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Is telemedicine the de-evolution of medicine?
Having passed a year's worth of COVID-19 lockdowns, stay-at-home orders, self-quarantines and other social distancing strategies, it is a good time to reflect on the extent to which we have shifted our lives online. We shop for groceries, consume entertainment, get schooling and attend our yoga classes via the web. During this rapid transformation, telemedicine became one of the major industries that forcibly advanced. According to McKinsey & Company, in 2020, 46 percent of consumers were using telehealth services to replace canceled health care visits, compared to 11 percent who used such services in 2019. We pushed doctors' office visits online and freed patients from the shackles of waiting rooms into the comfort of their own homes, all in the name of reducing COVID-19 exposure.
And while this "brave new world" of telemedicine has been deemed a good thing, it is not a panacea. Telemedicine initially was created to fill the void in medical care accessibility for patients in remote environments. But it has become more about survival for doctors. Like any business during the pandemic, fewer services could be rendered because of stay-at-home orders, resulting in less income. Physicians were not immune to this model of compensation. The Canadian Institute for Health Information reported a 50 percent reduction in emergency room visits in April 2020. This presents a potentially dangerous scenario in which medical practices were near the brink of bankruptcy until virtual visits quickly became the norm. Although this appears as a win-win for patients and physicians, there is much more here than meets the eye. From price wars to outsourcing to substandard care, we should consider all the unintended consequences of the telemedicine trend.
COVID-19 has provided the impetus (at least temporarily) for physicians to provide telemedicine solutions to their patients and, in some cases, for their entire practices. Many doctors will favor this approach over seeing patients in person: There is no need to pay office expenses such as rent and staff salaries; patients and physicians alike just need a laptop and a camera. No longer is there a need to perform a physical examination or spend significant time with a patient; one can simply have a five-minute telephone call. Yet the remuneration for an in-person visit is equal to a virtual visit even though it requires considerably less time. How can a physician accurately assess chest pain in a virtual setting? And many patients and physicians can recall multiple instances of incidental findings leading to lifesaving diagnoses when they were examined for completely unrelated ailments.
Telemedicine presents a new set of obstacles for trainee doctors as well, who arguably are already losing the art of the physical examination because of advancement in diagnostic technologies. Many of the tests that physicians order - be they MRIs, CT scans or blood work - are done ahead of time. Skipping physical exams and losing vital in-person clinical encounters has made medical training even tougher.
Where there is a crisis, there is often opportunity for massive monetization. Companies such as Amazon Care in the US, Telus Babylon in Canada and WeDoctor in China have rolled out their respective mega health projects, aiming to capitalize on the digitalization of medicine. Like the food industry and agribusiness, the telecommunications giants, and private energy providers, health care carries the risk of being dominated by a few major players. Telemedicine may become a race to the bottom: pressure on price reduction with medical care going to the lowest bidder. This bypasses the brick-and-mortar businesses. Your friendly neighborhood doctors' offices may become extinct, replaced by a faceless corporate behemoth.
Other challenges that need to be addressed before the proliferation of telemedicine include complying with existing privacy laws, maintaining secure data collection and storage, and attending to the many issues related to medical malpractice insurance. Where do you draw the line in terms of medical malpractice jurisdiction when patients can go to providers across provincial, state or even national borders? How will health insurance, liability and licensure issues be solved? Taking this one step further, how do we stop the outsourcing of disease diagnosis and treatment to developing countries whose doctors can do it more cheaply? Or maybe it is not a trained medical professional at all and just artificial intelligence (AI), a machine-learning program spitting out the correct diagnosis in nanoseconds.
And that is the other major disruption in medical care: What happens when there is no human at the other end of the telehealth call? The art of medicine is at risk of dying. No friendly banter. No warm touch. No empathy. Just algorithms and a corporate billing system.
We all know AI is coming to the medical world - we are collaborating in the paradigm shift of our profession on a daily basis. Some might even deem it as our eventual demise. But if our patients benefit with better outcomes at lower costs, then we have to get past our professional self-interest. Machine-learning algorithms do not get fatigued or make decisions based on emotion or financial gain as human physicians do. Telemedicine eventually will allow for a direct connection between a patient and a non-human expert opinion that will be rendered first, not last.
The hard truth is that a standard of care does not really exist in medicine, despite the naive belief and hope that we are all treated equally. Telemedicine is here to stay in some capacity, but can it replace the human touch? Do we - or should we - care if it does? Only time will tell.
Drs. Jaspreet Rayat, Toby Chan and Richard Weinstein are eye surgeons based in Ontario, Canada, and co-founded EyeStart Inc. Drs. Rayat and Chan are adjunct professors at the Michael G. DeGroote McMaster University School of Medicine in Canada. Professor James Cooper is associate dean of experiential learning at California Western School of Law in San Diego.