When virtual care kills (rarely)

A UK evaluation of rare incidents in which primary care provided by telephone or video has ended with the death or serious harm to a patient provides insights into what can be done to make sure use of virtual care remains safe.

The study published in BMJ Quality and Safety evaluated 95 serious safety incidents involving what the researchers call remote interactions between 2015 and 2023. The study also evaluated the use of virtual care in a diverse range of 12 general practices throughout the United Kingdom from mid-2021 to the end of 2023.

Many reports of the study published in general UK media have focused on the downside of virtual care. For example, the Daily Mail had a headline saying, “Patients are ‘dying from remote GP consultations as major study warns virtual and phone appointments can miss serious illnesses.” However, the study authors repeatedly note throughout the article the rarity of serious adverse events associated with virtual care.

Writing on the social media platform Bluesky, Dr. Trish Greenhalgh, one of the study authors and professor of  primary care sciences at Oxford University states: “this paper is MAINLY (emphasis hers) about how remote care in GP land is remarkably SAFE. We followed 12 GP practices for 2y, looking for (among other things) evidence of patient harm from remote consultations. We found NONE.”

In an associated post, she added: “a BIG finding from this study was how safety incidents are almost always AVOIDED through the conscientious actions of front-line staff (from receptionists to senior docs).”

In their analysis of the series of safety issues associated with remote care, authors of the study identify a wide range of contributing factors especially at the system level.

“Introduction of remote triage and expansion of remote consultations in UK primary care occurred at a time of unprecedented system stress (an understaffed and chronically under-resourced primary care sector, attempting to cope with a pandemic),” the study notes.

System issues associated with adverse events and identified in the analysis include:

• Technically complex access routes which patients found difficult or impossible to navigate requiring non-clinical staff to make clinical or clinically related judgements.
• High demand, staff shortages and high turnover of clinical and support staff making remote encounters inherently risky.
• Single episodes of care for one problem often involving multiple encounters or tasks distributed among clinical and non-clinical staff 
• Not sufficiently adapting organizational routines to virtual care
• Training, supervising, and inducting staff being made more difficult when many were working remotely. 
   
• Communication is singled out as an important factor associated with adverse events and virtual care.

“Many safety incidents were characterised by insufficient or inaccurate information for various reasons. Sometimes, the telephone consultation was too short to do justice to the problem; the clinician asked few or no questions to build rapport, obtain a full history, probe the patient’s answers for additional detail, confirm or exclude associated symptoms and inquire about comorbidities and medication. Video provided some visual cues but these were often limited to head and shoulders, and photographs were sometimes of poor quality.”

The additional burdens faced by patients and caregivers through use of virtual care was also identified. “Given the greater importance of the history in remote consultations, patients who lacked the ability to communicate and respond in line with clinicians’ expectations were at a significant disadvantage” the study states. “Several safety incidents were linked to patients’ limited fluency in the language and culture of the clinician or to specific vulnerabilities such as learning disability, cognitive impairment, hearing impairment or neurodiversity.

In a section on lessons to be learned from the study, the authors note that with virtual care relying more on history taking and dialogue, “verbal communication is even more mission critical.” They add that a final message from the analysis is that “clinical assessment provides less information when a physical examination (and even a basic visual overview) is not possible. Hence, the remote consultation has a higher degree of inherent uncertainty.”

In their summary of the article the authors give a shout out to front-line staff: “Rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer.”

(Graphic credit: HA.com)

#Rainbowbridge: A sad metaphor

A car hurtling towards a barrier at high speed and then exploding and killing the occupants is a sad but perfect metaphor for the state of news today.

The recent incident at the Rainbow bridge on the Canada/US border in Niagara Falls demonstrates just what goes wrong when too many people – including prominent politicians – rely on hasty and poor reporting and social media posts to support preconceived perceptions.

When the car exploded at the border on Nov. 22 the social media platform ‘X’ was immediately populated with posts about a possible terrorist attack, all nicely packaged under the hashtag #Rainbow bridge or #Explosion). Fox News then greatly amplified these by almost immediately quoting unidentified sources stating this was indeed a terrorist incident.

Post after post quickly piled on with reports of how the incident was the result of terrorists attempting to ram their way into the US with a carload of explosives to wreak havoc on Thanksgiving festivities in New York.  The rare posts recommending a wait-and-see attitude until more facts were in were swamped in the deluge.

Several hours after the incident, the New York governor and FBI stated there was no evidence of a terrorist attack and no explosive were found. As a CBC analyst wrote that evening “There was no attack from Canada; the incident occurred entirely on U.S. soil; in fact, authorities don’t believe it was a terrorist attack at all.” (In fact, posts almost 24 hours later indicate the incident seems to involve a high-priced Bentley and a Kiss concert)

For a decade now ‘X’ and other social media platforms have provided almost instantaneous reporting on news events around the world. With more people relying on social media for their news the problem is the information these days is more likely to be wrong when first reported. More worryingly, more people are weaponizing this information for their own ends and/or deliberately posting false information. The innate desire for sensationalism further fuels the tendency to exaggerate or even fabricate news.

The #Rainbowbridge incident comes as the Middle East conflict continues and where all of the shortfalls of news reported on social media are writ large. That war is the enemy of truth cannot be denied nor can the need or desire to be informed about what is going on around us.

