No absolute answer in debate over online doctor consults

Here's a multiple choice question for you.

Online physician-patient consults:

A) Are a brilliant way to improve access and reduce costs. In the future, online consults will replace many kinds of care that used to be conducted in-person--for example, patients will be able to perform surgery on themselves (with emails or text messages to guide them through the process, of course!)

B) Are a dangerous alternative to in-person care--they raise ethical and legal concerns, put patients in danger and put physicians at risk for malpractice suits. Quite frankly, there is no condition that's appropriate for an online physician-patient consult, not even a stubbed toe.

Oh, were you looking for a third or fourth choice?

That's just the problem: Sometimes it feels like there are no other choices. Online consults are good or evil. Take your pick. Choose a side. Prepare for battle.

Those who argue in favor of online consults and other forms of remote and mobile health say that it reduces the cost of healthcare and can prevent readmissions. Just this week, in fact, a study came out that found patients were largely satisfied after virtual consults with specialists.

And the concept of online consultations has already taken root. The Cleveland Clinic's MyConsult program, for example, offers virtual second opinions for "high-end" diagnosis such as cancer. Doctors only render second opinions when there is enough data from imaging and pathology reports, for example, to make a diagnosis without seeing the patient in-person.

On a much smaller and simpler scale, advice sites such as HealthTap connect patients with medical questions and doctors who provide answers--the site has just added the option of a doctor consultation by text.

The latest volley from the con camp comes from an open-forum discussion at the annual meeting of the American Medical Association about the ethics of online medical consultations.

"There is a potential conflict between the ethical and legal practice of medicine on the Internet," Ron Clearfield, a radiologist and member of the council, told the forum, noting that 10 states allow limited telemedicine licensure. "Although doctors may be legally permitted to engage in online consultation, it doesn't mean that they ethically should do so," he said.

Sounds perfectly logical. Then again, a physician could bill an insurance company for an in-person visit he or she never conducted. That would be certainly be unethical. Should we caution against in-person visits? Or insurance billing?

What about physicians who accept gifts from pharmaceutical companies and then prescribe the company's medicines to their patients? Unethical if the doctor would otherwise prescribe a different medication. Fine and dandy if that wall calendar or pen has absolutely no bearing on his or her prescription patterns.

The fact is that doctors can behave in any number of ways that are unethical. But we don't assume the worst of all docs based on the practices of what I'm sure the AMA would describe as the few.

Another argument against online consults: The "feel and touch" issue. Another physician speaking at the forum said that in order to do her job correctly, she must see patients in her office.

And that is her prerogative.

But another doctor might say that he or she must conduct house calls or provide concierge care in order to deliver the best care to his or her patients. Should every physician be required to do business this way?

Meanwhile, before I upset anyone, I should make it clear the AMA isn't suggesting that we ban office visits, insurance billing or even the practice of online consults.

The logical solution is to implement standards and guidelines and best practices. And while AMA and other professional organizations certainly can--and should--raise concerns, they should also offer the industry these kinds of solutions.

In the meantime, could we start by agreeing that patients should not conduct surgery on themselves guided by text messages? And could we also agree that it is OK to go online to ask a doctor for advice on the best way to treat a stubbed toe?

If there are no objections, perhaps we could move on from there. - Gienna

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