The present model of general practice, whereby a patient telephones a secretary to book an appointment with a doctor, is given an available time, arrives into the waiting room, waits an average of 30 minutes, sees the doctor for an average of 10 to 15 minutes, receives a diagnosis, management plan, and a prescription, is rapidly becoming an example of ‘one size fits some’. The availability of telephones and transport in the past 50 years moved the doctor-patient consultation out of people’s homes into the surgery. Computers, broadband, and smartphones are gradually moving it back to the home again. Like shopping, holiday and business travel, entertainment and online banking, medical information and advice is only ever a few clicks away.
Doctors have understandably been reluctant to embrace this new development. We are trained to be cautious, to consider the unintended consequences of changes to the status quo. Medical school makes us into, what Edward De Bono describes as, “black hat thinkers”, the Devil’s advocate, keenly aware of dangers and difficulties and what might go wrong. Add to this the fact that medicine is much more regulated than other industries and it is easy to understand why GPs are not clamouring to provide online consultations. But whether we like it or not, patients are looking for online doctors and they are finding them, only they are not finding their own doctor – yet.
So who is occupying this virtual space and what sort of services are they offering?
The website www.treated.com says it will provide an “efficient and speedy healthcare service… treatments for infections, chronic diseases, acute illnesses, skin conditions, male and female health, and lifestyle treatments”. www.pushdoctor.co.uk charges stg£1 for a first appointment and further GP online consultations for just stg£14. www.babylon.com claims to be “everyone’s personal health service” with “doctors at your fingertips whenever you need one”. www.justanswer.co.uk allows you to type in a medical question and a doctor will answer you immediately. www.webdoctor.ie offers online consultations with an Irish-based doctor for just €28. www.lloydsonlinedoctor.ie suggests you select a treatment, answer a short questionnaire, which will be assessed by a doctor, who will then post your prescription to you to be exchanged at any pharmacy. www.drEd.ie will treat only select conditions, which include asthma, acne, and chlamydia. Select your condition, fill out a questionnaire, and have it reviewed by a doctor, who will then send your script to you or a designated pharmacy. DrEd claims that he will save you €40 on actual doctor consultation fees, as his fee is only €20.
Many patients find these online medical services convenient and accessible. They are available 24 hours a day, seven days a week, 365 days of the year – the kind of service Jeremy Hunt is trying to achieve for the UK. There is no travel time, no parking problems, no squeezing oneself in to the last available seat in the waiting room. No questions regarding smoking and drinking habits. No unnecessary (or necessary) medical examinations. No conflicting or negotiating regarding antibiotics. As these doctors do not have premises or staff costs they have significantly lower overheads and can afford to offer this service at a fraction of the cost of an actual surgery visit. All that is needed is a laptop or smartphone and broadband access.
Is there anything that can be learned from these services that can be applied to general practice? A (non-systematic) review of today’s surgery consultations indicated that at least one-third could have been conducted online, with no reduction in clinical standards. This number could be increased with the addition of home-monitoring wearable devices that track, record, save, and electronically transmit relevant physiological parameters, such as peak flow, blood pressure, heart rate, and oxygen saturation straight to the patient’s file. As Dr Eric Topol, the US cardiologist and medical technology guru, outlines in his book, <em>The patient will see you now</em> – <em>The future of medicine is in your hands</em>, this technology is already available and affordable and is changing how patients consult and how doctors gather information. While accurate history-taking, acute observation, and thorough physical examination is still the mainstay of good clinical practice, it is not necessary or indeed best medical practice, for every doctor-patient interaction. Self-monitoring of physiological parameters has transformed the fitness industry and is on course to do the same for medicine.
Actual GP consultations are a precious resource that have immeasurable beneficial outcomes. Such consultations are essential for complex medical problems, physical examinations, and have an inherent therapeutic value in many situations. An online doctor will never provide the same service as one who is physically present, but that does not mean that online consultations have no value or cannot be adapted to enhance current general practice.
Bertalan Mesko’s, <em>The guide to the future of medicine: Technology and the human touch</em>, describes how technology is transforming medicine in ways reminiscent of <em>Star Trek,</em> with medical holograms replacing human doctors, remote robots performing major surgery across continents and specially designed powered exoskeletons restoring motor function to limbs damaged by illness or injury. With such science fiction now a reality, it is reasonable to consider online consultations as a means of extending medical care beyond the surgery walls to homes and offices, schools and universities, holiday resorts and nursing homes in the same professional and compassionate manner employed in surgery consultations. Many patients are online and would be delighted to meet us there.