No one in the practice wants to see Charlie—not me, the technicians or any of the other doctors. It’s not because he doesn’t appear cute and cuddly—his tail wags, his expression is relaxed, he approaches us and lets us pet his head. It’s because if you attempt to impose your will upon Charlie—restrain him, pick him up or poke him with a needle—without warning or hesitation, he instantly transforms into a 12-pound ferocious, eat-your-face-off, lunge-at-your-throat, back-you-into-a-corner beast with the strength of a grizzly bear and the speed of a feral cat. Even his owners are helpless in the face of Charlie’s supernatural transformation. Everyone involved fears for his or her life. It makes for miserable exam room visits.
I’m sure I was subconsciously taking all of that into consideration when Charlie’s owner called to request a refill of metronidazole that we had prescribed when Charlie suffered recent diarrhea. She informed the receptionist that Charlie’s previous vet had diagnosed him with inflammatory bowel disease. We had diagnosed him with colitis just a few months ago. He must have eaten something that caused a flare-up. The owner described how he was only making small, soft stools and straining excessively. Even though he had been symptom-free for months, it looked to her just like his last episode and the metronidazole had cleared him right up. She was certain that was all he needed.
I verified that he was eating and drinking, and his activity was more or less normal. Then, against my better judgment, I agreed to refill the prescription. Fortunately, I specified to Charlie’s owner that if his diarrhea was not significantly improved after two doses of the medication I wanted her to bring him in for a recheck to verify we were on the right track with our diagnosis and treatment plan.
Two Days Later
I wasn’t surprised, then, when I saw Charlie on my appointment schedule. I entered the exam room to speak to the owner, carefully ignoring Charlie so as not to appear as if I was interested in touching him. He looked like a little dust mop, but he couldn’t be groomed without sedation, and his owners had to be exceptionally careful bathing him. Brushing was out of the question. I couldn’t see his eyes, and the hair on his belly and legs nearly dragged on the floor.
The owner reported that she hadn’t seen any change in Charlie’s bowel movements since starting the metronidazole. He was still straining and only making small, semiformed stools. I told her that I needed to get my hands on him to do a good physical, and she reluctantly agreed.
We used our “distract and pounce” technique to bundle him in a blanket so that his teeth were neutralized by the layers of fabric. He was restrained just enough for a tech to administer IM sedation in his back leg. We carefully released him to his owner’s care while the sedative kicked in. We backed cautiously out of the exam room using our blanket like a bullfighter’s cape in case he decided to come after our ankles in retaliation.
Minutes later, when I carried him to the treatment area, I noticed a swelling by his tail. With his long, matted haircoat, I couldn’t see anything unusual just by looking. But when I scooped my hand around his back end to lift him up, it didn’t feel quite right. I laid him on the exam table, and the clinical picture came into focus more clearly. Charlie wasn’t having diarrhea at all—his colon was packed full of formed poop. His prostate was huge, and both the colon and prostate were reflected caudally into a perineal hernia that was perfectly hidden under his long, thick dreadlocks. He was straining to push out whatever semiformed poop he could, making it appear to the owner as if he had colitis.
I informed the owner of our findings, made the necessary phone calls to schedule his surgery and breathed a sigh of relief that I had at least planted a seed of doubt in the owner’s mind about the colitis diagnosis. No telling how long Charlie had been suffering miserably from this perineal hernia affecting his ability to poop. It was at least two days longer than it should have been because I didn’t get him in sooner for a recheck, but better late than never, I rationalized.
A Lesson There
Charlie’s case is a good example of the limitations of telemedicine. I point this out because there are factions within our ranks pushing aggressively for more widespread use of telemedicine, and this is just one example of a case where telemedicine became dangerous.
Speaking strictly about applications of telemedicine in companion animal practice, often our initial impressions about a case based on the owner’s observations end up being mistaken and even misleading. Our clients usually don’t intentionally mislead us, but they often misinterpret what they are seeing at home.
Hardly a day goes by that I don’t have to gently convince an owner that their coughing poodle doesn’t have something stuck in his throat; or that their cat is not vomiting, she is coughing; or that their dog is not constipated, he actually has diarrhea. The list could go on. Owners just don’t always know how to interpret the abnormal signs they see in their sick pets, and they don’t know that they don’t know. As the doctor involved, we are tasked with sorting it all out.
