In the age of e-consultations
Though convenient, telemedicine should be preferred for convalescence or medical advice over diagnosis so as to prevent mismanagement
With time, medical treatment pattern has seen drastic changes. Medical education has moved from Gurukul to modern medical colleges and hospitals. The present-day medical student does not have to roam about in forests in search of herbs, shrubs or animals to find medicines. Methods of treatment have undergone a sea of changes. There have been changes in the relationship between doctors and patients. Even though personal examination of the patient remains key to reaching a diagnosis, investigations give tremendous information into the pathology of illness and in managing the treatment.
With newer gadgets, particularly the telephone and the internet, communication methods have changed as well. Many patients contact the doctor on the telephone for advice. This is not a foolproof method to approach the patient because one is not able to directly examine the patient. The doctor has to depend on what the patient tells. At times the patient may tell the symptoms which he/she thinks are important. But for the doctor, these symptoms may not be of much value. On a telephone, the doctor has limited questions which are important to clinch the diagnosis. Many times, a patient may panic for something which in actual practice is not so serious. The doctor is not able to physically examine. He/she can neither palpate nor auscultate. He is not able to see actual signs which the patient is developing. Therefore, the chances of being misled and error are high.
In this context, it is important to refer to the decision of the Bombay High Court in 2018 where the Hon'ble Court indicted the Gynaecologist couple Dr. Deepa and Dr. Sanjeev Pawaskar of gross negligence. The couple had conducted a caesarean operation in Ratnagiri in February 2018. They discharged the patient after two days in normal condition. After that, both of them went to a conference. The next day the lady developed some problem. She was brought to their hospital where the staff tried to manage her through telephonic consultation with the doctors. As she became sick, she was referred to some other institution. But she could not be saved. The court felt that this amounts to culpable homicide as the doctors tried to treat the patient without examination which the court felt is gross negligence.
Sometimes the patients cannot visit the doctor they trust because of many reasons. It could be distance, cost of travel, cost of consultation, waiting time at the clinic, busy schedule of the patient. So they seek primary advice from the doctor telephonically who is generally well-known to them and has attended them in the past. After discharge, the patients may have some questions to ask for clarification in the treatment. The doctors in such circumstances cannot refuse to attend to the patients call. Whereas it is obligatory to obey the court order, it is difficult to abolish telephonic consultations completely in a day to day practice.
In a study, Josip Car, PhD student in patient-doctor partnership and Aziz Sheikh, NHS/PPP national primary care postdoctoral fellow, published in the British Medical Journal in 2003, concluded that 'Public satisfaction with telephone consultations is high, and patients increasingly wish to have this option. Speed, improved access, convenience to patients, and possible cost savings are the principal advantages of consultations by telephone'. Telephones are used for accessing a broad spectrum of health care, ranging from delivery of routine and emergency care to obtaining repeat prescriptions and results of laboratory investigations and facilitating health promotional interventions. Interventions range from a simple transfer of information to education and, in many cases, complex management decisions.
However, they suggested a careful approach to a telephone consultation. Speak directly with the person who has a problem. Take a detailed and structured history. Request the caller to repeat the advice given (several times throughout the consultation). Ask if the person has any outstanding questions or concerns. Advise about follow up and when to contact a doctor (for example, worsening symptoms despite treatment, symptoms failing to improve within a week, onset of new symptoms).
The practice of telemedicine is the latest in modern medical practice with ultra-modern technology. This is distance management. One does not see the patient directly here. There may be a visual conversation but one cannot palpate or auscultate or peep into the ear canal or view the retina personally.
No doubt there is no alternative to a personal examination of the patient and that continues to be the practice. Telephonic consultation is not the first visit consultation. It is more during follow up or convalescence period that the patients seek medical advice on the telephone. However, in addition to obligations to law, it is important for all medical professionals to be careful when giving a telephonic opinion to avoid mismanagement. After all, our ultimate aim is to cure the person.
(Dr. Arun Mitra is Vice President, Indian Doctors for Peace and Development. The views expressed are strictly personal)