The Coronavirus Crisis: What Ifs and Teleconsultation ?
Friday 10 April 2020
The Coronavirus crisis, like any collective or individual challenge, remains an opportunity to encourage us to think forward, reflect on our past organizations and methods and prepare for the future. After the acute period and mourning will come the time to reinvent ourselves. Some of us who are lucky enough to be only "confined" have the opportunity to reflect on this "after". It is this opportunity that we are seizing to reflect on the role of e-medicine, online or tele-consultation in our activity.
In our daily clinical practice, we see a lot of patients who come to see us, sometimes have travelled far. This generates a cost (travel), a waste of time (working day), a carbon footprint. Often, an answer can be given that would not have required this trip. Prescribing an additional examination, drug treatment or physiotherapy. Sometimes it ends there and sometimes the patient has to come back anyway, for example with the result of an additional investigation that could be organized during the same trip. Of course, it depends on the degree of emergency and the specialty considered.
In the end we want to consider here an unpublished (but we are working on changing that !) study (i.e. not reviewed by pairs who could potentially not accept its publication if it did not have the required scientific quality) on 800 primary referral consultations to our practice (99% elective, private practice foot and ankle orthopedic surgery and a few relative emergencies that can wait a few days). In this study, we summarize the primary consultations in 3 types by order of frequencies (this may vary depending on the specialty concerned, but it can certainly be applied to many other fields of medicine):
1-Patients who need: either a treatment that can be prescribed (in our case, medication, orthopedic insoles or physiotherapy), or advice that can be given, or referral to another specialist, with the possibility of re-examining the case either in an "online" or "live" format according to the result of the initial treatement.
2-Patients who will have to be seen "live": either with the result of an additional investigation or to perform a procedure, either investigational or therapeutical, surgical or not.
3-Patients who were "in fact" urgent or semi-urgent patients who need to be taken care of immediately or soon.
We will see that in each case, teleconsultation can in fact be a great tool, even a better option than the current practice. Maybe "after" has already become "now", imposed to us by the coronavirus? In any case, our political and health authorities seem to think so given the speed with which the unlocking (and therefore official recognition) of this tool is taking place today.
Like many of our colleagues, we have been forced by confinement for several weeks to use teleconsultation to follow our recently operated patients. It is clear that this opened our eyes: teleconsultation systematically allowed us to provide an answer to patients, to reassure them, and to send them the documents they need and it does not prevent them from coming if necessary. Those who need to be seen and examined clinically will be seen anyway. In the context of a surgical intervention to be programmed, for example, they lose nothing, on the contrary.
Teleconsultation allows them to have time before the preoperative consultation to prepare their questions. They already understand certain aspects of the operation that we have explained to them and had time to organize themselves in their personal lives according to this knowledge.
We ask the question: what if teleconsultation became the norm, rather than the exception, even before any real consultation, for all primary referrals? (of course, from the moment the patient and the caregiver have access to it)?
Let us try to look at what is gained or lost for patients according to our three categories.
1- patients who need non-interventional treatment, advice or another re-orientated referral can have the same benefits without having to travel.
2-the patients who must be seen again "live" will be in any case but we can immediately program the additional elements that we need (diagnostic procedure, imaging, bloods ...) rather than sending the patient home with prescriptions. He will have avoided a trip back and forth from our home to our offices and a day's worth of work.
3-patients requiring urgent or semi-urgent care will also be directed with a delay but not a longer delay than through a normal "live" referral, because the teleconsultation in that case is equivalent to the phone call that preceeds the live consultation and does not obliviate the possibility of a phone call if this is deemed to be a faster necessary faster option by the referrer (in fact it will be faster anyhow because teleconsultation saves everyone time, so consultation delays and waiting lists will be reduced whatever the degree of emergency).
In the context of scheduled surgery, teleconsultations allow a real period of reflection (which is compulsory but not always as significant as it should), the planning of additional examinations which can therefore be combined with the "live" consultation and limit the number of trips for which the patient or the health insurance system has to pay. It goes without saying that it is not (apart from emergency cases) possible to perform surgery without having met and examined "live" a patient. This physical empathetic bond between a surgeon and his patient should remain unbreakable. Between his first teleconsultation during which the first elements could have been put in place and the "live" consultation, the patient will also have time to organize himself personally and to plan the date of the procedure to be planned as well as possible. That's actually more opportunities for the surgeon and the patient to be able to communicate on the important information to remember in the perioperative period. With less time consumption and less costs for everybody on multiple levels.
In the end, there is a lot of "more" with these teleconsultations and very little "less". The clinical examination will always be carried out when the initial consultation leads to the need to see the patient "live". In this case, it saves anyway at least one trip and increases the time for conscious planning. It will be necessary to make the best of this experience after confinement. Let us use the extra time imposed on us by confinement to proactively and optimistically make this change happen in the best way for our patients, ourselves and our environment. It is certainly a road paved with questions, but our patients will give us the answer to those!
Dr François Lintz, MD, MSc, FEBOT
UCP Toulouse L'Union, Ramsay Healthcare Clinique de l'Union. Orthopedic Foot and Ankle Senior Consultant.