'Treating' patients via email

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I was wondering what you all thought about the following scenario and handing out Podiatric advice over the internet to places that are remote and health care is hard to find.

I have a patient who's daughter and grand daughter live in PNG. The grand daughter has a verrucae which is being a little stubborn and the GP they are seeing is not being aggressive enough with it. There are a few additional factors in that environment, including getting the dressings to stay in place with the humidity and the obvious increased risk of infection.

I have included the email from the mum below which outlines the history.

Curious to know what your thoughts are on the ramifications of handing out advice on-line under these circumstances.



"Dear Trent,

Thanks for giving my Mum your email address and allowing us to ask you some questions.

Have attached some pictures of the wart. Anna (age 9) also has 2 smaller warts close by which we are treating with wart kill.

It is proving to be very difficult to treat here in PNG. We’ve been seeing a GP here for 2 months now and he’s been cutting away at it. The wart now seems to be quite flat but is very tender for Anna to walk on and also for the Dr to treat. He is now leaving it for a week as he feels that it may be becoming infected.

I wonder what treatment you would suggest if we were to come to Australia? Also if you have an idea of what you might be able to do, do you have a rough idea of how long in time the treatment could take.

Our Doctor here tells me that burning a wart off on the base of the foot is not a good idea as it can leave permanent scaring which may make walking difficult. I would be interested to know what you think as it would seem to be a quick solution.

If there is anything you feel that we could use to treat the wart here in PNG maybe you could tell us about it. Sorry about all the questions, but as you can imagine we’re very keen to have her walking comfortably again. Thanks in advance for your help."




Guys, please understand I'm not asking for VP treatment advice here. I'm asking what you all think about giving advice via email in this situation.

Regards
Trent

 

Re: Treating patients in PNG via email

Trent

I see a number of international and interstate patients, as well as getting my fair share of e-mail enquiries.

The # 1 rule is to protect your backside and remember you are a professional. A medical practitioner, for instance, will rarely provide any direct response to an enquiry of this nature.

If you haven't taken a history and performed a physical examination, restrict your advice to generic statements and encourage them to see you/or someone when they are in a 1st world country again.

Most people will respect this, and be more than happy if you simply provide a link to a professional quality website for more information about their perceived problem.

LL

 

That's all great information, thanks. I have so far been quite brief in my correspondence with these people.

I have only asked for further history.

I would have thought that responding with specific advice was a bit risky, so I have stayed clear of that. I think the problem with this scenario is access to supplies and health care. I think the best course of action is to encourage them to come back to Australia for treatment. I'm sure a Pod in Nth QLD would just love a stubborn VP to deal with, lol.

 

I thought someone on this thread might

 

My practice in New York now uses Relay Health to provide secure online communications that satisfy legal requirements here in the US. They also will bill out credit cards or even insurance companies that reimburse for online visits.
Still, the idea of giving advice without seeing the patient is frought with risks for valid reasons. There are dozens of differentials for verruca plantaris that you probably rule out just based on clinical appearance. Encouraging them to go to Australia is probably the best bet. What if Verrucous Carcinoma, SCC, or another malignant lesion looked like a verruca in a picture.

Shibu

 

That reminds be of a conversation I had a couple of years ago ... it was related to the "ownership" of email content when the email passes though the ISP and the issue of privacy. Apparently in some countries (I think it was Canada I was having the discussion about); is that the "ownership" of the email passes to the ISP while on its way to the recipient (or something like that) ... this raised all sorts of privacy concerns that were not necessarily protected by law (unless I misuderstood it or it may have changed). I tried to find out if it applied in Australia, but never got very far.

 

This all being said, I did ask the patient's mum to bring her to Australia for tx. I treated the VP (which was in fact one big VP) and resolved the lesion within two weeks. The patient and family were so happy they sent in a letter and photos to our state association monthly mag' (Footprints) and I had a write up (full page spread) in our September issue. Everyone was a winner on this one! Thanks for all your comments here.

Trent

 

Sorry to be ignorant but what is your tx for VP? I treat conservatively but without great success.
Cheers Lorraine

 

Lorraine,

With great caution and respect for the chemical, I use Potassium Hydroxide. It is an aggressive option but after years of fluffing about with cryotherapy and sal' acid with limited results, we decided to pull out the big guns.

There is often a post tx wound which resolves quickly with appropriate care and the tx itself is quite uncomfortable for the patient, however if they are informed well and the lesion resolves quickly then they are prepared for the tx and happy little campers with the outcome.

 

E-mails from People Requesting Medical Advice

Colleagues:

Over the last two years I have had a dramatic increase in the number of people e-mailing my private e-mail address who I have never seen and who are requesting me to give them medical advice regarding their foot and lower extremity pathologies. Early on, when they were infrequent, and I tried to answer them. However, now I sometimes get 3-4 e-mails a week from patients from the US, Canada and many different countries, some of them going into great detail about their pain and frustration with their current treating clinician, asking me my advice. In fact, this morning, I just got an e-mail from a 66 y/o lady who lives about 2,000 miles away from me that has posterior tibial dysfunction, had surgery and still has pain in her foot and asked me five different questions about her diagnosis, treatment and prognosis.

