ABC | Volume 113, Nº1, July 2019

Viewpoint Telemedicine and the Doctor/Patient Relationship Protásio Lemos da Lu z Universidade de São Paulo – Hospital das Clinicas Instituto do Coração, São Paulo, SP – Brazil Mailing Address: Protásio Lemos da Luz • Avenida Dr. Enéas de Carvalho Aguiar, 44. Postal Code 05403-000, 5andar - Bloco II sala 08, São Paulo, SP – Brazil E-mail: protasio.luz@incor.usp.br Manuscript received April 04/2019, revised manuscript April 10, 2019, accepted April 10, 2019 Keywords Physician-Patient Relations; Telemedicine; Cost Saving; Medical Care; Humanism; Patient Participation. DOI: 10.5935/abc.20190117 Introduction A.C., a friendly Italian man, received coronary stents 8 years ago and had been feeling well until 3 months ago. He then had progressive breathing difficulty with tightness in his chest. He had loss of appetite and lost 4 kg in that period, but continued to work with good disposition. He had been to two hospital visits, in which he was informed that his lung was normal, based on X-ray. They had not reached final diagnosis, so he came to the office. His general appearance was normal; no abnormality was found on visual inspection. He had normal vital signs; no pallor to suggest anemia. The lungs, heart, abdomen and lower limbs were normal on examination, and resting ECG revealed no abnormalities either. As I palpated his neck, I noticed a mass on the left side. Subsequent examinations proved that a tumor compressed the trachea, which explained his respiratory difficulty. This is a typical example of a case in which only complete clinical examination leads to diagnosis. Telemedicine (TM) would not allow this, as simple inspection did not give any clues, and the clinical history suggested several possibilities, such as heart disease, pulmonary disease, diabetic decompensation, uremia or anemia. There is now a major debate, both at the health system and at the individual telemedicine level. Telecommunication technologies have long been used in teaching, in science, in the formation of groups for the study of diseases, in the transmission of diagnostic or therapeutic medical procedures, in imaging interpretation by specialists, in teleconference with undisputed efficiency, and will not be considered here. An interesting fact: many even said that, with the Internet, medical conferences would be emptied, because everything could be seen from a distance. That simply did not happen — medical conferences continue to attract large audiences, as much as before the online broadcasts. This proves that man is a social being and likes to live with his peers. Telemedicine and the Doctor/Patient Relationship Telemedicine here is considered the medical care for patients without face-to-face contact. An essential aspect is that telemedicine requires its own structures. It requires a central station that can receive information, equipped with medical professionals ready to respond; it also requires the other end, i.e., doctors or patients providing correct data for evaluation. Recent iPhones are fundamental; they allow the exchange of images, texts; etc. Other devices record ECG, heart rate and blood pressure. And we are not far from the day that laboratory parameters will be transmitted online from skin sensors. Therefore, telecommunication systems are not an important limitation for telemedicine. Another fundamental aspect is the impact on health systems, including efficiency, costs, satisfaction and adherence of patients and doctor. As the implementation of telemedicine is relatively recent, there are only a few studies on this topic. A Cochrane review, 1 which included 93 studies and 22,047 patients, analyzed 36 studies of cardiovascular diseases, 21 of diabetes, 9 of respiratory conditions, 7 of mental health, 6 in which a specialist needed to be consulted, 3 urogenital conditions, 3 with neurological lesions, and other minor ones. Comparing telemedicine with usual care, they showed that there was no difference in overall mortality from heart failure, that hospital admissions were reduced by 64% in some studies, and increased by 60% in others. There was some evidence for improved quality of life and, in diabetes, lower glycated hemoglobin was found; greater reductions in LDL and blood pressure were also found. There were no differences between face-to-face healthcare and telemedicine in cases of mental health. Regarding costs and patient acceptance, the authors found that there was insufficient data for conclusions. The authors concluded that the efficiency of telemedicine depends on multiple factors, such as whether it is used to monitor chronic conditions and known patients or to facilitate access to diagnostic services. Worthy of note is that all studies refer to monitoring of known chronic conditions, rehabilitation training offerings, healthy life education, specialist consultations or cognitive therapy; that is, those would always refer to cases of known diagnoses rather than primary evaluations. Another analysis by Ekeland et al. 2 included 80 studies and found that 21 of them considered effective telemedicine, 18 were promising, but still inconclusive, and the others had limited and inconsistent evidence. Bertoncello et al. 3 analyzed the factors involved in the efficiency of telemedicine according to reports from 25 critically chosen reviews, comprising 15 years (2000 to 2015) of observations. Hypertension, diabetes, asthma, chronic obstructive pulmonary disease, heart failure and elderly care were included. This analysis considered several factors that may influence efficiency in telemedicine, such as the geographical location of patients, demographic characteristics and diseases (the so-called “targets”), intensity of intervention, patient perspectives and engagement, education, caregivers, organizational model and ethical and economic issues. Interestingly, none of the studies looked at all of the factors; 44% focused on the “targets” and 24% on intervention 100