Hello, Habr! Today I want to talk about telemedicine from the point of view of a practitioner. And since my main specialty is the most suitable for telemedicine: radiology, I will also tell you about my work. If you don't have time to read my ultra-longread, just scroll to the end. At the end there will be a bonus: a guide for telepatients - what makes a virtual reception different and how to spend this time with maximum benefit.
My story contains many digressions towards the description of American medicine. This happened because, firstly, the United States is considered the birthplace of telemedicine (this is not entirely true: already in 1920-1940, medical centers in Italy, France and Norway were consulting on the radio for patients on remote islands and ocean ships), as well as that country where it is already widespread today. According to some reports, up to 60% of practicing doctors, clinics and hospitals in America use telemedicine methods to one degree or another. In addition, most of the economic research on the feasibility of telemedicine is conducted there.
The idea of telemedicine in the United States was first developed in the fifties of the last century, with the aim of reducing health care costs and making its services available to residents of remote regions. Telephone consultations, however, did not receive much distribution at that time. At the beginning of the new millennium, American spending on medicine has grown so much that it became clear that something needs to be done about it. Telemedicine seemed to be just such a solution. Two decades later, it is clear that hopes for this have not been fully justified. The cost of medical services and health insurance is growing steadily. In 2017, the United States spent $ 3.5 trillion, or 18% of GNP , on this - double the average of other developed countries. If you believe Wikipedia, the federal budget of Russia a year earlier (2016) amounted to $ 21 billion.
Why is medicine in the States so expensive?
Among the factors, they often like to mention the complicated and expensive licensing, the high cost of medical education, which should pay off, a high level of service and technical equipment, and a high level of salaries. But none of this explains why the doubling of spending over the past decade has not been accompanied by a noticeable improvement in the quality of services or staff salaries. Despite the astronomical sums spent by the main payer, the government, on medicine, there are still no real levers to control prices and costs in health care. Medical bills are huge... Any attempt to introduce even limited state control is instantly branded as an encroachment on the sacred - the free market. But in fact, the free market has not been there for a long time. The American healthcare system is owned by big business (at least most of it) and is so monopolized that the laws of the market do not work in it.
The average bill for a hospital stay for 3-5 days is 25-30 thousand dollars. Ambulance services are also paid - from $ 1,300 per call. In the intensive care unit, only one day will cost the patient 10-12 thousand dollars.
Large corporations buy up clinics in whole chains, and then dictate who and on what conditions can take patients there (so-called privileges). In this case, invoicing is accompanied by a lot of add-ons and extra charges, often just absurd. It's not uncommon for an invoice to look something like this:
- hospital bed stay - $ 500
- surgeon's services - $ 213
- nursing care - $ 670
- medicines - $ 120
- analyzes - $ 140
- facility fee - $ 13,700.
What is this Facility? And this is the payment for the fact that the patient was lying in this particular hospital network, in fact, the payment for the brand. And now it is charged in horse sizes. On the one hand, the clinic can be understood: by law, any hospital must provide emergency medical care to everyone. These are all and clogged up the admission ward. In addition to people who really need urgent help, you can see homeless people, drug addicts, mentally unstable people - and anyone else ... No one can be denied, and while waiting everyone gets a cola and a turkey sandwich. If some marginal person has nothing to do with his leisure time, then the admission department is a good way to have a good time and get a lot of attention. There are those who go there almost every night with a flashing light. As a result, the queues at the reception reach a day, or even more, and the clinic itself loses a lot of money,as from the marginalized nobody pays for admission. The facility fee was originally intended to compensate for these costs. But since there were no special limits on them, these fees quickly skyrocketed.
It is clear that no one wants to be left without pants, having received a bill for the treatment of pneumonia or for opening a boil. Therefore, insurance is needed. Health insurance is most often provided by the employer, and this ties the employee to one place of work simply because when changing jobs, which means insurance, there is a high risk of receiving unfavorable conditions of new insurance or denial of payments for current medical bills.
