Telemedicine is not medicine

The COVID-19 pandemic has brought many insidious maids into their rotten gear. From zoom meetings and school closures to masks and lockdowns, our world has been torn apart and finally brought back to a place where almost everything has changed, big and small, perceptible and imperceptible. No wonder that medicine is one of the more clearly perceptible areas of life that have changed irrevocably. One such area in medicine that differs drastically from the BC era (pre-COVID) is the concept of telemedicine.

With the lockdowns of 2020, people became much more open to the possibility of virtual visits to their doctors and the market took notice. Here was and is indeed a burgeoning market. The telemedicine industry is estimated to be worth around $90 billion in 2021 and is projected to grow well over $600 billion by 2028. There are clearly many motivated players hoping to capitalize on the burgeoning gold rush. While I recognize the futility of standing between such a lucrative market and its profits, I think it’s important for someone to stop for a moment and not ask, “Can I participate?” but to ask, “Should I?”

It would be unfair not to support the counter-argument as strongly as I can in the limited space I can. Telemedicine has potential opportunities, particularly for patients in remote locations who cannot easily see a family doctor or who are tied to certain aspects of specialties such as psychiatry. There has been some success in using telemedicine in acute stroke patients when the patient is far from a stroke center, and drugs like tPA can potentially make a profound difference in a patient’s ultimate outcome. The ability to consult a neurologist remotely has been healing for many stroke victims across the country.

And while it’s one thing to use new technology to fill supply gaps, it’s quite another to create an entirely new ancillary industry. Telemedicine will reinvent the world of medicine for both patients and doctors. It seems, therefore, that one should ask a vital question. Is this good medicine? And, perhaps as a result, cui bono?

Answering the second question, who benefits from it, helps answer the first because if it’s not the patients, it’s not good medicine. It can also be argued that, mutatis mutandis, this cannot be in the interest of the doctor either. The problem is not corporate greed, medical expediency, or the allure of a new (similar) technology, although all three can contribute. The problem lies more in the technology itself – the feature is the bug. Medicine generally cannot be practiced through a screen between a doctor and a patient. This is representative medicine. Rather than being present, the patient is represented to the doctor, and while this would obviously preclude any procedures to be performed or any significant physical examination, it is less obvious how contrary this is to the practice of medicine. A decent analogy might be that if medicine is sexual intimacy with a loving partner, telemedicine is just pornography – a representative encounter that mimics a higher good to the detriment of those who would participate.

Medicine requires a patient and a doctor in a shared space, because real medicine requires the interaction of two people facing each other. This is not just because a physical exam can be performed, although it is vital, but rather because there is so much nuance and context that goes into each unique interaction between a patient and a doctor. How a patient speaks, the clothes they wear, their gait, the tremors of their hands, the condition of their feet, the demeanor and demeanor of those accompanying them to the ER, their posture, their eye contact, and their overall impact, to name but a few to name a few Just a small selection of what the wise doctor contemplates, all contributing greatly to the explicit and implicit reasoning of the astute doctor. The tacit art of intuition and the necessary role of the imagination are both paralyzed when presence is forced across a screen that merely represents a patient but can never adequately convey the spark of humanity that medicine must capture in order to function properly. The flow of a life is somehow interrupted and minimized by the screen, and this intangible whole, somehow greater than the sum of its parts, cannot be observed and understood by the attentive doctor. Everything important is lost, doctors become mechanics and patients become machines.

This is of course a philosophical argument and probably won’t convince many, but it’s the best reason, in my opinion, to buck the current trend towards the isolated and distant reality of telemedicine. After all, this is a kind of semi-medicine removed from any real doctor-patient interaction and isolated from medicine’s true purpose of trying to heal a person struggling with terrible anxiety, hopeless fear, indescribable pain, tortured heartache, and desolation can be filled with malaise or the gray despondency of modernity. After all, it’s usually a friendly look, the perfect word at the right moment, or a gentle touch that is the most therapeutic weapon in a doctor’s arsenal.

The truth is, if we’re to keep our fine art intact, physicians should avoid allowing more and more technology to come between them and their patients. Patients should avoid the simple allure of a quick video chat if they think something is wrong with them (not to mention the second bill, when they’re almost always advised to come to the ER anyway). Hospital management should resist the profits that might accrue to them at the expense of the local citizens they purportedly serve, reserving this technology for specific niche areas (rural medicine, acute stroke, psychiatry, etc.) as needed. While this scenario seems quite unrealistic, the benefits that would accrue to our healthcare system if it were to materialize relative to the almost certain lack of trust that telemedicine would generate for medicine at large if not seized would be in indeed wholesome.

Perhaps we should heed the wise advice of Cornelius, the queen’s physician in Shakespeare’s Cymbeline, who, upon hearing of the queen’s dishonest plan to test poison on small animals to “gather their various virtues and effects,” replies: “Your Highness shall through this practice, but harden your heart.” If the advent of social media has taught us anything, it’s that becoming a cynic when confronted with another human being is a lot harder, and a lot easier , if you can hide behind a screen. To pretend to care for our fellow human beings from afar is to invite cynicism into our souls and hardness into our hearts, for it is not at all a “real” encounter, but rather a virtual representation of one. In short, it is not medicine, but the representation of medicine; not a calling based on philanthropy, but a job based on the need for a paycheck. Let’s keep the cynicism at bay and the softness in our hearts. Let’s keep telemedicine within its limited and reasonable scope. Let’s be doctors, not technicians, and always human first.

Andrew Ross is an emergency doctor and author of The Sweet and Bitter Taste of Moonshine.

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