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Virtual What?
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
I
n case you all did not know, medical
practices based in actual buildings are
referred to by the medical virtual-care
people as “bricks and clicks.”
They are enthusiastic about the elec-
tronic delivery of medical care, as opposed
to actually seeing the patient, live and in
person, not in technicolor. In fact, in the
February 6 JAMA, authors Michael Nocho-
movitz, MD, (pulmonologist now adminis-
trator) and Rahul Sharma, MD, MBA, (an
ER doctor), both at New York Presbyterian,
propose a whole new specialty, the Medical
Virtualist. I quote:
“We propose the concept of a new spe-
cialty representing the medical virtualist.
This term could be used to describe physi-
cians who will spend the majority or all of
their time caring for patients using a virtual
medium. A professional consensus will be
needed on a set of core competencies to be
further developed over time.
“Physicians now spend variable
amounts of time delivering care through
a virtual medium without formal train-
ing. Training should include techniques
in achieving good webside manner. Some
components of a physical examination
can be conducted virtually via patient or
caregiver. Some commercial insurance
carriers and institutional groups have
developed training courses. 5 These are
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LOUISVILLE MEDICINE
neither associated with a medical specialty
board or society consensus or oversight nor
with an associated certification.”
I have never conducted an e-visit, which
is possible in the Epic/Norton system. I have
read my patients’ visits when they have
elected to have one, with various APRNs
and MDs who have signed up to do these.
They read universally as though a computer
wrote them. Mostly, they are for acute minor
ailments. The patient will present his sore
throat to the camera using a bright light, but
for respiratory complaints, there is never a
lung exam, a nodal exam or an ear exam.
There is never a comment about the feel of
a pulse, or the sound of a blood pressure
in one’s examining ears. Temperatures are
hardly ever recorded for adults without chil-
dren at home, since they rarely can locate
a thermometer. The ones for rashes have
pictures, but only of the parts of the rash the
patient has yet seen, or is willing to show
on camera.
The authors’ “some components of a
physical exam” part sounds like a sellout
of any standard of real doctoring, favoring
instead the worship of “cost-saving” tech-
nology. Does the person with a headache
think the e-doc can listen for temporal ar-
tery bruits? Feel for cervical muscle spasm?
Look in the fundi? The demeanor of a per-
son who is being filmed is often different
from that seen in person; being on-camera
changes people sometimes. I cannot imag-
ine attempting diagnosis without any sense
of my medical gestalt. Nearly all headaches
are pinned down by the person’s description
of them. I concede that the e-visit could
accomplish a history. But a confirmatory
exam? Hopeless.
The commercial insurance carriers’
training courses part is medically terrify-
ing, to be frank. I foresee new definitions
of primary-care gatekeeping. I envision the
insurance boardrooms of the future sigh-
ing in ecstasy at being able to get rid of the
pesky premium-using sick people by foist-
ing on them a “virtual assessment” of the
problem. Only if the company-trained (!!)
e-person allows it, will the poor sick patient
get approved for an actual doctor visit by us
“bricks and clicks” types. Some health insur-
ance companies own the clinics and employ
the staff and insure the patients, all in-house.
The patient is totally at their mercy. Can’t
afford the out of network internist? Guess
your breast mass/new pleural effusion/new
murmur got missed, huh? Guess you end
up with horrible ICU bills that might end
up getting opened by your widow, huh?
Guess that might be related to the fact that
the e-person has never practiced any critical
care but is real good at giving out Tessalon
Perles and Flonase? Huh.