Dr. Amy Fan Conrad
10 Reasons why pediatrics has unique potential in telemedicine
Among the rapidly growing number of telemedicine options available today, very few have curtailed its model to serve pediatric patients. There are many reasons for this:
· There are more adult patients
· Adults statistically have more illnesses and medications
· Adult medicine is more profitable in the current healthcare fee structure and leads to higher reimbursement due to more interventions
· An adult has the resource and autonomy to make healthcare choices, and it's faster to find patients
Another apparent reason, which I was proud to hear from the CEO of an urgent-care-style telemedicine company, was that pediatricians "do a much better job with their patients already and so maybe there is less need."
Taking a moment to acknowledge and celebrate my colleagues, I am happy to agree that pediatric clinics have strived for more ownership of their patients and families. However, that doesn't mean there is less need. In fact, even though telemedicine is more prevalent as urgent care today, its full potential for primary care is even more enticing.
In other words, the short game of random urgent care encounters might work well for adults, but we need to play the long game for kids. A virtual clinic-school has the potential to change the way we think about pediatric care, and here's why:
1. Pediatrics is, or should be, education-heavy.
A doctor is nothing if not a teacher first, and this is especially true for pediatricians.
I started my YouTube channel as a resource for parents after noticing a majority of questions and bad outcomes are due to a lack of accessible and reliable information. What is the correct Tylenol dose? Can Motrin and Tylenol be used together? How many diapers should my 3-day-old have? My son has had a fever for 2 days, when should we go to the clinic? What is asthma anyway?
A good pediatrician will anticipate these questions and try to address them in clinic. But time is limited during a visit, the baby is crying, the parents are tired, and it's simply human to forget. Has anyone seen that green piece of paper the pediatrician gave us last year with all the information?
A virtual pediatric practice can be a school within a clinic. The most important people in a child's life -- their family and caretakers -- should not be passive participants in his/her health. Parents and families need trustworthy information that can be accessed repeatedly, efficiently, and in ongoing dialogue with the doctor.
And if the video explanation doesn't cover it, shoot the doctor a text or email.
2. "Well or not well" benefits from fast and early access to a pediatrician.
If an adult had a 104F fever, he or she would most likely be in the fetal position. Not so for kids - until close to real danger. Instead of a gradual decline like adults, a sick child might run around, seemingly normal, until sudden decompensation.
Much of the residency training for a pediatrician is to immediately recognize a sick child. The "sick" vs. "well" picture becomes a gut instinct with clinical experience.
Even for experienced parents, it can be frustrating and scary to try to pinpoint the correct time to escalate care without fast and early access to a pediatrician. Between in-home video (see #3) and the growing pool of tools to make remote exams equivalent to traditional exams (see #5), having a relationship with the family's own telemedicine pediatrician is the fastest and therefore safest way to make an assessment - as well as to talk about how to prevent a simple viral illness in a well child from worsening!
3. Seeing children in their home environment is extremely valuable.
Early in medical school, a pediatric mentor told me 50% of the physical exam for kids is just watching them for a few seconds, and I have found this to be more and more true. When doctors moved from in-home visits towards clinics and hospitals, a key component of the medical history was lost, until now. It was a necessary sacrifice at the time in order to achieve the complex operation of modern healthcare, but technology has made it possible to bring back the home-based assessment.
A frequent challenge in pediatrics is that a child will act differently in clinic compared to in the home. While this doesn't usually prevent the diagnosis of obvious illnesses, a large component of primary care for children involves behavioral counseling for parents. Opening up the home to the pediatrician through video and letting me observe the child play in his/her own environment provides precious information that helps me get to know him/her.
4. Parents should participate in the physical exam.
Another common challenge for pediatricians is the difficulty of examining a child who is screaming and resisting while hiding behind parents.
"Stranger anxiety," we assure the parents while crawling after the child, "this is normal."
