Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link

Online consultations can be very attractive. They promise fast, convenient, secure consults and often a prescription at the end. But at what cost?

The medical profession is old. Very old. One of the most famous names in medicine, Hippocrates, was alive around 2500 years ago. The medical profession is even older than this, dating back to probably 2000 BC. Prescriptions were once written on a tablet.

tablet
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No not one of these

ancient tablet
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But one of these.

Thankfully since then things have moved on slightly. Whilst some doctors are still doing things by hand with stacks of notes busting out of barely-closing filing cabinets, most have moved on to computerised medical records, much to the relief of everybody. General Practice has really been leading the charge with this, especially in countries like the UK where typically GP practices are light years ahead of other NHS organisations when it comes to going digital, but we are entering in to a new age of medical technology and consultations along with that.

online consult showing on phone
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We are now entering the age of the digital consultation

Online, telelphone, video conferencing. These are words you would not typically associate with a consultation with your doctor, but more and more we are seeing adverts for these new enterprises promising no wait times, instant access, the ultimate convenience, and usually a prescription to boot. Virtually guaranteed (including that elusive ‘script’).

These are ads, taken from the websites of these companies. Virtually guaranteeing whatever you want.

ads for digitial services
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another ad for digital consult
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ads promising prescriptions and 24/7 access
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Sounds fantastic. You know what you want right? Why do you even need to see a doctor? Why take time out of your busy schedule, just to get told you don’t need those antibiotics that you know you need. After all, you googled your symptoms so you definitely know what’s up. Or do you?

Well despite popular belief, doctors aren’t told to refuse patients antibiotics. We aren’t incentivised in any way to decline treatment options to you. In fact many people think we are in cahoots with ‘big pharma’ to prescribe when people don’t need it. We can’t really be both, – Schrodinger’s GP – refusing to prescribe you those much needed medications, whilst simultaenously pushing medications on to you to get paid by big pharma.

Ok I joke slightly, but really, doctors are not ordered to not prescribe. What we are asked to do, rightly so, is prescribe appropriately. This means prescribing those antibiotics when you need them. Not when you think you need them. There are guidelines that we follow. Guidelines for most medical conditions, infections, diseases. These are evidence based guidelines, not just made up on the spot. They aren’t 100% but they do vastly reduce inappropriate prescribing. This is important.

Image result for who threats to world health
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The World Health Organisation (WHO) lists antibiotic resistance as one of the highest threats to world health. in 2019 the UK listed antibiotics resistance as the highest global health priority affecting its population.

One of the problems with online consultations is the fact they are online. The same applies to all non face to face consults. There’s companies trialling systems that transmit health data like blood pressure, oxygen saturation, heart rate, and temperature for example, which is great, but what about the basics? We are taught in medical school to treat the patient, not the numbers. If a patient looks unwell in front of us, but their numbers look fine, we don’t just say “ah well ya know, your chest sounds terrible and you look really unwell, but your oxygen sats are good so you’ll be ‘right”. No. We use them as an adjunct to the consultation. To help us to examine the patient. The problem with these telehealth consultations is that usually that is the only part of the examination they can do. If you use a video call they might be able to see you (usually in terrible quality mind you), but they can’t do much else. They might be able to see your chest, but they can’t listen to your lungs. They might be able to see your child’s rash, but they can’t put a hand on them and tell you how it feels. They might be able to see your tonsils (and that’s a very big might if you’ve ever tried to take a photo of your tonsils) but can they see in a good enough quality to tell whether it’s pus or membrane?

A phone call is usually even more restrictive.

So they are missing a huge portion of a medical consult. They have much less information to go on. So they might have to guess. They will tend to fall back to acting defensively, just in case. This often means prescribing antibiotics, or other medications, often when they are not needed. ‘Just in case’.

I should know. I used to do this work.

Well kind of. In the UK where I used to work, the patient demand was never ending. They would sometimes be queued up around the block waiting for the GP to open.

