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I was wondering what you all thought about the following scenario and handing out Podiatric advice over the internet to places that are remote and health care is hard to find.
I have a patient who's daughter and grand daughter live in PNG. The grand daughter has a verrucae which is being a little stubborn and the GP they are seeing is not being aggressive enough with it. There are a few additional factors in that environment, including getting the dressings to stay in place with the humidity and the obvious increased risk of infection.
I have included the email from the mum below which outlines the history.
Curious to know what your thoughts are on the ramifications of handing out advice on-line under these circumstances.
"Dear Trent,
Thanks for giving my Mum your email address and allowing us to ask you some questions.
Have attached some pictures of the wart. Anna (age 9) also has 2 smaller warts close by which we are treating with wart kill.
It is proving to be very difficult to treat here in PNG. We’ve been seeing a GP here for 2 months now and he’s been cutting away at it. The wart now seems to be quite flat but is very tender for Anna to walk on and also for the Dr to treat. He is now leaving it for a week as he feels that it may be becoming infected.
I wonder what treatment you would suggest if we were to come to Australia? Also if you have an idea of what you might be able to do, do you have a rough idea of how long in time the treatment could take.
Our Doctor here tells me that burning a wart off on the base of the foot is not a good idea as it can leave permanent scaring which may make walking difficult. I would be interested to know what you think as it would seem to be a quick solution.
If there is anything you feel that we could use to treat the wart here in PNG maybe you could tell us about it. Sorry about all the questions, but as you can imagine we’re very keen to have her walking comfortably again. Thanks in advance for your help."
Guys, please understand I'm not asking for VP treatment advice here. I'm asking what you all think about giving advice via email in this situation.
Over at the Foot Health Forum, Foot Doc who responds to a lot of patient enquires, as this disclaimer at the top of each of his messages:
Quote:
DISCLAIMER:
THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
I see a number of international and interstate patients, as well as getting my fair share of e-mail enquiries.
The # 1 rule is to protect your backside and remember you are a professional. A medical practitioner, for instance, will rarely provide any direct response to an enquiry of this nature.
If you haven't taken a history and performed a physical examination, restrict your advice to generic statements and encourage them to see you/or someone when they are in a 1st world country again.
Most people will respect this, and be more than happy if you simply provide a link to a professional quality website for more information about their perceived problem.
LL
__________________
***************************************** Remember, it's just a foot.
When using e-mail or the Internet to communicate with patients, risk-management experts advise psychiatrists to do the following:
Make sure that information posted on their practice's Web site is up-to-date and accurate.
Monitor online scheduling programs carefully to ensure that confidentiality is preserved.
Establish security and encryption precautions prior to using e-mail with patients.
Obtain and document patients' informed consent to communicate with them by e-mail.
Discuss with patients those topics that you are willing to discuss via e-mail, as well as the benefits, risks, and limitations involved with e-mail communication.
Check e-mail frequently.
Print e-mail exchanges with patients and keep them with patients' medical records.
and this: Risk Management FAQ's E-Mail Advice We’re thinking about using e-mail to answer simple medical questions. What issues should we consider?
Quote:
E-mail nowadays is an efficient and viable means of communication between doctor and patient. Because of the nature of the medium, however, several risk management concerns must be considered:
• The apparently informal quality of e-mail can be misleading. When communicating with a healthcare provider, patients rightly expect (whether they realize it or not) an appropriate level of decorum. An innocent humorous message later viewed out of context (like by a jury) may appear to be impolite or indifferent. All messages should thus reflect an appropriately respectful tone.
• Since even deleted messages are retrievable, every e-mail should be viewed as, and made a part of, the medical record. That means printing and filing all messages in the chart.
• Prompt receipt and response to messages cannot be presumed. Even though e-mail communication may look spontaneous, messages may sit unread for hours and even days. Therefore, information that is at all urgent should always be conveyed through more immediate means.
• Patient confidentiality should not automatically be assumed. Physicians who communicate by e-mail must use reasonable care to safeguard patient information. In Internet terms, that means appropriately using firewalls, passwords, and sometimes encryption.
• Clinical accuracy cannot be assumed. Put another way, even sophisticated, Internet-savvy patients sometimes have difficulty accurately describing their symptoms. Physicians should, therefore, always err on the side of caution and bring patients in to personally examine them.
