What Is Telemedicine?

It sounds like a dream come true, doesn’t it?  You’re sick and you just pick up the phone and call your doctor.  Ten minutes and a secure video call later you’re on your way to the pharmacy to pick up a prescription for something to get you better.  No lost work time, no need to drive to the office and wait to be seen, and best of all, no long wait at the urgent care or emergency room.

This is the vision that telemedicine proponents would like you to believe.

What is telemedicine?  Telemedicine is defined as “the remote delivery of health care services using telecommunications technology: internet, wireless services, satellite and telephone media.”  It was initially developed in the VA system as a way to bring specialty services to underserved areas.

Veterans live everywhere in the USA and have a right to access the VA health system’s resources for their care.  However, if a veteran who lives in Copper Mountain, Colorado (population 385 and 2.5 hours from the VA medical center in Colorado Springs) needs care, the VA has developed technology to allow him to receive consultations with specialists via a secure video call using the health resources in his community.

This is very cool and an awesome use of technology to promote health in a very at-risk population of aging men and women who deserve the very best the US health care system can provide.  It is also starting to bleed over into other areas of medicine.  Super-sub-specialists with very targeted skills can be consulted from all over the world.  Dermatologists can be sent photos of rashes and skin spots and provide opinions without needing to see patients in-person (and can be paid by insurance companies for these consultations).  Pathologists and radiologists can do the same thing with images of tissue specimens and MRI scans.

I am very excited that this may soon be an option in my office.  I sometimes have to bring people in to the office to discuss complex test results and decide on a plan of care, not necessarily because I have to lay hands on and examine patients (most of the time I’ve seen the patient recently) but because it’s going to be a fairly complicated and time-consuming conversation.  Being able to have those discussions face-to-face via secure video conference would be a dream come true!

However, there times when a video “virtual” visit is NOT appropriate.  If physical examination (listening to heart, lungs and abdomen, looking in ears and throats, manipulating a painful joint or checking an in-office lab test) is required to diagnose a problem, then an in-person visit is most appropriate.

For instance, do I absolutely need to see someone in the office to tell if they have a cold or sinus infection?  No, not really.  I can tell a lot by the patient’s symptoms and how those symptoms have changed over time.  However, I can NOT diagnose bronchitis, pneumonia, ear infections or strep throat over the phone (or video call).  If someone thinks their respiratory symptoms are more than just a common cold, they need to be seen in the office because without examining them I am less likely to get the right diagnosis and prescribe the right treatment.

Before you call the Skype doctor to get an antibiotic for what feels like strep, consider whether you are doing yourself harm by not being properly evaluated for your illness.  Every treatment has benefits AND risks.  That antibiotic, if taken for what is actually a viral sore throat, can cause diarrhea or a vaginal yeast infection or even a life-threatening allergic reaction or C. diff infection WITHOUT doing a thing to help the sore throat.

Does the doctor you are calling know you well?  Does he or she know your history?  Do YOU know THEM and trust them to make the safest and best recommendation for you?  And if they tell you they can’t be sure what’s wrong without seeing you in the office, will you be OK with that?

If the answer to any of these questions is no, you probably would be safest calling your primary care doctor for a quick visit.  If you don’t have a primary care doctor, you should!  Ask friends and family for a referral, call your insurance company, or check ZocDoc.com.

There’s a reason why every doctor visit has 3 components: history (the story of your illness), physical examination, and medical decision making.  Don’t handicap your doctor!  Most of the time reaching the correct diagnosis and choosing the right treatment, especially for a new problem, requires all three.

QUESTION: What do you think of telemedicine?  Would you choose to see a doctor via Skype video call if you were sick or hurt?


Prescription Heroin

Canada has just approved prescription heroin injections for treatment of addiction.  Diacetylmorphine, as pharmaceutical grade heroin is known, will be injected by a nurse at special addiction treatment clinics for free.

The goal is to keep people off the streets, put dealers out of business, and protect people from overdose deaths.  The question is, will it work?

Those who are addicted to heroin will be able to enroll in a clinic treatment plan where they will come in and receive prescription heroin injections using sterile needles by a nurse.  They may need injections 2-3 times daily, which would be difficult for people trying to manage a job and family at the same time.

We have similar programs here in the USA for heroin addicts.  Suboxone and methadone clinics provide long-acting narcotics to prevent cravings and reduce the risk of addicts going back to the streets looking for a high.

In spite of these clinics, heroin abuse and heroin overdose deaths continue to climb.  Current thought is that addicts start with narcotic pills and then, when the supply of pills dries up, they switch to cheap and plentiful heroin to get their fix.  Heroin is now commonly mixed with fentanyl which is much more powerful and may be partly to blame for the recent surge in overdose deaths.

Since we have treatment options that decrease the risk of overdose, why do we have increasing numbers of overdose deaths?  Why do people choose to shoot heroin when they can get pills, prescribed by a doctor and paid for by insurance, that reduce the cravings for narcotics?

That’s a pretty complicated question, but an important one to discuss in trying to predict whether Canada’s approach of providing prescription heroin will be effective.