It is also possible to conclude a private insurance contract that is not tied to work. And here the market again does not work, since it is impossible to compare insurance against each other when concluding a contract, this is an absolutely non-transparent system. Nobody can say in advance how much the insurance contract will cost. The price depends on gender, age, place of residence, existing diseases, options. At the same time, even the presence of an expensive contract does not save you from high costs. Grisha is a former classmate of mine, now a resident of one of the sunny American states. In order not to be tied to a work contract, Grisha bought private insurance, for which he pays $ 2300 a month. When he needed an ultrasound of the gallbladder, the clinic billed $ 2,500 for the services. After negotiations with the insurance account, the bill was reduced to $ 500,but it was required to pay 90% to Gregory himself.
Bottom line: you pay 2300 insurance premiums, which ultimately only covers 10% of your bill. Is this a good deal? Surprisingly, yes, as the main advantage of insurance is the strong position of the insurance company in terms of bidding for price reductions. You got it right: a modern American hospital, packed with the latest technology, operates like an Arab bazaar when it comes to invoicing. Prices are set not just from the ceiling, but absolutely fantastic. And then, in the course of negotiations (which sometimes last for months), they are reduced, sometimes tenfold! For comparison: the average cost of an abdominal ultrasound in the first world is somewhere around 120-300 dollars, it cannot be much lower,since the price of modern devices in different countries is approximately the same, and it is this that determines the lion's share of the cost of the survey itself.
National health insurance comes to the rescue when a person or his employer cannot provide insurance: Medicaid for the poor and Medicare for retirees. Government insurance costs are enormous and are one of the main reasons for the huge US budget deficit. At the same time, even this money is not enough for everyone, and about every sixth or seventh American does not have health insurance. These are people who are not poor enough to use Medicaid and at the same time, unable to shell out a couple thousand a month on private insurance. These are the people to whom, for one reason or another, the employer does not provide insurance. There are about 50 million such people, almost all of them are in their prime of working age.
Insurance companies go to great lengths not to pay and often cheat, especially when the amounts payable are high. For example, they put forward absurd requirements for prior authorization. This means that any prescribed treatment must be previously agreed with an expert of the company, otherwise it will not be paid. Such an agreement sometimes lasts for weeks, causing a delay in the necessary treatment and a huge expenditure of the doctor's time for calls to the insurance company to justify treatment and tactics. Often they refuse to cover bills, referring to the small print on the tenth page of the insurance policy. In such cases, the patient has to pay himself. All these bureaucratic tricks lead to additional price increases. Administrative costs associated with billing and insurance settlement are about25% of the invoice for treatment.
Who are telemedicine doctors?
First of all, these are therapists, but in principle a doctor of any specialty can become a teledoctor.
Claire Young's example shows that nowadays a doctor can also become a “digital nomad”. Claire completed her medical school and residency in the UK, after which she and her husband left for Canada, where she led a private practice for 12 years. In the end, they got tired of the cold, they bought a residential trailer and went to winter in California. After a patient told her about the telemedicine company, Dr. Young decided to try: why not? She signed a contract with a Canadian telemedicine clinic and on the third day she was seeing the first patients from a California camping. She continued to do this throughout the winter. In British Columbia, home to seven hundred thousand people, patients were delighted. Every sixth of them had no other opportunity to receive medical care, as they live or work in hard-to-reach places.
Over the next two years, Dr. Young continued to televise 10-12 hours a week. She was connecting the laptop to the Internet via the phone's hotspot. Contrary to expectations, cellular communications were reliable throughout America and even when the van crossed the Mexican border. Beaches, deserts, jungles, Indian villages swept past the window, but the reception was constant even at an altitude of 4 thousand meters in the Andes. All you need is a 25-30 gigabyte per month card, which is different for each country. What was originally planned as a one-off wintering in the United States was the beginning of a trip around the world. As you read these lines now, Dr. Claire Young, a Canadian family doctor, is televising patients from a van crossing Columbia. Her husband is also a remote consultant and is a sports psychology specialist for extreme sports.Next year Yangiintend to get to Russia and who knows, maybe someone from the Khabrovites will be able to meet them.
