Online Cosmetic Surgery Consultation: what’s up with that?

I saw a very interesting article in the New York Times (1-21-2010, page E3) recently about how many cosmetic surgeons are offering virtual online consults for patients.  This article discussed how many cosmetic docs are currently offering online video consultation for patients where the surgeon and patient are connected via web cam and a telemedicine consultation is performed, frequently for a fee.  A group called Surgeonhousecall.com has recruited 55 plastic surgeons to provide online consultation for cosmetic surgery. This got my mind churning about the pros and cons of this technology.

If someone told me 30 years ago that I could take all of my record albums and cassettes and put all that music on my pocket sized telephone I would have thought that was a radical statement.  Admittedly, when I purchased my “100 CD capacity CD player” I never saw the digital music revolution coming.  We can all relate similar stories about the fax machine, email and Internet surfing.  So when someone suggests that cosmetic surgeons may be someday (or currently) performing consultations via a computer screen, I must consider this plausible and possibly a paradigm shift for medicine and surgery, although it somewhat rubs me the wrong way. 

Medicine and surgery are historically based on “the laying of the hands” and for the last thousand years, has been practiced in that manner.  Not being able to actually see and touch a patient probably makes any surgeon feel at a disadvantage.  We use all of our senses to consciously and subliminally formulate thousands of impression about a patient and their diagnosis and treatment.  When you think about it, a flurry of information streams through our brain via sight, touch, smell, hearing, and analysis.  We lose much of this sensory input, staring at a two dimensional picture on a monitor.  Regardless of your surgical discipline, there are many cases where an accurate diagnosis and treatment plan could be formulated via a video conference.  Personally, I could probably perform a relatively accurate consult for blepharoplasty, facelift, skin resurfacing or Botox and fillers by looking at a patient on a monitor and talking to them over the Web, but would I feel comfortable enough with this information to meet them in the operating room the next day?  Probably not!  There is simply not enough sensory input to cover all the minute specifics that are imperative during consultation.  Do they have lower eyelid laxity, how much of the submental excess is fat versus skin, is the skin pigment epidermal or dermal, how many syringes of filler will they need would be information that I would be lacking.

I don’t think that the surgeons who advocate or are currently performing online consultation intend for the consult to be “final or comprehensive” in nature, but rather to serve as a general informational or screening tool in advance of actual personal consultation.  So from that aspect, this process has merit.  Whether we realize it or not, many of us are already performing some form of digital consultation anyhow.  I routinely look at patient’s pictures that are emailed to me for informal discussion.  It is important that I do not render an official medical opinion and I have the following disclaimer on my emails.

Any correspondence should not be construed as medical advice, evaluation, or consultation and should never be considered a replacement for a formal evaluation by the physician in his office and related consultation. Therefore, the information and correspondence that is involved with this email or future emails do not constitute a formal doctor-patient relationship. If you desire to schedule a consultation, please feel free to call the office to arrange for this type of appointment. Please be advised that your own physician should approve any change that should be undertaken regarding to your therapy. Explanation of off-label services and/or products that are mentioned herein does not reflect an endorsement nor promotion and should not be construed as such.

Doctors must be very careful not to construe casual opinion as formal medical consultation for numerous reasons.  First of all, if you do not have a license in the state or country of the recipient you may be in violation of the law.  Secondly, if you offer an opinion that somehow turns out to be incorrect or damaging, you may find yourself named in a law suit.  As farfetched as this sounds, I have a friend in that exact position, so it can and does happen. Also, patient confidentially and HIPPA concerns come into effect as you never know who may somehow obtain this sometimes confidential information or pictures by hacking into your computer.  Given all of these potential problems, we have to wait for medical societies, state boards, and possibly the federal government to set standards of how this activity should or can occur.  Right now, the cart is in front of the horse.

I was a bit surprised to see that there are some pretty well known practitioners that currently have free or paid video consultations available on their websites.  This bothers me because I consider myself and my website to be pretty technologically advanced.  “How did I miss that boat” was my first thought.  My second thought was ” I am not sure I want to be part of that boat at this time”.  It makes me wonder if doctors that offer these online video consultations are hurting for business and need this marketing tool to stay alive.  It also begs the question “if I did this in my practice, when would I find the time to do this”?  I already spend too much free time in the evenings updating my website, blog, etc, so I don’t want to be “seeing patients at home”.  At work, I am too busy with face to face patients to incorporate this technology into an already overly hectic surgery and consult schedule.  Then there is the frank reality that if this kind of thing really becomes popular, I will have to do it to maintain a competitive edge.  This bothers me more than anything as none of us enjoy doing something because everyone else is doing it and now we have to!  Finally, there are so many “tire kickers” out there in cyberspace that are not serious about having a procedure but would relish the opportunity to obtain a free video consult, “just in case” or “just for the fun of it.  I already have too many of those in my real time practice.

So I ask myself if this is a flash in the pan marketing ploy for those that are not already busy enough or is it the crest of a paradigm shift in digital medicine and in the future I will be intentionally leaving open spaces in my schedule for my “virtual patients”.  I have never charged a patient to look at email images and I don’t charge for in office consultations, but if this technology becomes mainstream, I will have to be compensated for my time is some way.

I am one that feels that still feels that accurate diagnosis still requires a hands on approach and that the doctor/patient relationship should remain personal.  I feel that unregulated virtual consultation somehow cheapens the entire relationship.  Having said this, I have always been an early adapter of technology and have in the past eaten words concerning “I will never do that” dogma.  I think telemedicine is a great situation for emergency scenarios and underserved areas or populations that may otherwise not have access to care.  I frequently have out of town patients or even local patients send digital or cell phone pictures to address concerns and have more than once seen an impending problem and was happy to have this early intervention opportunity.  Having said this, I guess I am talking out of both sides of my mouth.  In many ways being able to see a patient before an actual consult may save time for both the patient and surgeons as the proposed surgery may be out of the question and save wasting further time.  Seeing post operative patients that either cannot come in for consult due to geographic, transportation or after hours may in fact head off a potential serious problem such as hematoma, infection, etc.  So there is certainly merit to this technology.

In conclusion, there is no doubt that telemedicine will become a part of contemporary surgical practice.  I am not sure that want to begin seeing online consults just because other surgeons are doing it.  I, again, feel that this entire process needs standardization, regulation and security before it becomes mainstream. Does a patient who gets a plastic surgeon’s recommendation before a face-to-face visit really “win?” Can poor quality video or pictures provide inaccurate diagnosis or misinformation?    Will the “best” surgeons be available or just those who aren’t busy?  . I also fear that virtual consultations may become bidding wars for patients to simply look for the cheapest price.

Supporters cite that shy patients or others may desire a semi anonymous consultation and they want to know cost, and what they get for that cost before they make a commitment, or walk through the office door.” No doubt, some early adaptors will encounter some problematic aspects including lawsuits while this all gets sorted out.  I love technology and gadgets and I am sure that online video conferencing will impact my practice in my working lifetime.  It is an exciting thought but still a bit disconcerting as to when and how I will find time to do this and protect myself and the patient in cyberspace

Time will tell.

To learn more about Dr. Niamtu and Cosmetic Facial Plastic Surgery in Richmond, Virginia visit www.lovethatface.com.

Joe Niamtu, III DMD