Is anyone else getting an increased number of these unsolicited requests for medical advice over e-mail, or is it just me? I simply don't have the time to answer all these people and even though I sympathize with them I honestly don't think it is appropriate for me to give such advice to someone I have never met, examined or spoken with.

Any ideas?? When you answer these e-mails, do these people you have never met now become your patients?? What do you do when you receive such e-mails?

 

Re: E-mails from People Requesting Medical Advice

Hello Kevin,

Although my practice is less cutting edge than yours I too feel slightly less inclined to respond to external enquiries of this nature.

I have recently received enquiries both by telephone & email from clients previously unknown to me regarding my thoughts on another clinicians previous treatment.

In my case both were regarding the now defunct Parish & Bell. A) Did I consider their treatment unnecessary.

B) In my opinion were the patients the subject of an elaborate scam. (Their words, not mine).

In both instances I declined to proffer an opinion stating that I cannot comment with regard to the treatment of another without the full facts of the individuals case.

Personally speaking unless I were prepared to become an expert witness in a potential future court case (which I would not offer my services as) I would happily decline in commenting either over the phone or online via email to an individual.

Preservation of self.

Only my thoughts.

Kind regards,

Mandy.

PS. Understatement of the year award goes to: Hello Kevin,

Although my practice is less cutting edge than yours

 

email enquiries

As email contact and the www become more standard in peoples lives , how are you dealing with email enquiries .....

Ive got this pain here and it hurts when type stuff. Ive got a standard type response which states that we don´t make diagnosis via the internet and that a full medical history and assessment needs to be undertaken until a treatment plan can be discussed. Please ring to book in a time etc etc.

For most this works well but for some I get the response, I don´t want to come if it a waste of time so want to know if you can help.

I would like to write back something along the lines . How the **** do I know via an email.

But there must be a better way. Than writing the above or sending and email written differently but saying you must book in for an assessment.

ideas ?

 

Re: email enquiries

How about this?

Dear *****,

Thank you for your emailed enquiry. Due to legislative and practice constraints, we are unable to offer such advice prior to making a (visual ) assessment of the condition. However, we would be very pleased to see you in clinic appointment, which you can access via the following email/telephone contacts…

 

Re: email enquiries

Mike,

I get 2-3 emails every day through my website, some very detailed and some very very vague but all wanting essentially the same - some 'free' advice. I personally don't have a problem with this (and quite enjoy responding if I'm honest) but it is always in an incredibly ambiguous tone and I would expect the recipient to be understanding of that. There is also a disclaimer at the bottom of my signature, which if memory serves me correctly I may have plagiarised from this site some time ago:

Perhaps controversially I also try to never even hint at them booking in to see me. I aim to offer free 'advice' without it feeling like I'm trying to reel them in. Not saying thats a wrong approach - it's just never sat well with me. If they book in off the back of my email then great. If not, no worries. I'll also happily give them details of other Podiatrists if I think it will be more beneficial for them to see them. I'd like them to feel they have been given good quality complimentary information without an ulterior motive or slaes pitch. Altruistic eh?

IG

 

Ah, now the threads are merged I can see I 'borrowed' the disclaimer from the arena over 2 years ago. My thanks to Foot Doc from the Foot Health Forum!

 

Andy has merged the most recent thread on this to an older one...since this original thread started the number of emails I get from the public has sky rocketed; also from non-LaTrobe students with questions requiring a novel to be written in reply - the only time I usually reply to them is if it can be answered in a few words.

I ignore most of them now. I just do not have the time and neither am I resourced in my job to spend the extraordinary amount of time answering them. I have got to the stage that I even no longer answer my office phone in order to screen calls. Most are from the public who have read something I wrote and they have that problem and the want to get my advice (....for free!)

Most I just refer to the Foot Health Forum and they can ask the question there. I sometime even reply there (and I a bit sneaky and answer the question under the name of my wife's clinic and include a link back to her clinic's website in the signature .... so at least there is some benefit in taking the time to answer it publically!)

 

This whole area is a legal minefield.

I see that Jeff Oster has shut down his discussion forum for the public at MyFootShop:

 

I am envious of others in this thread. I don't get any! Well, I did get one six or so months ago and was pretty annoyed that they expected a free consult via email! In the future, I think I will do what Paynie suggests:

 

Re: email enquiries

I get occasional out of area e mail questions and like you Ian, I always try to give some generically good advice, never criticise others treatments/opinions and if possible try to find a clinician in their area who I can recommend and know that they will get similar/better treatment than I can offer.

Local e mail enquiries, I usually give some type of response but that implicit in my response is that they need to be examined by a professional, be that me or some other appropriate professional. Again, like you, I don't push it as I find that not pushing it tends to lead to a greater conversion rate for self referral so my reasons are a little more selfish than yours!

Robin