My own telemedicine experience is as follows: a general practitioner in a rotational enterprise, a telephone consultant-therapist in a subsidiary of an insurance company, an intern in one of the highest mountain clinics (telemedicine services in the valleys, which are cut off from the outside world for weeks from December to March), trainee at the tox center (poisoning counseling) and on the "hot" line for suicide prevention. Today, as a radiologist, I serve 4-5 regional hospitals, transcribe images remotely and conduct surgical and oncological conferences at Zoom.
How to become a doctor (including a telemedicine doctor)
Anyone can become a doctor in the United States. To do this, you need to graduate from a medical university (not necessarily in the States, Saratov, Karakalpak, and Bangladeshi medical institutes will do, if only they were on the approved ECFMG list (and this list contains almost all higher medical educational institutions in the world) and pass exams - exactly the same as American graduates take - with a fairly high score. After that, there is a distribution by specialty and you can start working as a resident. After residency (duration 3-5 years) you need to pass an exam for a medical license, and you are an American doctor.
In most countries of the world there is no such transparent and simple system of admission to medical practice, but you must first find a job, obtain a work permit within quotas, fulfill a number of other requirements, and the result at any stage is not guaranteed and often does not depend on your own efforts. and talents, but from bureaucratic whims and blind luck. In the United States, the requirements for everyone who want to become a doctor are the same and must be met. This path is open to anyone, especially now, when a lot of useful resources for preparing for tests are available online and there is no need to attend expensive face-to-face courses, as it was when dinosaurs walked the earth (and the author of these lines was preparing for the USMLE tests). It's another matter if this one is not ready to work hard in an adult way to reach the level of compliance with basic requirements, then yes,the path to American medicine is closed for such a candidate. IT specialists have a completely similar situation: the requirements in America are the same for both Rajiv and Vasya.
So becoming a doctor in America is easy. Simple, but NOT EASY. In order to reach the level of an American university graduate, you need to understand how education takes place here. In order to become a general practitioner, that is, a general practitioner, you need to spend more than ten years: four years of bachelor's degree, four years of medical school and at least three years of residency.
For other specialties, the duration of residency is even longer and can be up to 9 years. For some specialties, after residency, you also need to complete a fellowship, about two years. Only after that you become a doctor of a certain specialty. Neurosurgeons and plastic surgeons study the longest. A friend of mine, a plastic surgeon, first completed a residency in general surgery, then in reconstructive surgery, then a fellowship in aesthetic surgery, and only recently, after 17 years of training, she finally started her own practice.
In Western Europe (Bologna) the training system for doctors is slightly different and is completely focused on acquiring knowledge and practicing skills directly related to medical practice. There are already no fine arts, no social sciences in the curriculum. The bachelor's degree takes three years, is held under the motto "Normal man" and includes biochemistry, genetics, pathology, anatomy - everything that is associated with the normal structure and functioning of the human body. The master's program (also three years) goes under the motto "The patient is a patient" and there are clinical disciplines, and not in specialties (hospital, faculty surgery, therapy, etc.), but in thematic blocks. For example, "Diseases of the respiratory tract." This includes thoracic surgery, pulmonology, phthisiology and that section of pharmacology,which studies medicines for lung diseases (steroids, beta mimetics, antibiotics, etc.). Or "Diseases of the reproductive sphere": urology, gynecology, endocrinology, and so on. But in this system there is no residency shorter than five years, so the minimum duration of training as a doctor after school is the same 11 years. The result is a specialist who is completely equivalent to an American one.
I often heard the following from my Russian colleagues:
- Students, forget everything that you were taught in the medical institute, in practice you will have to learn everything anew.
- In America, they teach a lot of unnecessary things, that's why their training is so long and expensive. If I am an optometrist, why do I need a Krebs cycle? Why should I know about hormones ?!
- Medicine is an art, not a science. You have it there in the decaying West - evidence-based medicine, standards, rigid frameworks, templates and stencils, while we have our own developments and clinical intuition.
To this I always want to answer with a quote from Stephen King:
« , , , . , , - . , , ».Training in Western medical universities is structured so that any specialist leaves the university with a baggage of skills, which allows him to work at the basic level without any problems. This means that any ophthalmologist is able to read the cardiogram and recognize a heart attack that suddenly happened at the appointment. Any urologist will know how to act immediately if a patient suddenly has a severe allergic reaction to an injected drug. I'm a radiologist, but if I have to give birth, I know what to do. This is not excessive wastefulness, but a necessary condition for the work of any doctor. In medical schools, you are honed to think and react in any situation.
