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Telehealth is not fit for purpose in primary care

As a response to Covid-19 in Australia there is the scope to consult a doctor by telephone or video. The appointment is scheduled at a specific time and the doctor will ask your name, date of birth and address to confirm your identity. Some practices will offer these consults to people who are not eligible for the government rebate for a private or insurance fee.

The type of problems presented to doctors vary from acute to chronic illness. There might be requests for repeat medications or a discussion about test results. Reflecting on the variety of problems presented it is evident that in many cases people are seeking to talk to doctors about issues that need a face to face appointment to be managed safely.

Do you know what this tiny red spot is on my eye lid?

I just want a referral to a psychologist. I don’t want to talk about why on the phone.

My two year old daughter had a rash yesterday. It’s getting better I just need a note to say she can go back to child care.

I think I’ve got meningitis, but it’s getting better today. What do you think?

I had a migraine yesterday and need a day off work.

I think my daughter has nappy rash.

I’ve got iron deficiency anaemia. Another doctor far away did the test for me. I don’t like eating meat and I don’t like taking iron tablets. I’ve googled it and I want a injection of iron. Please leave a script at the desk for me.

It may be true that the patient should not travel to the clinic if possible to reduce any risk of infection. On the other hand it may also be true that the convenience of having an appointment when it suits has made it all too tempting to present problems that need an in person visit. It is often impossible to diagnose the problem based on an exchange over a crackly telephone line with patient who may not be able to hear or speak the language fluently. The patient may believe that a doctor who they know has been paid for the service will satisfy them with a script, certificate or referral in the way that any other telephone service operates. However the model for Uber Eats or Amazon does not fit healthcare where the need for information exceeds just the name, address and date of birth.

Covid will change everything including the way we consult doctors however not all changes will be for the better and telehealth consults that nurture unrealistic expectations will do more harm than good. It is rarely possible to meet the needs of all patients who might possibly have a telephone call with a doctor. In a trial of telephone consults more than 60% of patients needed to be seen face to face. If then those patient are advised that they must be seen in person, notwithstanding Covid the reality that the doctor is unable to meet their expectations may become a source of dissatisfaction and stress for all concerned. The art of doctoring is primarily an in-person activity. Telephone consults are adding to the challenges in primary care at the most stressful time.

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It’s not the symptoms, it’s the context.

More on the Art of Doctoring in my conversation with the one and only Baktash Ahadi

Objective. People with RA have episodes of worsening disease activity (flares) that prompt them to seek clinical review or medication change. This study explored patients’ perspectives of flare that prompts them to seek medication review.

Methods. Fourteen focus groups across five countries comprised 67 RA patients. Transcripts were analysed by several researchers and a patient, using inductive thematic analysis.

Results. Patients use flare for five different scenarios, including flare that prompts medical help-seeking, where six themes were identified. In ‘Symptoms and early warnings’, pain is intense (wanting to die), constant and persistent and considered a key feature. Systemic features predominate, including fatigue, feeling generally ill (flu-like), physical and cognitive shut-down and social withdrawal. Warning signs (prodrome) comprise fatigue and flu-like symptoms. ‘Self-management of intensifying symptoms’ includes pacing, heat/cold, rest and increasing medication, often without medical advice. Patients ‘Define this as uncontrollable flare’ when clusters of unprovoked, persistent symptoms halt their ability to run daily life, until prompted into ‘Seeking help when symptoms can’t be contained’. Underpinning themes are ‘Individual context’ (e.g. different symptom clusters) and ‘Uncertainty’ (e.g. when to seek help). Patients report that the current patient global visual analogue scale (VAS) does not capture flare.

Conclusion. Patients use flare for multiple events and seek help for complex clusterings of intense, unprovoked symptoms that defy self-management, not necessarily captured in joint counts or global VAS. Flare terminology and definition have implications for clinical practice and trials, therefore further research should establish a professional/patient consensus.

Hewlett et al

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Could the greatest hope for primary care be in a laboratory?

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and damage of the joints affecting about 0.5% of the general population. Early treatment in RA is important as it can prevent disease progression and irreversible damage of the joints. Despite the high diagnostic value of anti-citrullinated protein antibodies (ACPA) and rheumatoid factor (RF), there is a strong demand for novel serological biomarkers to further improve the diagnosis of this abundant disease. During the last decades, several autoantigens have been described in RA including Ra33 (hnRNP A2), fibrinogenfibronectinalpha-enolasetype II collagenimmunoglobulin binding protein (BiP), annexins and viral citrullinated peptide (VCP) derived from Epstein Barr Virus-encoded protein (EBNA-2). More recent discoveries include antibodies to carbamylated antigens (anti-CarP), to peptidyl arginine deiminase type 4 (PAD4), to BRAF (v raf murine sarcoma viral oncogene homologue B1) and to 14 autoantigens identified by phage display technology. This review provides a current overview of novel biomarkers for RA and discusses their future potential to improve the diagnosis of the disease.

Trouw and Mahler

See also my podcast with Sam Mazin

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Frailty begins in the forties

Background: There is little known about pre-frailty attributes or when changes which contribute to frailty might be detectable and amenable to change. This study explores pre-frailty and frailty in independent community-dwelling adults aged 40–75 years.

Methods: Participants were recruited through local council networks, a national bank and one university in Adelaide, Australia. Fried frailty phenotype scores were calculated from measures of unintentional weight loss, exhaustion, low physical activity levels, poor hand grip strength and slow walking speed. Participants were identified as not frail (no phenotypes), pre- frail (one or two phenotypes) or frail (three or more phenotypes). Factor analysis was applied to binary forms of 25 published frailty measures Differences were tested in mean factor scores between the three Fried frailty phenotypes and ROC curves estimated predictive capacity of factors.

