Saturday, November 22, 2008

dr im sick. :-( rofv.

I've been spending the weekend thus far studying for an upcoming biochemistry exam, so I thought I would drag myself up from the mess of initiation factors, ribosomes, and lipoproteins in which I am immersed to update my blog. The consistently heavy workload that defines medical school tends to curtail the amount of time I have to spend writing updates. But study breaks spent pondering subjects only tangentially related to the material tend to reinvigorate the mind. Or at least that's the goal.

Anyway, this past week, a disheartening post on the NYTimes Bits blog came across my Google Reader. The gist of it is thus: a new physician-led,
internet-based company--American Well--is in the process of rolling out a service that offers patients online consultation with a physician over video and chat weblink. The company's founder claims to be motivated by a desire to make the most basic element of healthcare--talking to a doctor--easily available to the numerous healthcare consumers who obtain the majority of their health-related information through online means.

At first blush, this may sound like a desirable proposition. Both the typical, and I use that word broadly,
healthcare consumer and the physician who treats him or her are time-starved. The opportunity to consult over chat with a physician for ten minutes rather than set aside a minimum of an hourlong (counting trip, time spent in waiting room, etc.) block of time for a trip to the physician's office might provide a significant benefit to the patient. Instead he or she can, from the comfort of a favorite chair, sit and dicuss the most intimate of subjects with a caring and compassionate physician.

This is the point at which the premise begins to crumble for me. Aspiring doctors are introduced to the proper methods of interviewing sometime within their first year, hopefully prior to the first contact with living, breathing patients. We learn the importance of sitting on the same level as the patient, asking open ended questions, maintaining eye-contact, and
proferring encouraging statements when subjects cover topics that might be hard for a patient to relate to a stranger. These techniques are taught with a single goal in mind: to communicate our willingness to listen confidentially and non-judgmentally to our patients, while remaining attuned to the salient issues of their lives.

By virtue of its basis in
realtime video chat, the interaction between physician and patient offered by American Well suffers from an interruption of this attentiveness. As a student who lives far away from friends and loved ones, I use Skype nearly every day to keep in touch. Yet despite a high-speed connection, there are often technical issues that interrupt the flow of conversation. And anyone who chats via webcam knows that it is no substitute for the type of interaction available through a face to face conversation.

I can see you saying to yourself now, "you're overreacting, American Well doesn't aim to replace face to face conversation between doctor and patient. It's just a useful tool for checking in with your physician and getting some advice." To which I respond: just wait. Supplementing the doctor-patient interaction is not the American Well's aim. The founder of the company puts it best: "without reworking the budget, without going through Congress, we can bring affordable health care to people who cannot access it." This ephemeral, vapid talking point would almost make me laugh, if access to healthcare weren't such a pressing issue. American Well markets their product to physicians on the notion that it will permit them to "Increase revenue and care for patients on [their] own terms. [And] Introduce a new balance to the way [they] practice by offering [their] services online for a fee." Clearly, the number of those with access to healthcare isn't expanding.

And how, may I ask, will this bring affordable
healthcare to anyone who currently lacks access? It won't. Let's offer a scenario in order to illustrate. Let's say American Well allows physicians to charge 50 dollars for a ten minute online consultation:

Ms. B, a post-menopausal 56 year old woman, works as an insurance agent. She has been having headaches off and on for the past few weeks. She doesn't think her symptoms are anything to worry about, though she would like to get them checked out just to be sure. But Ms. B doesn't have health insurance. Her headaches have been worsening over the past two days, so she decides to pay 50 dollars and see a doctor on American Well. Dr. X, prudent physician that he or she is, sees that Ms. B is overweight, is concerned that these headaches could be related to possible undiagnosed hypertension, and tells Ms. B that she needs to see a physician in person. The doctor's concern worries her, and she agrees to pay $110 dollars to see a physician in person.

Outcome A
The doctor rules out hypertension, talks to her about some lifestyle improvements, prescribes 800 mg ibuprofen, and tells her to schedule another visit if the headaches continue to worsen. Total cost of treatment rises from $110 to $160, not including the cost of medication .

Outcome B
Despite the physician's advice, Ms. B decides her headaches aren't that bad and that she can tough it out for a few more days to see if they get any worse.
Little does she know, her blood pressure is sky high. She wakes up in the middle of the night three days later in a cold sweat, unable to move her right side. Her husband calls paramedics and she is rushed to the hospital, where she is diagnosed with a severe stroke. She spends a week in the hospital, her blood pressure is brought under control, and she slowly regains function in her right side. Six months of physical therapy follow. Cost of treatment: $50 + ambulance ride + stroke treatment + rehabilitation.

Outcome C
Thankfully, Ms. B isn't aware of American Well in the first place. When her headaches worsen she goes to see a primary care physician for $110. She is diagnosed with severe hypertension, the physician prescribes her a relatively inexpensive generic medication, tells her to come back in a few weeks, and has a conversation with her about lifestyle changes. On her second visit, her blood pressure is back in the normal range, she has lost a few pounds, and plans to lose a few more. Cost of treatment: $220 plus cost of medication. Stroke averted.

Outcome D
Again, Ms. B isn't aware of American Well. She pays $110 to see a doctor, who finds her to be mostly healthy, except for a few extra pounds. They have a conversation about healthy lifestyle changes, and she gets a prescription for 800 mg ibuprofen to take as needed for her headaches. Total cost of treatment: $110 not including the cost of medication.

I ask you, American Well, which outcome is better for the patient? For the American healthcare system? Is this really even a question?

(image via Wikipedia)

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