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Traditionally, doctors have relied on all of their senses to diagnose and treat patients; detecting subtle changes in body language, actively listening and applying their professional wisdom and experience to clinical cases. This traditional model may be threatened by the increasing use of electronic consultations (‘e-consultations’). This editorial focuses solely on the use of emails to conduct electronic consultations and does not consider other models, such as Skype or video conferencing. In this editorial piece, the authors consider the potential advantages and disadvantages of e-consultations for doctors, patients, health services and society.
The concept of the electronic consultation is barely a decade old and is evolving.1 A meta-analysis conducted in 2016 by Liddy et al was unable to confidently define the prevalence of their use in the UK, but concluded that e-consultations are becoming increasingly utilised globally, particularly in the USA.2 The explosion of information and digital technology combined with increasingly busy lifestyles has led to the quest for convenience in accessing professional services. In a US poll, 90% of respondents wished to communicate with their physician electronically3 demonstrating a public perception that email communication offers quick and effective access to healthcare.4 E-consultations are also increasingly being adopted by other healthcare disciplines, including nursing.5
We find ourselves in a rapidly changing healthcare climate driven by an ageing population, increasing survival and life expectancy and growing clinical complexity. Coupled with challenges to service funding, alternative cost and time-saving clinical measures must be sought. E-consultations may provide part of a solution to the growing volume of clinical work. E-consultations can be used to take a clinical history, diagnose, reassure and treat.6 Some uses are contentious, however, particularly as part of therapeutic treatment algorithms, leading to the remote prescribing of medications. This has been identified as a key concern for physicians conducting online consultations in addition to their appropriateness for use in complex cases, medicolegal aspects and logistical difficulty.7 8The General Medical Council (GMC), the UK’s medical regulator, issued guidance on conducting remote consultations in response to this change in consultation style9 with particular emphasis on remote prescribing.10
…remote prescribing should not be a matter of routine and should only be done if you have adequate knowledge of the patient’s health and are satisfied that the medicine serves the patient’s needs.
You are also expected to consider the limitations of communicating with a patient via the telephone or other technology; whether a physical examination is required and whether you have access to the patient’s medical records. (General Medical Council, 2012)
As clinicians, we recognise that the application of emotional intelligence11 12 and career experience may be equally or more important than purely scientific interpretations of clinical presentations. However, by conducting consultations online doctors may become ‘blinded’ to the subtleties and nuances which are central in face-to-face consultations. Words in an email, without visual cues, risk being misinterpreted. There is a perception that the widespread adoption of the electronic consultation could erode the essence of the doctor–patient relationship and even reduce job satisfaction.8 Some feel it could devalue the personal nature of the conventional therapeutic interaction and have labelled it a ‘disruptive innovation’13 carrying with it a risk of deprofessionalisation,14 perhaps even leading to dilution in the quality of care.
The counter argument is that e-consultations are practical and cost-saving, although this has not yet been definitively demonstrated.2 In a climate of convenience and patient-centred care, the electronic consultation may save time and enable flexibility. Efficiency may be in part traded for effectiveness. One advantage that is becoming apparent is that remote consultations may allow the revealing of sensitive topics which may be too challenging for some patients to disclose face-to-face. For example, certain ethnic groups who have historically avoided presenting to doctors, may consider the e-consultation a less threatening or less stigmatising environment.15 Similarly, other geographically hard to reach populations may benefit from having electronic access to doctors.16 This may have wider applications such as within the prison population, visiting whom has long been a time-consuming activity and to which e-consultations could offer a pragmatic compromise.