Results: Of 656 participants (67% female; mean age 59.9 years, SD 10.6) 59.2% were classified as not frail, 39.0% pre-frail and 1.8% frail. There were no gender or age differences. Seven frailty factors were identified, incorporating all 25 frailty measures. Factors 1 and 7 significantly predicted progression from not-frail to pre-frail (Factor 1 AUC 0.64 (95%CI 0.60–0.68, combined dynamic trunk stability and lower limb functional strength, balance, foot sensation, hearing, lean muscle mass and low BMI; Factor 7 AUC 0.55 (95%CI 0.52–0.59) comprising continence and nutrition. Factors 3 and 4 significantly predicted progression from pre-frail to frail (Factor 3 AUC 0.65 (95% CI 0.59–0.70)), combining living alone, sleep quality, depression and anxiety, and lung function; Factor 4 AUC 0.60 (95%CI 0.54–0.66) comprising perceived exertion on exercise, and falls history.

Conclusions: This research identified pre-frailty and frailty states in people aged in their 40s and 50s. Pre-frailty in body systems performance can be detected by a range of mutable measures, and interventions to prevent progression to frailty could be commenced from the fourth decade of life.

Gordon et al BMC Geriatrics.

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To what extent will telemedicine survive this pandemic?

Advances in medicine during wars

Our research findings prior to the pandemic were guarded about the potential of video consults:

Background: There is unequal access to health care in Australia, particularly for the one-third of the population living in remote and rural areas. Video consultations delivered via the Internet present an opportunity to provide medical services to those who are underserviced, but this is not currently routine practice in Australia. There are advantages and shortcomings to using video consultations for diagnosis, and general practitioners (GPs) have varying opinions regarding their efficacy.

Objective: The aim of this Internet-based study was to explore the attitudes of Australian GPs toward video consultation by using a range of patient scenarios presenting different clinical problems.

Methods: Overall, 102 GPs were invited to view 6 video vignettes featuring patients presenting with acute and chronic illnesses. For each vignette, they were asked to offer a differential diagnosis and to complete a survey based on the theory of planned behavior documenting their views on the value of a video consultation.

Results: A total of 47 GPs participated in the study. The participants were younger than Australian GPs based on national data, and more likely to be working in a larger practice. Most participants (72%-100%) agreed on the differential diagnosis in all video scenarios. Approximately one-third of the study participants were positive about video consultations, one-third were ambivalent, and one-third were against them. In all, 91% opposed conducting a video consultation for the patient with symptoms of an acute myocardial infarction. Inability to examine the patient was most frequently cited as the reason for not conducting a video consultation. Australian GPs who were favorably inclined toward video consultations were more likely to work in larger practices, and were more established GPs, especially in rural areas. The survey results also suggest that the deployment of video technology will need to focus on follow-up consultations.

Conclusions: Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools.


Jiwa M, Meng X. Video Consultation Use by Australian General Practitioners: Video Vignette Study J Med Internet Res 2013;15(6):e117 DOI: 10.2196/jmir.2638 PMID: 23782753 PMCID: PMC3713911

The geography of large and relatively underpopulated countries like Australia makes it attractiveto use increasingly cheap information technology to improve access to general practitioners. People are already using the internet to access many other services. However, there are some moderating influences on the use of video-consultations in general practice. These include technical limitations, patient confidentiality concerns, regulatory issues as well as the willingness of general practitioners to consult patients other than face-to-face. Theories predict that a relatively small cadre of innovative doctors are those most likely to try video-consultations for routine consultations. However, much will depend on research that demonstrates that video-consultations are unlikely to harm patients or increase the risk of litigation; on the scope toincorporate diagnostic equipment on home computers; on the financial incentives offered to doctors and on the public proclamations of opinion leaders on the question of video-consultations.

Jiwa et al Quality in Primary care

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Covid will impact all of our health

Homebound status is associated with poorer physical and mental health, as well as disability in the elderly. We aimed to examine the prevalence and the role of homebound status on mortality in a representative sample of the French non-institutionalized population. This study included 7497 people aged 65 and over who were interviewed in 1999 and 2001 about the consequences of health problems on activities of daily living. Homebound status was defined as staying permanently inside the home, excluding an accident or a temporary illness. The influence of the homebound status on two-year mortality was assessed in a logistic regression model adjusted for the main confounders (age, sex, living as a couple, physical and mental impairments). The prevalence of homebound status was 4.7% (95% CI: 3.9–5.4) in this study. The number of homebound elderly was estimated at 421 000 in France. The prevalence of homebound status increases with age and reaches 33.9% in people aged 95–99 years (95% CI: 13.1–54.6). Compared to non-homebound subjects, homebound elderly were more likely to be female, widower, to live alone and to have had a former low level job. Homebound status was associated with a number of physical and mental impairments. It increased the risk of dying within two years with an adjusted OR 3.45 (95% CI: 2.66–4.46). Homebound status should be considered as an indicator of frailty and used in the identification of old people likely to benefit from preventive interventions.

Herr et al. Homebound status increases death risk within two years in the elderly: Results from a national longitudinal survey

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Making it more likely you’ll be heard doctor

Background Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting Qualitative study in urban and semi-rural areas of north-west England.

Method Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.

Simon Cocksedge, Bethan George, Sophie Renwick and Carolyn A Chew-Graham
British Journal of General Practice

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Why does a haircut cost more than a visit to a doctor?

These conversations with Diana Anderson and Cheryl Janis may be relevant in this context.

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If you’re feeling grumpy, try this trick

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Most of what happens in medicine is talk

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Interview with Michael Bungay Stanier- author of the Coaching Habit is available here.

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