Beware crappy telephone medicine

The Pediatric Insider

© 2016 Roy Benaroch, MD

Someday we may miss the quaint idea of going to see your own doctor for your medical concerns.

I realize taking your children to see their doc is a pain. So is taking your car in to the mechanic, or waiting for the cable guy, or going out for groceries. There are other things you’d rather be doing with your time. Can a quick phone call substitute for a doctor visit?

Apparently at least one huge insurance company thinks so. My own family’s health insurance comes from Aetna Healthcare (the letters of which can be rearranged to spell “At Heartache Lane”.) They’re really pushing me to try out “Teladoc” (which, ironically, can be rearranged to spell “late doc” or “eat clod” or “led taco.”) One of the many promo brochures they sent shows a sad-looking child in the background, with an app open on mom’s phone in the front. “How would you like to talk to the doctor?”, it says, in big friendly letters. Holly, presumably the child’s mom, is quoted “One night my child was running a high fever. I called Teladoc & the doctor prescribed a medication & plenty of fluids. Glad I avoided the time and expense of the ER.”

24/7 doctors! What could go wrong?!

What Holly’s mom should have done was called her own child’s doc. Depending on the kid’s age, health history, and symptoms, it would have been appropriate to either: (1) stay home and give a fever medicine, then come in for an exam in the next few days if still feeling poor; or (2) if there was chance of a genuinely serious medical issue, to go get evaluated right away. The child could have had meningitis, pneumonia, or a viral infection, or one of a thousand other things. But there could have been no way to know a diagnosis over the phone. What was needed was a risk assessment, not a prescription. Holly’s story, to a pediatrician, makes no sense. It doesn’t represent anything close to good or even reasonable medical care. A high fever means “call in a prescription”? That’s completely, utterly wrong.

So why is Aetna pushing Teladoc? It’s cheap. Aetna’s payout to the telemedicine company is far less than what they’d pay for an urgent care or emergency room visit. Insurance companies aren’t eager to spend money for people to see doctors. Cheap is good for insurance companies, but is it good for your children?

I couldn’t find any studies in pediatric patients looking at the accuracy of this kind of service for making a diagnosis and prescribing medicine for acute problems over the phone. I emailed the Teladoc people, introducing myself as a physician whose patients might use their services. Do they track their accuracy or outcomes? Do they have any data showing that what they’re doing is even close to good care? I got no response.

Though there are zero pediatric studies, I found one good study in adults,  reviewed here. Researchers contacted 16 different telemedicine companies specifically about rashes. They uploaded photos and basically “posed” as patients. The results were abysmal – there were all sorts of crazy misdiagnoses, and many of the telephone clinicians failed to ask even basic questions to help determine what was going on. Two sites linked to unlicensed overseas docs, and very few of the services even asked for contact info for a patients’ primary care doc to send a copy of the record.

I think I know why telemed companies don’t bother to send records to primary care docs. I have gotten just 2 copies of telemedine records in the last few years, and they’re frankly embarrassing. One was about an 8 year old with a sore throat (who wasn’t even asked about fever). It says the mom “looked at the throat and saw it was pink without exudate.” (Let me mention here that throats are always pink. That’s what’s called the normal color of a throat.) Amoxicillin, in an incorrect dose, was called in for “possible strep throat.” This is terrible medicine that contradicts every published guideline for evaluating sore throats in children. If this is the kind of Krappy Kare we’ve decided we want for our children, we ought to just make antibiotics over-the-counter and skip the pretending over the phone. The other telemedicine record I have was nearly identical, a 15 month old also diagnosed with strep , amoxicillin called in. More Krap Kare for Kids.)

There can be a role for telemedicine. I see it as a useful tool for follow-ups, especially for psychiatric or behavioral care where a detailed physical exam isn’t needed. Telemedicine can also be a great way for physicians in isolated or rural areas to get help from a specialist for complex cases. And telemedicine technology is already being used successfully to allow expert-level interpretation of objective tests, like pediatric EKGs and echocardiograms.

But current available technology (like this Teladoc service) doesn’t allow a clinician to really examine a patient, look in their ears, or even assess whether their vital signs are normal. They cannot help decide whether a child is genuinely ill or just a little sick – and that, really, is what parents need to know in the middle of the night. Calling in unnecessary antibiotics is cheap and easy. But it’s no substitute for genuine medical care.

