Telemedicine “brings” much needed medical care to remote areas
March 11, 2019 3:38 AM Subscribe
What happens when you need an actual person to give bad news? Telemedicine has given rural areas access to medical care while giving doctors the opportunity to provide care without a long commute. People need to see and speak to actual people sometimes.
Every day I feel more and more like I'm living inside of a reality envisioned by someone like David Lynch and/or David Cronenberg. It seems their films were less science-fiction/horror than we imagined. They were simply prophets.
I don't want to live in this timeline.
posted by Fizz at 4:40 AM on March 11, 2019 [14 favorites]
I don't want to live in this timeline.
posted by Fizz at 4:40 AM on March 11, 2019 [14 favorites]
it seems like the problem is real but neither deeply institutional ... or intractable
It's both. I'm from a rural town (population 60, an hour to the nearest basic clinic), and the problem is that rural areas face systemic, long-time and deep problems that dissuade qualified medical personnel from wanting to live and work there, for very legitimate reasons. The very fact that health care is limited is reason enough to not want to become a rural doctor. There are a wide variety of specialities that would be utterly non-existent if not for telemedicine in many places. There is a limited supply of people capable of being doctors who are also willing to live in places where services are limited. That isn't the fault of doctors, it's not the fault of the people who live there, it's the fault of the system. It's probably not intractable, but it's unlikely to change anytime soon. Direct action to change the form of the US health care system is probably the best option, second to some radical change to our economic system that can somehow motivate or at least make not it not bad to live and work in rural areas.
So I wrote all that and then looked up the town the article mentions and it has a population of about a quarter of my entire state, so I guess I don't know what 'rural' means anymore. It's utterly insane that a population center the size of the largest city where I'm from can't sustain an actual hospital with actual doctors for this kind of thing. I read this thinking it was a town of a couple thousand or something, and what I said still stands, but damn do I not know why this happened there. Telemedicine isn't the upsetting part, it's that this happened in a dang city, where the advantages of telemedicine are minimalized. From that perspective, this doesn't read like an access issue, but a cost cutting issue, in this specific case.
posted by neonrev at 5:23 AM on March 11, 2019 [21 favorites]
It's both. I'm from a rural town (population 60, an hour to the nearest basic clinic), and the problem is that rural areas face systemic, long-time and deep problems that dissuade qualified medical personnel from wanting to live and work there, for very legitimate reasons. The very fact that health care is limited is reason enough to not want to become a rural doctor. There are a wide variety of specialities that would be utterly non-existent if not for telemedicine in many places. There is a limited supply of people capable of being doctors who are also willing to live in places where services are limited. That isn't the fault of doctors, it's not the fault of the people who live there, it's the fault of the system. It's probably not intractable, but it's unlikely to change anytime soon. Direct action to change the form of the US health care system is probably the best option, second to some radical change to our economic system that can somehow motivate or at least make not it not bad to live and work in rural areas.
So I wrote all that and then looked up the town the article mentions and it has a population of about a quarter of my entire state, so I guess I don't know what 'rural' means anymore. It's utterly insane that a population center the size of the largest city where I'm from can't sustain an actual hospital with actual doctors for this kind of thing. I read this thinking it was a town of a couple thousand or something, and what I said still stands, but damn do I not know why this happened there. Telemedicine isn't the upsetting part, it's that this happened in a dang city, where the advantages of telemedicine are minimalized. From that perspective, this doesn't read like an access issue, but a cost cutting issue, in this specific case.
posted by neonrev at 5:23 AM on March 11, 2019 [21 favorites]
For those of you unfamiliar with the remote areas of Northern California, this particular case happened in Fremont, a dusty one-horse town of not even a quarter of a million people that is known primarily for its proximity to a little-known gulch called "Silicon Valley".
posted by Etrigan at 5:25 AM on March 11, 2019 [45 favorites]
posted by Etrigan at 5:25 AM on March 11, 2019 [45 favorites]
I have seen nothing to dissuade me of my initial impression of telemedicine, which is that it is a way for policymakers to pretend that they are addressing health access problems by adding technology. There are certainly cases in which telemedicine / telehealth meets a need, but while meeting that need it distorts the market -- especially in rural areas -- in ways that are going to really hurt people and communities.
Until recently I did consumer-side health policy in New York State and this is basically my concern: A family doctor in, say, Lewis County, NY, which is a relatively remote and pretty rural county in upstate NY, is likely to be closer to retirement than to graduation. As neonrev points out, there are not a lot of young doctors looking to move to very rural parts of the country and run a small practice. Our doctor's practice may be stable but it is not growing: let's say that it serves 100 people just to have a round number. In a given year, the doctor does the work of treating 100 regular patients with a variety of levels of treatment from well patient checkups to sick child visits to diagnosis and referral of more serious issues which may be treated by specialists in, let's say, Watertown or Utica or Syracuse, an hour's drive or more for a patient in Lewis County.