Apples to Oranges
Our counterparts in the human medical profession, where the practice of telemedicine is gaining more widespread acceptance, aren’t faced with this same dilemma. They have the luxury of a verbal patient who, in most situations, can provide a first-person account to their caregiver of their history and symptoms. They can pinpoint pain, describe sensations, answer questions and follow instructions. Our patients cannot. Therefore, as my colleague Matt Edson pointed out, “A human patient telling their doctor that they have a stomachache is very different than a pet owner telling a veterinarian that they think their dog has a stomachache.”
Our patients complicate matters with their innate stoicism and natural tendency to mask their signs. As clinicians, to achieve acceptable accuracy with our physical exam, we need to be able to engage all our senses in our investigation. We need to listen to them. We need to feel their body, palpate the lymph nodes, press on their abdomen, feel the joints move and discern the reaction, manipulate the neck, press on the spine, assess the consistency and the attachments of their lumps and bumps, and pick at their scabs. We need to smell their skin, probe their orifices, observe their movement, flip their feet over and swipe the crevices between their toes with our fingertips. We need to be able to use magnification and bright lights and stains and instruments.
Without being able to touch our patients, how do we determine if the cat that presents with a history of straining to pee and producing small amounts of bloody urine has a tiny, empty, inflamed bladder or a huge, hard, obstructed bladder? How do you determine if the amount of pressure on the trachea necessary to illicit a cough is normal? How do you tell if a swollen abdomen is filled with fluid or a huge spleen? How do you determine if the lump in the throatlatch is lymph node, salivary gland, thyroid tumor or just a lipoma? How do you determine if the dog that presents with a rear limb lameness has limited and painful extension of the hips; an effusive, unstable stifle; or tenderness on palpation of the LS region?
These are just a few scenarios where simply hearing a history and seeing a picture or a video of your patient does not provide the information you need to make a clinical determination. We must have our patients in the room with us to be able to perform a decent physical exam. To claim that we can complete a meaningful physical exam over a video feed diminishes the value of the services we provide and puts our patients at risk.
The Future of Telemedicine
Is there a place for telemedicine in veterinary medicine? Yes. I would argue that we have been utilizing telemedicine for years; those of us in the trenches have learned when it’s helpful and when it’s dangerous. The recently published American Veterinary Medical Association position paper on telemedicine is very much in line with this idea. If you haven’t read it, I encourage you to do so. It’s very clear in specifying that telemedicine can be a useful tool within the context of an existing veterinarian-client-patient-relationship (VCPR) to improve client communication, document progress and aid in making clinical care decisions. However, telemedicine alone, with technology as it currently exists, is insufficient to establish a VCPR.
Proponents of more widespread use of telemedicine in veterinary medicine have attempted to draw conclusions about its use in our field by highlighting the use of telemedicine in human pediatrics. It is true that toddlers and infants cannot give a first-person account of their symptoms. However, the pediatricians I know who are being asked by their hospital systems to utilize telemedicine exams share my concern for the safety of their patients and the accuracy of their diagnoses. It seems it is not usually the primary care doctors who are lauding the potential applications of telemedicine—it’s the hospital administrators, the accountants, the MBAs and the general public who favor the practice. I believe that is largely the case in veterinary medicine as well.
Don’t Be Dictated To
At a recent veterinary meeting in Texas, a group interested in providing telemedicine services polled the audience regarding what conditions they regularly see in their practices that they believed they could diagnose and treat via telemedicine with confidence. The veterinarians in attendance produced a list of conditions they felt met those criteria. However, if you scrutinize the situation a bit more closely, the list is really meaningless. No doubt the listed conditions were simple and common, but the question is inherently biased because respondents are operating under the assumption they got the diagnosis right. The scenario they imagine is predictable when in reality it will be an unpredictable situation similar to Charlie’s case that puts their patient or the outcome at risk.
My fervent hope is that veterinary clinicians in academia and private practice will not cave to corporate interests or public pressure on this issue. I hope that we confront greed and misinformation about telemedicine by educating the public and providing insight into the complexity of diagnosing disease in animals. I hope that primary care veterinarians will insist on staying in the driver’s seat in the policy-making process as we move forward to protect the value of the services we provide. And, by doing so, I hope that we manage to balance the potential economic benefit of telemedicine with the safety of our patients and the integrity of our profession.
Dr. Randall, a graduate of the University of Georgia College of Veterinary Medicine and owner of Foothills Veterinary Hospital in Greenville, S.C., a five-doctor, two-location private practice, was a member of the American Veterinary Medical Association’s practice advisory panel that helped to draft the AVMA white paper on telemedicine.
Originally published in the May 2017 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!