One of the interesting issues I have had to grapple with in the last year or so is how to best integrate new technology and medical practice. One major technological advancement in the last 1-2 years is the ability to do video conference appointments with patients from almost any location in the province. Technically, the only real requirements are a high-speed internet connection, and a smart phone with a camera, microphone and speakers. Current LTE wireless connections are fast enough to produce sufficient video quality to do a video appointment even when a person is walking down the street or riding on public transit. The ability to provide advice on the phone or by email has also been around, for even longer. So, why not give advice using these technological channels?
There is a strong case for video conference appointments, especially in the field of psychiatry, where it is not necessary most of the time to be able to physically touch the person or do a physical examination. There are a lot of compelling reasons to allow for providing medical treatment remotely. Trying to get patient into the office had a specific time when the doctor is available requires the coordination of two schedules and it requires the patient, usually, to take time off of work. Then, the person needs to commute, and more than likely burn a lot of carbon-based fuel in order to get from wherever they are and come in to the office. Video conference appointments alleviate some of these difficulties, because people do not have to travel as much and, because of the time saved with commuting, they could potentially be able to do an appointment early in the morning or at the end of the day, potentially, and still be able to work for a good part of the day, if they do not have to travel further to get to the doctor’s office, and instead they can just to the appointment from home before they leave work, or immediately after they get back. These are all good reasons why a pilot project was initiated to finally allow doctors to be paid through public health insurance to provide appointments remotely by video conference, connecting directly from the patient’s PC or smartphone to the doctor’s telemedicine setup.
For the longest time, the main reason I gave for not giving advice by phone or email is that there is no fee code under OHIP to cover this service. If videoconference appointments are so good, why not extend coverage of video telemedicine to compensating phone advice or even email advice? Doctors who have salary-based compensation are probably already dealing with the question of how much of their time they should devote to providing phone or email advice, and under what circumstances. Maybe we should all be spending a lot less time face-to-face with people and more time just delivering medical advice in other formats, if the technology enables us to do so.
In my opinion, however, a line needs to be drawn in terms of what physicians do, and it excludes phone and email advice. In order to understand why, let us do thought experiment. What would happen if we were to start a practice of attending a family member’s wedding or funeral by phone conference, or one could email thoughts and wishes without attending in person? You could watch a live stream of the event on your computer and post your reaction on social media in real-time. Or, you might record a video greeting to be viewed by the grieving or wedding parties, at their leisure. This could save the expense of booking a large venue or spending money on airplane tickets and lodging. Of course, most people would think this is ludicrous (I hope). Why? Because these are solemn events, and it matters that you are there – your presence contributes to the emotional atmosphere and you being present allows you to participate in the experience in a more immersive and emotionally present way. Going to the concert of your favourite band is different from watching the video on YouTube, and going out and seeing a tailor to have an expensive suit made, or at least going to the store to try one off the rack before you buy it, is different from ordering on Amazon. Most people, I think, I can appreciate this. Hopefully, then, it makes sense why email and phone advice are least-preferred options, to be used in case of extraordinary circumstances where other engagement is not possible, or perhaps for the most trivial, mundane matters.
So, how important is your medical treatment to you? Should you treat your health the way you shop for diapers or pencils, and do you want your doctor to approach matters that affect your health in the same way? There is a ritual quality to going to the doctor’s office. Before my time, so I’m told, people used to dress up for the occasion. When you take the time off work to attend an appointment, this sends message to your unconscious, and to the people around you, that you are attending to an important matter that takes precedence over your job, your career, your clients, your reputation, and your material achievements. If you relegate your medical care to sending your doctor an email message whenever you have time, that is an indication of how you think about your health, or your family member’s health, if you are doing it on their behalf. Your doctor, unconsciously or consciously, will probably take note of that, and more importantly, you are enacting and concretizing your priorities for yourself and the people you love, inscribing it into your consciousness. You value and take time for your healing and wellbeing… or you consider it to fit, in your list of life priorities, somewhere below making reservations to eat at a restaurant.
Therefore, if I tell somebody to just make an appointment with me, I am not just doing it because I want to get paid. It is also a matter of establishing the right kind of mindset and the right setting to do something important, and ensure that both parties are at least somewhat prepared and emotionally present for the experience.
That brings me to the matter of video appointments. I believe the convenience, the reduction and commuting, and the environmental benefits, justify their use, and outweigh whatever intangible element of direct human contact is lost when doing an appointment by video instead of in person. There can be intangible benefits, as well, in the sense that people sometimes seem to be more open and introspective when they are in their own space, rather than someone else’s office. However, I believe there also needs to be decorum around conducting video conference appointments. Just because they technically can be done from any location, does not mean that they should. Obviously, doing an appointment in public space, or where one may be interrupted or overheard, is not going to be conducive to doing anything psychotherapeutic, because the person is going to be apprehensive about privacy. The setting needs to be safe and private, and person needs to approach the appointment as though they are going to see the doctor. That is, they need to set aside time so that their attention is available, and they need to be psychologically ready. Some aspects of this, I believe, are ensuring that distractions are minimized – nowadays people often take their cell phones into appointments and might get distracted by text messages or calls. That is just a reality of modern life… but those things need to be minimized. Eating during appointments is along those lines… it could be done, but probably better to minimize it. I would also include dressing for the appointment; you probably would not leave your house and go to the doctor’s office not fully dressed, or in your pyjamas – probably because of the embarrassment factor or because of social expectations – but the more important reason is related to the discussion above regarding weddings and funerals. A person dresses for those events to show respect to others and to the seriousness of the situation; in doing so they contribute to the dignity of the event and to their own sense of dignity. That is why it is important to dress for a video appointment and to choose a suitable location.
When we are dealing with technologies that have the potential for breaking down boundaries, we also need to be considerate of why those boundaries exist, and whether it makes sense to disrupt them. We need to avoid the extremes of clinging to the old way of doing things because that is they way we have always done them, but we also need to avoid doing things thoughtlessly just because we can.