The doctor will Skype you now

    31 May 2014

    The average European visits their doctor six times a year. Each consultation lasts around ten minutes; add to that waiting and travelling time, and that’s around three and a half hours per year. Throughout our lifetime, each of us spends some 90 hours with our GP. In a few years, however, that could drop to zero.

    At the root of this change is technology. Digital and electronic communication is fundamentally changing patients’ relationships with their doctors — how, when and why they go to see them. Medicine has moved on from house calls and GP surgeries, with both parties seeking more efficient and effective forms of contact. In 1995, 3 per cent of consultations were by telephone; by 2008, this had soared to 12 per cent. In 2014, it continues to rise.

    Twenty years since the boom in teleconsultations, clinicians have developed even more innovative ways of carrying out their work. Modern computing and the internet have paved the way for texting, emailing and videoconferencing on topics ranging from diagnoses to test results. As you read this, new forms of communication are being developed for the medical sphere. Technology is serving as a useful diagnostic tool, too, with a wealth of comprehensive medical information available on apps and online databases.

    But what effect is this inexorable march having on the profession? Are the days of the face-to-face surgery numbered? And, with people increasingly resorting to Google and Wikipedia for quick-fix diagnoses, what does it mean for the doctor-patient relationship?

    In Manchester, Dr Sirfraz Hussain, a GP at the Moss Side Family Practice, has been using Skype to contact his patients for nearly two years. One of the first doctors in the UK to do so, he says online consultations have ‘revolutionised’ his practice, cutting down patients’ waiting times and providing medical advice to those unable to leave their homes. It is 8 p.m. on a weeknight when I connect to his webcam via Skype from the comfort of my living room, and within minutes he’s carried out a general health check — from 164 miles away.

    ‘I can tell that your respiratory rate is about 80, your capillary refill less than two, your blood pressure is fine, you’ve got a rosy colour so you’re not anaemic and your eyes are white so you’re not jaundiced,’ he explains. ‘The key thing is the face. If you’re worried about one of your patients, this is a great check — do I need to see this person today, tomorrow or in two weeks?’

    Dr Hussain introduced Skype consultations in response to patient demand — and now all three GPs in his practice use it. ‘It started with access,’ he says. ‘People were ringing up for appointments and couldn’t get them. On the phone, one of them asked if I had Skype, and it grew from there. Technically, I could see everybody this way if they wanted. Mostly, I use it for people who can’t get to the surgery — elderly patients, people in rural areas, someone who is in a wheelchair with MS, someone with an autistic child. Ask any patient and they will say it’s fabulous — why isn’t everyone using it?’

    With NHS data showing that millions of people wait more than a week to see their GP, it’s not hard to see why, in non-emergency situations, Skype offers a solution. In America, where doctors have been enthusing about the notion of the ‘virtual house call’ for nearly a decade, advocates say feedback is positive.

    ‘The patient is appreciative that they can receive high quality medical care from their home, on their terms,’ says Dr Ben Green, a practitioner with Franciscan Virtual Urgent Care in Seattle. ‘In some cases, care should be delivered this way — should a patient really be expected to get out of bed to go to the doctor when they have influenza? I see virtual care as an opportunity to better engage patients and create closer environments.’

    Of course, video consultations are only appropriate in non-urgent scenarios. And, without the patient in the room, doctors have to work harder to create an environment of trust, openness and confidentiality. To achieve this, certain safeguards must be built into the digital model. Online consultations often last around 20 minutes — nearly double the length of a face-to-face meeting. Virtual contact is always supplemented with regular in-surgery checks, including blood pressure and cholesterol tests.

    ‘There are medico-legal pitfalls to consider so that patient care is not compromised,’ warns Dr Barry Parker, medical adviser at the UK-wide medical defence organisation MDDUS. ‘Are the patient’s medical records secure? Are the electronic systems protected to prevent breach of confidentiality?’ Indeed, he adds, not every patient — or doctor — wants to embrace modern technology. ‘There is a risk that increasing its use will favour those with internet access to the detriment of others,’ he adds.