Journalists have always tried to scoop each other and provide the news more quickly – however there used to be less of a reliance on unnamed sources and slightly more attempt to confirm the information before going live. While Fox News retracted its original statements about the terrorist attack and said it was mislead by its sources, the original perspective remained up for many hours.

There is now also more of a tendency to believe news on social media that comes from less credible media outlets or even just friends, family and people you would like to believe. The gutting of traditional newspapers and reduction in the number of professional working journalists has just exacerbated these problems.

Trust in traditional media is low and many do not have the skills or knowledge to objectively assess the news that they see on social media. Bots spreading false information, whether AI assisted or not, are not helping matters.

The last half-century may have proven to be the high point for journalism with relatively well-financed media outlets trying to provide objective information in a truly balanced fashion.

Absent this, what is needed is providing far more education in our schools and to the public in general on how to assess the news and who is feeding it to you.

(Image – screen capture of Rainbow Bridge explosion sourced from X)

Physician health and well-being in the spotlight: CCPH 2023

Representatives of a battered and stressed medical profession gathered in Montreal and virtually last week for the 7^th annual Canadian Conference on Physician Health (CCPH) – the first such meeting in four years.

Acknowledging the tremendous pressures facing physicians today, the 450 delegates in attendance – the largest ever at such a meeting – heard about the wide variety of initiatives underway to address physician health and well-being both at the individual and at the system level.

“Medicine has changed. The world around us has changed but we are all here to discuss important issues,” said Dr. Jeff Blackmer, chief medical officer and executive vice president of global health for the Canadian Medical Association (CMA), which hosted the meeting. “Many of us are stretched so incredibly then (and) have been targets of harassment and bullying at work and in training programs,” CMA President Dr. Kathleen Ross added.

Later in the meeting, Dr. Ross released a statement referring specifically to the current conflict in the Middle East. “The Hamas-Israel conflict is causing significant tensions for Jewish and Palestinian physicians, with many experiencing antisemitism, racism, Islamophobia and other forms of aggression,” the statement noted.

The impact of the COVID-19 pandemic and its hugely negative impact on physicians was also referenced repeatedly. “COVID is not over it has a lingering presence. It has altered our ability to offer quality patient care … and we will never recover,” said opening keynote speaker, Dr. Jane Lemaire, co-director of WellDoc Alberta.

What emerged very clearly this year was the recognition of how interlinked the well-being of physicians is with the healthcare system as a whole and the health of the patients of which they care. “We are caught in a vicious cycle of work overload, burnout and attrition of the health workforce which has critical population health and health system impacts,” said Dr. Ivy Bourgeault, leader of the Canadian Health Workforce Network.

At one point in the meeting, an emergency physician from Montreal rose to ask why it was so hard to persuade people that good physician health translates into better patient outcomes.

Dr. Edward Spilg, an associate professor of medicine at the University of Ottawa noted that a decade ago individual resilience was identified as the way physicians could best deal with wellbeing issues. Now, he said, there is a recognition that system-level interventions are essential. Dr. Lemaire said a multi-pronged approach to culture change is required to improve physician well-being and the healthcare system must support such a change.

While much of the focus of the meeting was on these system-level approaches, some sessions also dealt with how individual doctors could deal with the stress of medical practice today. In a keynote address, Dr. Kristen Neff, a clinical psychologist at the University of Texas, Austin advocated self-compassion consisting of “kindness, mindfulness and common humanity”.  In another session, Collingwood family physician Dr. Caroline Bowman who has been diagnosed with MS discussed shame resilience as a missing component of physician wellness.

A focus on improving the well-being of medical learners and the environment of academic medicine came from two sessions discussing the Okanagan Charter, an international framework to support well-being at academic centres. Deans of all 17 Canadian medical schools have committed to following the charter, said Dr. Melanie Lewis, chief wellness officer at the University of Alberta.  But she added only 12 of the 17 schools (soon to be 13) have formally adopted the charter to date and she is the only person to currently hold the position of chief wellness officer at a medical school.

The ambivalence with which many physicians view practising medicine today was encapsulated in a plenary session at the conclusion of the conference where speakers engaged in a formal debate on whether there are still compelling reasons to practise despite the challenges involved.

Manitoba physician and best-selling author Dr. Jillian Horton who moderated the debate noted both that “we leave jobs we love because they have become undo-able,” and that “most of us are here because we are looking for reasons to continue to do what we do no matter how difficult is.”

“The healthcare system values efficiency over patient care and values data over relationships. The painful reality is very little money and very little decision-making effort goes into our well-being,” said Dr. Julie Maggi, director of faculty wellness at the Temerty School of Medicine, University of Toronto, one of the two physicians charged with arguing the futility of continuing to practise.

Tasked with arguing in favour of continuing to practise, Dr. Saleem Razeck, professor of pediatrics at the University of British Columbia talked about the satisfaction of being a physician even with “a full bladder, empty stomach and dry mouth.”

“We are at the precipice of greatness,” said his debating colleague Dr. Andrew Ajisebutu, a neurosurgery resident at the University of Manitoba, in noting all the current advances in medicine. “At times the job does suck, but the profession does not.”

(Image: Dr. Jillian Horton moderates final plenary at CCPH 2023)