Telemedicine is not a 100% substitute for an in-person doctor visit. At some point, every single one of those 100 people will need to see the doctor in person. But suppose that telehealth is able to perform the easy things that amount to 30% of the doctor's work in a given year, more cheaply than the doctor is able to do them. Insurance companies will direct people to use telehealth in gentle and overt ways. Some people will know their rights and insist on using their doctor, but some won't. Some just won't bother to fight it. Over a relatively short amount of time the doctor will lose let's say 15% but potentially up to 30% of her revenue. What had been a stable practice that might have continued for years is now in real danger of closing. At exactly the moment when rural areas need to be able to attract young doctors, telehealth will destabilize and gut the rural general practice market.
posted by gauche at 6:36 AM on March 11, 2019 [20 favorites]
Until recently I did consumer-side health policy in New York State and this is basically my concern: A family doctor in, say, Lewis County, NY, which is a relatively remote and pretty rural county in upstate NY, is likely to be closer to retirement than to graduation. As neonrev points out, there are not a lot of young doctors looking to move to very rural parts of the country and run a small practice. Our doctor's practice may be stable but it is not growing: let's say that it serves 100 people just to have a round number. In a given year, the doctor does the work of treating 100 regular patients with a variety of levels of treatment from well patient checkups to sick child visits to diagnosis and referral of more serious issues which may be treated by specialists in, let's say, Watertown or Utica or Syracuse, an hour's drive or more for a patient in Lewis County.
Telemedicine is not a 100% substitute for an in-person doctor visit. At some point, every single one of those 100 people will need to see the doctor in person. But suppose that telehealth is able to perform the easy things that amount to 30% of the doctor's work in a given year, more cheaply than the doctor is able to do them. Insurance companies will direct people to use telehealth in gentle and overt ways. Some people will know their rights and insist on using their doctor, but some won't. Some just won't bother to fight it. Over a relatively short amount of time the doctor will lose let's say 15% but potentially up to 30% of her revenue. What had been a stable practice that might have continued for years is now in real danger of closing. At exactly the moment when rural areas need to be able to attract young doctors, telehealth will destabilize and gut the rural general practice market.
posted by gauche at 6:36 AM on March 11, 2019 [20 favorites]
Hell, we are in a non-remote, but non-urban (1 hour drive to a decent metropolitan center) place and the fact that my wife's office offers telemedicine access/support to a psychiatrist that can help manage meds for folks is huge. The wait list is tremendous even for that.
Say what you will, and I'm not educated enough to get into the systemic problems that brought us to this place, but it's one way of delivering service to folks that are clamoring for it. Under served populations are not at all hard to find when it comes to medical care in the US. It's disgusting and everyone hates dealing with the insurance hoops to get folks care when they need it. Her life/practice would be much easier, and likely more lucrative, if they simply said 'screw it' and just did private pay/evaluation type work but they try to get on as many insurance lists as they can because the services they offer, ya'know, actually help people (and not just folks that are rich enough to fork out $1k for an evaluation or assessment).
posted by RolandOfEld at 6:53 AM on March 11, 2019 [13 favorites]
Say what you will, and I'm not educated enough to get into the systemic problems that brought us to this place, but it's one way of delivering service to folks that are clamoring for it. Under served populations are not at all hard to find when it comes to medical care in the US. It's disgusting and everyone hates dealing with the insurance hoops to get folks care when they need it. Her life/practice would be much easier, and likely more lucrative, if they simply said 'screw it' and just did private pay/evaluation type work but they try to get on as many insurance lists as they can because the services they offer, ya'know, actually help people (and not just folks that are rich enough to fork out $1k for an evaluation or assessment).
posted by RolandOfEld at 6:53 AM on March 11, 2019 [13 favorites]
It costs roughly 200k to become a doctor. Sure, once you become a doctor you can bring in 150-300k a year, but that depends upon specialty/location. You still have to get the money upfront and the price of failure is astounding. If you spend a decade of your life trying for a doctorate and fail, you still have to pay that money back.
There aren't enough doctors because we make it too difficult to become one.
posted by domo at 7:00 AM on March 11, 2019 [7 favorites]
There aren't enough doctors because we make it too difficult to become one.
posted by domo at 7:00 AM on March 11, 2019 [7 favorites]
It was once my job to research the feasibility of setting up telemedicine for a large urban hospital, and despite the promise of being able to provide Level I trauma center expertise to rural/out-state hospitals, I could never get the financial numbers to work. The finances only made sense for multi-hospital corporations spread over a large geographic area whose patients could be seen “virtually” by doctors in a central telemedicine bunker, thus reducing transportation costs for patients who may need to be transferred to a higher-level of care somewhere else within their own hospital system. Just like Kaiser Permanente in that article, which resulted in the awful situation that the family described.