No textbook can teach you to analyze the way teachers do. Medicine is discipleship. Mechanically memorized will be forgotten, but the ability to think remains forever. This is why, at the undergraduate level, students are taught knowledge in a wide range of disciplines. This includes both the exact and social sciences, foreign languages, the ability to coherently express one's thoughts in writing, social studies and economics. Such an education system provides students with the necessary tools that will be useful to them in later life and a general understanding of a number of disciplines. For example, at the university where I studied, it was compulsory for all students to attend the Writing Lab up to twice a week. We wrote essays, abstracts, reports and analyzed their structure, sentence construction and compliance with accepted standards (APA or Chicago style) with a special instructor.This was seriously useful to me later in the preparation of articles, books, speeches at conferences.
The same happens at the master's / doctoral level. You are taught to understand the basic principles by which the human body operates, the interconnections of systems. Why does the patient have shortness of breath? Because fluid builds up in the lungs. Why does it accumulate there? Either the outflow does not work, or the inflow is too large. How to distinguish one from the other? What laboratory parameters would you expect in this case? What will you think about first if these parameters turn out to be different?
After repeated training and repetition, you can be woken up in the middle of the night and you will immediately know how to get an answer, it's like two and two. This is medicine, one of the most logical and exact sciences. It remained “art” until the middle of the twentieth century, but today much more is known about the human body. You just have to not be afraid to use what has already been researched and known, and not to lock yourself in "your own best practices", trying to reinvent the bicycle.
Oh well. The residency is over, let's see what a freshly baked specialist should possess? For this, there is a catalog of skills that is required for all graduates of the residency. For example, what does a radiologist do?
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Well, of course, you need to be able to conduct and decipher studies of all regions of the body by all methods of visual diagnostics of adults and children - radiography, CT, MRI, ultrasound, scintigraphy, PET, as well as create 3-D reconstructions using rendering, etc. Only these skills are applied in telemedicine , everything else listed above cannot be performed remotely by a radiologist.
What health problems are best for telemedicine screening and treatment?
In the first place - mental problems, first of all, affective disorders. There are already bots out there that are great at diagnosing and treating depression. There are also services where, for a relatively modest fee (from $ 30-40 per month), you can get consultations from psychotherapists at any time of the day. I have not tested them, but I believe that they should be arranged like a tech support call center, where Dr. Vijay from Bangalore or Dr. Jose from Costa Rica will answer you. It is possible that the good cream will be skimmed by the one who is the first to launch such a service in Russian.
Second, most skin diseases. In general, dermatology is one of those areas of medicine that will be the first to fall under the onslaught of AI. Diagnostics there are mostly visual, well amenable to systematization. It is also important that the cost of an error in dermatology is not particularly high. In other words, few die from misdiagnosed or incorrectly treated skin diseases. And the treatment there is not particularly diverse - only one group of drugs dominates.
Third. Minor infections. Cystitis, sinusitis, pharyngitis, small boils. Uncomplicated cystitis, sinusitis, pharyngitis, small boils. Redness of the eyes without pain, without loss of vision. The teleconsultant will prescribe a trial treatment and will be able to identify emerging complications.
Fourth. Control after discharge from the hospital. Checking the condition of postoperative sutures, signs of infection.
Finally, miscellaneous. Anything that requires medical advice, but that does not directly fall under the category of diagnosis and treatment:
- consultations before a trip to the tropics,
- control of chronic diseases with home devices (e.g. glucose levels, blood pressure monitoring),
- explanation of test results and interpretation of medical reports.
What should NOT contact a teledoctor?
If you have problems from the following list, then you only need to go with them for a real examination, not a virtual one. And without putting it on the back burner:
- chest pain
- severe headache ("never had this before"),
- ear pain
- stomach ache,
- loss or significant decrease in vision or hearing,
- sudden weakness or numbness in the limbs,
- injuries of the musculoskeletal system.
