One of the main differences between advanced hospitals for animals and humans is that the majority of veterinary referral hospitals may lack one or more of the primary “on-site” specialists and outsource the activities they would typically perform to larger scale organizations through “telemedicine.” Only the largest private practice hospitals or veterinary schools have each of the sub-specialties physically represented in-house.
Telemedicine has many pros, including cutting costs, providing owners with access to specialists who would have otherwise been limited by geography, and a more rapid turn-around time for results due to increased throughput.
One of the cons to telemedicine is that the specialist who is working remotely is unavoidably physically and emotionally detached from the patient.
I was fortunate to complete my residency in medical oncology at a veterinary school where I had direct access to any specialist I needed. If I had questions about a biopsy report, or needed to discuss specific aspects of an MRI in further detail, I could walk down to the office of the doctor working on the case and talk to them face to face.
I could also ask for clarification regarding confusing wording in their reports in person. In many instances, I could even bring the patient directly to their office to show them tumors or surgical scars to help aid in their interpretation. There’s a lot to be said for the degree of personal attention and attachment this type of relationship creates.
In the “real world,” the pathologist who interprets the samples I submit works at a remote location and I couldn’t tell you much about their surroundings. The radiologist who reads out my imaging tests exists somewhere in time and space, but I don’t know them personally. Although I can call or e-mail them at any time to speak with them about specific aspects of my patient’s case, there isn’t the same personal attention to detail that comes from direct contact.
In the digital world we exist in, telemedicine doesn’t seem like such a bad idea. Why should we need to have everyone in the same building when we can each use our talents and experiences to their fullest capacities from the comforts of a remote location? Sure, we may lose out on the personal attention, but I can overcome this hurdle by providing my specialists with as much detail as possible on the submission forms that accompany my samples. That’s just as good as speaking with them directly, right?
Yes and no. Theoretically, telemedicine should work as well as “hands on” medicine. Yet, there are times when an incorrect diagnosis or interpretation is made as a direct result of a lack of “face time.”
As an example, I recently saw a case of a dog I was sure had a mass located in the front part of his chest, between his lung lobes and just in front of his heart. This is otherwise known as a mediastinal mass. My interpretation was based on radiographs (x-rays) performed to investigate the cause of a chronic cough.
We performed a CT scan of the patient’s chest cavity, and on the submission form to the radiologist, who would be responsible for interpreting the images from the scan, I indicated the pet had a mediastinal mass on radiographs. We also obtained a fine needle aspirate of the mass for cytological analysis. On the submission form for the aspirate sample, I also indicated the pet had a mediastinal mass.
The list of potential underlying causes of a mediastinal mass are short, and the most common causes would be either lymphoma or thymoma. The CT scan report confirmed the presence of a mediastinal mass. The cytology report showed thymoma. The pet was taken to surgery to remove the mass.
Surprisingly, at surgery the mass was actually found to be encompassing a portion of the right lung, and was not located within the mediastinum.
This finding made the original diagnosis of a thymoma incorrect, as this type of tumor would never be found within the lung tissue itself. This also made the radiologist’s report for the CT scan and the original cytology report incorrect.
More importantly, it showed me how both the pathologist interpreting the biopsy sample and the radiologist interpreting the CT scan were both nearly 100 percent biased by the information I provided on the submission form. My initial incorrect assessment created a domino effect of two other incorrect assessments. We are each equally responsible for the outcome.
Had I not provided any history to the pathologist or radiologist, would their answers have been different? If they both worked alongside me in my hospital, would they have interpreted the results in an alternative fashion? Should I have given less data rather than more? Did my actions result in a less than optimal outcome for this patient?
Fortunately, the treatment of choice for the majority of primary lung tumors would be the same as for a thymoma – surgery to remove the mass. And the patient is currently doing well.
But this case made me wonder: how often in veterinary medicine does a doctor’s bias influence the outcome for a case? And how often can this influence result in a less than optimal outcome for the patient? Fortunately, in the example I’ve given, the outcome was not adversely affected. But what about other times?
I still err on the side of giving more information, especially when submitting things to outside specialists. I’m certain it ensures a more thorough interpretation of the sample and a more accurate diagnosis. But I also recognize how important it is to avoid adding my biases to a submission form.
I also remain cautious about the progression of telemedicine for both people and pets and prefer to keep my interactions on a much more personal level. I urge my colleagues to consider the benefits of doing the same.