The doctor will Skype you now

Professor Sir Bruce Keogh, the NHS medical director, is drawing up plans to introduce online consultations, and said that IT will “completely change the way we deliver medicine” The Times

NHS doctors ‘to examine sick patients over Skype’ The Telegraph

NHS Medical director urges GPs to use Skype GP for consultations GP news

‘What we don’t do – our mindset isn’t quite in the right place [to consider] – how can we also use it to drive costs down? All other industries when they look at technology, one of the first questions they ask is does it improve quality and does it lower costs?’

He said some GPs already offer consultations via Skype and may interest many others. ‘Then I find myself thinking that’s the sort of thing that will appeal to some people. It would appeal to me,’ he said.

He argued it would be much more convenient for patients and GPs.

‘In a world where immediacy and convenience influence how people perceive the quality of a service, you can see how that kind of thing might catch on.’

When I called Old George from the waiting room this morning I watched him stand slowly from his chair, I watched how he hesitated before he walked across the waiting room, I noticed him reach out to steady himself as he came to the door. When I shook hands I noticed the stiffness in his arm and the swelling of his joints, the deformity of his fingers, the clubbing of his nails, the coarse tremor, his pale mucous membranes, the slow-growing cancer on his right temple, the raised respiratory rate and faint wheeze … and then we began the consultation.

I am a GP in Hackney in East London. It is not the Scottish Highlands or the Australian outback. My patients do not live far away. I work 7 clinical sessions a week. 6 of these sessions are face to face surgeries with 5 patients booked every hour and one blocked appointment (to catch up) so that in a 3.5 hour surgery I see 18 patients, roughly every 12 minutes. I have described a typical surgery here. One of my surgeries is for phone calls and emergencies. This is very varied. At this time of years it is relatively relaxed with about 20-40 patients over 4-5 hours. In the winter it goes up to 80 or more patients, predominantly phone calls. For this service a patient calls the reception to say they need to speak to a doctor and their name and phone number is added to my surgery list and I call them back in the order the calls come in, unless I am warned that someone sounds very sick, for example a feverish baby or an adult with chest pain or breathing difficulties. I invite a few patients to come in after I have spoken to them on the phone and made a decision that they need to be seen, by me, urgently. Others I fit in with their usual doctors and some need a home visit which either I or their usual doctor will do, usually by bicycle. Other visits and phone calls for my own patients are arranged around my other sessions. Paperwork is done either very early, or increasingly very late in the evenings. I’m rarely home much before 9pm.

So where and when might Skype ‘improve quality, lower costs and be more convenient’? (as Sir Bruce claims)

When I called Young George I noticed that he wasn’t playing with the other 2 year olds that like him, had been up all night with high fevers and coughs. He was sitting quietly on his mother’s lap. When she held his hand so that he could walk while she pushed his baby sister, I noticed that he didn’t want to walk. When his uncle Joe tried to pick him up I noticed how afraid he looked and I saw his mother snarl at Joe and tell him to wait. When Young George came in to my consulting room I noticed how he immediately cheered up, but still clung to his mother, his eyes were sunken, he felt hot and clammy, his heart rate almost 200 and his oxygen saturations only 93% and his temperature 39.3 …

This evening my patient-participation group met. They included a digital marketing consultant and an architect. The chair of the group typed up notes on his ipad as the meeting progressed. They were not impressed with the idea of me consulting on Skype, their concerns included:

• Does this mean you’ll do less surgeries?
• Will it be harder to get an appointment to see you face to face?
• How many elderly patients have Skype?
• How well can you see with a webcam? Isn’t it a bit risky?
• What if you call back and I’m out? I can answer my phone anywhere, but not my computer.
• Wouldn’t it be quicker to phone and for you to see me face to face if necessary?
• Why is convenience always more important than quality these days?
• Is this just to save money?

Georgina opened the door of her flat on the 4th floor of the fashionable converted warehouse. It was the first time I was aware that some of the flats there were reserved for social housing. It was early afternoon but she was still wearing a nightdress, torn and stained with so far as I could tell, coffee, blood, cigarette ash and faeces. She thanked me for coming to look at her rash. She led me to her bedroom, past the living room where, sprawled over the only piece of furniture, a fake leather chair, lay a man in dirty jeans and a leather jacket, seemingly unconscious with a bottle of cider in his lap. There was an empty bottle of martini beside her bed, and the bare matress was filthy. Her rash was florid, a mixtrure of different bacterial and fungal infections and infestations, she had bruises and cracked ribs, no teeth, and signs of liver disease and malnutrition …

If the business of medicine, and particularly General Practice was as straightforward as it is so often portrayed, then we GPs would very soon be redundant, superseded by Google doctor and teams of medical technicians in developing countries  answering the residual queries with the aid of protocols and search engines.

My practice covers not only some of the worst estates in Hackney, but also Old Street, so-called, Silicon Roundabout because of the concentration of high-tech companies. Many of the people who work there are now my patients and whilst many use the internet to research their symptoms, or more fruitfully to learn about their diagnoses, the majority come in for help with the stress, exhaustion and anxiety related to their work, or injuries sustained whilst training for an iron-man (or woman).

The touch of a handshake, the contact of human flesh is about more than a diagnosis. Physical connection is of profound importance. A physician’s touch is a vital part of how we communicate with our patients. It conveys kindness, compassion, confidence, professionalism and responsiblity long before organs are palpated. It is not long since doctors put on gloves before touching patients with HIV and I have recently been accused of examining a patient aggressively, a complaint that has made me reconsider very carefully what happened, how I might have proceeded differently and what it means when we lay our hands on our patients.

I can see why for some patients, in some circumstances with some doctors, Skype might confer some advantages, but we need to think very carefully before being seduced away from our traditional consultations.

The Doctor that Never Sleeps. Atlantic 15/10/2014

From the Guardian: How to Skype your GP: a handy Guide. 01.01.2013