Telemedicine--what might doctors miss during online exams

This article discusses something I've wondered about since routine medical exams have gone online because of Covid. This was something that was starting to happen anyway, as it allows doctors to cram even more appointments in each day and it probably saves money not to have to do all that other stuff.

https://www.npr.org/sections/health...es-the-physical-exam-what-are-doctors-missing

It's occurred to me even before I read this article that there are some things a doctor won't be able to do online:


--listen to a patient's heart and lungs
--palpitate their abdomen, thyroid gland etc. for lumps, ascites, and swellings, test a patient's muscle tone
--see any body part that is inaccessible to a web cam
--notice subtle differences in a person's skin tone, coloring etc. that may be indicative of some ailments
--test reflexes
--look in their ears and up their nose with the otoscope/auriscope (whatever the pointy thing with the light is called)
--maybe get a really good, well-lit look at the back of their throat
--notice edema and swelling in extremities
--blood pressure, pulse, O2 saturation (unless the patient has a pulse oximeter and spygmomanometer at home)
--Anything that the patient doesn't specifically mention but the doctor may notice and ask the patient about in an exam room
--collect scrapings and samples and cultures
--get a patient's accurate weight (not the weight they tell the doctor based on a less-accurate home scale paired with wishful thinking)
--and sometimes things just come up during a face-to-face encounter that don't over the phone or on webcam.

Plus there is the whole relationship, emotional support thing that is stronger in person for many people. As with teaching, a move to online instruction definitely changes the nature of a relationship-based profession in many ways. If these changes stick around after the worst of the pandemic has passed, what will it mean for doctor-patient relationships, job satisfaction, and our approach to diagnostics in general. My brother is an oncologist, and he says he often doesn't need to perform an exam on his patients, because the information he needs comes from their tests. But he feels the office visit is important to get a real sense for how they are doing overall, and some patients are concerned if he doesn't examine them, as it's part of a ritual they find reassuring.

Also, could virtual visits lead to important tests not being ordered because the doctor misses a symptom? Or conversely, could it lead to increased costs, because doctors might get overly-cautious and order tests for things they couldn't rule out with an online exam?

Has anyone had an experience with online medicine since the pandemic started, or before? If so, what was missing?

For me, certain routine dermatological appointments that involve injections for a chronic condition I have (alopecia areata) had to be cancelled entirely for several months, as there is no way to do those over the web and the dermatology department was closed to all but online visits for a while. I had some moderate anxiety over this, because I occasionally get bald patches on my scalp (the flares happen every couple of years, and lucky me, I started one around the time the Covid crisis was taking off). They often resolve on their own with time, and over the past decade or so they generally don't show, as my hair is thick enough to cover them. But when I was in my early 40s, the condition came out of nowhere and progressed rapidly to complete baldness while I was waiting for my first dermatology appointment. I was bald for about two years, which was lots of fun (not). An experimental trial (since discontinued) allowed my hair to regrow, as might some changes in my own body (hard to say there), but there is always that lingering worry that the same thing could happen again and a few bald patches that move around on my scalp could turn into complete baldness again if I can't get the topical injections.

I did some televisits with my therapist, and it was a bit klunky. It worked, but doing it in person was far more comfortable for both of us. He said there are definitely things you miss with a patient's affect and body language over a webcam, and people's connections and hardware vary greatly, so you can get stuttering, freezing and so on, which is more of an issue with a visit focused entirely on back and forth for 50 min or whatever.

With online teaching, one thing driving me nuts is not being able to address issues with the class as a whole. Even with multiple group e-mails, announcements on canvas, instructional videos, and handouts I have had to answer the same e-mails over and over and over. This might be different than for online medicine, because doctor's relationships with their patients are always one on one anyway, instead of group centered. With teaching, there are benefits to being able to get all of them in the same room at the same time.

Don't get me wrong, I think they are great for some things and are far preferable to no visits at all for people who are housebound or living very far from health care providers. For certain matters it would be preferable to having to drive, find a parking spot, and worry about traffic making me late. So much of our lives in US cities and suburbia is spent in cars or transit, getting to where we need to be. Telecommuting could save time and reduce pollution/traffic.

