Monday, May 31, 2010
Primum Succurrere: Telemedicine and fast access
Should telemedicine be prohibited because the doctor doesn't physically touch the patient? That's the argument being made by the Texas Board of Health, according to a recent article in the New York Times at http://nyti.ms/aGY3SO. The issue raised is that there might be subtle cues that are more likely to be noticed if the patient is there than over a video connection.
Like everything, this position has to be taken in moderation. Good decisions aren't made by looking only at the possible risks, but at the possible benefits as well. There will always be more information that could be gathered, but the real point is whether sufficient information is available to justify an action, and whether inaction would be worse.
We all make medical decisions, and we make them frequently. My shoulder hurts: do I have bone cancer? Should I drop everything and race to the emergency room? I evaluate my options using the information available to me, including the fact that I spent much of yesterday digging in the back yard, and conclude that it's more likely a soreness from fixing the plumbing under my wife's lawn fountain than something more ominous down in the marrow. I feel reasonably confident that my arm will not snap off if I give it a couple of days and see what happens. I'm not a medical doctor and I have no scans or X-rays to support my decision, but I'm making a decision of proportional scope and, in all likelihood, consequence.
Doctors do the same. The real questions are how good the information is and what actions are appropriate based on that information. And - at least as important - what level of inaction is acceptable? Is it better to take some action, even if some things remain uncertain, or to wait until fuller information is available? It’s the kind of question that faces doctors and paramedics every day.
Along with the familiar medical dictum, primum non nocere or "First, do no harm," there’s also a second one, equally important: primum succurrere, "First, hasten to help." Both philosophies, whether the considered evaluation prior to treatment, or the more urgent application of palliation or assistance, need fast, accurate information, and that’s home turf for telemedicine and medical telepresence.
One morning as a young engineer, I had a realization so vital that I made it into a sign and hung it in my office: "Every Decision Must Be Made on the Basis of Insufficient Information" (this was before computers, fonts and laser printers, so I actually had to exercise my drafting skills making that sign). I realized that the search for full and complete information was inherently impossible because there was always another piece of data, somewhere, that might - just might - be relevant to a decision. I realized that part of the value I brought to the job was my ability to evaluate the information available, to decide when I had enough to take action on.
The same is true in medicine. There’s always a process of deciding what information is necessary, and where enough has been accumulated to support a decision for a course of action. This is where telemedicine has become such a valuable addition to the medical arsenal: Telemedicine can cut the time for information delivery to a doctor by an order of magnitude or more. This facilitates the processes of triage, diagnosis and treatment. Siince time is often critical in medicine, this also means that telemedicine can save lives. It's the doctor's responsibility to determine whether the available information is sufficient and reliable, and to decide what actions to take on the basis of that information. This decision is never the same, however. It’s different for every circumstance, and the doctor is in the best position to decide.
Many of the major metrics of modern medicine are already available remotely, such as blood pressure, blood sugar, and pulse rate; even ultrasound scans are now available, delivered via iPhone. Yes, there's always a chance that a physical visit might add a piece of information, but the incremental advantage of the physical visit, relative to the high cost of delay in many cases, has decreased in modern medicine; as Dr. Boultinghouse says in the NYT article, "in today’s world, the physical exam plays less and less of a role. We live in the age of imaging.” Add in the growing availability of remote imaging devices such as microscopes and ear-nose-throat cameras, and the remote imaging arsenal is becoming extraordinarily powerful.
This is where modern telemedicine has become such a game-changer: by bringing secure, live high-definition video, both one-way and two-way, between doctor and patient, it enables not only the directed examination necessary to understand a problem, but also a significant degree of the relationship-building and random observation that can play an important role in medicine as well. In effect, HD telemedicine has brought much of the physical exam back into the game, even when doctor and patient are thousands of miles apart.