Telemedicine - The Yay and Nay

Telemedicine is not new.

My very first telemedicine experience started in 2013 when I was still practising in government hospital. The service was mainly for medical officers from remote part of Malaysia who has no access to specialist advice. So the medical officers will upload patient photos together with their clinical findings and specific questions so that we can give advice on further management of their patients. It wasn't directly link to the actual patient.

Then I started offering free telemedicine advice on TELEME platform (link at the right side of this site) in 2018, which was often abused by some, until I have decided to put a stop to access from new patients and only using it to advice my existing patients only. (Also wrote a frustrated blog post here. Haha.)

Then came COVID pandemic and Movement Restriction Control in Malaysia, during which our hospital and clinic actually work as usual but many patients could not attend their appointments for various reason. Some suffered severe flare-up of their chronic eczema, psoriasis, blistering diseases etc for running out of medicine supply. And then I started offering telemedicine service again via my hospital's Telehealth Plus platform.

Unfortunately not all consultations can be conducted effectively via virtual / video call. It remains a challenge to see new patient (which I do not do) or existing patient but with a new complaint. It is not easy to get a complete impression of their skin condition and the assessment of mental burden to one is not easy as well.

There are a lot of things that we cannot do virtually, blood taking and laser procedure etc is impossible for sure. It is easier to explain things face-to-face because we can use tools such as flip chart, drawings etc. Not to mention technical issue such as camera quality and network connection.

Having said that, sometimes we have no choice, and sometimes telemedicine is convenient and probably good for follow up of people with well controlled conditions, or review and continuation of an ongoing satisfactory treatment.

If you are my existing patient, to see me for virtual consult, click here. ;)

Telemedicine, Blindmen and the Elephant

We all know face-to-face consultation in the clinic is the best. However sometimes it is not possible, due to distance etc. Consultation over phone calls, emails, social medias and even proper telemedicine platform such as TELEME has a lot of limitation especially when it comes to dermatology. Not just because I cannot see the skin clearly but also because I cannot examine it.

To be honest, a lot of times, I feel like a blind man. Asking many questions rather than answering. How accurate and relevant my guess and advice is depends very much on whether the person on the other end decided to let me know the tail, the horn or whichever part of the elephant. And as a doctor, we have to be responsible for the advice we dispense.

Despite the best reasonable effort, many times I still can't be sure that I am getting the full picture of what the patient's true problem is. The information are often distorted. Worse still is that some people are asking questions on behalf of someone else. And expecting me to offer one miracle cream that will solve their problems through a blur picture, not even revealing which body part that picture belong to.

As my ex-colleague and friend put it, blind man touching part of an elephant + wearing a thick gloves.

Anyway, I must say Telemedicine is not without it's benefit, probably best general enquiry for non-medical person, or for second opinion among healthcare personnels, hopefully and likely we will be speaking the same "language".

My doctor(s) can't seem to help me. What should I do?

I have a serious skin problem. I have a red swelling on my cheek which started as a "pimple" but gradually getting larger. I had taken a few courses of antibiotics in the past one year, including a 6 months course of erythromycin from my family doctor. He took a small skin sample from my cheek prior to the long course of antibiotics but the report wasn't conclusive. Then I was given oral steroids which seems to get the swelling slightly smaller but it never goes away. I trusted my family doctor as my family has been under his care for years. But he can't seem to solve my problem. What should I do?

Here's what I think you should consider.

1. What is the diagnosis? Sounds like no definite diagnosis has been made so far. Effective treatments often comes from an accurate diagnosis. (Yes, I say "often", some people treat by hunches, and it works, sometimes. But the basic of medicine should be diagnosis first before treatment.)

2. How was the skin sample taken? Was it taken at the right place? Was it deep enough? Is the cut big enough for the laboratory to examine? What laboratory tests have been done? A histopathological examination? Any extra stain needed? What about culture for fungus and bacteria and other not so common bacteria?

3. Perhaps you might want to politely ask your family doctor if he thinks any other doctors or nearby dermatologists may help you with your problem? Most if not all good doctors do not mind writing you a letter, giving out your previous investigation and biopsy records. If a particular doctor is very defensive about you going for a second opinion, it may be, well, a warning sign perhaps.

4. Consider going to dermatologists in bigger or more well known medical centres because they may be more experienced in managing not-so-common skin problems.