcare Services, University of Oxford, was among the first major publications regarding telemedicine. It made some significant observations:
- It is more cost-effective, but maybe clinically risky
- Telemedicine faces significant technical, logistical and regulatory challenges
- It is a partial solution to the complex challenges of delivering healthcare
- It saves cost and the inconvenience of travel but economic evaluation is necessary.
- It is a viable option for unwell patients incapable to travel long distances.
Telemedicine offers other advantages as well. It reduces the chances of infection during the pandemic. There is improved documentation and data collection. Written documentation increases the legal protection for both parties.
It is much easier to get a second opinion from renowned consultants and institutions. It is also time saving and helps to decongest crowded hospital outdoors. In India healthcare can reach remote areas through telemedicine, as it requires a minimum infrastructure.
There are also significant limitations regarding telemedicine. It is not of much use during emergencies or where physical examination is mandatory. There is not much of an option to judge the quality of the opinion provided. Insurance cover may not be available and there are chances of misuse regarding prescription of drugs.
If the first consultation is via telemedicine, valuable clinical information may be missed. Video consultations will need high-quality internet connection at both ends. Text-based communication cannot establish good rapport and there may be an identity crisis.
However, whenever clinically appropriate, it is a safe, effective and valuable modality.
The telemedicine guidelines in India were made effective from March 25, 2020. It was formulated by the board of governors, in supersession of the Medical Council of India, with the partnership of Niti Aayog.
Important regulatory decisions were taken. Registered medical practitioners intending to provide online consultations need to complete a mandatory online course within three years of its notification. Most categories of medication cannot be prescribed during teleconsultation. Medicines which are safe and available across the counter like paracetamol, ORS or “refill” or “add-on” drugs, which have already been prescribed before, may be given. Prescription of narcotic or psychotropic drugs having a high potential of abuse are strictly prohibited.
A word of caution for “cyberchondriacs” regarding self-diagnosis.
Those solely depending on online information for diagnosis are always at a risk for mis-diagnosis. Symptoms of common cold may appear like advanced throat cancer. It may affect mental health.
Telemedicine is a much easier and better option for those who cannot visit the hospital.
Coming back to Shekhar‘s dilemma, I did offer him a probable solution for compromise but he disagreed. Opinions can differ but this face-to-face consultation gave him much solace.
Any suggestions for the young guy?
Advisory
- Always advisable to treat the patient, not just the reports
- The first consultation should ideally be in-person
- Rational and judicious use of telemedicine is welcome, especially during a pandemic
- Choose any modality for medical consultation but not self-diagnosis
- Setting up e-clinics by the government is a step in the right direction
- Clinical medicine cannot be replaced by telemedicine. The two can complement each other
Gautam Mukhopadhyay is secretary of the Bengal Oncology Foundation and clinical director of the department of surgical oncology, Peerless Hospital