First of all, it is a fact that there is still a huge stigma in seeking treatment for addiction.  People would rather risk death than admit they cannot stop without help.  This problem will NOT be addressed by Canada’s approach.

Second, it is difficult to get an appointment in the USA in a Suboxone or methadone clinic.  There aren’t enough clinics licensed and trained to administer the drugs to keep up with the number of patients who need treatment.  It is difficult to get certified and, to be honest, few doctors find treating addicts rewarding.  High relapse and recidivism rates combine with the generally difficult nature of treating addicts (they often have mood and personality disorders) and the result is there aren’t enough treatment programs available.  Simply licensing prescription heroin will not solve this problem in Canada, either.

Who will administer the drug?  What doctors are going to be willing to have a drug with such high street value openly available in their clinic?  How will law enforcement protect the clinics from addicts and dealers seeking to steal clean, safe heroin from clinics and pharmacies?

I’m afraid that prescription heroin will fail in Canada, if Canada does not address these two problems (stigma of treatment and lack of availability of treatment programs).

You can have the most effective and safest treatment options possible and, if no one can or will take advantage of them, they will not make a bit of difference.  Every car manufactured on the planet has seat belts built in, and yet there are plenty of people who refuse to wear them.

QUESTION: Do you think providing clean, safe drugs for addicts is a good idea?  Why or why not?


Antibacterial Soap

Are you one of those folks who is creeped out by the idea of bacteria on your skin?  Do you like the idea of sterile bathrooms and kitchen counters?  Do bacteria and viruses always equal illness in your world?

This week I would like to encourage you to think of the bacteria on your skin in a different way.  Most of the bacteria on and in our bodies are safe and actually helpful for us.  In fact, they provide a barrier and competition for harmful bacteria so they have a harder time getting a foothold on and in our bodies.

Infection and symptoms of illness are often related to a harmful species of bacteria or virus either getting into a part of the body where they don’t belong (like E. coli from the colon finding their way to the bladder and causing a urinary tract infection) or overgrowing and out-competing harmless bacteria.

Do you know anyone who has had MRSA boils on their skin?  This is often a problem with sports teams that wear pads (like football, soccer and hockey) or where shared equipment can spread infection (like wrestling or martial arts where mats can’t be completely sterilized).

Often athletes that compete in these sports are encouraged to not only clean their equipment as thoroughly as possible but to use antibacterial soap to wash their skin.  The idea is to use antibacterial soaps to kill the bacteria that cause infection.

The problem is that they don’t work.  There is no evidence that soaps that contain antibacterial products do anything to reduce infection rates.  They are no better than plain soap and water.

In fact the FDA just issued a ruling that certain antibacterial products (like those containing triclosan and triclocarban) cannot be marketed anymore.  Manufacturers have a year to remove the bactericidal ingredients from their products.

If it was just that antibacterial substances didn’t work to reduce infection, I don’t think the FDA would have issued the ban.  But these substances may actually be harmful.  For instance, triclosan has been shown to increase the rates of Staphylococcus aureus bacterial colonization in the nose.

When I have a patient who has recurrent boils or a culture that’s positive for MRSA, I make sure to tell them NOT to use antibacterial soaps.  Most patients (and parents, as a lot of these patients are teenage athletes) look at me like I’ve suddenly sprouted a second head.  They’ve been scrubbing themselves with antibacterial soaps like there’s no tomorrow (and bleaching everything in sight to boot) trying to get rid of the germ.

I take a step back and try to get them to consider their skin as a patch of soil in the garden.  There are plants that are very invasive and fast-growing, and there are plants that are a bit more delicate.  MRSA and other staph bacteria are fast-growing and invasive, and the healthy bacteria are a little slower.

If you take your garden and hose it down with weed-killer, it kills your pretty, delicate wildflowers faster than the tough, invasive species, leaving the stronger ones with no competition.  It’s better to avoid the weed-killer and plant lots of wildflowers while just pulling out the ones you don’t want.

In the case of recurrent boils and staph infections, we use oral antibiotics (which don’t disturb the bacteria on the surface of the skin) to kill the bacteria down in the hair follicles and mupirocin ointment in the nose to kill staph where they tend to hide.  It’s true that the oral antibiotics disrupt the bacteria in the gut but it’s temporary and using oral probiotics helps reduce the damage.

It’s estimated that there are 10 bacterial organisms on and in your body for every cell that is actually “you.”  90% of the person we see walking around is actually one big bacterial colony.  On your skin, in your nose and mouth, in your GI tract and, in the case of women, in the vagina.  The vast majority of those bacteria are harmless, helpful symbionts that stimulate our immune system to be healthy, give us vitamins and other helpful substances that we’re just beginning to understand, and help protect us from harmful invading bacteria.

The healthy, helpful bacteria on and in your body are PART of your body and belong there.  Please try not to think of them as invaders or as dangerous.  Help them help you, and your body will be healthier.

QUESTION: Do you use antibacterial soaps? What do you think of the FDA’s ruling?