Can Telemedicine Close the Endocrinology Access Gap?

Richard M. Plotzker, MD


October 24, 2022

As a relic of the class of '77, I can attest that the practice of at least occasional telephone medical care dates back to the era when telephones entered wide use. Gradually, each physician came up with a personal algorithm of how much could be done by phone and how much needed an in-person office visit.

COVID has been a game changer in many ways, not the least being a re-examination of the merits and limitations of medical care when the patient is not physically present but can communicate electronically. This change imposes a measure of formality and structure that simply telephoning a patient with lab results or troubleshooting a new medication never had. It also reveals what we have already known: Each person brings a uniqueness, even quirks, about when medical care without the patient present is best offered.

A recent survey explored some of the directions that telehealth has already taken, along with consequences of the limited standardization that currently exists. Rather than format a protocol, recruit participants, and assemble fixed data to analyze, the authors opted to capture the same free form as the telehealth subject they investigated. They did this by assembling a panel of 26 endocrinologists with a diverse composition of practice settings, years of clinical experience, frequency of telehealth use in their practices, and geographic distribution. In effect, they created a physician committee to answer a series of standardized questions that revealed their current practice preferences.

The invitations to participate were offered to colleagues the authors knew or to others recommended by people they knew, and the cohort was small; thus, the characteristics of the final panel probably differed from the more composite distributions of American endocrinologists. Physician demographics were weighted perhaps to younger-than-average practitioners, a greater fraction in academic settings, with a higher number practicing in the Northeast. Despite these limitations in representation, a reality of all small committees, the responses to the interview questions reflected considerable variations in current practices, though with areas of consensus as well.

In general, follow-up assessments of conditions of low complexity, where the appropriate lab or objective data were available and the focus of that visit was clear, were not compromised when done remotely. Less straightforward remote endocrine assessments may also be preferable based on patient rather than disease considerations, such as when the alternative is absence of care because the patient can't get to an office or for people at high risk for COVID.

There was agreement that those requiring an expert exam or a procedure such as a fine-needle aspiration needed to be present in person. There was less consensus about who needed physical contact when this could be approximated by looking at a foot or spine, for example, on a screen.

Individual physician comfort zones differed the most depending on their familiarity with the patient. Physicians were reluctant to depend on telemedicine for those seeking an initial consultation or for those they had not seen in person for a considerable time, even with intermediate computer or phone contacts. There were also differences in advising patients whose lab results were currently at hand, and patients needing decisions on what lab studies or imaging might still be needed, something many felt was better determined in person.

Sometimes it was the ability of the practice to facilitate what the doctor might need that enabled a virtual visit — patients could be provided blood pressure monitors or home scales, something easier to do for large institutional practices than for solo practitioners with much smaller budgets. Sometimes physicians had to abandon that common exhortation from the 1970s that the only valid exam is the one you do yourself. For telehealth to achieve selective parity with onsite care, what can be expediently but safely delegated needs to be expanded. While presented as a small and not rigorously scientific research paper, the results generate some serious commentary.

A recently published policy perspective in the Journal of Clinical Endocrinology & Metabolism provides insight into when telehealth is appropriate for endocrinologists. Patients and physicians should discuss telehealth and its appropriateness for the patient's care together. It provides a step toward standardization.

In retrospect, our generations of ubiquitous telephone interactions have never been standardized. As we move ahead to audio-visual as a medical care norm, and as money is exchanged and there are advocates for liability parity with office care, which allows each practitioner to pursue telehealth to their individual comfort level, we may need more formally articulated standards of care supported by published studies and expert consensus. Studies of diabetic outcomes with telehealth are emerging, but thus far there are fewer studies of other common endocrine disorders. Because technology is not distributed uniformly through the population, we will need to learn whether subsets of frail patients, minorities, or rural patients will have their care enhanced or harmed when it moves from exam room to screen.

A recent commentary on Medscape illustrates the importance of knowing what this fairly rapid transition to electronic healthcare delivery will ultimately achieve. Assessing a study published in Diabetologia that surveyed growing disparities in diabetic outcomes over 20 years, the authors concluded that urban dwellers benefited immensely from the technical advances in sophisticated diabetic management that occurred between 1999 and 2019, whereas comparable rural patients did not. Top among the contributors for this gap seemed to be the ready availability of professional assessment and intervention. The study interval concluded just as telemedicine went mainstream.

Access matters, both in its timeliness and professional expertise. This was similarly conveyed in Brian Alexander's The Hospital: Life, Death, and Dollars in a Small American Town, published in 2021, which included in its subplots a young diabetic person's body part–by–body part deterioration. Doctors who read this cannot help but think, This would never happen at my hospital. Telemedicine may help close this tragic outcome. But to get maximum benefit for these people and many others, an investment needs to be made to identify what the best practices of telemedicine actually are.

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