    While Drs Hussain and Green are among the growing number of independent practitioners using technology to improve patient contact, in other areas of healthcare, whole networks are forming around this new medium. Psychotherapy is one such field. Mootu, one of many UK-based online therapy tools, is a national network of 170 professionals who offer one-to-one counselling via Skype. Patients sign up, browse videos of potential therapists, make an appointment and begin — with Mootu taking a cut of the fee paid.

    John Witney, a counsellor and entrepreneur who started the network three years ago, reckons ‘Skypotherapy’ has three advantages over face-to-face methods: choice, convenience and privacy. ‘You may feel more comfortable talking to someone who has no connections with your local area,’ he says. ‘Many clients feel less intimidated and more in control of their own sessions. If anything, there can be a greater sense of getting down to business, which possibly speeds up the process.’

    Even further removed from the traditional model is therapy delivered by text — that is, via an instant messaging system accessible round the clock. is Britain’s leading service of this type. Set up in 2011, it now has 150 accredited therapists on its books, many of whom work for the NHS. Barnaby Perks, its chief executive, says the service is grounded in empirical evidence: a trial of 300 patients published in the Lancet in 2009 found that cognitive behavioural therapy via instant messaging helped more of them to get better than standard GP care.

    ‘The key outcomes were: one, it worked; two, it was quicker — so we got recovery in an average of six sessions, where you would normally expect it to be ten to 12; and three, the medium of text is very enabling for the patient,’ says Perks. ‘They are unencumbered by the embarrassment that often goes with talking about a mental health problem. It makes them get to the point more quickly, be more honest, more candid — all important things in therapy.’

    By moving away from the traditional model, practitioners are putting more control into the hands of patients.The internet is flooded with symptom-checkers and advice. Free apps, such as ‘Embarrassing Bodies’ (a tie-in with the Channel 4 programme) and ‘Virtual Anatomy’, are downloaded millions of times a day. Many patients now attend consultations armed with opinions gleaned online — which can both help and hinder face-to-face diagnosis and their relationship with their GP.

    Dr Parker says such changes are inevitable and, handled responsibly, should not jeopardise doctor-patient rapport. ‘Patients who take an active interest in their own health should be encouraged. However, doctors should not feel under pressure to provide treatment they don’t feel is safe or in the patient’s best interests. The large volume of material available on the internet is of variable quality and doctors are well placed to assist patients by commenting on its accuracy and placing it in context.’

    Many clinicians now text appointment times, email prescriptions and use the internet to confirm diagnoses during consultations. Some are even active on social media, communicating with patients through Facebook and Twitter. Users say such digital resources help communication between doctors and patients. ‘Doctors have anytime, anywhere access to the most relevant clinical information,’ explains Dr Denise Basow, general manager of UpToDate, an app offering peer-reviewed advice on over 10,000 health conditions. Patients, she says, are using technology to educate themselves — so why shouldn’t doctors? ‘Sometimes there’s a misperception that doctors don’t want patients getting information using the internet. Doctors desperately want patients to participate in their care. They just don’t want them getting bad or outdated information — and there is a lot of it out there.’

    PingMD, another widely used app, aims to ‘foster stronger relationships’ by letting patients upload details and photographs of their symptoms and relaying them to their doctor, who can reply via the app at a convenient time.

    Though it is currently only available in the US, doctors who’ve tried it there say patients are ‘thrilled’ with the results. Dr Edward Lewis, a private paediatrician from New York, started using the service in 2012 and has had 1,900 interactions with patients. ‘I have saved at least 95 hours in phone time,’ he says. ‘The parents of my patients love how quickly they can access me and how promptly I respond — weekends included.’

    In Manchester, Dr Hussain’s enthusiasm for Skype doesn’t extend quite as far. ‘I never use it outside of practice hours,’ he admits. ‘Work stays at work.’ But that might not remain the case for long.

    Last October the Health Secretary, Jeremy Hunt, announced a pilot scheme for 500,000 patients who will be able to see a GP seven days a week, from 8 a.m. to 8 p.m., including consultations at home via Skype, phone or email. If successful, it will be rolled out nationwide. ‘The way I see it, this is only the beginning of the digital doctor revolution,’ says Dr Hussain. ‘I’m excited to see what the future holds.’