I just worry that there will be a continued push to fit more and more health care in that box in the future, even when it isn't what works best. Ultimately, insurance companies drive health care toward what is cheapest, at least in the US, not necessarily what doctors think is the best way to practice medicine. And for some primary care doctors, it may leave them wondering if this kind of patient relationship is why they wanted to practice medicine at all.

I've seen some parallels withe the online education we are doing. Online is certainly far better than not having classes (or medical consults) at all, but far from being the tech-savvy scions of the computer and internet era, my freshman and sophomore students are largely bewildered, needy, often inadequately equipped with internet access and computer hardware/software. I feel like I'm herding them through the online course experience, and it's exhausting. I was amazed at how many people still don't have computers (or wired internet) in their homes these days.

I'd sort of thought home computers were a bit like televisions were when I was growing up--something almost every family (except for a few desperately poor or tech rebels) had at least one of and which were becoming more and more something where different family members had their own. But this is not the case. Or maybe home computer ownership dropped off once smart phones became ubiquitous. The problem is, phones don't allow easy access, or access at all, to everything online learning can offer. Maybe this is an issue for telemedicine too. I did an online appointment once via phone--before I had a web cam for my computer--and it was hard with such a small screen.

One thing that is interesting--and this doesn't apply so much to telemedicine--is that the one advantage I figured students would love about online education is its asynchronous nature. With pre-recorded lectures, they can access class content at their convenience, and it is closed captioned too. Given how many always missed meetings each week with face-to-face classes, and the people forced to drop classes because their work schedule changed or their childcare fell through, I figured online would be great for that. No excuse to miss lecture, right? No more frantic e-mails asking me for my nonexistent lecture notes or begging me to put the power point slides online.

But the opposite has been true: many students are bewildered and disappointed that we aren't having scheduled "live zoom lectures," which would not only be tough to manage in a 50 person class, but would not be able to be closed captioned as required as per the ADA (there is a captioning service, but it runs 2 weeks behind, and students wouldn't have access to all meeting transcripts in time for exams).

I did a zoom orientation where I explained how the class was going to work. I also included captioned orientation videos and handouts and announcements, and group e-mails. I STILL got a bunch of e-mails two days later asking why "there was no class on zoom today." And getting them all to do the proctorio installation and test quiz assignments has been ... interesting (several students sent me their profile pictures instead of the screen shot of their successful installation message). I have to do a second test quiz, because none of them did the correct scan of their testing environment for the first one.

I often find it takes 2-3 back and forth e-mails, over a day or so, to resolve a misunderstanding that would take 20 seconds to clear up in class (and benefit all the other students who witnessed the exchange). This is different from medicine, because medical visits are usually one on one.

I think they are finally starting to understand the class format and what is expected of them, but the proof will be when they take their first "real" exam, and also in how many continue to submit their assignments once I stop with the constant reminders. I don't know how much doctors have to deal with online patients who don't understand how to use the technology or follow instructions re the submission of needed information.

Many say they miss coming to class and campus and the human contact it offers. I have yet to have a student tell me they prefer online classes and are soooo happy the covid crisis made more of them available. So much for my my assumptions that Gen Z is a bunch of tech-savvy introverts.

I think the administrators and medical experts who think online is what everyone wants and prefers, and that it will be a great force for student and patient equity (when many still lack reliable internet or up-to-date hardware), are living a pipe dream at the moment.

I honestly hope so, because if this becomes the new normal for my career, I don't think I'd stay with it. If I wanted a job where I had to sit behind a computer all day, I could have picked from a number of more lucrative options. That's something some doctors have told me too--that sitting in front of a computer all day is not why they went into medicine.

I also imagine other services, such as legal consults, are going online during covid. The vets aren't doing telemedicine yet, though. We still bring our pets in, though we now wait in the car while they take the animals into the clinic for exams.

