Dr M K Mam
At the time of Lockdown in wake of Covid-19, Pandemic and consequent closure of medical institutes the people faced the crisis of seeking personal consultation from doctors. Having no option left with them, the patients opted virtual consultation to overcome the medical emergency. Having both positive and negative aspects virtual consultation is going to stay with us in the coming times.
Virtual consultation is a process whereby we get a medical opinion without visiting the doctor in person. In fact, it is a non face-to-face consultation. You get a medical consultation while sitting at home. All this has been possible with all the technological advances in the modes of communication like e-mail, instant messaging, WhatsApp, skype, video conferences, phone calls etc that are being used by the people in modern society. These electronic forms of communication in fact are very beneficial in allowing rapid exchange of information. Virtual consultation and telemedicine have been an important tool for specialised care especially for patients living in remote areas where the healthcare facilities are not optimum. The present pandemic has made it much popular and people in general started opting for this option as face to face consultations have been difficult, carry the risk of getting infected. All this could not have been possible but for increasing number of mobile phones users and the availability of the mobile network all over even in remote areas. Non face-to-face activity- communication can be i) synchronous – direct like video or telephone consultation ii) asynchronous- indirect like monitoring an email wherein we respond to questions. Video consultation is preferred as there is human contact, body language and we also get some insight into the lifestyle.
Advantages of Virtual consultation to patients:
Virtual Consultation(VC) provides safety to patients, reduces the risk of getting infected especially in a pandemic like the one we are having now. It avoids unnecessary exposure to high risk environment. We do not come in contact with the staff and other patients. It is all the more useful for elderly, people with medical problems as the risk of getting infected and subsequent complications are very high in them. Again, in a pandemic lot many doctors do not attend to the routine clinical practice, as such having a traditional in person consultation i.e. face-to-face consultation is a problem. Under these circumstances VC certainly acts as a boon and this was very much obvious in the current difficult times of COVID -19
VC certainly gives an access to specialised care to the patients particularly to those living in remote areas where healthcare facilities are not adequate. It is certainly a boon for the patients living in remote areas. A patient gets a specialist consultation and care while sitting at home.
It is all the more useful for patients with problems in mobility like elders and other physically less abled people as they can have access to a doctor without visiting him/her in person.
It spares the inconvenience and additional time spent in travel to doctor and back. It also spares the time spent in waiting in the queue at the clinic. You just have to book an appointment and be online at the given time of consultation and that is it. Again, we do not have to take off from the work which one has to do in order to have in person consultation, thus helps in reducing chances of work and or wage loss.
VC as a matter of fact provides a relaxed environment as the patients are within their familiar surroundings – home etc. Patients feel more confident and comfortable in talking about their personal issues when compared to an in person consultation. Patients speak more openly about their problem. which is helpful in better understanding of the problem and its management.
It eliminates the issues of child or elderly care that many of us usually face especially with nuclear families.
Time spent in VC is lower than in person consultation as is evident from some of the studies. A meticulous physical- clinical examination that usually takes time is not there. Consultation is of shorter duration and people do more talking than in face-to-face consultation.
There is increased accessibility to specialist care as has been shown in some of the studies. Patients can get in touch with doctor more frequently and conveniently, as such can help improve the doctor patient relationship.
It has been observed that patient borne cost is lower in VC. It spares not only the time and inconvenience but also the expenses involved in travel to have in person consultation.
Some of the studies report that VC is as effective as in person consultation at maintaining working alliance, adherence to treatment and follow up. It is said to be equivalent in efficiency and is an opportunity for better care. However, there are also studies that do not agree with it as losses to follow up are high in VC as compared to in person consultation..
VC also provides some societal benefits. It reduces time missed from work, has a positive impact especially in the people who are self-isolating, staying at home as to some extent it mitigates social isolation. Need to travel to hospital and back is avoided which to some extent may help in reducing traffic.
Advantages of Virtual Consultation to health care system
VC reduces treatment burden as less patients visit the hospital for in person consultation. It reduces the unscheduled visits to in-clinic consultation.
It increases accessibility to specialist care.
VC is said to be more cost effective as has been reported in some studies. It requires less resources and service cost is significantly lower. However, there are also studies that refute this.
Clinicians of different specialities can consult with each other irrespective of their locations .
We can have continuity of care, follow up appointments and tracking of investigations etc.
Fears that have been expressed
VC as it is, is virtual in nature, there is no direct contact- in person interaction between patient and doctor. In person interaction in fact involves not only verbal but also nonverbal and paraverbal components of communication that plays an important role in in the exchange of medical information and this is especially important for physical examination and in VC we do miss these except in video conference where can be there to some extent.
Physical- clinical examination has an important role and is very much relevant in spite of all the advances in diagnostics- technology. A meticulous clinical examination- eliciting various clinical signs helps improve diagnostic accuracy. Clinical examination also helps in judicious use of investigations- technology. In VC there can be lack of full personal context that can lead to incomplete information and incorrect conclusions and decisions. Many doctors feel that it interferes with good clinical practice and exercise of professional judgment. A study has shown almost 63 % diagnostic discrepancies were because physical examination was not performed, leading to delayed or an incorrect diagnosis. As such there are fears that VC may be clinically risky, less safe. It has been reported that VC appears to be safe, effective and convenient for patients who are preselected by the clinicians as ‘suitable’, but such patients represent a small fraction of clinic workload. There are complex challenges to embedding VC service in routine practice.
With VC, it may be difficult to build rapport and trust that is essential for building a good doctor patient relationship. In person consultation as a matter of fact is a social encounter, not just a forum for exchange of facts or making decisions. Clinical examination involves not only eliciting various clinical signs but also a compassionate and a caring touch of the doctor which helps build up trust, confidence and a better doctor patient relation that is important for delivery of a good health care and all this is not possible in VC. However, there are also studies to show that it may not be true.
There are concerns about patient privacy, security and confidentiality of the details of the information of the patient may not be ensured in VC. Right to privacy is an integral part of medical ethics. Data protection and privacy is most essential, has to be encrypted. Any activity done online has hacker related issue, so chances of leakage of the electronic records of patients- personal information like history , various investigations etc. are there even with all security measures – password security and privacy etc.
VC may not be for everyone when there is inequality of access to technology. Even if there is access, some of us may not know how to use it or maybe uncomfortable with it and this can be true for both patients and doctors. It is mostly being used by younger people, less by poorer and lower health literacy people. Again, illness of patient may affect his ability to use the technology.
Technology plays an essential role in VC, we need high speed network facility with high quality of voice and images. Technical issues like interruptions, delays of connectivity either on patient or doctors side, delay in audio/ video data transmission etc. can affect the consultation, however it has been seen that people generally find solution to resolve them.
There are also concerns about ethical issues and professional misconduct.
VC may not be acceptable to all patients and staff. Many doctors feel that it interferes with good clinical practice and exercise of professional judgment.
There are also technical, administrative, logistic and regulatory challenges in VC.
There is no doubt that new communication technology is very beneficial. Use of technology- video conference is good for healthcare, has advantages especially improved patient convenience and accessibility, however there are also things that are debatable. A systemic review has shown that cost and efficacy of VC varies considerably across the studies. It has to be done properly and without interfering with the patient-physician relationship. It is of utmost importance that with all technological advancement in communication, doctors do not lose sight of the physical, psychological, social, and spiritual totality of the patient. Lot of debate is going on as regards the pros and cons of VC, as such further research – large adequately powered randomised trials are needed to make the things very clear.
(The author is Formerly, Vice Principal, Professor & Head of Orthopaedics, Christian Medical College, Ludhiana, Punjab.)
Dr M K Mam