One of our doctors wanted to be able to provide telemedicine follow-up visits for burn/frostbite patients who were originally airlifted to our hospital but were recovering at home, so patients wouldn’t have to drive 4+ hours to see her for a quick outpatient visit. At the time, Medicare reimbursement only allowed for telemedicine services in a hub (urban) to spoke (rural) Model, but the interested partner hospital in North Dakota was also somehow designated as “urban” and our doctors would have to get licensed in North Dakota to “see” patients on the other side of the river, and it was just one barrier after another. The reimbursement rules have since been loosened, and I’ sure the technology is a lot better and cheaper now, but in this current era of hospital consolidation/closures I don’t know that telemedicine is going to do much to help struggling rural patients.
posted by Maarika at 7:02 AM on March 11, 2019 [4 favorites]
One of our doctors wanted to be able to provide telemedicine follow-up visits for burn/frostbite patients who were originally airlifted to our hospital but were recovering at home, so patients wouldn’t have to drive 4+ hours to see her for a quick outpatient visit. At the time, Medicare reimbursement only allowed for telemedicine services in a hub (urban) to spoke (rural) Model, but the interested partner hospital in North Dakota was also somehow designated as “urban” and our doctors would have to get licensed in North Dakota to “see” patients on the other side of the river, and it was just one barrier after another. The reimbursement rules have since been loosened, and I’ sure the technology is a lot better and cheaper now, but in this current era of hospital consolidation/closures I don’t know that telemedicine is going to do much to help struggling rural patients.
posted by Maarika at 7:02 AM on March 11, 2019 [4 favorites]
This particular kind of telemedicine has little to do with rural access and is about enabling care at smaller hospitals, often in suburban or urban contexts. Smaller hospitals are more agile and save money by not buying expensive seldom useful capabilities, but run into problems of small scale. A very common one is the lack of critical care trained physicians. If a hospital only has 4-8 ICU beds, the typical model is for the hospitalist or surgeon taking care of that patient to continue directing care if they are admitted to the ICU, perhaps with a critical care nurse practitioner on the ground and consultation with a specialist (like pulmonology if they don't know how to manage a ventilator). They could hire a critical care specialist, but that costs money and the CC doc wouldn't have many patients to work with to justify their billing. The next step down the road is to hire a CC doc for the daytime only, as most of the time the night crew can just carry on the plan from the day.
Tele-ICU docs help fill in the gap by essentially allowing the hospital to go part-time on a CC specialist to allow a single CC doc to cover multiple hospitals, especially at night. One of the things CC specialists are better at is pulling the trigger on comfort care when it's time, and I can see the primary doc being nervous about doing it themselves. Docs transitioning to telemedicine are often not good right away at picking up the essential communication differences
posted by a robot made out of meat at 7:02 AM on March 11, 2019 [6 favorites]
Tele-ICU docs help fill in the gap by essentially allowing the hospital to go part-time on a CC specialist to allow a single CC doc to cover multiple hospitals, especially at night. One of the things CC specialists are better at is pulling the trigger on comfort care when it's time, and I can see the primary doc being nervous about doing it themselves. Docs transitioning to telemedicine are often not good right away at picking up the essential communication differences
posted by a robot made out of meat at 7:02 AM on March 11, 2019 [6 favorites]
Telemedicine of the more modern sort is driven - unsurprisingly - by profit. In our hospital in FL (county population 150k), the ICUs we’re staffed by very competent multiply board-certified pulmonologists/critical care specialists. These private physicians charged and received payment for their clinical services. The hospital then decreed that the ICU patients would now be cared for by a critical care group on a contract (much like the hospital contracted with an ER staffing group, a remote pathology group, and a remote radiology group for those services). Functionally, nurse practitioners supervised remotely by physicians in another state managed the ICU patients. The hospital thus was able to capture an additional revenue stream of the ICU care (minus the expense of hiring NPs and the contract costs of the remote MDs). The local docs ... well, sucks to be you. Of course, they might get called in for a bronchoscopy rarely.
The Kaiser hospital is doing the same thing. Instead of hiring hospitalist MDs, they hire NPs for 1/3 the cost to manage hospital patients, supervised at some level by an MD. It’s force multiplication and profit multiplication as the NP can bill the same amount for a service as a MD provided they are ‘supervised’ by a MD.
So all the talk of ‘increased access’ and ‘rural outreach’ is propaganda. Most telemedicine applications are not in underserved areas but in hospital chains as a business strategy.
posted by sudogeek at 7:32 AM on March 11, 2019 [9 favorites]
The Kaiser hospital is doing the same thing. Instead of hiring hospitalist MDs, they hire NPs for 1/3 the cost to manage hospital patients, supervised at some level by an MD. It’s force multiplication and profit multiplication as the NP can bill the same amount for a service as a MD provided they are ‘supervised’ by a MD.
So all the talk of ‘increased access’ and ‘rural outreach’ is propaganda. Most telemedicine applications are not in underserved areas but in hospital chains as a business strategy.
posted by sudogeek at 7:32 AM on March 11, 2019 [9 favorites]
I work for a pediatric hospital that does a fair amount of outreach work. We've started using telehealth as a supplement & I've found it useful for things like pre-op visits, when the family is coming up from somewhere far and will see me in person right before surgery but this way we can go over the surgical plan in detail a few weeks before and they can ask questions well in advance. That way I can also confirm there haven't been any major changes and make sure we have the right plan in place, etc, and the family feels better having done that before they get on a plane, I think. It can also be useful for quick check-ins or to order studies or something where it doesn't make sense for the family to travel hours to see me only for me to say we need an MRI & come back again after that, and can also be great if you want to consult another doctor somewhere else (or they want to consult you) on something rare/difficult and again this way the family doesn't have to travel so much.
