Spring 2020 (Volume 30, Number 1)
Virtual Care in Rheumatology
By Philip A. Baer, MDCM, FRCPC, FACR
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“I like live audiences, with real people – virtual reality is no substitute."
– Hillary Clinton
“The incredible thing about the technology is that you feel like you’re actually present in another place with other people. People who try it say it’s different from anything they’ve ever experienced in their lives.”
– Mark Zuckerberg
Rheumatologists seem to be in short supply across much of Canada, or at least not distributed very well: too many in some big cities, not enough everywhere else. I received a fax from one academic centre within the last year asking me to accept their overflow patients, who would have had to travel a minimum of four hours to reach me! I was more sympathetic to the next request for help: a smaller community which used to have five rheumatologists was down to one, and the patients were only 90 minutes away. So I accepted the first patient referred: a middle-aged man who was said to have “joint, neck and back pain.” The referral letter was brief, and the only other information provided was a report of spinal X-rays showing degenerative disc disease (DDD). My intuition whispered that this was probably not an inflammatory rheumatic disease presentation, but we booked the patient nevertheless. The referring physician was unknown to me.
Upon arrival, the patient was very pleasant. He told me he had met the referring doctor virtually. The clinic displayed the doctor on a video monitor, and that was how they interacted. Fine for history taking, but no physical exam was conducted, other than asking the patient to demonstrate his range of motion in various joints. The history uncovered multiple fractures and other musculoskeletal (MSK) injuries and a lifetime of physical work, and now chronic pain.
Leaving my patient in a mental “waiting room” for now, virtual medicine is suddenly very fashionable. At the same time, it is also controversial. In some formats, such as through the Ontario Telemedicine Network and similar formats in other provinces, it is covered by provincial health plans. In other situations, patients may be charged for the convenience of immediate appointments without leaving home. Family doctors may wish to participate but, in other situations, bemoan the lack of continuity of care and the duplication of services these video encounters may generate, akin to what is seen with traditional walk-in clinics.
In the American context, virtual direct-to-consumer telemedicine clinics are springing up, targeting specific diagnoses and treatments, such as erectile dysfunction (Hims, Roman), acne (Curology) and contraception (The Pill Club, Nurx). A recent Journal of the American Medical Association (JAMA) article raised concerns about the focus on prescribing a medication rather than offering other treatment options, off-label prescribing, and the tradeoff between convenience and quality.1
So, back to my patient from the virtual clinic. Why was a rheumatology referral requested? Well, the patient was very clear on that: he had gone to the virtual clinic to have some disability forms completed, but apparently that required an in-person encounter with a physician. So the video doctor was unable to help, other than by making a referral to me.
I imagine prescribing opioids was also not feasible after such a virtual encounter, so the situation could have been worse. As it was, I completed the forms with the patient’s input, making no guarantees as to whether his claim would be accepted, and he was quite satisfied. I also made a mental note to be very careful when reviewing any future referrals from video doctors.
Reference:
1. Jain T, et al. Prescriptions on Demand. JAMA Sept. 2019; 322(10):325-26. Doi:10.1001/jama.2019.9889
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario
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