Medicine and Telemedicine in the Times of Covid-19
There is no doubt that we live in tragic and fascinating times. The toll of the pandemic in terms of both lives and livelihoods is sadly yet to be fully realised. While it is already clear that the societal shifts the pandemic has created will define the decades to come, the field that is likely to change more than any other is possibly medicine itself. This piece describes some of the challenges that the medical profession has had to overcome to embrace technology-aided services like telemedicine, and highlights the lessons we’ve learned from delivering teleconsultations in Turkana … if we could do it there, then surely we can deliver telemedicine anywhere!
First, an overview of the situation
The pandemic is forcing a change in medical practice in two ways. The first is linked to the Covid-19 illness itself: being so contagious and deadly, everyone – healthy individuals, patients, health workers, managers, employers, businesses – have a part to play in ensuring the virus does not infect more people. This is a big shift for medicine – moving from almost an art wielded by a privileged few to something everyone is responsible for. The second is in how medicine is practiced when medical professionals reduce the risk of becoming infected. Reducing contact between doctors and patients seems like walking away from the ‘sacred touch’ that has defined the profession.
But as everyone socially distances themselves, doctors are being forced to forego touch and rapidly adapt to the new normal of “zooming” into their patients’ bedrooms. For a profession that considers physical contact central to its practice, this is a seismic shift that is being forced in within the space of weeks. While it may herald a new era of medicine, it is worth looking into the history of telemedicine for lessons.
Some background on telemedicine
The desire to practice medicine over distance has likely existed almost since the profession came into being. The best documented example of such practice prior to the rise of modern medicine is the use of letters by Dr. William Cullen in 18th century Scotland to communicate to patients as far away as Australia. Almost every communications technology invented by humans – telegraph, radio, telephone, television, satellites, email and the internet – have all been used to practice medicine remotely. It is therefore greatly ironic that in 2020, besides exchanging images and messages over WhatsApp, we still do not systematically use technology to deliver healthcare over distance.
While this pandemic is likely to change this, it’s worth understanding why remote medical practice is not more widespread. On the face of it, telemedicine is simply the use of technology to connect doctors and patients. While most people in wealthy countries have had access to telephones for a few decades, the practice of medicine requires the ability to transfer images and other information over short time (e.g. requesting and sending a picture of the affected part of the body) – this has only become possible at large scale with the smartphone. So, while it has been possible for telemedicine to be practiced between two well-equipped hospitals for more than a century, practicing telemedicine between a hospital and an average person’s home is only possible now.
In the meantime, technologies for supporting medical practice have focussed on where they could be used and paid for easily – the hospital. Hospitals are infamous for charging as much as they can for services, and any technology that hospitals can bill for is almost guaranteed adoption. On the other hand, keeping patients away from a hospital reduces the number of services (and technologies) hospitals can charge for, and has been resisted. This combination of factors has slowed the pace of innovation in telemedicine technologies used for serving patients at home.
What have we learned?
There is still limited evidence to support the large-scale use of telemedicine, as evidenced by high-profile “failures” of telemedicine interventions. The lack of evidence is likely due to a focus on the “health impact” of such services and not enough attention on the wider benefits of teleconsultations. Our work delivering teleconsultations in Turkana has shown that virtual links between nurses in remote primary healthcare clinics and doctors in Nairobi (and elsewhere) have wide-ranging benefits – improved communication and team work between healthcare professionals, higher motivation and morale among health workers, equity in access to services, reduced social disruptions, and more. We have only lacked the gumption to systematically demonstrate all these benefits to policy makers.
In the times of Covid-19, we can use two lessons learned from delivering telemedicine to some of the most remote locations in the world. Firstly, we have to “meet everyone where they are” in terms of technology. Telemedicine will be a non-starter if we expect everyone to download an app, and everyone to be trained in using it! The second lesson is that services with technology should work very much like services delivered without. It’s important to keep the technology almost invisible, and for doctors and nurses and patients to keep doing what they usually do (but with a little help from our digital friends). These two lessons have served us well in Turkana, and they should serve us well in the times of Covid-19.
To wrap up
As the pandemic exposes the weaknesses at the heart of the ‘noble profession’, changes that the field has long resisted are banging at the gates to be let in. These include “big ideas” like a taxpayer-funded universal health system, or re-organising healthcare from being hospital-centred to community-centred or even patient-centred. They also include changes at an individual level, like lowering egos and hierarchies, and increasing communication to improve team-work. Equally, they include changes needed in the “middle” – technologies and processes that make it easier for individuals (whether patients or doctors) to be part of the larger system. Telemedicine is one such change, and its time has likely arrived.