So I think it has a place/use but I cannot imagine giving someone bad news this way.
posted by n. moon at 7:57 AM on March 11, 2019 [8 favorites]
So I think it has a place/use but I cannot imagine giving someone bad news this way.
posted by n. moon at 7:57 AM on March 11, 2019 [8 favorites]
> David Lynch and/or David Cronenberg. It seems their films were less science-fiction/horror than we imagined.
Re Cronenberg: he explicitly states in an interview somewhere that he made horror/sci-fi movies simply because it was easier to make whatever movie he wanted. The sci-fi angle in his work is as much an accident of the studio funding system as it is artistic expression.
posted by cirgue at 8:01 AM on March 11, 2019 [1 favorite]
Re Cronenberg: he explicitly states in an interview somewhere that he made horror/sci-fi movies simply because it was easier to make whatever movie he wanted. The sci-fi angle in his work is as much an accident of the studio funding system as it is artistic expression.
posted by cirgue at 8:01 AM on March 11, 2019 [1 favorite]
Takes all types. I would very much want to receive news like that via teleconference. I don’t need someone — particularly a stranger — all up in my face while I’m digesting life changing information.
posted by Tell Me No Lies at 8:24 AM on March 11, 2019 [7 favorites]
posted by Tell Me No Lies at 8:24 AM on March 11, 2019 [7 favorites]
They are having one of the worst days of their lives and much like their grandfather's condition there is little to nothing that can be done for the pain.
Death is always just going to feel wrong and some of that is going to leak out at any possible target.
posted by srboisvert at 8:41 AM on March 11, 2019 [5 favorites]
Death is always just going to feel wrong and some of that is going to leak out at any possible target.
posted by srboisvert at 8:41 AM on March 11, 2019 [5 favorites]
At exactly the moment when rural areas need to be able to attract young doctors, telehealth will destabilize and gut the rural general practice market.
But in the absence of telemedicine, how can we deliver care to those rural areas? As you noted, no doctors want to set up shop there, and it's not the threat of telemedicine that's keeping them out. Isn't this better than the nothing that seems to be the alternative?
I'm thinking specifically of where my wife's grandmother lives, in Eudora, Arkansas. There's nothing there - the main street is literally full of abandoned storefronts. What's someone in that town supposed to do if they need to see a psychiatrist? Drive two hours round trip every week to the nearest city in Mississippi? Obviously the best thing would be for there to be a psychiatrist nearby, but what would induce a psychiatrist, especially one carrying a full load of med school debt, to move there?
posted by Ragged Richard at 9:00 AM on March 11, 2019 [12 favorites]
But in the absence of telemedicine, how can we deliver care to those rural areas? As you noted, no doctors want to set up shop there, and it's not the threat of telemedicine that's keeping them out. Isn't this better than the nothing that seems to be the alternative?
I'm thinking specifically of where my wife's grandmother lives, in Eudora, Arkansas. There's nothing there - the main street is literally full of abandoned storefronts. What's someone in that town supposed to do if they need to see a psychiatrist? Drive two hours round trip every week to the nearest city in Mississippi? Obviously the best thing would be for there to be a psychiatrist nearby, but what would induce a psychiatrist, especially one carrying a full load of med school debt, to move there?
posted by Ragged Richard at 9:00 AM on March 11, 2019 [12 favorites]
I am an emergency physician working at a busy rural and remote facility (12 bed ED, 50 bed inpatient hospital which is about 60 miles from the closest large tertiary center) as my full-time job. Ask me anything, I guess?
We make extensive use of telemedicine and it enormously augments the care we're able to provide locally, without taking patients out of their community and away from their support network and without breaking continuity of care with a transfer out to a larger center. Most of our telemedicine docs are outstanding.
During the daytime we're staffed by inpatient hospitalists but at night we move to a tele-hospitalist model, with our remote docs logging into a telemedicine "robot' (basically a telepresence camera setup and screen with some weird attachments) to assess patients. We have 24/7 telenephrology services to facilitate emergency hemodialysis. We have teleneurology and telestroke services available in minutes for patients with neurologic emergencies. We have telepsychiatric services to facilitate assessment and treatment of patients in psychiatric crisis.
In summary, telemedicine is a land of contrasts, but mostly good ones in my experience.
posted by killdevil at 9:04 AM on March 11, 2019 [19 favorites]
We make extensive use of telemedicine and it enormously augments the care we're able to provide locally, without taking patients out of their community and away from their support network and without breaking continuity of care with a transfer out to a larger center. Most of our telemedicine docs are outstanding.
During the daytime we're staffed by inpatient hospitalists but at night we move to a tele-hospitalist model, with our remote docs logging into a telemedicine "robot' (basically a telepresence camera setup and screen with some weird attachments) to assess patients. We have 24/7 telenephrology services to facilitate emergency hemodialysis. We have teleneurology and telestroke services available in minutes for patients with neurologic emergencies. We have telepsychiatric services to facilitate assessment and treatment of patients in psychiatric crisis.
In summary, telemedicine is a land of contrasts, but mostly good ones in my experience.
posted by killdevil at 9:04 AM on March 11, 2019 [19 favorites]
I would very much want to receive news like that via teleconference.
