Your children deserve better than telephone medicine

The Pediatric Insider

© 2018 Roy Benaroch, MD

Someday we may miss the quaint idea of our children having their own doctors – doctors who actually get to know their patients and families. We keep all of your records, we know how many ear infections your child has had, we make sure they’re protected with vaccines and we monitor their growth and development – you know, the important, big picture things. The things you just can’t get with a quick phone call to an anonymous telephone doc. Can a phone call substitute for an in-person visit with a doctor who knows your child?

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 “del 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.”

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 does not mean someone should “call in a prescription”? That’s completely, utterly, and despicably wrong.

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 or the outcomes of 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 a handful 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 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. I’ve also got records from kids treated with three days of antibiotics for a sinus infection, and urinary tract infections being treated without any testing of the urine (again, these examples completely contradict evidence-based care guidelines) 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.

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 – and that’s why this kind of care is being pushed by insurance companies. But it’s no substitute for genuine medical care from your own child’s doctor. Your children deserve better care than pretend medicine over the phone.

 

Adapted from an earlier post

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6 Comments on “Your children deserve better than telephone medicine”

  1. Bob Best Says:

    Well said. I wouldn’t disagree with a word of it. But I would add a thought. What makes Teledoc a rising trend isn’t just the insurers. Consumers will use it, and probably sing its praises because it’s easy. Much easier than an emergency or urgent care visit. Calling the PCP should be just as easy as teledoc, but in reality it isn’t. So, convince us consumers not to be so lazy, or improve the good stuff so that it isn’t so much harder to use, compared to something like teledoc. (I don’t mean that you personally should do this).

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  2. Dr. Roy Says:

    That’s certainly a valid point — we need to our part to make visits with us less painful.

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  3. DrStuppy Says:

    Too many people want an easy (and cheap) fix. You get what you put into everything…

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  4. DMJ Says:

    Hear hear. Telemedicine also interferes with continuity of care. If the child isn’t getting better and has to go to see the pediatrician in person, then the pediatrician has not been able to see how the situation has involved. Telemedicine also interferes with the ability to do responsible “watchful waiting” for things like ear infections, to avoid antibiotics where possible.

    On the other hand, I understand busy parents wanting a solution for any time of the day. Our pediatrician is across town, and it takes at least half a day off to get there. I also feel like we pick up another virus every time we see her.

    One possible solution: housecalls by pediatric nurse practitioners. We have a nurse who does housecalls in our neighborhood for a very reasonable price ($80). We’ve used her several times in adjunct with our pediatrician. It works out very well.

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  5. LBA Says:

    Thank you for this article. I was notified that beginning June 1 my insurance company was going to be offering this service for FREE, no co-pays. I assumed this service was only for adults but I was shocked to learn from HR that it would be available for anyone on our insurance, children included. An urgent care I visited in the past wouldn’t even see my child who was 2 years-old at the time but a phone doctor will? No thanks. I’ll suck-it-up and pay our co-pay to see one of your physicians despite how “inconvenient” it might be.

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  6. Sylvia Says:

    I’ve only had a couple of experiences using a nurse line – and I think it was somehow related to CHOA. I can’t find a number for it now and it’s been 8 or 9 years, so it went away or is well hidden (or I’m wrong about the CHOA bit). In my case it was holiday/late at night. For me, it was useful for the check of “am I being a paranoid new mom” or “is there something wrong here?” In one instance I was told to take my child to the ER and the other, I was told to keep him home but what to watch for that might indicate a real concern. Both calls were right.

    I’m not sure if this is what you’re saying it can’t do, or if the difference being there was no firm diagnosis, just helping with the immediacy of care needed. 11 years into the parenting gig, I trust my judgement far more than I did those first 2-3. At this point I have a pretty good feel for when we can wait or when we need to seek attention now. But those first couple of years? Not so much.

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