Telehealth Video Blues - Reflections on COVID-19 Medicine

It is now mid-May, and about two months since since COVID-19 requirements changed the whole nature of my medical practice. It is been something of a journey, which no doubt many of you who have consulted with in this time will know. This is an essay on some of those changes, and an apology for patients who I have let down in Mosman Integrative Medicine’s transition.

I am a technophile!  I have been since 1978 when I was just a medical student and I bought my first Apple Computer. I think computers and communications have the ability to democratise access to health care, and may in the fullness of time revived and experience so similar to being in the presence of another person that it could work. But that time is not now.

Two months in, I am exhausted. Days run longer but they used to, paperwork remains undone at the end of every day, and the process of managing all restrictions on the new item numbers for Telehealth (and the consequences should I fail to do so precisely) whilst also explaining it to almost every patient is just, well, exhausting.

I have 40 years experience in seeing patients face-to-face, and that has become second nature to me. That may seem simple, but it took more than a decade for me to feel comfortable in the role. In my early days, everything was handwritten, and small handwritten notes were given to each patient to stick on their refrigerator door. I still occasionally see those notes from patients returning from those many decades ago.

Telephone consultations became an increasing proportion of my work in the late 1980s as my practice became more specialised in the area of chemical toxicity and sensitivity and chronic fatigue syndrome. Patients were being referred from far away, and although I always made it a practice to see them face-to-face on the first consultation, subsequent consultations, testing and review of those tests could be more efficiently done by phone than in forcing them to travel to the big smoke of Sydney. Their own GPs and health practitioners were essential collaborators in this. Over time, the telephone consultation became an increasingly useful and understood part of my medical practice, and I adapted to it. It took years.

Prior to COVID-19, I did once or twice weekly Skype or FaceTime consultations, and that worked out fine. I  thought it was obviously better to see my patient than to simply hear them. 

Ask me now, and I am not so sure.  More than half my current consultations are video consultations using one of the myriad of communications platforms. And the video feels more like performance than comfortable consultation. With the person in the room with me, or on telephone calls, I can tap away quite comfortably the important points and paperwork required for the consultation and follow-up. 

With video, there is an intensity and a need to stare towards the camera that I feel very strongly, and when I do turn aside to type, there is a hesitancy and an unnatural flow in the consultation. Prior to every video consultation, I have to sit down and mark up the results of any test results, and email those to the patient for discussion. This would normally take place over printed results on my desk. 

Most consultations still take five to 10 minutes of setup and getting video and audio working, often with multiple callbacks, and frequent change of platform, searching for the best pathway. Often, the latency is more than a full second, making the whole consultation a series of pauses and talking over each other. 

My patients often show me labels of medications and even skin and other visible lesions on a screen not built for that. It is rare to be able to confidently diagnose over video. The lighting is uncontrolled, and my patients seem to love garden window backgrounds that, while very pretty, often reduce my patient to a silhouette. Without facial expression, communications are hard work indeed. 

At the end of every video consultation I need to type my notes as well as my pathology requests and prescriptions. 

The net effect is that a consultation of 30 minutes in actual video communications (the only part that Medicare may even possibly rebate) takes between 40 minutes and 50 minutes, adding 10-20 unbillable minutes for every video Telehealth consultation. 

Finally, the Telehealth medical item numbers, which patients need if they are to receive Medicare rebates under the new legislation, are a nightmare. In two months, discussion about these has resulted in over 20 hours of a nonbillable consultation time. Medicare does not pay to explain to a patient the mismatch between what what politicians promised and the legislation that severely constrains every doctor. 

Firstly, if the patient could not reasonably have attended my surgery, COVID-19 rebates simply do not apply. Who knows what that radius will be for Medicare to make me a doctor for hounding later for rebates. 5 km? 50 km? 1000 km? I see patients face to face regularly who fly interstate for the consultation, and who now cannot. Will Medicare take into account past face-to-face appointments? I am betting not.

Secondly, I am not, never have been, and never intend to be a bulk billing practice.  The contract of Medicare is between the government and the Australian people, but when one enters bulk billing as a doctor, one enters a contract with government that I am extremely uncomfortable with (based on a lot of highly public negative experience over many years with Medicare and its past incarnations).

So all the groups who most need support in this COVID-19 period can receive no benefit from my practice. They are excluded, legislatively, unless I bulk bill. But the main reason I am referred patients is that the bulk-billing approach leaves many Australians with complex and chronic conditions that take time and hard work to unravel and manage. So, I have simply decided to discount all consultations for those patients to the amount equivalent to the Medicare rebate for the consultation. Although the full details for this are in my Financial Consent on my website, it still consumes my time in a way that no longer benefits may patients’ health, and therefore cannot be billed to Medicare.

I would say that Telehealth video consultations have technical and other reasons why they are not the same as telephone or person-to-person consultations. I do not trust Medicare, and I assume that they will, in the not-too-distant future, come trawling around medical practices across the country with their list of complex conditions to see what will have to be repaid to Medicare by the doctor who cared for their patients. I assume that they will retrieve hundreds of millions of dollars from doctors who acted in good faith and at the limits of their abilities to provide medical care during this period.

The bottom line, however, is that I (and I suspect other doctors) and experiencing an unexpected burnout which has complex contributions from politics, technology and time management that I and others have not seen before. I apologise in advance for any deterioration in my ability to serve my patients, any missing paperwork, and the 82 items on my to-do list that have currently not been done!

One day soon, I hope to return to the consultations I know and love, with the person I care for either in my consulting room or on the phone. That may not be any time soon, though, so I have work to do in adapting to the new post-COVID-19 world.

I suspect I am not the only one.