Pediatricians have developed many techniques and tricks. Some are nice (toys with flashlights, distracting stuffed animals, dancing parents and siblings), while others, such as the wrestle to look in the ears, involve brute physical restraint that is understandably terrifying to the child. For that reason, I usually save the ear exam for last, knowing that the kid will never let me come close again after that experience.
Much of this terror would be alleviated by teaching parents and caretakers to participate in the physical exam - as more than just straitjackets. While video conferencing, parents can learn how to use the modern tools to do the physical exam as the pediatrician guides and gives feedback. The captured data is transmitted to the doctor in real time and stored. Not only will this lead to a more cooperative exam, the process will also tap into telemedicine's ability to empower parents to be partners with the physician in taking care of children.
5. Important primary care issues can be taken care of remotely with improved timeliness.
Did you know that the two-week and one-month* newborn visits to the pediatrician are primarily for a weight check? Weight gain is an important issue in those first few weeks, but these check points can be done remotely with a little creativity.
Similarly, pediatric primary care's scope of practice can be remotely taken care of, with the added benefit of increased access to the pediatrician for questions as they come up. We will go into more detail in a future blog post to break down the different components of a checkup and exam!
*May depend on the particular vaccination schedule of a given clinic.
6. Pediatrics care needs to be in the context of the family.
A child cannot be understood without the context of his/her family. When it comes to a healthy childhood, pediatric care has to be in the context of the environment. Telemedicine gives the physician a chance to not only see the home but increase face-time (get it?) with more members of the family.
7. Parents are busy!
Not only is it more and more difficult for busy parents to take off time from work to sit for hours in a pediatric clinic's waiting room, the time wasted is even more difficult to justify when it's unnecessary. In today's multitasking world, healthcare needs to be incorporated into daily life instead of be in competition with it.
8. A long and uninterrupted relationship with a doctor is especially important for children.
Precious few people today have a designated doctor, let alone a doctor who knows them. Telemedicine has made the urgent care model more convenient for adults, but children benefit more from consistency in care. Pediatricians have traditionally done well with this continuity, but the limits of a brick-and-mortar clinic (physicians move, families move, office schedules, job changes) often interrupts the relationship. Even with the best medical records and even in-person handoffs, nothing can replace the personal knowledge that comes with time.
A telemedicine primary care practice can do for pediatrician-family relationships what Facebook has done for friendships - eliminate the issue of geography. Not only is it more reassuring when the doctor you call at 3 a.m. has known your child since birth, the consistency also provides the valuable presence of an additional trusted adult as a resource, especially during the teenage years.
9. "Problem-based" rather than "schedule-based" care makes more sense.
Do you have a running list of questions to ask the pediatrician the next time you see him/her? Have you agonized between not wanting to miss a potential problem vs. the frustration of taking off a whole day to go to the doctor's office and being told "it's nothing?" When those are the only two options, problems can fall through the crack. Furthermore, parents should not be alone in trying to decide if something is wrong. "Johnny seems more tired lately, is it just stress?" "I feel like Oscar is putting on more weight but I'm not sure how to change his diet." "Is Rachel falling behind in school because of concentration problems?"
When questions arise, it should be just as easy to reach your pediatrician as your friend. Telemedicine is more than icing on the cake - it's an opportunity to completely change the current style of practice (arbitrarily schedule-based to create a schedule an office can handle according to insurance reimbursements) to a more efficient/effective one (problem-based).
10. Telemedicine is more cost effective.
The average emergency room cost in 2017 was $1533, with the median being $749. An ambulance ride costs anywhere from $200-$1200 more. Without going too deep into the dysfunction that is the American healthcare system and the debate of how care should be paid for, it's sufficient to say that the money spent at the emergency rooms for non-emergent issues (not to mention time and energy) reveals a failure of access to primary care.
Access, patient-physician relationships, and education should be the cornerstones of effective pediatric primary care. Used correctly, a virtual clinical community improves all three components. A telemedicine pediatrician can both help to prevent emergencies as well as identify the point at which in-person medical care becomes necessary. The potential savings in money, time and energy can transform primary care as we currently know it.
Go Kinder Kid!
Dr. Amy and the Kinder Team