This pandemic has unleashed a dormant beast. Telehealth is here and many believe it will stay even after the COVID-19. It may be true but as a doctor for me is hard to understand this idea. It is even harder for me to understand when doctors themselves defend telehealth as a major tool for daily clinical practice. Probably because they can be in several clinics at the same time. Unreal. When the world is suffering from the confinement because we cannot hold hands, because we cannot touch each other, telehealth looks like a demon. Although having advantages during the pandemic, in some way it is a drawback for those who enjoy medical practice, for those doctors who actually enjoy medicine. I will explain my view in the following lines.
It is impossible to disagree with the advantages of telehealth during the outbreak. The opinion paper published last month in “The American Journal of Surgery” by Dr. Abraham Hakim from Cooper Medical School in USA, clearly present those advantages. Telehealth can be videoconference, telephone calls and instant messaging. It is interesting to read that the authors believe telehealth is important to use during the pandemic mainly for oncological patients aiming at reducing time gap between diagnosis and treatment. On the contrary telehealth use is not a priority when we are dealing with patients with benign diseases, whose treatment can be postponed. Telehealth can allow a preoperative evaluation and videoconferencing with patient and family explaining indications and complications of surgery. However, doctors should always do an in-person evaluation on the morning of the surgery. The lack of physical examination is the major drawback of telehealth. For me this is one of the reasons why it cannot be here to stay. Even though, the authors suggest using videoconference with a primary physician who performs the physical examination for the surgeon as one way to overcome this major drawback of telehealth. This is unreal, I think. A surgeon’s hand has different sensibility than another doctor’s hand. I would never operate a patient based on another doctor’s physical examination. Would you?
Then comes the postoperative evaluation and complications diagnosis. This is also possible with telehealth according to Dr Abraham Hakim. Using pictures taken by the patients themselves and shared with the doctor by telephone or videoconference, postoperative complications are possible to diagnose. How can this be true without physical examination? How can we rely on pictures taken by a non-doctor patient to diagnose something the patient himself does not know how to identify? One day, one patient who I operated to a colon cancer entered my office with a huge smile on his face. He told me everything was great. However, an incisional hernia was found during the physical examination. Because the patient thought everything was normal and was happy with the results, he could not identify this simple complication. Can you imagine how a telehealth consultation would be with this patient? Also interesting is the fact that the authors say that must be the patient to decide whether he wants to be or not be evaluated by telehealth. In medicine there are decisions too important to be ultimately taken by a non-doctor person who is also a patient.
The lack of physical examination is a major drawback.
How can we rely on pictures?
Because non-oncological surgeries have been postponed, the authors suggest that telehealth can be used by primary care doctors and urgent care doctors to obtain a surgical consult to decide if a particular patient needs an urgent surgery. Although telehealth avoids the risk of COVID-19 exposure of an emergency department going, I do not believe a surgeon can accurately decide if the patient is or is not in the need for an urgent surgery by telehealth. Sometimes he can but many times he cannot. A patient is much more than a telephone call or a videoconference.
The Covid-19 pandemic brought new challenges for doctors and for all healthcare systems. In that setting, telehealth is a true advantage because it decreases the risk of COVID-19 exposure for both patients and doctors. During the COVID-19 outbreak, telehealth was of major help trying to minimize the negative impact it caused for diagnosis and treatment of several pathologies. But it cannot become the rule. Humans are social animals. Humans need personal contact. Patients and doctors are not different. Consulting a patient is not reading imaging reports, reading blood tests or asking for more exams. Consulting a patient is touching the person we have in front of us, is doing a good physical examination, is watching how the patient behaves, how the patient walks, how the patient moves, is watching the eyes’ movement and head movement when talking about his disease, is knowing if the hands are sweaty or shaking, is understanding the breath rhythm when we are explaining a procedure, is touching a hand to calm down an anxious patient and is the blink of an eye to say everything will be ok. Consulting a patient is much more than a videoconference, telephone call or instant messaging. In-office consultations cannot be routinely replaced by telehealth. Medicine as well as many things in our lives cannot be tele…something.
Consulting a patient is touching the person we have in front of us (...) is the blink of an eye to say everything will be ok.
The authors say “COVID-19 pandemic has already plunged the American Healthcare System into a technological world it may not have been ready for, an so we must adapt”. Attention to this dangerous idea which can be misunderstood. Telehealth emerged to help doctors treat patients, but doctors must not change their practice to give telehealth space in healthcare systems. Medicine and medical practice do not need to adapt to anything. This is a wrong idea supported by the many non-doctor people who is undermining the healthcare systems and who do not understand what Medicine is and what it needs. The administrative procedures and informatic tools are the ones that need to adapt to what Medicine and medical practice need. Additionally, the administration boards and the non-doctor personal are those who need to adapt their practices to what doctors need to better treat the patients. A patient goes to the hospital or health center to see the doctor, not to see the administration board or the informatic engineer. Doctors, patients and medical practice are the main core of the health system. The entire health system must work to help doctors treat patients. In a global view, this is not the case in the present days. The “system” is making doctors’ job harder and harder every day. But let’s keep our focus…
Although important in some exception situations, Medicine will go all to pot if telehealth become the rule.
I fully agree with the final sentence of the authors where they state, “it is clear that telehealth can be a powerful tool to maintain quality healthcare while preserving the safety of patients amid the current pandemic”. However, the pandemic is one of several exceptions. Telehealth must be the exception because it cannot fully replace an in-office consultation. As a final idea I tell you another true story which should make you doubt the accuracy of telehealth. One male patient was sent to surgery consultation by is general practice doctor because of symptomatic gallstones and the need for cholecystectomy. During consultation and physical examination an abdominal pain in the right quadrants with suspected palpable mass was found. We decided to perform a colonoscopy before cholecystectomy. A right colon cancer with multiple hepatic metastases was the final diagnosis. In a telehealth consultation the patient would be sign in for elective cholecystectomy. It would have been a disaster and bad medical practice.
Always remember that you as a doctor must not change your practice because of telehealth nor other non-medical procedures. Although important in some exception situations, Medicine will go all to pot if telehealth become the rule.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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