JJ Litke said:

In regard to students having trouble with classes, you can’t underestimate how much stress is affecting them right now. A lot of them have lost their jobs, or they’re stuck in low-paying high-risk jobs, they’re facing eviction, struggling to get by, and even if they’re hanging on for now, the job market they’re going to graduate into is so trashed they have little hope of getting a good job. That’s assuming they don’t get sick and die. None of this is helping create the kind of mindset that’s good for learning. To say the least. I know I’m not functioning at my best these days, either, and I’m not in near the dire straits some of my students are.

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It's really, really hard for them right now. We are trying to be as understanding and flexible as we can (though we also have to take care of ourselves and have healthy boundaries). One of my students is actually in quarantine right now in a hotel, though she will hopefully be done and okay soon. Many of my students work food service and in essential retail, so there's a real risk they could be exposed on the job. The younger ones are very, very unlikely to die (unless they have certain health issues), but there's the constant worry about bringing it home to more vulnerable family members, and now there is that constant, nagging worry about long-term deleterious effects, even possibly with mild or asymptomatic cases. Some of our students are older too.

My goal is to provide them with a roadmap through the class and a certain amount of flexibility for getting assignments in and frequent feedback and so on but still enough structure they are motivated to keep doing the work. It's hard, and it still won't work for all of them. Long-term the institution must provide them with the ability to re-take classes if needed and to work towards their degrees on a more flexible schedule. This has been a point of contention for a while, though, with more state funding pressure to get students in and out quickly, like little sausages going through a factory. There's less room for part timers, people who want to explore for a while before settling on a major, non-traditional students, and lifelong learners than there once was in the CA community college system.

It is still very hard to get data on the intersectionality between age and various common and less common chronic health issues in the population as a whole. This is something I just haven't found much on, presumably because the virus is still so new. For instance, how does the death risk for an obese forty year old compare to the risk for a fit, healthy seventy year old? No wonder people are so anxious. I read research and review papers on Covid-19 when I can get my hands on them, and there are so many things they just don't address yet!

It's the same thing at our college. Only a handful of clinical classes that are required to be hands on by credentialing agencies are meeting in person. And I don't know of any faculty or students who think classes should be in person during the covid crisis either. To be completely clear, my students (and myself) are not complaining because we made this choice during a crisis. In fact, the faculty would probably strike if they tried to make us teach in person right now. I can't think of a way our campus could offer in person classes safely and remain solvent.

One can be sad and melancholy, miss access to facilities and resources, and miss the various face-to-face interactions one experiences on campus, not to mention being stressed by all the changes, unfamiliarity, extra work teaching and learning online actually entail, however. This isn't the same as thinking these temporary shutdowns aren't needed, given the situation. And faculty can certainly be frustrated by the things we simply can't do in our classes right now, things we think are important. We're forced by circumstances to give our students educational iron rations instead of more nourishing and balanced fare, but it's better than starving!

There are also serious equity issues with online education, and societal resources to rectify this are very limited at the moment. But what can we do?

If I gave the impression that I think we should ignore covid and open up, believe me that's not true at all. But I think we need to be aware of the problems and limitations, both so we can get as much out of the circumstances as we can (and be aware of potential issues, like things doctors might not catch in a televisit), and so we don't allow various insurance companies, businesses, politicians, and administrators to insist that since we did all these things online during the crisis that this should remain the norm after the crisis is over.

Lyv said:

No, your concerns (in this post and the one above) are valid, Roxxsmom. I posted about my video and telephone visits to show how they can work in some circumstances, but I also know having been an RN how much you use your senses in practice. I knew when a patient had a GI bleed or UTI by smell. I once caught an aortic aneurysm that the excellent ER staff has missed, just by doing a routine admission exam (I used to have eerily good hearing). And if there's a way to make more money at the expense of the public, insurance companies will exploit it.

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Oh I know, and I agree there are circumstances when online access to medicine or classes is very important. I think I gave the impression that I didn't agree with teaching classes online or offering telemedicine during the crisis, and I want to be perfectly clear that this is not the case.

I was a bit surprised how many students have expressed sadness over missing in-person interactions with instructors and fellow students, though, and also how many need to come to campus to access quiet study space, computers, or textbooks (library reserve checkout, which is currently unavailable) and so on.

