“You don’t need a room to do rheum” – Canadian rheumatologists and virtual care

Canadian rheumatologists are conducting virtual visits to a significant degree during the COVID-19 pandemic but most are not using video – which many feel is the best platform for this specialty – and the majority are still not comfortable with telemedicine.

These were a couple of the conclusions that emerged from a discussion of telemedicine and virtual care at the recent annual meeting of the Canadian Rheumatology Association (CRA) framed as a “great debate”. As those who have attended annual meetings of clinical medical societies know, these debates are often positioned with amusing graphics, good-natured personal attacks, and protagonists often asked to defend positions opposite to their true beliefs.

When one cut into this particular confection there were some productive insights about virtual care and rheumatology. More came from the numerous comments posted in the associated chatroom during the debate.

In the debate, Dr. Tommy Gerschman, a pediatric rheumatologist in North Vancouver and member of the CRA telehealth working group described telemedicine as “excellent care in brand new, patient-centred packaging.” In BC, Dr. Gerschman said rheumatologists last year provided about three-quarters of their visits virtually during the pandemic period – a far higher percentage than any other specialty.

A survey by clinicians from the rheumatology division of The Ottawa Hospital and presented at the conference as a poster showed that 89% of patients said they were satisfied were satisfied with phone visits undertaken during the first 3 monhs of the COVID-19 pandemic.

In the debate, Dr. Alexandra Saltman, a Toronto rheumatologist, noted that clinicians can take a number of measurements remotely such as weight, blood pressure and swollen joint counts. She also said evidence suggests use of virtual care is not likely to miss serious diagnoses or issues when used in rheumatology.

Tasked with arguing against telemedicine, Dr. Brent Ohata, co-chair of the CRA working group on telehealth argued “we’re not ready as a community ready to provide telehealth,”. He noted that providing virtual care properly requires training, specialized knowledge, proper equipment and preparation – on the part of the patient as well as the rheumatologist.

Dr. Ohata said a survey of Canadian rheumatologists done in December found that while respondents said about 47% of their current patient appointments were being done by phone, only 19% were done using video. Even during the pandemic, the remainder (34%), were being done as in-person visits. In addition, the survey showed only 45% of rheumatologists said they were comfortable or very comfortable using telemedicine.

“The gold standard in virtual care is video,” said Jocelyne Murdoch, a Sudbury occupational therapist with advanced training in rheumatology who has been using telemedicine since 2008. In another session at the conference, Dr. Ohata agreed that rheumatologists felt they could provide better virtual care through video than over the phone.

Dr. Ohata also presented data showing that while 66% of rheumatologists indicated they could evaluate swollen joints visually, there were a number of other investigations by rheumatologists that could be done in virtual visits that were not.

Murdoch who was also asked to argue against the value of telemedicine said the supports needed to provide telemedicine in rheumatology are not yet present. She noted that in rural and remote areas many clinicians and patients do not have access to to high-speed internet connections required to do virtual video visits.

Murdoch also noted how informal many patient visits have become since the pandemic and switch to virtual visits. This issue was underscored by a number of anecdotes from participants in the virtual chat room during the debate who described patients expectations of being able to meet virtually with their rheumatology while in the most unusual circumstances.

While other physicians have also voiced similar concerns about inappropriate patient behavior during virtual visits one should note this is not all one-sided – as evidenced by the case publicized this past weekend of the surgeon who tried to contest a traffic ticket in court via Zoom, while preparing to perform surgery in the operating room.

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