Anyone who doubts that doctors will consult patients on line hasn’t heard of the hugely successful Sherpaa. It’s happening already in the US and in some other parts of the world. Elsewhere doctors will soon consult via the internet. It is only a question of how the service will be configured.
In a previous post I offered a way to consider what motivates doctors, what determines their ability to do things and what might trigger that action. The key questions in relation to video consults is how doctors might respond when faced with the variety of clinical problems that could possibly present on line. Also what that might tell us about the implementation of such technology. We set out to explore these questions recently. You can read our paper and watch videos of how patients might present on line here.
A: Rewards for action
Funding restrictions were a major factor in deterring doctors from consulting on line. Unless governments subsidise the consultation it is unlikely to happen for people relying on government funded schemes. Where it is happening, private providers are stepping in to offer the service to paying customers.
In a previous study we demonstrated that telephone consultations significantly reduced consultation time relative to face to face meetings. There is no reason to suppose that video consults would be any different.
This was perhaps the greatest factor moderating the motivation for video consults. Some scenarios were regarded as extremely high risk for adverse events and for litigation. Patients presenting with symptoms of an acute life threatening condition were considered the least suitable for a video consultation. Some scenarios were deemed too difficult to manage without a physical examination. Others were considered suitable if there was scope to see the patient in person in the near future. A literature search also raised concerns about potential breaches of patient confidentiality when consults are conducted via video technologies.
The issue of cost was not explored in our study. However this may be related to the lack of remuneration for video consults. No payment would result in a significant opportunity cost.
Some scenarios were considered too difficult to manage without a physical examination. Indeed the need for physical examination to establish a diagnosis was a common concern. Unexplained abdominal pain and upper respiratory tract infections were of particular concern. In other cases the scope to establish a rapport was considered insufficient, for example in the case of the patient with substance abuse:
…the use of an online consultation in this case inhibits developing rapport particularly with a patient whom I have only seen occasionally.
We also recorded a significant difference in attitudes to video consults based on the demographic profile of respondents to our study. Participants who had been practicing as GPs for longer, GPs in training, those who worked in remote practice, and those from larger group practices were most enthusiastic about video consultations.
R: Recognising the suitable patient
Our data indicate that access to video consultations will need to focus on patients with on-going medical illness, where the purpose of the consultation is to offer support. Medical practitioners appear confident about their ability to conduct video consultations however in the context in which we explored this question it is not yet routine practice.
K:Knowing what is available
Doctors in our study were unequivocal in asserting that the video consult option was not available to them at this point in time. In a previous review we explored the possibility that internet speeds and access to the relevant hardware and software may be a rate limiting step in the adoption of video technologies.
Video consults will become routine practice in most countries when they are supported with the infra structure to make is easy for doctors to make the choice to offer the service to their patients. In many scenarios motivation and ability appear to be high. The majority of doctors in our study would either conduct video consults or consider doing so. The service is most likely to be offered to patients who either will be seen in person in the near future or seeking support for an established condition.
Picture by Matthew Hall