That was exactly my reaction the other day when a coworker pointed out how egregious this was. I would prefer talking to a robot. I know I'm in the minority here, but it isn't as simple as "bad news must always be delivered in person." Coworker said "What if your mom was shot? Would a text message be better than several cops at your door to tell you?" and she wouldn't believe me when i said yes to that too. I don't think people are wrong to be upset that a robot told them the news, but it's not as simple as it might seem.
posted by Clinging to the Wreckage at 9:10 AM on March 11, 2019 [7 favorites]
That was exactly my reaction the other day when a coworker pointed out how egregious this was. I would prefer talking to a robot. I know I'm in the minority here, but it isn't as simple as "bad news must always be delivered in person." Coworker said "What if your mom was shot? Would a text message be better than several cops at your door to tell you?" and she wouldn't believe me when i said yes to that too. I don't think people are wrong to be upset that a robot told them the news, but it's not as simple as it might seem.
posted by Clinging to the Wreckage at 9:10 AM on March 11, 2019 [7 favorites]
Throughout the conversation, Mr. Quintana was having trouble hearing the doctor, Ms. Wilharm said. She said the machine was on the side of her father’s deaf ear, so she had to repeat the doctor’s news.
In this case the patient didn't really get the bad news from his doctor via teleconference. He got it from a family member who then had to process the news and then deliver it.
Obviously there's no guarantee that the physician being physically present would have resulted in smoother communication, but I think it's at least more likely to have gone better: being physically there the physician would have been more mobile and (I would hope) more able to pick up on the guy hearing better out of one ear.
Better awareness of the patient's communication needs would likely have helped (i.e. not placing the screen on his bad side), but these are the kinds of things you need to think of and address before rolling out a new process.
posted by ghost phoneme at 9:26 AM on March 11, 2019 [2 favorites]
In this case the patient didn't really get the bad news from his doctor via teleconference. He got it from a family member who then had to process the news and then deliver it.
Obviously there's no guarantee that the physician being physically present would have resulted in smoother communication, but I think it's at least more likely to have gone better: being physically there the physician would have been more mobile and (I would hope) more able to pick up on the guy hearing better out of one ear.
Better awareness of the patient's communication needs would likely have helped (i.e. not placing the screen on his bad side), but these are the kinds of things you need to think of and address before rolling out a new process.
posted by ghost phoneme at 9:26 AM on March 11, 2019 [2 favorites]
There aren't enough doctors because we make it too difficult to become one.
Who is "we"? There aren't enough doctors because the AMA has designed it that way. Other countries have lots more doctors than the U.S. The AMA rigidly controls the supply of doctors in order to keep healthcare prices high.
posted by JackFlash at 9:54 AM on March 11, 2019 [8 favorites]
Who is "we"? There aren't enough doctors because the AMA has designed it that way. Other countries have lots more doctors than the U.S. The AMA rigidly controls the supply of doctors in order to keep healthcare prices high.
posted by JackFlash at 9:54 AM on March 11, 2019 [8 favorites]
I live in a large city and have friends who voluntarily use tele-options for therapists and psychiatrists. Even if there are closer options, it's important to find one you can have a good relationship with.
posted by tofu_crouton at 10:11 AM on March 11, 2019 [1 favorite]
posted by tofu_crouton at 10:11 AM on March 11, 2019 [1 favorite]
It seems to me that there could be a protocol that can make telemedicine work better in this scenario. Perhaps the specialist can brief the doctor in charge of the patient's care in the hospital by phone in advance of the patient call, then the on-site doctor can sit at the patient's bedside while the specialist speaks on TV. The on-site doctor then has all the same information as the patient, can watch the patient's reaction, can ask the specialist to repeat information, slow down, etc if the patient needs it, and can follow up after the call.
posted by crazycanuck at 10:35 AM on March 11, 2019
posted by crazycanuck at 10:35 AM on March 11, 2019
My medical center uploads test results to the patient portal immediately - before the doctor gets to see it. I'm a cancer patient, and this means I can potentially get extremely bad news via reading the results of a CT scan written up by a radiologist for a doctor to read - in other words, I get bad news from reading a report that often has information I don't completely understand. Sometimes I make myself wait until I get a call or message from the doctor, but this is very hard to do, as I'm usually very anxious about these tests.
I don't know why they do it this way. I hate it. My oncologist hates it. It doesn't seem it would be that hard to let patients opt out, but they don't. They used to only make the information available to patients after doctors OK'd releasing it - that made a lot more sense to me.
But it sounds like some people here would prefer this because it is like getting the news from a robot, though you could probably set a robot up to answer questions or at least give the news in nonspecialist-friendly terms.
posted by FencingGal at 12:07 PM on March 11, 2019 [2 favorites]
I don't know why they do it this way. I hate it. My oncologist hates it. It doesn't seem it would be that hard to let patients opt out, but they don't. They used to only make the information available to patients after doctors OK'd releasing it - that made a lot more sense to me.
But it sounds like some people here would prefer this because it is like getting the news from a robot, though you could probably set a robot up to answer questions or at least give the news in nonspecialist-friendly terms.
posted by FencingGal at 12:07 PM on March 11, 2019 [2 favorites]
I think there are two different problems tele-medicine can potentially solve and there are different things that need to be considered for each of them. They're similar, but not quite the same.