I sort of had the impression that Gen Z were a bunch of very introverted and tech savvy sorts who wanted to take classes from home, but this hasn't proven to be the case. I'm sure some are, but a surprising number aren't, and many of my students struggle with everyday tech glitches they run into and have trouble installing apps and software on their computers or figuring out that sometimes simply rebooting their computer or updating a video driver solves a problem (and is a good thing to try before asking for help).

JJ Litke said:

Same here. I keep bringing up how I pushed for more online classes because students wanted them, but to be clear that doesn’t mean that students wanted only online options. The ones who wanted all in-person classes were getting that before the pandemic, so they didn’t need me to lobby for them. I wasn’t trying to push for an entirely online program, either—as one of my full-time faculty once said, there are other places for people to get that, and our program is stronger for having resources those online programs can’t offer.

When I worked in the tutoring labs, I was initially surprised at how not tech-savvy a lot of the younger generations are, too. My theory is that while many (if not most) of them are comfortable with social tech and mobile devices, they haven’t had the kind of jobs that get them working on desktop computers organizing files or using serious software for work. So they aren’t tech-savvy in ways that are beneficial in the classroom. I’ve had to teach people a lot of basics, even things like how to copy files to a USB drive.

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I imagine there's been a shift with the Gen Z too, because the millinials remembered a time before smart phones, before smart phones were capable of replacing the near-ubiquitous family computer for so many things (and when entertainment was still something friends and family consumed together via larger screens and stereos and so on, rather than individually staring at small screens and listening to music through earbuds). Now poorer people can get by in daily life with just a phone, and many of them do.

Another thing I noticed, when looking at the practice footage for proctorio-proctored exams, was how many of them do not have their own room or a study where they can take their tests or even study without being disturbed. They are getting "flagged" by the proctoring software because a roommate, sibling or parent is sitting in the background watching TV, or someone is bugging them while they do schoolwork, taking a test they are supposed to be alone for.

But what can they do if they share a bedroom, or if their family lives in a 2-bedroom apartment and the only computer in the house is on a table in the living room or kitchen?

The proctoring software is supposed to make it easier for the instructor, but it actually means I have to scan through the test recordings by hand for many of my students who aren't cheating, because of their testing environment. So much easier and less time consuming to have them all in the same room, taking it together!

Teachers in general (I don't know about doctors and counselors and others working from home) have been dealing with people making jokes about how we're not really working and the students and (for K-12) their families are doing all the work, so we should have our pay cut or something. It's maddening, because online teaching is harder and more time consuming. Colleagues who taught online classes before covid-19 were saying this already, and it's really true.

I also wish the parents of K-12 kids would stop calling their online class formats "homeschooling," because it is not the same thing at all. With homeschooling, the parent is the teacher, though there may be some consulting with school officials or teachers for suggested curriculum and progress reports (depending on the state). With online, there is still a teacher who provides the instruction via online modalities of some type, and the curriculum is still what the district and state mandates. Parents are not the teachers, per se, though of course they play an expanded role in making sure their kids are online and on task at the correct times.

Had one strange experience with the online testing proctor the other day. Students are required to do a scan of their room and computer before starting the test. They use a mirror if their webcam is mounted on the screen. The point is to see that there are no notes or anything plastered to the screen and keyboard, desk etc. I have to watch this part of every test recording for all 130 of my students, because there's no AI that can determine what an adequate scan is. It has entailed several practice quizzes where I watch and give feedback--a real grind.

I am still getting students whining that they can't show me their computer because it's a laptop with a built-in webcam. So I have been sweetly asking in each and every e-mail if they watched the "how to" video and read that they should use a mirror.

The scans go by pretty fast, because they are sped up, but I have to freeze a lot, since some students really rush their scans and don't pause for a moment on their computer view. So it's time consuming and boring as crud.

Though the student who flipped me off at the end of his very sub par room scan was mildly interesting. I've been teaching college classes since the 90s, and it's the first time a student has flipped me off. Not sure what to make of that.