Wednesday, November 24, 2010

Medicine over the phone

Ontario has a service called Telehealth.  The idea behind this service is to have nurses available by phone 24/7 to give people advice on whether or not they should go to emergency, the doctor's office or do nothing at all about various health concerns they may have.  That idea sounds wonderful in theory because it should keep a lot of people who aren't actually very sick out of emergency rooms and reduce the workload of other health professionals.  In practice there seem to be real issues with the way the service is provided and there are a lot of frustrations with trying to use it.  I have called telehealth several times in the past couple years and every time has been very frustrating with the number of questions asked that are repetitive, contradictory or outrageous.  The last time I called them was this past Friday night and it was really the worst of the worst.

"So how long has Elli had this sore stomach?"
"Has she had this issue for more than 2 hours?"
"Is this something that just started, or has it been going for some time?"

You would figure that after I give a very comprehensive answer to the first question the other two would be unnecessary, but regardless the nurse asked them anyway.  After asking dozens of other questions she started reading me the advice blurb her script recommended and halfway through she stopped, realizing that she was reading the blurb for people who had just gotten the pain recently.  She then reasked a few more questions and began to read the blurb that actually matched the answers I had given in the first place.  It was also very frustrating because I gave her information like "The pain is very moderate, comes and goes, and Elli is mostly normal but complains sometimes." and then she would follow up with "Is Elli curled up in a ball in agony unable to move?"  No, she isn't, which should be obvious from the statement I just finished making!

During a previous call the questions actually got kind of funny as I described that Elli had a cut near her eye from a fall.  The nurse then asked me a series of questions like "Is her eye punctured?"  "Is internal fluid leaking out of the eye through a wound?"  I can imagine the existence of some kind of idiot who thought that a punctured eye might not warrant going straight to 911 !!! but I had clearly and completely described the wound in question and noted that no actual eye damage had occurred.

The nurses that answer these calls seem to have some notable tendencies towards incompetence but that is almost certainly not the whole story.  Surely they are legally bound to ask all kinds of ridiculous questions to avoid liability even when the questions make no sense.  They can't just let me describe the situation but must ask predetermined questions one after the other to make sure that they don't leave themselves open to litigation.  Certainly asking a lot of questions in this sort of situation is good but asking questions you already have answers to just to have that answer recorded in the appropriate spot is wasteful and annoying.  These calls tended to take a good 40 minutes to complete even though realistically the nurse could have gotten all the information they needed to give me advice in 5 minutes.  That wouldn't be much of a concern except that I did have to wait on hold a long time to get a nurse (bad if there is an actual emergency) and if this system was more efficient it would free up nurses for other duties.  I find it endlessly frustrating to have my time and the time of a medical professional dedicated to avoiding pointless litigation.


  1. As with most public services, it sounds like the idea was sound, but after being put into practice trouble ensued. You can imagine a range of people calling from complete idiots, to those looking for a way to profit from a public service - and everything else in between. In the states, our insurance companies make us pay through the nose no matter when or why we bring our children into the emergency room - real emergency or not. I have a modest interest in medicine myself, so I feel somewhat capable of making diagnostic decisions. Google is a great help also - as well as opinions from friends/relatives. I am jealous of Canadian health care for the most part, but I think I would skip this phone call if it were me.

  2. It's very interesting to hear from the users point of view how telehealth works. Have you ever been advised to go to the ER/MD or have you always been told it's likely to be ok?
    I'm sure that it is very difficult to make these decisions over the phone like they are supposed to ... there are times in medicine (as MDs) where we try and make decisions over the phone, and that can often be very difficult to do, even for the doctors, who are less trained in many ways than nurses, but who in my opinion, or more trained in the process of decision making and problem solving. It must be very difficult for them to ask enough questions to allow them to properly follow a script. Honestly, I didn't know it was script based ... that is a very interesting way to offer medical advice when every single patient presentation of every single condition has variations and nuances.
    I have to say that while I know I see a skewed population in the ER, I feel like every other patient I see has called telehealth who has told them to 'go directly to the ER'. Once in awhile it was a good call (ie: yes, you're having a heart attack, you should go to the ER) but it feels like 9/10 times the telehealth people have recommended coming to the ER because they are covering their tracks, rather than listening to what the patient is saying and making a decision based on it. I see A LOT of not-at-all sick people who have been told to come directly to the ER by their telehealth advisor. So it feels to me like they send EVERYONE to the ER and it doesn't matter what they have. I do realize however, that as an ER doctor, of course it is going to feel like that to me. It also makes it hard for us when the not-at-all sick people show up and then I do 'nothing' for them (b/c they aren't sick at all) and they are upset because 'the nurses on the phone told me to go straight to the Emerg. Why would they tell me that if there wasn't an emergency?'
    I imagine there are a lot of people call and are told not to go. It would interesting to see the stats of how their recommendations pan out. ie: % of recommendations to stay home, go to Fam doc, go to ER. I'm sure they are providing an important service, but from where I stand (which is admittedly very skewed) it doesn't help much, and certainly increases my daily workload and headaches.
    Neat topic! Thanks for your perspective on it!

  3. I wonder, are the nurses inputting your responses into some sort of database query? And as a result, are you being asked similar questions when the response that you gave didn't exactly fit any of the expected responses from a previous question? I did a sort of online diagnosis form that behaved in a similar fashion. Very annoying, I didn't finish it!

  4. That is pretty much it Pat. I would give them information that was very clear and they would follow up with questions with multiple choice responses that I had just answered. They obviously had a required list of things to ask which made the whole thing very frustrating. They always have told me that the things I called about were not serious and never sent me to the ER but they usually spent a couple of minutes trying to add an endless list of 'maybe's, and 'probably's until their statements couldn't possibly be held accountable.

  5. I've always been told to go to the ER by telehealth. I like telehealth a lot because I feel like they help me sort out whether the problem is worth getting addressed. Of course, the fact that they always tell me to go to the ER made me wonder a bit, but I realize there are certain problems that they can't rule out as being serious over the phone.

    As an example, I had a rather large, undiagnosed gallstone so I phoned on more than one occasion with prolonged severe chest pain. They did an ECG in the hospital and figured it was probably heart burn (of course the pain was always gone by the time they saw me), but without the ECG the nurses on the phone couldn't rule out a more severe problem, so they had to send me to a hospital.

    But I think there is a good reason they ask those questions. Though it's kind of hard to understand, people hold back information from health professionals all the time - either because its embarrassing or disgusting to them, because talking about it makes it too real for them, because they don't want to seem like they are complaining, and because of all sorts of other reasons. People lie a lot to doctors and nurses through omission, but are not nearly as prone to lie directly. Asking pointed and direct questions about specific things, "Is internal fluid leaking out of the eye through a wound?" will get you information that people might not have volunteered.

    On the other end of the phone, they can't tell if you are 1) reasonable person who has decided that they aren't qualified to decide exactly how serious the situation is; 2) a hypochondriac who uses telehealth as a kind of distress line; or 3) a person tends to downplay their medical problems and didn't want to call 911 despite an extremely severe situation but felt they had to do something so they went to telehealth instead, hoping to convince a nurse that they were fine.

    You say the questions are redundant, but I think you'll agree with me when I say that we should reasonably expect that as some point someone has called telehealth and said "I don't think so," to "Is her eye punctured?" and then "Yes," or "I guess so," or "Maybe," to "Is internal fluid leaking out of the eye through a wound?"

  6. I didn't even know that telehealth existed. Guess I should count my lucky stars that I haven't needed it.