One problem is how to efficiently provide specialist coverage to everyone who needs a specialist. This has a lot to do with costs and how to best fill the time of in-demand specialists. Like, that small suburban hospital could have a psychiatrist and an orthopedic surgeon and a paediatric surgeon and a ... or they could have general surgeon, an internal medicine specialist, and a tele-medicine presence. There's a point where this falls over the line into cost cutting and managing margins instead of providing better patient care, though.
The other problem is how to provide health care at all to people who live in areas remote enough that it's difficult to sustain health care at all. Where the choices aren't about whether you have this specialist or that specialist but about how many times a year a doctor or NP would even visit the town. Canada has a lot of small towns where medical services are provided by doctors who fly in for a few days or a week and then fly to a different small town the next week, etc. Tele-medicine could allow a nurse to implement the orders of a tele-present doctor and provide more regular care for the community. In these cases, tele-medicine bridges the community during times it wouldn't otherwise have any medical care at all.
posted by jacquilynne at 12:28 PM on March 11, 2019 [3 favorites]
One problem is how to efficiently provide specialist coverage to everyone who needs a specialist. This has a lot to do with costs and how to best fill the time of in-demand specialists. Like, that small suburban hospital could have a psychiatrist and an orthopedic surgeon and a paediatric surgeon and a ... or they could have general surgeon, an internal medicine specialist, and a tele-medicine presence. There's a point where this falls over the line into cost cutting and managing margins instead of providing better patient care, though.
The other problem is how to provide health care at all to people who live in areas remote enough that it's difficult to sustain health care at all. Where the choices aren't about whether you have this specialist or that specialist but about how many times a year a doctor or NP would even visit the town. Canada has a lot of small towns where medical services are provided by doctors who fly in for a few days or a week and then fly to a different small town the next week, etc. Tele-medicine could allow a nurse to implement the orders of a tele-present doctor and provide more regular care for the community. In these cases, tele-medicine bridges the community during times it wouldn't otherwise have any medical care at all.
posted by jacquilynne at 12:28 PM on March 11, 2019 [3 favorites]
BTW, I started seeing my therapist through Skype when he moved because I didn't want to change therapists. You do lose something when you're not in the same room, but it works pretty well. And he's not giving me bad medical news. My understanding is that it's especially hard to find psychiatrists who treat children in remote areas.
I have also consulted with some specialists remotely because I'm looking for information from people who are especially knowledgeable about vegan diets. That works for a consultation, but again, that's not the same as getting bad news.
posted by FencingGal at 1:43 PM on March 11, 2019 [2 favorites]
I have also consulted with some specialists remotely because I'm looking for information from people who are especially knowledgeable about vegan diets. That works for a consultation, but again, that's not the same as getting bad news.
posted by FencingGal at 1:43 PM on March 11, 2019 [2 favorites]
They are having one of the worst days of their lives and much like their grandfather's condition there is little to nothing that can be done for the pain.
Death is always just going to feel wrong and some of that is going to leak out at any possible target.
Yeah, I'm not sure this would have gone super much better given that the whole point is to deliver bad news. It's like the endless "break up in person vs. on phone vs. text" arguments, or using cute euphemisms like "passed away" or "went to meet his Maker" or whatever instead of "died." You can nitpick and complain about how the message was delivered and yeah, that sucks, but you're still getting bad news and the medium delivery only slightly improves anything under that circumstance.
That said, I am still at a loss as to why they had to do a teleconference in Fremont. This wasn't Alaska.
posted by jenfullmoon at 1:49 PM on March 11, 2019
Death is always just going to feel wrong and some of that is going to leak out at any possible target.
Yeah, I'm not sure this would have gone super much better given that the whole point is to deliver bad news. It's like the endless "break up in person vs. on phone vs. text" arguments, or using cute euphemisms like "passed away" or "went to meet his Maker" or whatever instead of "died." You can nitpick and complain about how the message was delivered and yeah, that sucks, but you're still getting bad news and the medium delivery only slightly improves anything under that circumstance.
That said, I am still at a loss as to why they had to do a teleconference in Fremont. This wasn't Alaska.
posted by jenfullmoon at 1:49 PM on March 11, 2019
CBS Sunday Morning had a segment yesterday about the closure of rural hospitals that is a good complement to the discussion here.
posted by theartandsound at 1:52 PM on March 11, 2019 [1 favorite]
posted by theartandsound at 1:52 PM on March 11, 2019 [1 favorite]
I recently had a tele-medicine appointment where the doctor was remote but a nurse was still in the room with me. Nurse positions are easier to fill in rural areas than doctor positions, and a nurse can handle things like making sure the audio is audible and holding someone's hand (if they want) when they get bad news.
posted by sdrawkcaSSAb at 2:09 PM on March 11, 2019 [2 favorites]
posted by sdrawkcaSSAb at 2:09 PM on March 11, 2019 [2 favorites]
At exactly the moment when rural areas need to be able to attract young doctors
It’s not “a moment”. Rural areas have needed to attract young doctors for decades, but generally haven’t been able to.