Bleak: The patients lined up from 6.30am because it was their only hope of a same-day appointment with their GP at a heavily oversubscribed practice. The Sunbury Health Centre in Surrey is one of the biggest in Britain
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Credit: Roland Hoskins / Daily Mail

The inevitable result of this barrage of patients was that you had to find a way to deal with this demand. This meant phone calls rather than face to face consults. After hours GP care which I also did in the UK was the same. So I know first hand what telehealth is like, and how difficult it is, and the pressures to prescribe ‘just in case’.

Why you should care about antibiotic resistance

Well simply put the next time you have that UTI, or that chest infection, or that sore throat, it could kill you. If we have no antibiotics that work to treat the infections because of misuse and antibiotic resistance then even simple infections could kill you.

What about other medications?

Unfortunately many medications are unsafe if misused or inappropriately prescribed. That’s why many doctor’s dislike the term ‘just a script’, there’s so much more that should go in to prescribing than just click+print+sign. Let’s take the contraceptive pill for example. If prescribed to the wrong patients then the results could be disastrous. Side effects can be problematic, but worse there could be serious health problems resulting like blood clots in your legs or lungs, breast cancer, or stroke. There are certain risk factors that we ask about when doing these consults to determine these risks (e.g. history of migraine). The problem with some telehealth platforms is that whilst they attract patients who seek convenience, speed and a transaction rather than a consultation, they also tend to do the same for the whoever is on the other end. Just google it and you’ll find there are numerous reports of doctors rushing, barely asking any questions, or just plain not asking any at all. Basically not doing a proper consultation at all and this is extremely risky.

Now all of this is just about medications, but what about other issues? I honestly cannot recall the number of telehealth consultations I did. Probably numbering in the thousands over my time in the UK. It wasn’t just infections. Falls. Head injuries. Eye problems. Chest pains…the list goes on. I forget the number of times I called an ambulance because I just couldn’t be certain the patient didn’t have an emergency problem, only to find out they were perfectly fine. All because I couldn’t actually see and examine them.

Now this was in the UK. Where healthcare is free, and generally patients aren’t expected to pay for their health care (at least not directly anyway), but what about here in Australia where patients usually pay their GP for health care? This presents a unique issue when money is changing hands for healthcare. It starts to become a transaction. It is difficult to detach this from the medical consultation. This is hard enough for face to face consultations, but I imagine this becomes much harder when the patient (or is that customer) is nigh on promised a prescription by the telehealth portal before they’ve even got to the doctor. This then has the potential to lead to a very consumerist, transaction driven model of healthcare which can become very damaging to the doctor-patient relationship and ultimately lead to poor health outcomes.

Security of telehealth consultations is also a major issue

Telephone calls are insecure. Despite what many think, they can be intercepted. We are forever hearing stories in the media about telephone scams. Criminals love personal data, and health data is no exception. it’s useful. Very useful. It’s the reason why health data is one of the biggest growing data industries in the world right now, and why companies are investing heavily in this market. Telephone calls are insecure, but what about online consults or apps through your phone? Many offer secure encrypted systems. Great. But that doesn’t mean it’s secure. Do you know where the doctor is and what they are doing on the other end?

doctor at a desk and computer
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Is your doctor in their office? On a secured system? In peace and quiet? Able to focus on you and your problem?

medical consults in a coffee lounge
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Or are they sitting in a busy coffee shop on unsecured wifi with people peering over their shoulder at your medical records?

Loneliness

Another very real downside of this method of consulting is the lack of basic human contact. Loneliness is becoming a major health concern across the world, and evidence shows sometimes the only human contact our patients get is with their GPs. Loneliness can lead to much higher rates of mental health illness such as anxiety and depression, but it also has links to increased risk of physical health diseases like cardiovascular disease. Taking this basic human contact away from those most at risk could prove catastrophic.

Now telehealth definitely has its place, and in the future technology will improve, and new models of care will be trialled, but at present in my opinion it causes more problems that it solves.

Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link