E-mail communication with patients is a reality, so it cannot be ignored. Regardless, it should be used carefully to yield the greatest patient benefit with the least amount of risk.
That's all great information, thanks. I have so far been quite brief in my correspondence with these people.
I have only asked for further history.
I would have thought that responding with specific advice was a bit risky, so I have stayed clear of that. I think the problem with this scenario is access to supplies and health care. I think the best course of action is to encourage them to come back to Australia for treatment. I'm sure a Pod in Nth QLD would just love a stubborn VP to deal with, lol.
My practice in New York now uses Relay Health to provide secure online communications that satisfy legal requirements here in the US. They also will bill out credit cards or even insurance companies that reimburse for online visits.
Still, the idea of giving advice without seeing the patient is frought with risks for valid reasons. There are dozens of differentials for verruca plantaris that you probably rule out just based on clinical appearance. Encouraging them to go to Australia is probably the best bet. What if Verrucous Carcinoma, SCC, or another malignant lesion looked like a verruca in a picture.
secure online communications that satisfy legal requirements here in the US.
That reminds be of a conversation I had a couple of years ago ... it was related to the "ownership" of email content when the email passes though the ISP and the issue of privacy. Apparently in some countries (I think it was Canada I was having the discussion about); is that the "ownership" of the email passes to the ISP while on its way to the recipient (or something like that) ... this raised all sorts of privacy concerns that were not necessarily protected by law (unless I misuderstood it or it may have changed). I tried to find out if it applied in Australia, but never got very far.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
This all being said, I did ask the patient's mum to bring her to Australia for tx. I treated the VP (which was in fact one big VP) and resolved the lesion within two weeks. The patient and family were so happy they sent in a letter and photos to our state association monthly mag' (Footprints) and I had a write up (full page spread) in our September issue. Everyone was a winner on this one! Thanks for all your comments here.
With great caution and respect for the chemical, I use Potassium Hydroxide. It is an aggressive option but after years of fluffing about with cryotherapy and sal' acid with limited results, we decided to pull out the big guns.
There is often a post tx wound which resolves quickly with appropriate care and the tx itself is quite uncomfortable for the patient, however if they are informed well and the lesion resolves quickly then they are prepared for the tx and happy little campers with the outcome.
Over the last two years I have had a dramatic increase in the number of people e-mailing my private e-mail address who I have never seen and who are requesting me to give them medical advice regarding their foot and lower extremity pathologies. Early on, when they were infrequent, and I tried to answer them. However, now I sometimes get 3-4 e-mails a week from patients from the US, Canada and many different countries, some of them going into great detail about their pain and frustration with their current treating clinician, asking me my advice. In fact, this morning, I just got an e-mail from a 66 y/o lady who lives about 2,000 miles away from me that has posterior tibial dysfunction, had surgery and still has pain in her foot and asked me five different questions about her diagnosis, treatment and prognosis.
Is anyone else getting an increased number of these unsolicited requests for medical advice over e-mail, or is it just me? I simply don't have the time to answer all these people and even though I sympathize with them I honestly don't think it is appropriate for me to give such advice to someone I have never met, examined or spoken with.
Any ideas?? When you answer these e-mails, do these people you have never met now become your patients?? What do you do when you receive such e-mails?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Although my practice is less cutting edge than yours I too feel slightly less inclined to respond to external enquiries of this nature.
I have recently received enquiries both by telephone & email from clients previously unknown to me regarding my thoughts on another clinicians previous treatment.
In my case both were regarding the now defunct Parish & Bell. A) Did I consider their treatment unnecessary.
B) In my opinion were the patients the subject of an elaborate scam. (Their words, not mine).
In both instances I declined to proffer an opinion stating that I cannot comment with regard to the treatment of another without the full facts of the individuals case.
Personally speaking unless I were prepared to become an expert witness in a potential future court case (which I would not offer my services as) I would happily decline in commenting either over the phone or online via email to an individual.
Preservation of self.
Only my thoughts.
Kind regards,
Mandy.
PS. Understatement of the year award goes to: Hello Kevin,
Although my practice is less cutting edge than yours
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
Last edited by twirly : 9th April 2009 at 11:38 AM.
Reason: Award?
'Treating' patients via email
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