ABC | Volume 113, Nº1, July 2019

Viewpoint Luz Telemedicine and the doctor/patient relationship Arq Bras Cardiol. 2019; 113(1):100-102 intensity; 16% analyzed the patients’ perspective. On the other hand, issues such as location, ethical issues, patient engagement or caregiver perspectives were the least addressed items. The researchers’ main conclusion was that there is not yet enough concrete data on the multiple factors that influence efficiency telemedicine, and that further studies are needed to fill knowledge gaps in this area. A major discussion is the doctor/patient relationship (DPR) in telemedicine. Traditionally, medicine has been based on the individual relationship between doctor and patient. 4 This relationship has multiple cultural influences. In Brazil, people are very affectionate and zealous of their family relationships and their friendships. This affection extends to the doctor, which makes us all more sensitive. In the Anglo‑Saxon culture, personal relationships are more distant and “colder”. In practice, this means that brazilians like to have “their doctor,” rather than being treated by a stranger. The patient’s trust in his/her doctor is not acquired in an instant, but in prolonged coexistence, especially in situations of risk. Patients are quite protective of their privacy, and rightly so; no one will talk about sexual impotence, relationships with spouses, children or family to a device that can record the conversation and even post it on Facebook. Likewise, an executive is not expected to report that his/her stress is a result of unsuccessful business; if this is announced, the situation will only get worse. How is it possible to convey affection, understanding, commitment, compassion, human warmth at last – without looking into the patient’s eyes? Another significant point is body language. It is well known to psychologists that about 80% of messages one person conveys to others is not verbal; 5 it is conveyed through body posture, voice intonation, the way the person looks, how they move their hands and arms, the way they sit, whether they smile or not, and whether their smile is spontaneous or not. In short, there are whole books dedicated to this topic. 6 Also, when the jury meets to judge major crimes, witnesses and defendants are heard personally. The purpose of that is precisely for the jurors to assess the authenticity of the accounts. Doctor/patient contact has a similar meaning. Both the doctor evaluates the patient and the patient evaluates the doctor. It is questionable whether an image could replace that personal contact with the same precision. In amore general view, howdo you know if the doctor on the other end of the line has the authority to give an opinion on that case? Countless patients seek the opinion of renowned doctors, even after they have gone through a number of other doctor’s visits. This only emphasizes one of the basic principles on which medicine is based: trust. In addition, does telemedicine lessen medical error? According to J. Groopman 7 – doctors make mistakes in 15% of the cases on average. That’s a high percentage! The impact that telemedicine will have on this is unknown; there is no data. Another key aspect is compensation. There are no established criteria; this should be a reason for wide discussion, as there are several points to be considered, such as public healthcare, health insurance and private patients. In this particular case, many medical entities and providers should participate. Another point to consider is who/which entities should establish the rules of telemedicine practice. Usually, the Federal Medical Council, medical societies, medical colleges and patient representatives should be heard. So far, patients have been systematically excluded from similar discussions. This needs to be fixed. After all, patients are the goal of medical actions, they take the risks and pay for healthcare. Besides, this is critical – in the case of telemedicine, as in all medical procedures, the patient must explicitly agree with the process, as it involves potential privacy and confidentiality issues. Along these lines, patients’ rights to privacy, alternatives, potential risks and benefits must be preserved. As previously said, the patient does not always accept new technologies like the telemedicine. It is necessary to be clear that they have freedom of choice. Therefore, which stance should we take on the current medical practice? Conceptually speaking, it is clear that telemedicine is here to stay. It is simply a matter of adapting it to medical practice. Having said this, I believe that: a) the first visit must be in person; neither anamnesis nor physical examination can be eliminated – this is indispensable for the diagnosis and referral of the case; regular re-evaluations are also required. b) On the other hand, telemedicine may be useful in several circumstances, including the ones below, among others: b.1. in the reassessment and monitoring of known patients, to adjust medications, answer simple questions, check for adherence and others. b.2. to share information on additional tests, especially when these are normal. The patient does not have to go back to the office just to know that everything is normal; they should lead a normal life and be re‑evaluated within a year, and so on. b.3. patients in remote regions where there are no medical resources; such people can receive general guidance as in cases of diarrhea, fractures, childbirth, trauma and other ordinary situations. General guidance will be at the discretion of the central physician. b.4. to avoid unnecessary hospital visits, such as to get results of simple tests, prothrombin time, in which case medical advice can be given at a distance, saving time and discomfort in addition to reducing costs. b.5. to advise on the choice of specialists for specific cases. b.6. to reduce hospitalization time – this is perfectly possible as long as the patient is monitored after discharge. b.7. in cases where there is a long waiting for a visit, as in public healthcare, follow-up by telemedicine may facilitate or redirect the case. In short, any innovation can bring progress and also new challenges. With telemedicine, it is not different. The concept, however, needs to be well understood. Telemedicine has not come to fully replace traditional practice. It is here to perfect it. The doctor’s responsibility remains the same; the doctor is the one who will make the main decisions. 101