Thursday, October 29, 2020

Virtual visits

One of the myriad ways that Covid-19 has changed our lives is the explosion in “telemedicine.” As hospitals, clinics and doctors’ offices shut down for non-critical illness visits, many shifted quickly to the use of “virtual” visits: visits done by connecting patients to their doctors and nurses via computer. While this has been done on a small scale for several years, most insurance plans had limited coverage for virtual visits, a major stumbling block to having them widely used in a revenue-driven fee for service environment. Medicare and most commercial insurers rapidly offered to cover these visits as the pandemic unfolded, and their use expanded 100-fold during the spring and summer.

Somewhat to their surprise, most patients found virtual visits to be satisfactory. It is obvious that for mental health visits, just as much can be done via remote communication as in person. Neither psychiatrists nor other mental health professionals normally do anything other than talk or listen. For other types of care, a virtual visit can be less than ideal. A good quality smart phone can allow the doctor to see a rash, but not to listen to the heart and lungs or feel an abdomen. As I noted in a prior post, the large majority of the information needed to make a diagnosis comes from a patient’s history – and this is done as well virtually as in person.

Advantages that have turned many patients into supporters of virtual visits include convenience and cost. Rarely does a patient with a 10 AM visit get seen at 10 – and cooling your heels in a waiting room is not high on most of our lists of favorite things to do. In-person visits also involve driving and parking (or taking public transportation), which add considerable time and often expense to the visit.

Doctors who were skeptics have widely come to accept this type of visit as well – having a patient seen conveniently and comfortably makes for a happier patient.

Are virtual visits for everyone? Almost certainly not. Specialties in which most of the data can be conveyed verbally will certainly continue to do this type of visit much more than those requiring high touch. A follow-up visit for diabetes revolves around reviewing test results and symptoms and is an easy one to do virtually. A visit for congestive heart failure requires much more physical examination and would be much harder to conduct via teleconferencing.

Another problem is access. Recent surveys found that 13% of the population, some 42 million people, do not have high speed internet access. Beyond that, many people do not have the technical skills to feel comfortable doing virtual visits, and these people are predominantly elderly and/or from minority communities that are already underserved. 25-30% of Medicare recipients and people with household incomes below $30,000/year lack both smart phones and high-speed Internet. An alternative for these people is the good old-fashioned telephone. This loses the ability to see facial expressions and other visual clues, but still allows for two-way communication “in real time,” which email does not provide.

Clearly virtual visits, no matter how high-tech, cannot (and should not) replace all in-person visits. Along with the inability to do more than a rudimentary physical exam, at a virtual visit one cannot give vaccinations or do procedures. Lab tests may be needed and require an in-person visit somewhere.

Our forced conversion to virtual visits in these uncertain times has, however, shown us that this is often a valuable addition to the medical care armamentarium. I think it is here to stay.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, October 17, 2020

Public health: what is it? Why should I care about it?

Clinical medicine is very much a one-on-one interaction. A doctor will sit with a patient to make a diagnosis and/or discuss treatment. A nurse will sit with a patient with newly diagnosed diabetes and teach them how to manage their insulin. Even very complex medical interactions such as major surgery may involve multiple professionals but only one patient. Very rarely in clinical medicine is the health of the broad community considered. Public health comes at health problems from the opposite perspective: the health of populations: local, national or world-wide.

John Snow, M.D. (1813--1858), a legendary figure in epidemiology, provided one of the earliest examples of using epidemiologic methods to identify risk for disease and recommend preventive action. Snow had an interest in cholera and supported the unpopular theory that cholera was transmitted by water rather than through “miasma” (i.e., bad air).

On August 31, 1854, London experienced a recurrent epidemic of cholera; Snow suspected water from the Broad Street pump as the source of disease. To test his theory, Snow reviewed death records of area residents who died from cholera and interviewed household members, documenting that most deceased persons had lived near and had drunk water from the pump. Snow presented his findings to community leaders, and the pump handle was removed on September 8, 1854. Removal of the handle prevented additional cholera deaths, supporting Snow's theory that cholera was a waterborne, contagious disease. This became a model for modern epidemiology.

Because communities, rather than individuals, benefit from public health, it must be taxpayer-supported, and this is its Achilles heel. Whether you believe, as I do, that medical care is a basic human right, or that it is just another service that people should be prepared to pay for, needed medical services are usually provided and charged for. Those without or with poor insurance may be bankrupted, but they usually get the services they need. As a taxpayer-funded activity, public health must compete with myriad other demands for public funds, and since its successes are usually invisible, it does not have the same constituent pressure that do police, fire or public works.

At the local level, public health staff work to make sure restaurants are serving sanitary food; unless you have suffered from a food-borne illness caught at a restaurant, the need for this surveillance is probably not high on your radar. The very success of disease prevention makes it less visible. At the national and international level, public health agencies should protect us from major disease outbreaks such a Covid-19, or at least limit the damage. Again, since pandemics are thankfully rare events, it is easy for governments to cut the funding of public health agencies without much pushback from the citizenry.

A huge problem at the national level is the conflict between politics and science. We saw this early on in China, when Wuhan authorities tried to hide the emergence of the novel coronavirus. We saw it in spades in the United States when the warnings of the lead scientists at the renowned CDC (Communicable Disease Center) were ignored by Trump and his administration because their advice to slow down economic activity did not fit with his desire for a booming economy. We saw it in the wholesale rewriting of various CDC guidelines when they did not fit the narrative that Trump wanted to present.

The United States should have been among the countries best prepared to deal with Covid-19: our hospitals are first rate, our financial resources are more than adequate, and we have the world’s leading agency in dealing with disease outbreaks. We did not have adequate stockpiles of things like ventilators and personal protective equipment, because carrying rarely used inventory was bad for a hospital’s “bottom line,” and because other needs for public funds were given higher priority. What we also lacked, and still lack, is public trust in the government, a factor made worse by the actions of Trump and his enablers.

Countries such as Taiwan, Korea and Canada, all of which have performed much better than did we, had credible spokespeople, a consistent message, and a public inclined to listen. We thus find ourselves with 4% of the world’s population but 25% of the world’s Covid-19 cases and are among the top 10 in per capita deaths. Covid-19 will eventually be tamed, through some combination of vaccines, better treatments and eventual “herd immunity.” Unfortunately, the next pandemic is almost certainly brewing in some animal species, ready to make the jump to humans. NOW is the time to ensure that we do better next time. Public health must be adequately funded, and scientists must be allowed to have a leading voice (though not the only voice) in making public health policy.

Prescription for Bankruptcy. Buy the book on Amazon