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

10 responses to “The doctor will Skype you now

  1. I use skype consultations- it’s a good way of keeping in contact with patients and their relatives. Nothing replaces the gentle hand of a clinician but remote care does have a place
    All best

  2. So how can we ensure that the right people are seen in real life and others are seen via Skype? The patients above will not have access to Skype anyway so that is one way. But how can we ensure that Doctors have the freedom to deliver whatever they believe is appropriate? The problem you describe here is symbolic of the whole challenge facing GPs and the upcoming new NHS, how to respect humanity. People do usually adapt to technology so I think you will resist having to use it too much. How can your patients be encouraged to improve their living conditions so that they are not allowed or even encouraged to slip through the net, other than by your care?

  3. Having read how the GP in this inner city practice conducts his clinical activities, if I were living in his catchment area, I would give my eye teeth to be registered as one of his patients.
    What the general public and Professor Keogh seem to be unaware of, is that the process of medical diagnosis depends on a great deal more than a conversation over the internet, even if this is enhanced by seeing the patient on a web cam. I can remember many occasions when an incomplete or inappropriate physical examination of a patient has led to a delay in making the right diagnosis.
    A doctor may risk the life or wellbeing of a patient by omitting that vital physical examination.

    Since you cannot conduct a physical examination on Skype it is a dangerous irrelevance.

  4. Professor Sir Bruce Keogh and his merry men have found a new toy. Yes, there is a place for hard copy handouts, telephone consultations, email consultations, website information, and Skype consultations and whatever else the future may bring. The Witch Doctor has done quite a lot of some of these things. In fact she has even had telephone consultations while she and her patient together sat by their own firesides many miles apart with our respective laptops on our knees. We both leisurely discussed clinical information on The Witch Doctor’s website (her real one – not the one she frequents in the blogosphere!) Two different types of remote consultations simultaneously. How cool is that, for goodness sake!

    However, these toys are dangerous and in The Witch Doctor’s view, and I suspect it is also the view of most patients (not clients – they’ll love it), they should only be used in special circumstances. Individual GPs and their own individual patients know when it is appropriate and more importantly when it is not appropriate.

    NHS Direct and NHS 24 were the beginning of the slippery slope that ratified the concept that taking a medical history and examining a patient properly was un-necessary and rather old fashioned. Protocols designed by “experts” were the thing. These outfits only work because most patients, most of the time are not very ill. I have seen some calamities using telemedicine and protocols, but probably nobody audits them, unless perhaps if the patient dies a dramatic and emotive death.

  5. This is interesting.

    As the director of a company that is in the process of recruiting doctors for a UK based (skype-like) doctors video consultation portal called we would obviously take the view that anything that improves access to reliable medical information online is a good thing.

    These days it appears that more and more people are turning to “Dr. Google”. Here you will find the good, the bad and the ugly in terms of reliable medical information and advice. But just who knows which is which.

    I agree that the first port of call should always be your own doctor, as they know you best and have all your records. But don’t discount modern technologies, as out of hand.

    Graham McAndrew

    • Thanks for your comments. I don’t think I’ve dismissed anything as ‘out of hand’, rather I’ve used this blog consistently to show that health care in general and General Practice in particular, is more complicated and more embedded in personal relationships, than people realise

  6. Graham McAndrew,

    We witches are very keen on modern technologies and hope we have been embracing them sensibly.

    I notice as well as having the website registered in your name, you have another one called

    This seems like a good idea to The Witch Doctor because tele-consultations do indeed require a bit of clairvoyance if they are to work well or indeed at all.

    We witches also find The Book of Spells a boon when we tele-consult. However we are not keen on Skype, since we generally like to have our curlers in our hair when we do leisurely remote medical consultations.

  7. Maybe they’ll get us to take our own blood and test it at home with special USB probes!

  8. You are making skype out to be more disruptive than it really is. If you are sitting at your desk and a patient, who prefers skype or to have a ‘face to face’ contact with you would it completely disrupt your day to click your mouse instead of dialing a number?
    To answer your question about when will you do it? Probably the same time as when you do your phone calls. Clearly the person who chooses to do a skype call is now not on your phone list. Magic!

    Curious as to how many home visits a year do you do? In 15 years in victoria I haven’t even heard of them. With my son it is muppets on NHS direct plus a taxi ride to st Charles 6 miles away.

    • Thanks for your comments. I personally do about 2-3 visits a week. As a practice we do an average of about 6 a day for a population of 11 000 patients. I am aware that there are practices that fail to visit their patients, and I don’t think enough is done about it. In fact I don’t know what can be done, I think PCTs failed there and worryingly CCGs won’t have any sanctions about poorly behaving GPs who refuse to visit. Having used Skype and phones I find phones a lot quicker. We have between 50 and 130 phone calls per 3 1/2 hour duty session and I cannot think of when I’d prefer Skype to either a phone-call or a face-face meeting. Working in a very densely populated urban practice, distance is rarely an issue.

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