Are Smartphones Going to Replace Doctors?
Telemedicine is on the rise, but some experts say we're not ready to swap doctors' offices for mobile devices.
Illustration: Ray Oranges
"You have to see a doctor," my boyfriend insisted groggily one night, his own sleep destroyed by my nagging cough, which hadn't subsided in three weeks. As much as I hate going to the doctor (the scheduling, the waiting room, the festering germs), I knew he was right. There was one problem: I had recently switched insurance plans and had yet to find a new primary care physician. The next morning, in a pinch, I decided to take advantage of my insurer's telemedicine service: All I had to do was go online, fill out my basic medical history and explain the current issue. There. Done. And I didn't even have to get off my—cough, cough—couch.
Within an hour, my phone rang. As the doctor quickly read my medical profile aloud, I described my symptoms. "This cough, it's relentless," I told him, hacking into the phone. "Do I need to be worried? Is it weird that it's been going on so long?"
"Do you have a temperature?" he asked.
"I don't know," I said. "I don't have a thermometer."
"You don't...own...a thermometer?"
Before I could ask whether a fever would signal a more serious problem, he was giving instructions: "This is what I want you to do. When you go to bed tonight, make yourself a hot toddy. NyQuil is loaded with alcohol anyway, so it's basically the same thing."
Wait, what? Is this 1950?
"Uh, sure," I said, staring at my bar cart and feeling increasingly less confident that my health was in good hands. "But this cough—do you think it's viral? Bacterial? Allergies?" The doctor never answered my question, but he did tell me he would send a prescription for a sleep aid and a cough suppressant just in case the toddy didn't cut it. Then, after what had been a five-minute conversation, we hung up.
Still, not knowing the cause of my cough made me nervous, so I immediately scheduled an in-person appointment with the first doctor I found who accepted my insurance and could squeeze me in at the last minute. After examining me, she diagnosed me with adult-onset allergies and recommended an over-the-counter antihistamine, which did the trick in just a few days. That cough and shot of bourbon wouldn't have helped much. Which makes you wonder: Is telemedicine really such a good idea?
Doctors have long answered calls from their patients, sometimes prescribing medication over the phone; the difference now is that the doctors employed by telemedicine companies, such as Teladoc and American Well, are treating patients they've never met and may never speak to again. (Most people using these services have acute conditions, says Lori Uscher-Pines, PhD, a researcher at the think tank RAND Corporation, who is studying the telemedicine trend. The most common complaints, according to a 2014 study she coauthored in the journal Health Affairs that analyzed claims for more than 2,700 people using Teladoc: respiratory illnesses, urinary tract infections, abdominal pain, vomiting, diarrhea and skin problems, like a sudden rash.)
And the industry is booming—by 2018, the number of patients using telehealth services is expected to increase to seven million, according to a 2014 report by IHS, a research and consulting company. In 2013, there were fewer than 350,000. In June, even the Cleveland Clinic began offering the service to its patients in Ohio. According to a 2015 American Well survey, 64 percent of Americans are willing to have an online video visit with a doctor, and 70 percent prefer such a visit to traveling to their doctor's office for a prescription. In the age of Uber and Netflix and same-day everything, can we really be surprised that our healthcare has also gone on-demand?
Telemedicine's supporters argue that it fills a void, with the added bonus of being convenient, cost-effective and accessible. But as you might expect, medical boards and healthcare organizations have their concerns; chief among them is misdiagnosis. À la carte care, in which a patient sees a different doctor for each condition, lacks an orchestra conductor, says Robert Wachter, MD, professor and interim chairman of the Department of Medicine at the University of California, San Francisco, and author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. "With episodic care, you run the risk of missing the big picture," he says. This might not be a big deal for a healthy 25-year-old, but for older patients—especially those with a chronic condition—piecemeal treatment can be hazardous. "Anyone with chronic problems is more likely to benefit from a physician who knows them well," he says. "If you have someone with emphysema and a history of lung cancer who is on five medications, and they have a new cough, that's very different from a young person with a new cough."
There's also the growing concern of inappropriate treatment, particularly when it comes to prescribing antibiotics: Doctors can't reach through the phone or screen to conduct a throat culture or a urine test before determining the right course of action. This may explain why a 2015 RAND study found that phone and video patients are likelier to be prescribed a broad-spectrum antibiotic—a drug that kills a wide range of bacteria rather than specific types—than patients who see a doctor face-to-face for the same condition. Unfortunately, broad-spectrum antibiotics kill more good bacteria than narrow-spectrum drugs. And overusing them increases the likelihood of antibiotic resistance—the more antibiotics we use, the less effective they become for treating infections.
Yet, despite telemedicine's current drawbacks, many experts see real promise for the service. "What's really going to allow telemedicine to take off is a fully digital healthcare system, in which all computers and devices talk to one another," says Wachter. Right now, many doctors—primary care, ob-gyn, etc.—keep separate records. An ER visit results in one file; a trip to the walk-in clinic, another. But in five to seven years, Wachter estimates, we'll have a system similar to what banks use, allowing different doctors to access the same data for a patient and thereby eliminating the issue of fragmented care. Your primary care doc, for instance, would be alerted when you speak to a telemedicine doctor; if you were given a prescription, your doctor could immediately flag any concerns. It's not a seamless system (yet), but as the demise of the Rolodex and encyclopedias will tell you, resistance is futile. Now the challenge is to incorporate the best of the old with the best of the new—the perfect (non–hot toddy) cocktail, you might say.