It is clear that these lists are indicative rather than exhaustive. And depending on the circumstances, sometimes you have to act differently.
What are the challenges facing telemedicine?
1. Risk of personal data leakage .
2. Problems of legal responsibility.
In the context of virtual contact with the patient, the risk of misdiagnosis or misinterpreted recommendations is higher than during a regular visit. This is a potential breeding ground for all kinds of legal prosecutions. One of the factors directly affecting the cost of medicine in the United States is the numerous lawsuits with hugethe amounts of compensation. Up to 33% of a doctor's salary is spent on paying taxes and about 15% on medical liability insurance (malpractice). The average American orthopedic surgeon becomes a malpractice defendant every 18 months. But the largest payments for claims are made by obstetricians-gynecologists. Therefore, it is impossible to work without appropriate insurance to pay for legal defense. In many clinics, such personal insurance is a prerequisite for employment, even though the hospital itself is required to have a collective bargaining agreement for legal support to defend against claims. The annual insurance premiums are very high (up to 200 thousand dollars a year) and are additional expenses that the doctor has to include in the cost of his services.
3. Problems of licensing.
Even after going through a long and difficult path of study, having passed all the exams, a doctor has the right to practice only in the state where he is licensed. This license needs to be renewed after a certain time, while paying high license fees, annual fees, fees for passing certification tests. The tests themselves can be taken only at certain times in certain centers. Time for preparation, for a trip to the center, for taking a test - these are all additional expenses in the form of lost income. If a doctor is going to practice in several states (for example, if he is a telemedicine), then he needs a license in all. Sometimes it comes to the point of absurdity. A colleague told, then a story on his behalf:
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Usually I serve several clinics remotely, while physically being in one of them. At my service is PACS (picture archiving and communication system), access to electronic medical records, voice recognition system. Thanks to all this, one conclusion takes me, on average, five to ten minutes. And this is great, since the volume of work is very large. For a 12-hour shift, 15-25 CT and MRI scans, 1-3 ultrasound scans and about 50 X-rays are required. When quarantine began, we switched to cohort mode at work (a week at home - a week at work, seven days for 12 hours). So when I started home week, I suddenly realized the importance of infrastructure. For work, I need at least three or four monitors, two of them - with a special resolution, plus some other equipment (dictaphone, etc.). It revealed,that the cost of a mammogram monitor alone could exceed € 8,000. With a single laptop, performance immediately dropped by 90%!
5. Instead of the expected cost reductions, telemedicine may lead to new costs.
A recent study from the University of Pittsburgh found that children with upper respiratory tract infections were significantly more likely to be prescribed antibiotics during telemedicine visits than during routine doctor visits. In turn, excessive use of antibiotics leads not only to additional costs for the drugs themselves, but also to the development of resistance, imbalances in the intestinal flora, and possibly allergic reactions. That is, again, to further expenses for eliminating the consequences.
What are the advantages of telemedicine?
We live in a unique time. Today, each of us can get a virtual appointment with a foreign or domestic medicine luminary without leaving our own room. This opens up unprecedented opportunities for choosing a place to work and live, to maintain health. Telemedicine is something that we will use more and more often in the future. But in order to get the most out of it, a certain level of trust between the patient and the doctor is required, a willingness to compromise, moderate expectations on both sides, not rely solely on technical advances, but try to pump communication skills. In fact, all this would not hurt ordinary medicine.
Is telemedicine saving money? In the case of the USA - definitely not, since the reasons for the high costs of Americans on medicine lie in a completely different plane. But for other countries, those in which the state uses effective levers of influence on medical institutions, telemedicine can really turn out to be economically profitable.
What needs to be prepared before the TV set to the doctor
- Your identification and insurance documents, at least one of them with a photo.
- List of complaints and symptoms, when each of them started and how severe they are,
- Any measurement data (weight, height, body temperature, pressure, pulse).
- Information about any contact with anyone with similar symptoms.
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- Patience is enough, as the beginning of the visit may be delayed due to various unforeseen circumstances, for example, technical. Prepare what to do with yourself at this time.
And the last thing: to all Khabrovites - do not get sick, be healthy!