posted by the agents of KAOS at 2:53 PM on March 11, 2019 [1 favorite]
It’s not “a moment”. Rural areas have needed to attract young doctors for decades, but generally haven’t been able to.
posted by the agents of KAOS at 2:53 PM on March 11, 2019 [1 favorite]
BC/BS is aggressively pushing tele-medicine for routine stuff - allergies, sinus infections, etc. I have no idea how a doctor online is going to decide if I have a cold or an infection requiring antibiotics. However, I'm currently looking at a $282 bill for 10 minutes with my internist's partner last month (discounted to $174 because people with expensive insurance should pay less than people without insurance), and I'm wondering how much less it might cost me to let a doctor in a call center somewhere give the prescription versus my doctor.
posted by COD at 4:12 PM on March 11, 2019 [1 favorite]
posted by COD at 4:12 PM on March 11, 2019 [1 favorite]
It's worth noting that the doctor in question thought that the information had already been delivered. It seems like there may have been a problem in carrying out their protocols, not necessarily with the protocols themselves.
That said, I am still at a loss as to why they had to do a teleconference in Fremont. This wasn't Alaska.
I assume it was a specialist. With the whole country to choose from it's easy to pick and choose who your doctor is and if it's the great oncologist your sister had in New Jersey, why not?
BTW, I started seeing my therapist through Skype when he moved because I didn't want to change therapists.
I'm still seeing my long-term therapist in California over FaceTime from the Yucatán. I'm glad we had six months in person before I moved, but the last year has worked out really well. I also have a psychiatrist down here, but I only see him twice a year so he can write prescriptions.
posted by Tell Me No Lies at 4:31 PM on March 11, 2019 [1 favorite]
That said, I am still at a loss as to why they had to do a teleconference in Fremont. This wasn't Alaska.
I assume it was a specialist. With the whole country to choose from it's easy to pick and choose who your doctor is and if it's the great oncologist your sister had in New Jersey, why not?
BTW, I started seeing my therapist through Skype when he moved because I didn't want to change therapists.
I'm still seeing my long-term therapist in California over FaceTime from the Yucatán. I'm glad we had six months in person before I moved, but the last year has worked out really well. I also have a psychiatrist down here, but I only see him twice a year so he can write prescriptions.
posted by Tell Me No Lies at 4:31 PM on March 11, 2019 [1 favorite]
I find this thread bewildering. The subject of the article isn't whether or not telemedicine has a role in health care it is that a patient was told they were going to die and that the hospital couldn't do anymore for them by an Ipad on a stick on top of a Roomba. I really am confused that the disrespect in this isn't obvious. To me this is just another case of an institution satisfying it's own needs without regard for the putative mission for which it was founded.
posted by Pembquist at 11:39 PM on March 11, 2019
posted by Pembquist at 11:39 PM on March 11, 2019
This is a quite sad story, and I wish that it had turned out better for this family.
That said, it seems more complicated than their stated expectation of having a doctor deliver the news in person. I'm sure that there are plenty of people with stories of loved ones being given terrible news in an awful manner by in-person doctors. If some doctor had yelled the "death sentence" into this man's ear, because of his difficulty hearing, we'd likely still be aghast. Poor bedside manner can be demonstrated by a person standing right next to you, by phone, video-conferencing, or VR/AR. That they made a video of this consultation compounds the horror, no doubt, tainting their final memories with their loved one.
Having conversations about end of life is always going to be a place to tread with care, and I hope that particular physician is better aware of their role in the process from here on out (e.g. "I thought that the patient knew of the poor prognosis already, but was cautious enough to double-check and check-in about this before acting like everyone was already aware."). Talk early, talk often, make your plans and expectations known.
posted by the letter at 12:18 AM on March 12, 2019 [2 favorites]
That said, it seems more complicated than their stated expectation of having a doctor deliver the news in person. I'm sure that there are plenty of people with stories of loved ones being given terrible news in an awful manner by in-person doctors. If some doctor had yelled the "death sentence" into this man's ear, because of his difficulty hearing, we'd likely still be aghast. Poor bedside manner can be demonstrated by a person standing right next to you, by phone, video-conferencing, or VR/AR. That they made a video of this consultation compounds the horror, no doubt, tainting their final memories with their loved one.
Having conversations about end of life is always going to be a place to tread with care, and I hope that particular physician is better aware of their role in the process from here on out (e.g. "I thought that the patient knew of the poor prognosis already, but was cautious enough to double-check and check-in about this before acting like everyone was already aware."). Talk early, talk often, make your plans and expectations known.
posted by the letter at 12:18 AM on March 12, 2019 [2 favorites]
"Grandma's on the roof."
There isn't a good way to deliver bad news.
posted by domo at 6:44 AM on March 12, 2019 [1 favorite]
There isn't a good way to deliver bad news.
posted by domo at 6:44 AM on March 12, 2019 [1 favorite]
There are plenty of bad ways, though.
posted by Etrigan at 6:55 AM on March 12, 2019 [1 favorite]
posted by Etrigan at 6:55 AM on March 12, 2019 [1 favorite]
I really am confused that the disrespect in this isn't obvious.