Within an hour, my phone rang. As the doctor quickly read my medical profile aloud, I described my symptoms. "This cough, it's relentless," I told him, hacking into the phone. "Do I need to be worried? Is it weird that it's been going on so long?"
"Do you have a temperature?" he asked.
"I don't know," I said. "I don't have a thermometer."
"You don't...own...a thermometer?"
Before I could ask whether a fever would signal a more serious problem, he was giving instructions: "This is what I want you to do. When you go to bed tonight, make yourself a hot toddy. NyQuil is loaded with alcohol anyway, so it's basically the same thing."
Wait, what? Is this 1950?
"Uh, sure," I said, staring at my bar cart and feeling increasingly less confident that my health was in good hands. "But this cough—do you think it's viral? Bacterial? Allergies?" The doctor never answered my question, but he did tell me he would send a prescription for a sleep aid and a cough suppressant just in case the toddy didn't cut it. Then, after what had been a five-minute conversation, we hung up.
Still, not knowing the cause of my cough made me nervous, so I immediately scheduled an in-person appointment with the first doctor I found who accepted my insurance and could squeeze me in at the last minute. After examining me, she diagnosed me with adult-onset allergies and recommended an over-the-counter antihistamine, which did the trick in just a few days. That cough and shot of bourbon wouldn't have helped much. Which makes you wonder: Is telemedicine really such a good idea?
Doctors have long answered calls from their patients, sometimes prescribing medication over the phone; the difference now is that the doctors employed by telemedicine companies, such as Teladoc and American Well, are treating patients they've never met and may never speak to again. (Most people using these services have acute conditions, says Lori Uscher-Pines, PhD, a researcher at the think tank RAND Corporation, who is studying the telemedicine trend. The most common complaints, according to a 2014 study she coauthored in the journal Health Affairs that analyzed claims for more than 2,700 people using Teladoc: respiratory illnesses, urinary tract infections, abdominal pain, vomiting, diarrhea and skin problems, like a sudden rash.)
And the industry is booming—by 2018, the number of patients using telehealth services is expected to increase to seven million, according to a 2014 report by IHS, a research and consulting company. In 2013, there were fewer than 350,000. In June, even the Cleveland Clinic began offering the service to its patients in Ohio. According to a 2015 American Well survey, 64 percent of Americans are willing to have an online video visit with a doctor, and 70 percent prefer such a visit to traveling to their doctor's office for a prescription. In the age of Uber and Netflix and same-day everything, can we really be surprised that our healthcare has also gone on-demand?
Telemedicine's supporters argue that it fills a void, with the added bonus of being convenient, cost-effective and accessible. But as you might expect, medical boards and healthcare organizations have their concerns; chief among them is misdiagnosis. À la carte care, in which a patient sees a different doctor for each condition, lacks an orchestra conductor, says Robert Wachter, MD, professor and interim chairman of the Department of Medicine at the University of California, San Francisco, and author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age. "With episodic care, you run the risk of missing the big picture," he says. This might not be a big deal for a healthy 25-year-old, but for older patients—especially those with a chronic condition—piecemeal treatment can be hazardous. "Anyone with chronic problems is more likely to benefit from a physician who knows them well," he says. "If you have someone with emphysema and a history of lung cancer who is on five medications, and they have a new cough, that's very different from a young person with a new cough."
There's also the growing concern of inappropriate treatment, particularly when it comes to prescribing antibiotics: Doctors can't reach through the phone or screen to conduct a throat culture or a urine test before determining the right course of action. This may explain why a 2015 RAND study found that phone and video patients are likelier to be prescribed a broad-spectrum antibiotic—a drug that kills a wide range of bacteria rather than specific types—than patients who see a doctor face-to-face for the same condition. Unfortunately, broad-spectrum antibiotics kill more good bacteria than narrow-spectrum drugs. And overusing them increases the likelihood of antibiotic resistance—the more antibiotics we use, the less effective they become for treating infections.
Yet, despite telemedicine's current drawbacks, many experts see real promise for the service. "What's really going to allow telemedicine to take off is a fully digital healthcare system, in which all computers and devices talk to one another," says Wachter. Right now, many doctors—primary care, ob-gyn, etc.—keep separate records. An ER visit results in one file; a trip to the walk-in clinic, another. But in five to seven years, Wachter estimates, we'll have a system similar to what banks use, allowing different doctors to access the same data for a patient and thereby eliminating the issue of fragmented care. Your primary care doc, for instance, would be alerted when you speak to a telemedicine doctor; if you were given a prescription, your doctor could immediately flag any concerns. It's not a seamless system (yet), but as the demise of the Rolodex and encyclopedias will tell you, resistance is futile. Now the challenge is to incorporate the best of the old with the best of the new—the perfect (non–hot toddy) cocktail, you might say.
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