Skin Deep: Should Surgeons Meet Patients Online?
Should Surgeons Meet Patients Online?
By CATHERINE SAINT LOUIS
Published: January 20, 2010See full article here.
IMAGINE the ease. It’s 2 a.m. and you can’t stop thinking about your saggy midsection. You log on to SurgeonHouseCall.com and create a free patient profile declaring your wish to get a tummy tuck. You fill out a brief medical history and include photographs of the problem area.
In no time, three plastic surgeons offer detailed opinions on the best course of action — with price quotes. It’s as if SurgeonHouseCall.com co-opted the LendingTree slogan, “When banks compete, you win.”
In less than a year, SurgeonHouseCall.com has recruited 55 plastic surgeons nationwide to offer opinions. Meanwhile, dozens of plastic surgeons also offer virtual consultations on their own Web sites. But does a patient who gets a plastic surgeon’s recommendation before a face-to-face visit really “win?” Conservative plastic surgeons say it’s fine to send an e-mail message with general information about a range of procedures to a patient, but the practice of offering a diagnosis without ever having met a patient can be problematic.
What’s more, offering a surgical recommendation to a distant patient may violate state laws, if the plastic surgeon isn’t licensed in the home state of the patient, according to the Federation of State Medical Boards, a nonprofit group representing 70 boards in the United States and its territories.
Critics also say that patients’ poor-quality pictures don’t provide doctors with adequate information. And patients seldom realize that no virtual recommendation is solid without an office consultation and medical clearance.
Advocates of virtual consultations suggest that they are convenient and that receiving multiple opinions online benefits a prospective patient. “It changes the first in-person consultation, empowering the patient with knowledge of the procedure, decreased anxiety level and financial readiness,” said Dr. Jason L. Mussman, the founder of SurgeonHouseCall.com. (Dr. Mussman, a resident at Loma Linda University in California, isn’t one of the board-certified plastic surgeons offering his services on the site because he hasn’t been certified by the American Board of Plastic Surgery.)
Out-of-town patients are the primary users of virtual consultations, in which a doctor may offer an opinion in a video chat, an e-mail exchange or a phone conversation. Convenience is the main draw, but a few surgeons also cited the anonymity of the situation, which is attractive to shy patients.
“They want a semi-anonymous type of evaluation,” said Dr. Dean P. Kane
, a plastic surgeon in Baltimore
who offers online consultations. “They want to know cost, and what you get for that cost before they make a commitment, before they walk through that door.”
Most plastic surgeons don’t offer virtual consultations. However, in an age when many Web-savvy plastic surgeons answer questions at cosmetic enhancement sites like RealSelf.com, plenty feel comfortable dispensing opinions to patients they’ve never met.
Some promise to evaluate pictures quickly and to call back with their expert opinion. Others charge $100 to screen patients to see if they are appropriate candidates.
The Web site of Dr. Barry Eppley, a plastic surgeon in the Indianapolis area, promotes “Webcam consultations with Skype.” But in a phone interview, Dr. Eppley called them “online conversations” because, he said, “Technically it’s not a consultation. You’re not going to jump from an online consultation to surgery. You’re using the online thing as a connection.”
And because those virtual connections bring in new patients, they are, in effect, marketing tools that some plastic surgeons consider crucial in this difficult economic climate.
Dr. Eppley said he often persuaded out-of-state patients after just 20 minutes of a Skype chat. “They do move ahead,” he wrote in an e-mail message. “Regardless of where they are geographically,” he said, “people will come to you because they connected with you.”
Experts like Dr. Loren S. Schechter, the chairman of the patient safety committee for the American Society of Plastic Surgeons, worry about patients getting a hard sell. Consultations “shouldn’t be about selling the surgery,” he said.
Providing a diagnosis to patients across state lines also raises legal issues. Dr. Humayun J. Chaudhry, the president of the Federation of State Medical Boards, said that according to its guidelines a patient-doctor relationship is “clearly established and begun when a physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees.” Such a distinction matters, because usually doctors should only be able to care for patients in states where they are licensed.
All the plastic surgeons interviewed for this article insisted an in-office consultation took place prior to surgery. However, when doctors first examine out-of-towners — who often arrive 24 to 72 hours before the scheduled procedure — the doctor’s recommendation might change, or the cost might increase, said Carol M. Martin, an independent plastic surgery consultant who works on behalf of patients. On Skype, Ms. Martin said, the doctor might have stated, “It was going to be X, Y, Z and cost $10,000 but now that I see you in person, it’s going to be $13,000.”
Not being prepared for last-minute changes “seems like the biggest pitfall to me,” said Ms. Martin, who tells clients to meet with three to five surgeons before committing.
Angela Segal, a patient consultant, reviews quotes for women seeking plastic surgery and negotiates a price. (She also helps plastic surgeons with “online social networking marketing.”) But if a patient didn’t have an in-office consultation, she won’t even look at a price quote. “Nothing is more true and correct than actually seeing a doctor in person,” said Ms. Segal, who worked 12 years as administrator in two plastic surgery practices.
She doesn’t trust the pictures patients send in e-mail messages to plastic surgeons for evaluation any more than the ones the lovelorn post at online dating sites. “You expect the doctor to trust the pictures, which is ridiculous.”
Since some family practitioners have begun using electronic visits, the American Academy of Family Physicians has established guidelines, including the stipulation that a physician should evaluate only established patients virtually, and only over “safe, secure, online communication systems.”
The American Society of Plastic Surgeons has no policy. Some plastic surgeons make it clear to their patients that communications through their Web site “are not necessarily secure” and that “you assume the risk of unauthorized use” of say, the topless pictures you send for evaluation.
Paramount in this brave new world is ensuring that patients receive the same standard of care online and in person, said Dr. Chaudhry of the medical board association. “It should be the same exact standard as if the patient was in your examining room. You can’t cut corners.”
Plastic surgeons are not the only doctors who do consultations on the Web. Radiologists and dermatologists do some that entail communicating with a far-flung physician; primary-care physicians also keep tabs on established patients virtually.
Dr. John W. Bachman, whose family practice department at the Mayo Clinic in Rochester, Minn., did a two-year pilot study of more than 2,500 online consultations, said the aim should be to improve the standard of online care. One issue that plagues any doctor is that they sometimes forget to ask a crucial question. A computer asked patients in the pilot study questions tailored to find potential oversights.
A more structured virtual consultation might have helped Dr. Kane
. The day before surgery, he saw an out-of-state woman with whom he had exchanged e-mail messages about rhinoplasty. It was only then that she mentioned her occasional cocaine use. “The problem here is it adds significant risk to the surgery,” said Dr. Kane
, who canceled the operation. “Your expectations get knocked down and your patient’s expectations are knocked down.”
So why then does Dr. Kane
even bother with virtual consultations? “If I don’t do it, somebody else will do it,” he said, citing the difficulty of having a solo practice in a competitive world. “The technology is there.”
A version of this article appeared in print on January 21, 2010, on page E3 of the New York edition.