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It used to be that the doctor would make a house call when you got sick. Then we all had to start going to doctor's offices. Now we can have a medical examination by Skype, but there are things a virtual doctor can't do that a 3-D doctor can.

As more and more hospitals, clinics, and insurance companies embrace the idea of telehealth in the United States, virtual doctor visits are becoming all the rage. Videoconferencing methods such as FaceTime and Skype make it possible to visit with your doctor the same way you would visit with a family member or friend, even though some older patients find the technology intimidating.

The business model behind telehealth is similar to that used to plan the shopping mall clinics and "minute clinics" that opened in the USA 10 to 15 years ago. Offer very fast service for a very limited range of conditions. Internet and telephone interviews are appropriate for non-threatening conditions such as urinary tract infections, earaches, and sore throats. They can be useful for follow-up care for high blood pressure and diabetes. They are a convenient way to discuss lab results from blood draws or tests done at the office earlier, saving the patient a trip back to the doctor's office for discussion.

An entire industry has sprung up around telemedicine. Telemedicine companies American Well and Teledoc provide doctors with telemedicine technology for documenting their patient visits and billing, reducing the need for office staff. Some insurance companies, such as Blue Cross Blue Shield of Massachusetts, have started making virtual visits through telehealth technology available (possibly as a prelude for making them a requirement) for their insured.

But how good is the quality of care in a virtual doctor visit? A team of researchers at the University of California at San Francisco and Harvard University decided to find out. They trained 67 actors to pose as patients with one of six common complaints: ankle pain, lower back pain, strep throat, a women's urinary tract infection, sore throat due to a cold, or sinus infection. The doctor visit was conducted by videoconference, over the phone, or by webchat. The researchers then rated 699 virtual visits to eight on-line providers to determine whether:

  • Patient histories were complete.
  • Physical examinations were complete.
  • The doctor made the right diagnosis.
  • The doctor adhered to key management guidelines.

Just how good were the virtual doctors?

  • In 69.6 percent of visits, the doctor completed the patient history and the physical examination
  • In 76.5 percent of visits, the doctor made the correct diagnosis.
  • In 53.4 percent of visits, the doctor followed management guidelines for documenting and closing the visit.

Some common conditions were more successfully diagnosed online than others. 

  • Up to 40.4 percent of the cases of urinary tract infection and ankle pains were diagnosed or treated outside of accepted parameters of adequate examination and correct diagnosis with appropriate treatment.
  • Up to 82.1 percent of the cases of acute viral sore throat and sinusitis were assessed, diagnosed, or treated outside of guidelines.
  • Up to 96.5 percent of the cases of strep throat and lower back pain were assessed, diagnosed, or treated outside of guidelines.

Doctors got the diagnosis right in 458 out of 599 patient encounters, which is to say they got the diagnosis wrong in 141 our of 599 (23.5 percent) of cases. Doctors sometimes get diagnosis wrong in office visits, too. So how does telemedicine compare to office medicine on that count?

Where Teledoctors Go Wrong

In another study, researchers with the RAND Corporation, the California Public Employees' Retirement System, and Harvard University took a retrospective look at 4,647 Teladoc visits by State of California employees as part of their health insurance coverage. They looked at the same ailments covered in the other study, and noted whether virtual doctors were any better or worse at following guidelines for good practice than office doctors.

In this study:

  • All of the doctors given a strep throat patient were expected to order a strep test. Just 50 percent of the brick-and-mortar office doctors ordered the test. Only 3 percent of the virtual doctors did.
  • All of the doctors given a lower back pain patient were expected to order x-rays or other forms of imaging. Only 21 percent of the office doctors ordered these tests. Only 12 percent of virtual doctors did.
  • All of the doctors were expected not to order antibiotics for bronchitis patients, based on the information they were given by the actor. However, 72 percent of office doctors and 83 percent of online doctors ordered the unnecessary drugs.

There may be a simple explanation of why online doctors did not order throat cultures to test for strep throat. It is extra work for the doctor to order and then review the test for step bacteria. Patients may be left wondering "If I have to come in to the office anyway, why did I bother to do this online?" Similarly, the doctor may want to cover all bases and order antibiotics just in case the bronchitis actually was caused by bacteria despite the information the actor-patient gave.

The general impression from these studies, however, is that doctors don't do quite as good a job when they are seeing patients online, through videoconferencing or Skype, or speaking with them over the phone. How can you tell which kind of doctor visit will work best for you?

  • Recognize that many health conditions can't be diagnosed or treated without an in-person visit to the doctor's office. It may be necessary to go into the office for blood draws, X-rays, or an in-person medical exam allowing the doctor to feel and listen as well as see you.
  • Recognize that if you live in a remote or rural area, your doctor may alter your treatment to save you travel if you don't make it clear that you are willing to come in as necessary. If you live considerable distance away from the doctor, then you are more likely to get prescriptions you don't need (in case they could keep you from having to travel to the doctor's office) but also less likely to get testing that you do need.
  • Don't be hesitant to use emails, text messaging, video, or chat in dealing with your doctor, assuming your doctor is comfortable with the technology, but don't forget you need to come in to the office occasionally, too. Nearly everyone needs to see a primary care provider in person once or twice a year, to provide the baseline from which the doctor can make better decisions even if future exams are conducted online or over the phone.

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