Obvious things aren't very interesting to talk about. The question of whether tele-medicine offers sufficiently important benefits to overcome the deficits is a much weightier and more interesting issue.
posted by jacquilynne at 7:57 AM on March 12, 2019 [1 favorite]
Obvious things aren't very interesting to talk about. The question of whether tele-medicine offers sufficiently important benefits to overcome the deficits is a much weightier and more interesting issue.
posted by jacquilynne at 7:57 AM on March 12, 2019 [1 favorite]
Obvious things aren't very interesting to talk about. The question of whether tele-medicine offers sufficiently important benefits to overcome the deficits is a much weightier and more interesting issue.
Reaction to condescension aside I disagree. This is not about tele-medicine per se it is about problems in healthcare which this stupid incident is the result of. This particular little cruelty is not a deficit of the technology to be offset by some benefit it is a misuse. The compelling questions to me are why and how do you stop doing this kind of thing?
posted by Pembquist at 1:15 PM on March 12, 2019
Reaction to condescension aside I disagree. This is not about tele-medicine per se it is about problems in healthcare which this stupid incident is the result of. This particular little cruelty is not a deficit of the technology to be offset by some benefit it is a misuse. The compelling questions to me are why and how do you stop doing this kind of thing?
posted by Pembquist at 1:15 PM on March 12, 2019
I really am confused that the disrespect in this isn't obvious. To me this is just another case of an institution satisfying it's own needs without regard for the putative mission for which it was founded.
This particular little cruelty is not a deficit of the technology to be offset by some benefit it is a misuse. The compelling questions to me are why and how do you stop doing this kind of thing?
I mean, I feel like discussing the specific ways and places in which telemedicine is implemented, and if its benefits outweigh the inherent costs in those places and cases is the conversation you are asking for, the other two options being specific internal hospital procedure and policy, or the same over-broad, endless conversation about the failings of the US health system as a whole we've had dozens of times. I feel like the useful part of this post is to frame a smaller part of that conversation so we can all keep it in our heads at once (not to denigrate it at all, it was a good read). For some hospitals with poor funding, such as rural hospitals, providing a lower quality of care than is possible rather than no care at all is the question at hand. This particular cruelty might actually be the trade-off for having something like a specialist oncologist available, and the other option is total systemic change top to bottom of society so a specialist oncologist wants to live in a town of a thousand. I'm not arguing that it's good, just that it's what we have, and worth discussing.
I don't think anyone is missing the disrespect and trauma that occured, it's just that public health issues are best discussed systemically and not case by case, and unfortunately instances like this, both more and less severe, are a systemic public health problem in how health care is metered out right now.
I don't like describing my work as medical, because basic consumer optical work is nothing like hospital work, but sometimes I do phone optician work for our patients for whom getting here is a problem. I know, and it's inherent to the process, that I do worse work for them than I do my in-store patients, because I can't see their face, and we don't have ipads on roombas. I also know that for those patients, the slightly lower quality of care we can provide is miles better than the nothing we could provide without doing that. This is so not on the same level, but it's the same inherent, systemic issue. The actual way to solve it is to be able to transport them to us or vis versa every time, but that's not happening.
I've really enjoyed this thread
posted by neonrev at 7:16 PM on March 12, 2019
This particular little cruelty is not a deficit of the technology to be offset by some benefit it is a misuse. The compelling questions to me are why and how do you stop doing this kind of thing?
I mean, I feel like discussing the specific ways and places in which telemedicine is implemented, and if its benefits outweigh the inherent costs in those places and cases is the conversation you are asking for, the other two options being specific internal hospital procedure and policy, or the same over-broad, endless conversation about the failings of the US health system as a whole we've had dozens of times. I feel like the useful part of this post is to frame a smaller part of that conversation so we can all keep it in our heads at once (not to denigrate it at all, it was a good read). For some hospitals with poor funding, such as rural hospitals, providing a lower quality of care than is possible rather than no care at all is the question at hand. This particular cruelty might actually be the trade-off for having something like a specialist oncologist available, and the other option is total systemic change top to bottom of society so a specialist oncologist wants to live in a town of a thousand. I'm not arguing that it's good, just that it's what we have, and worth discussing.
I don't think anyone is missing the disrespect and trauma that occured, it's just that public health issues are best discussed systemically and not case by case, and unfortunately instances like this, both more and less severe, are a systemic public health problem in how health care is metered out right now.
I don't like describing my work as medical, because basic consumer optical work is nothing like hospital work, but sometimes I do phone optician work for our patients for whom getting here is a problem. I know, and it's inherent to the process, that I do worse work for them than I do my in-store patients, because I can't see their face, and we don't have ipads on roombas. I also know that for those patients, the slightly lower quality of care we can provide is miles better than the nothing we could provide without doing that. This is so not on the same level, but it's the same inherent, systemic issue. The actual way to solve it is to be able to transport them to us or vis versa every time, but that's not happening.
I've really enjoyed this thread
posted by neonrev at 7:16 PM on March 12, 2019
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Maybe I just feel optimistic compared with other problems...
posted by solarion at 4:02 AM on March 11, 2019