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3 Comments on “Beware crappy telephone medicine”

  1. Dr, Henry Says:

    Dr. Roy,

    I applaud you for raising several important issues regarding telehealth. As you cited Teladoc in your post, I wanted to take this opportunity to bring to the forefront our beliefs, a number or all of which align with yours.

    At Teladoc, we believe that:
    1. Everyone’s first choice should always be to contact their own Primary Care Physician (PCP).
    2. In the case where that is not an option, for whatever reason, all people should have access to convenient, safe and cost effective care.
    3. The sharing of an electronic health record between the patient and treating physician should be required prior to any patient encounter.
    4. The record, along with the clinical summary for the encounter, should be shared immediately with the patient’s own PCP, should they have one.

    Your patients and their parents in the Atlanta area may not be feeling the impact yet of the supply (too few doctors) – demand (so many patients) issue in healthcare.

    We also recognize that the families you help are busy caring for their children and putting their faith in the healthcare system. They need it to work for them. To help them. Safely. So to that point, we have several “guardrails” around our service, some of which other telehealth providers may not have:
    1. We only offer treatment for the subset of conditions that can safely be treated remotely (4% of patients are referred for in person care)
    2. All of our doctors are highly qualified, Board Certified physicians
    3. We have received National Committee for Quality Assurance Certification for our physician credentialing program
    4. We have established a community physician-staffed Quality oversight committee and program
    5. All of our physicians must adhere to our proprietary, evidence-based clinical practice guidelines
    6. Our clinical outcomes are at least equal to those related to in person care

    At the end of the day, we agree with you that “Krappy Kare” is not good for the industry, nor for those patients who receive it. That is why clinical excellence is job 1 at Teladoc.

    Dr. Henry
    Chief Medical Officer
    Teladoc

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  2. Dr. Roy Says:

    Dr. Henry, thanks for your thoughtful reply.

    I’d like to know: how can you possibly include “ear infections” as one of your over-the-phone conditions to diagnose and treat? This was one of the conditions listed on the promotional materials I received. I know there are smart-phone enabled otoscopes that could potentially allow a remote photo or video of an eardrum, but Teledoc doesn’t use that device. (Besides, I have used one of them, and they’re woefully inadequate for parents correctly “aim” to get a good view, especially in an infant.) Are you suggesting that an ear infection can be appropriately diagnosed and managed without an ear exam?

    How about strep throat? As you know, well-established national guidelines from the IDSA require an objective test prior to antibiotics (because a clinical diagnosis is about as accurate as flipping a coin.)

    Can you share with us some references for your statement that “Our clinical outcomes are at least equal to those related to in person care”?

    I would be very happy to continue this conversation to bring PCPs and remote-health companies together. I can certainly see the advantages of families being able to access this kind of care, but I remain concerned that current technology requires “cutting some corners” when it comes to diagnosis.

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  3. Noorjahan Ali Says:

    Dr Roy,
    I am employed as a pediatric physician for Teladoc. I cannot tell you how often parents are grateful that they even have this as an option- especially in rural areas, when their own pediatrician is unavailable or in inclement weather. The consults do not always culminate in a prescription being called in. Sometimes parents get “supportive care” guidelines or things to look out for that would require something like an urgent care visit or an ER visit, or a PCP visit.
    Every Teladoc consult is ended with a plan for follow up, or if the physician deems it a case where the patient requires a visit – a referral to the relevant medical care.
    We also engage in video consults more and more often now, where you see the patient in front of you. Granted, you cannot auscultate or palpate or fully examine the patient, but you can guide them further…maybe the patient has pink eye, or their rash is hives, and you can further educate the patient/family. Sometimes I get phone consults simply asking whether a medication is safe to give to their child.
    As an aside, Teladoc regularly reviews their providers and get feedback from clients. They also evaluate the rate of prescriptions provided to clients, and even do antibiotic surveillance. They aim to educate their clients as well, by providing them with anticipatory guidance or written educational material about their diagnosis.
    That being said, I run a private practice, and many times I get phone calls from my patients with questions that I basically do the same thing as I do for patients on Teladoc…triage them…is it something we can handle over the phone or do they require a visit? That’s truly what Teladoc does!

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