For me, telehealth is a revelation – sometimes it’s better than seeing patients in person

My move into emergency telemedicine, after decades of public hospital practice, has been a revelation. I like to call this type of practice ‘community emergency medicine’.

It separates the specialist knowledge and skills from the facility, and fills a service gap in a unique way. I have been forced to rethink many of my previous assumptions about good clinical care. Much of the discussion about telemedicine on a recent Medical Observer opinion piece has revealed some widespread misunderstandings. Using my six years of emergency telemedicine experience (starting before COVID), I want to dispel some of those.

First, nobody is arguing that telemedicine should totally replace face-to-face clinical consultations. There are certainly occasions when my audio or video assessment of a patient leads me to direct them to ED straight away.

Conversely, I can reassure them that there is no need to rush to ED in the middle of the night. They may need a face-to-face examination to clarify a diagnosis, but are safe to wait until the next day.

Next – and perhaps more importantly – the quality of medical care is determined by the aims and structure of the service and the diligence of its practitioners, not the modality of communication used.

Certainly, telemedicine has fostered a pathway for ‘prescription mills’, but those already existed. There were always clinics catering for ‘two-minute medicine’ or for people wanting Viagra or cannabis products.

The problem here is not the platform, but the emphasis on providing a particular product rather than assessing patients’ clinical needs. Telemedicine services like the one I work for present the antithesis of this approach. The service is collegiate, structured and closely audited. Both formal and informal education are constant features. Our clinical notes are thorough, and our safety-netting is robust.

Those features don’t necessarily exist in face-to-face medicine – they have to be intentionally incorporated. I have also come to understand the primacy of the medical history, with physical examination coming as a significant second. There are times when an issue can’t be adequately assessed without ‘hands on’, of course. In that case, the teleconsult can advise on the urgency of that face-to-face review.

However, there are so many ways of examining a patient via telemedicine – even just audio. Is the person cheerful or distressed? Can they converse normally? Are they short of breath? Are they coughing every few words? Are they retching?

There are also the ‘surrogate’ ways of examining. Most people can locate their radial pulse – does it feel steady or chaotic? Is it faster than their partner’s pulse? Many patients have home blood pressure monitors which can also report heart rate. Parents can feel the tummies of their children, put their ears to their children’s chest, ask the child to jump on the spot, describe the way the child’s chest is moving, report whether their breathing is noisy. In a rural or remote nurse-staffed ED, one can watch the onsite nurse examine the patient, with some direction if required.

At the extremes of age, telemedicine can occasionally be better than face-to-face. For scared infants or confused elderly, being able to assess them across a screen in their own familiar environments can give a better clinical picture than seeing them screaming, agitated or combative. Then there are all those functional signs that are more significant than some of the examination signs we learned as students. Those include mentation, work of breathing, peripheral perfusion, ability to walk, ability to eat and drink, self-care. Just as telemedicine should not be seen as a compromise, face-to-face should not be seen as a panacea.

Telemedicine saves travel and waiting times. It reduces spread of infection for both patients and clinicians. It allows for triage, reassurance, explanation, prescribing and onward planning – which may include a face-to-face visit. Those of us who are gregarious and love speaking with patients will do so over telephone or video just as well as in-person. Those who are reticent communicators or just plain curmudgeonly are not made better by seeing the patient in front of them.

Telemedicine, like AI and transcription programs, is a tool. In many situations, teleconsults present better solutions than face-to-face. It’s our skills and dedication as clinicians that matter, not the tools we use to supplement them.

Dr Sue Ieraci, FACEM

link to AusDoc.