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Is virtual medicine essentially unprofessional?
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How the College of Physicians and Surgeons of British Columbia

Fails the Citizens of the Province

Below the banner of the College of Physicians and Surgeons of British Columbia (CPSBC) web site, College of Physicians and Surgeons of British Columbia (cpsbc.ca), they proclaim that their mission is “Serving the public by regulating physicians and surgeons”.

In the actual mission statement they add “The College’s overriding interest is the protection and safety of patients. The role of the College is to ensure physicians meet expected standards of practice and conduct.” A little further on they add “Regulatory decisions are evidence-based and rationale is clearly explained and defensible.”

In passing it must be observed that the terms “expected standards of practice and conduct” and “evidence-based and rationale” are conveniently left undefined.

Since November 2013, updated in April 2020, the CPSBC has had a written policy pertaining to telemedicine. The written document can be viewed at PSG-Telemedicine.pdf (cpsbc.ca)

Regarding telemedicine the said document conveys zero information on how “to ensure physicians meet expected standards of practice and conduct”, which is most likely because there is zero ‘evidence’ to suggest that telemedicine is either effective or safe!  Nowithstanding, a significant number of CPSBC registrants are now engaging in the practice of telemedicine, and are even being paid for it by the Medical Services Plan of BC. Why is this ethically wrong?

It is an axiom as old as the history of medicine that in order to make an effective assessment of a patient, a physician must physically see, hear, and examine a patient. Even if a physician is able to have a ‘real time’ image of a patient by remote means, for example by some such internet application as Zoom or Skype, such ‘seeing’ is of necessity limited. Often only the head and shoulders are visible, and even if some particular body part (say, a sprained ankle or the chest of an asthmatic) is visible this does not allow for the process of proper examination according to accepted medical standards.

Moreover, examination should not be limited to a specific part or region that is the immediate focus of complaint. A patient with a hot, swollen knee should have their temperature, pulse and blood pressure measured. So also the general demeanour and appearance should be observed and noted. But I won’t belabour the point further. By now it must be obvious that a medical condition requiring a physician consultation necessitates an on-site consultation with the doctor.

The reader may ask ‘But what about COVID 19 and control of the spread of infection?’ The response is elementary. Management of infectious disease has been part and parcel of the role of medical doctors throughout the ages. Not so long ago there was SARS (another coronavirus, and probably deadlier than COVID!). And there has been polio, AIDS, tuberculosis, typhoid, typhus, cholera and smallpox to name but a few. Yet doctors didn’t run and hide behind their computers and telephones. That some are now doing so is a scandal and a betrayal of what the medical profession has stood for.

Throughout history physicians (and surgeons) have freely put themselves in harm’s way for the good of their patients. Even now, in some parts of the world, they still do: think of Ebola and Yellow Fever in parts of Africa. Of course, physicians have done so while exercising caution, washing their hands and using antiseptic and aseptic techniques as required. Until now they have never shunned their patients or kept them at a distance.

So why does the College of Physicians and Surgeons of British Columbia allow them to do so now? There is not a shred of evidence to suggest that telemedicine is safe, and by all existing standards it is manifestly unprofessional. Our nursing colleagues don’t have the privilege of attending their patients remotely. 

They are not alone. Within the last two weeks I’ve sat in the dentist’s chair to have my ‘routine’ hygienist appointment. She gets a lot closer than 2 metres and I’m not even wearing a mask! Same with my barber: I had to remove my mask for the beard trim. In 2 weeks time I get blood drawn by a lab tech. Hopefully she won’t want to use a 6 foot long needle. In August I had my annual visit with the cardiologist for an Exercise Tolerance Test, which as we know, involves heavy breathing in a confined space. Neither he nor the technician ran for cover. And my partner has, within the last 3 months,  had visits with an orthopaedic surgeon, a physaical medicine specialist and an orthoticist, all of whom actually laid hands on her as a necessary part of their examinations.

There is simply no excuse for a physician not to give direct patient care.

The Doctors of BC (the BC Medical Association) has no regulatory role, but instead has a leadership role. Why has the Doctors of BC not spoken out about the professional inadequacy of telemedicine? Could it have something to do with the fact that telemedicine provides an easy, risk-free income for some - but not all practitioners?

Our public – our patients - deserve better than this. From what I have been hearing they are not at all happy with us at the moment. What's more, if we treat our patients casually we should not be surprised if they treat us with the same lack of respect.

 

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Maple
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I too have concerns about telemedicine especially assessments that are text based or telephone based. I suppose there might be a place for telephone follow ups. For instance I have seen patients referred for depression when they were only assessed over the phone. I believe that getmaple is totally text based assessment! My mother in law had a facial rash which was assessed wrongly by her family doctor over the phone. I went over and it was clearly shingles. There's no excuse not to use doxy.me or zoom or any other approved video platform.

Thank you for sharing the limitations of telephone calls or text
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Thank you for sharing the limitations of telephone calls or text only as a form of Telemedicine and Virtual Medicine and providing names of several platforms being used. It seems like the number of platforms and businesses jumping into this field is expanding rapidly.

The https://getmaple.ca platform has a Terms of Use that allows them to terminate your usage or even their entire service at anytime (https://www.getmaple.ca/terms/) which appears contrary to the requirement that the last doctor a patient consults with is responsible for ongoing care. The rules seem to be eroding fast and it does not look like the regulatory bodies are doing anything about it.

It is difficult to know to what extent the www.getmaple.ca platform uses only text based interactions which clearly are their entry point although they appear to be trying to cover themselves with the comment "The healthcare provider may also request audio or video if it’ll help with your diagnosis." on the page "How it works", https://www.getmaple.ca/for-you-family/how-it-works/.

There is a detailed document by the Canadian Medical Association on Virtual Care from February 2020 available online at https://www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtu... but it does not appear to provide any critical insight as to the proper and improper use of virtual care methods or the rapid growth of private businesses entering this field with the added financial burden of these services on individuals, employers or even possibly our public health care system.

Cease fire banner, you don't speak for the people.