Groups less familiar with technology, such as the elderly, could suffer as e-consultations become more prevalent. Also disadvantaged could be those who cannot afford or do not own a smart phone or computer. In addition, good internet access is not ubiquitous, potentially introducing differences in availability. The situation may also further social and health inequalities among those with learning disabilities or illiterate individuals and these observations are reflected in the concerns of primary care physicians working in diverse communities.8 When advocating emails as a consultation option, doctors should consider the suitability of the patient’s condition, their technological ability and compliance.17
A further concern is the potential contribution of e-consultations to professional fatigue in doctors, and potentially other healthcare groups. Many doctors already experience ‘compassion fatigue’18 19 and are at risk of ‘burnout’.20 21 Some practitioners are unable to effectively detach themselves from clinical and administrative responsibilities. The legacy of more flexible and convenient services is rising patient expectation. One study showed patients with e-mail access to their doctor expected response times of less than 24 hours for routine questions or results.3 The threat of requiring continuous access to emails, may further test doctors’ vitality and resilience. Within certain healthcare systems, there are also questions about how remote consulting should be remunerated if not confined to the surgery or normal working day.22 Conversely, as electronic communication may allow flexibility in practice, with doctors and patients not being geographically constrained to particular sites, this may actually confer lifestyle advantages as well as lower infrastructural costs.
Provided that good governance is understood and achievable, and there is scrupulous recording of e-consultations with the ability to share communications within the multidisciplinary team in a timely way, this could offer a viable adjunct to face-to-face clinical work. Electronic backup systems are also vital in order to ensure safety. In reality, using electronic consultations to replace some traditional consultations may become a modern professional necessity. Furthermore, e-consultations could embody the collaborative approach between doctors and patients with greater autonomy afforded to patients.23
This type of innovation also facilitates movement towards the global workplace. Communities of practice now extend beyond geographical and sociological borders, largely enabled by advances in information technology and a more global ethos in healthcare. In large countries with remote and rural communities, such as Australia, e-consultations have successfully been used, not only for patient interactions, but for consultations and advice between specialties, improving access and knowledge sharing.15 22 24
Doctors have expressed concerns regarding the use of emails for inappropriate clinical situations, including emergencies.7 This concern is reflected in guidance from regulating bodies advising clinicians obtain informed consent from patients regarding the benefits and limitations of e-consultations.17 25 Guidance from both USA and UK bodies advises that legal, ethical and professional rules are still applicable when communicating with patients via email and there is a general consensus this is best reserved for stable patients with chronic conditions.7 Table 1 summarises this guidance.
Preparing future doctors for 21st century challenges means addressing these issues in their training, acknowledging the benefits and limitations and medicolegal and ethical pitfalls. Doctors in training need to learn how such new technologies can be used alongside traditional ones to augment communication skills and clinical reasoning. This may need to be incorporated into future medical curricula.
In summary, the changes discussed pose both a threat and an opportunity. This represents a paradigm shift in communication with a change in the classical consultation model. The associated reduction in non-verbal cues means that practitioners can no longer solely rely on their traditional clinical tools and training and need to acquire new skills to adapt to and manage these changes. This new model of consultation enables previously elusive, doctor-fearing groups access to physicians and offers flexibility and financial implications which may be significant and welcome. However, safeguards need to be put in place to ensure the safety and accountability of electronic consultations. We pose the question of how doctors are going to lead the way in preventing erosion of professionalism in this context?
We acknowledge that this editorial is limited by choosing email consultations as a focus and that remote consultations may take place via other, media such as video conferencing or apps. However, by choosing to discuss arguably the most established form of remote consultations we have highlighted that, despite no longer being considered technologically advanced, email consultations are still clouded by uncertainty with regard to what they can be used for, as well as medicolegal and professional issues. It is vital that the increasing prevalence and demand for remote consulting does not outstrip professional experience or guidance.
Turbulence and discomfort are to be expected with such professional shifts. Doctors and those professionally allied to medicine are beginning to appreciate and evaluate the depth, threat and implications of the electronic consultation on their professional and personal lives. It is important that doctors take a leading role in innovation, ensuring that it is what patients want while protecting the confidential relationship, promoting health equity and above all, ensuring safety. The remote electronic consultation may offer an opportunity for evolution in the art of medicine, a new art in clinical communication.
Contributors The idea was conceived and originally drafted by FG. Redrafting of the work and addition of further intellectual content was done by NG. Both authors took part in revising the work and gave final approval for its submission. Both authors agree to be accountable for all aspects of the work.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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