Virtual visits: Do the math

This week is Canadian Patient Safety Week and it will come as no surprise that the theme this year is virtual care. After all, wasn’t maintaining safety of both patients and providers during the COVID-19 pandemic the main reason we have seen the current transformation to virtual visits?

One of the best essays I have seen recently on how clinicians should evaluate how and when to offer virtual care comes from an unlikely source – the Canadian Urology Association Journal.

In the most recent issue, Editor-In-Chief Dr. Micheal Leveridge (@_TheUrologist), associate professor of urology at Queen’s University, has an editorial titled “The algabra of clinic and telephone medicine” in which he provides a philisophical take on where virtual visits fit.

Dr. Leveridge begins by noting his habit of directly interacting with the patient at the conclusion of an in-person visit. “When the bustling outpatient clinic era ended abruptly in March, these interactions vaporized with it,” he continues.

“Some seven months later, as we re-integrate patients into the clinic, we face the choice of reverting to the familiar before times or maintaining some proportion of virtual care”, he adds.

Dr. Leveridge notes that the main drawback to virtual care for the urologist is the loss the ability to perform a physical examination. On the other side of the equation, he writes, is the benefit to patients in saved time and travel when they don’t have to come to the clinic. “It has always felt problematic to me when a patient makes a 120 km round trip (never mind a 500 m walk) to discuss an ultrasound performed two weeks prior regarding a surgery performed four years prior.”

But another downside from some virtual visits, he adds, is accessibility issues for patients unfamiliar or unwilling to use the telephone or computers and the challenges for patients with physical or cognitive disabilities.

Dr. Leveridge then reverts to discussing the less quantifiable aspects of patient visits such as the personal connection many physicians feel they make that cannot be duplicated in a virtual visit. “I feel like I lose something important about who I am as a doctor when I’m on the telephone,” he writes but then adds “I really like telephone medicine though, despite the squall of paper and the curious persistence of a cord on the office phone, bafflingly chromosomed around invisible histones.”

He concludes by stating telehealth will clearly be part of clinic-based medicine going forward. However, he said, physicians must look at the equation and assess each patient and visit individually to decide what is right. “In a tossup, you can use your experience, your existing relationship, or (are you sitting down?) you can just ask the patient.”

The sound of tweets grows fainter

Recently I was live tweeting a major Canadian heath care conference dealing with virtual care and digital medicine when I came to the realization – not for the first time – that the most dense and lively interaction was happening elsewhere.

I usually don’t inhabit the chat forums associated with presentations on platforms such as Zoom or Microsoft Teams but in this instance I did and I found the discussion to be far denser and robust than anything occurring on Twitter using the hashtag for the meeting.

For someone who has developed somewhat of a focus on live tweeting medical and healthcare conferences this came as a revelation. Now, having attended several virtual conferences it is clear the current environment is shaping how conference materials are being disseminated.

I had already noticed that since the total transformation of major medical and health IT conferences to a virtual format that Twitter traffic around the meeting hashtags seemed sparser than usual. Not that it has disappeared, but rather than the volume in many cases is significantly reduced.

While it is great that discussion forums associated with the new virtual meeting platforms often have great engagement and are usually fundamental to promoting interactions between speakers and conferences attendees I do have a few concerns.

* Forums on virtual platforms are limited to those who are registered to a meeting or particular session, meaning comments – unlike with Twitter – are not being shared with a broader audience. The content from these discussion forums is also often immediately lost after the session has concluded.

* Discussion forums are often disabled for certain conferences – or just limited to posting questions, meaning many important medical or health conferences have no place for interaction and engagement.

* While many meeting platforms have specific functionality for people to initiate discussions on specific conference-related topics, these often seem to get little or no pickup.

* In a world where medical journalists and medical news publications are becoming endangered, the absence of any dissemination of information beyond a conference itself through live tweeting could be hamper the spread of important information and enlightened discussion about that information.

Of course, all media evolve and social media are no exception. I believe live tweeting has been an important if not essential component of medical and healthcare conferences for a few years and has shown its value. But while meetings remain virtual and take place exclusively on virtual meeting platforms I believe a fundamental shift has occurred, and this may no longer be the case.

Personally I still view Twitter as valuable in the healthcare space for both disseminating information and for networking and will continue to roost here.

But I do believe a transition to virtual meetings and whatever sort of hybrid evolves after we have braved the COVID-19 storm is going to once again transform how we disseminate and discuss ideas that matter in medicine and healthcare much as Twitter did initially and did again when the character count was doubled.

Health care professionals have a voice on social media, court rules

A major provincial court has provided strong support for the right of nurses, physicians and other health care professionals to express concerns about healthcare on social media.

Earlier this week, the Saskatchewan Court of Appeal – the province’s highest court – ruled in favour of Carolyn Strom, a nurse who was disciplined by the Saskatchewan Registered Nurses Association after she complained on Facebook about the care her grandfather had received at end of life in a long-term care facility in Macklin, Saskatchewan.

The decision by the nurses association had prompted widespread concern that the regulatory body was infringing on the right of a health care professional to express their views about healthcare.

“Nurses, doctors, lawyers and other professionals are also sisters and brothers, and sons and daughters,” Mr. Justice Brian Barrington-Foote wrote. “They are dancers and athletes, coaches and bloggers, and community and political volunteers. They communicate with friends and others on social media. They have voices in all of these roles. The professional bargain does not require that they fall silent.”

While the appeal court stated regulators have the authority to impose limits, Mr. Justice Barrington-Foote wrote that in this case the nursing association’s actions had an excessive impact on Strom’s right to freedom of expression.

“Ms. Strom posted as a granddaughter who had lost one grandparent and was concerned for the future of another. That fact was front and center for a reader of the posts. Although she identified as a nurse and an advocate, she was not and did not purport to be carrying out her duties as a nurse. She … spoke to the quality of care provided by a distant facility with which she had no professional relationship. The private aspect of the posts was made clear and was significant. Further … the posts have not been shown to be false or exaggerated and, on the face of it, would appear to be balanced.”

The Facebook comments by Strom were posted on Feb. 25, 2015 and she subsequently copied her concerns to the provincial minister of health and opposition leader on Twitter. Some employees of the home long-term care home took exception to the posts and reported them to the nurses association.

 On Oct. 18, 2016, she was found guilty of professional misconduct by a discipline committee of the nurses association and ordered to pay a $1,000 fine and $25,000 to cover the cost of the tribunal. She appealed the association’s decision to the province’s Court of Queen’s Bench, but this appeal was dismissed in 2018. The decision by the Court of Appeal came following a hearing which took place almost a year ago in September, 2019.

“Criticism of the healthcare system is manifestly in the public interest,” Mr. Justice Barrington-Foote wrote. “Such criticism, even by those delivering those services, does not necessarily undermine public confidence in healthcare workers or the healthcare system. Indeed, it can enhance confidence by demonstrating that those with the greatest knowledge of this massive and opaque system, and who have the ability to effect change, are both prepared and permitted to speak and pursue positive change. In any event, the fact that public confidence in aspects of the healthcare system may suffer as a result of fair criticism can itself result in positive change. Such is the messy business of democracy.”

The decision noted that having focused solely on the critical portions of Strom’s post, the discipline committee “failed to recognize that her comments were not only both critical and laudatory but were self-evidently intended to contribute to public awareness and public discourse. Ms. Strom spoke to the need for training and of the right of all residents to quality and compassionate care. She spoke to the need for the loved ones of residents in extended care to play a part in the accountability of the system.”

The appeal court said it made no findings about whether those employed at the long-term care home “failed to provide appropriate care to Ms. Strom’s grandparents.”