Health Service Focus

Online consultations – the future?

Leicester Medical School is the first in the country to teach its first year junior doctors how to hold online consultations. NHE spoke to teaching fellow Dr Ron Hsu, who has led on the initiative.

In our March/April 2014 edition, NHE interviewed Dr Mohammad Al-Ubaydli, the founder of the Patients Know Best (PKB) records platform.

We weren’t the only ones intrigued by the philosophy behind it, summed up as ‘my body, my data’. Dr Ron Hsu, teaching fellow at Leicester Medical School, saw Dr Al-Ubaydli speak at a conference and knew he’d found a kindred spirit.

He said: “I liked the concept that we could have something that would actually demonstrate that the patient could be in charge. Mohammad’s idea, which I think is absolutely correct, is that if you empower the patient to know what’s going on, and to control who gets access to what, they get ownership. That is the moral argument; but there’s also the practical argument – they become the co-ordinator, and can spot when things are going wrong.”

Dr Hsu and Dr Al-Ubaydli began discussing the possibility of using PKB to help teach medical students, and this academic year, the idea was put into practice.

The system has been used to teach first year students the principles of online consultations.

Volunteers were recruited –“normal people”, as Dr Hsu puts it, not clinicians or academics – to control online avatars. Those avatars would ask questions of the students via the online system, using simple text-based messages.

Dr Hsu said: “The questions weren’t focused on a medical condition, because of the stage they students are at, they’re year one – they were focused on the fundamental sciences that form the basis of medicine. So, ‘do I have to have cholesterol in my diet?’ The students will have learnt that it forms an integral part of cell membranes, and while too much is bad, not eating any cholesterol will cause your cells to collapse.

“The questions were closely linked to what they were taught the week before. The students cottoned on quite quickly. In the first semester, every fourth one was pot luck – something just came out of the blue.”

‘The medical profession are up in arms’

Dr Hsu, a former GP, explained why he’s keen to teach online consultations, despite the apparent opposition of most doctors.

He said: “There was a realisation – in some ways blindingly obvious, but in other ways actually very difficult – that it will not be long before the public will expect to be able to consult online. The medical profession, pretty well to a person, are up in arms against that.

“But we already know that GPs are having to adapt themselves to be able to do consultations over the phone. It won’t take long to go online.

“My reasoning was, I’m not preparing students to be doctors today – I’m preparing them to be doctors in the next decade.”

He was clear that online consultations are in no way a replacement for traditional face-to-face consultations.

He said: “I see it as an extra; as complementary. In some of the newspaper articles about this, there were doctors commenting that Leicester is ‘replacing’ the teaching of face-to-face consultations: adamantly not. The face-to-face consultation teaching starts in the first year here and is still going ahead.

“Where people feel they just need advice, it’s for that. If they have a specific problem they would like solving, I think that needs face-to-face or phone consultations continuing.

“Most doctors, me included, would be nervous if it started to replace face-to-face: there would be too many mistakes and too many over-investigations. You’d pick up the wrong end of the stick.”

He said anyone thinking that online consultations would be a way to cut costs out of the NHS would be wrong. “It’d be a false saving. You might save on the cost of the consultation, but you’d pay a huge cost as a consequence of those over-investigations or missed diagnoses.”

The patient in control

Dr Hsu suggested it was important to teach medical students the concept of the patient being in charge – he feels he is fighting a losing battle on that. “No matter what I preach, they’ll ignore it once they walk out of the seminar room – ‘everyone else does it this way’. Everything they see in practice is the complete opposite, and we need to change that.

“GPs could be doing online consultations now: it’s just culture and practice holding them back, and they blame training and teaching. That’s why Mohammad was keen for us to do this. If you can start teaching people how to do it, other people will realise they can also teach people, then we’ll get a whole group of people who’ve ‘done it at medical school’.”

Moving on from paper

Dr Hsu said: “We don’t have a healthcare system with one GP, one consultant and you’re done. You’ll also see other nurses and professionals even within primary care, let alone in the hospital system. We in the healthcare system have never properly worked out how to get the staff to cope with that. Our communication systems still come down to letters. It’s archaic, and it’s arcane – no wonder things are going wrong.”

Long-term, PKB brings the benefit of access to records and medical history on the patient’s own terms. But medical records have not yet been a part of the Leicester project: instead, students have been expected to ask questions of the volunteers/avatars.

Dr Hsu said: “They can ask the avatar for information. I created the avatars and gave each a household biography. The volunteers ‘worked’ the avatars – a bit like The Sims game. At the stage we’re at, it’s about exploring how people work with an online form of consultation.”

Intrusive questions

One early lesson from the pilot project was that socialisation is hindered when the only communication with someone is text messages on a screen. Dr Hsu explained: “I’m of the generation for which ‘talking’ means face-to-face verbal speech, but with teenagers – this is a Google generation, a social media generation. I assumed they would consider text on screen as socialisation. I thought doing it this way would be more natural for them than it was
for me.

“It turns out that assumption was incorrect – they didn’t ask the avatars questions. Initially, it was very stilted: it took six weeks or so to see some loosening of the terminology and for it to become more sociable, but even then, they were hesitant to ask. We asked them why, and they said they felt they needed permission.”

Dr Hsu suggested that the natural or instinctive ability to know how intrusive to be during a face-to-face or even a phone conversation is lost when the conversation is wholly online.

“We needed to demonstrate in a structured way what was ‘allowed’ and what wasn’t,” he said.

Feedback and evaluation

That lesson was one of many fed back at an evaluation event held at the Royal Society of Medicine in London in March. Dr Al-Ubaydli was among the speakers, and explained to NHE how PKB provided the software and training in it.

He said: “From my personal perspective, we know for sure that today’s medical students will be carrying out online consultations throughout their clinical career – we are not sure just how much though. Early studies show that 40% of GP appointments could be safely and efficiently switched to online consultations.

“We also know that preventing long distance travel to see super-specialists is a big clinical benefit, not just because of the convenience and cost saving of avoiding travel, but also because for many patients the long travel makes them sicker. In other situations, like cystic fibrosis, having patients travel to the same clinic waiting room increases their chance of infection. And in mental health, seeing the patient in their home provides valuable clinical diagnostic and therapeutic information that you would not get from a face-to-fact clinic appointment. Most interestingly for me, we also know that there is a lot we do not know – that as more and more professionals experiment with online consultations, we will learn about more scenarios where online consultations are a useful complements to the existing tools that professionals have in working with their patients.”

Improvements

Discussing the pilot, he added: “All our customers are our partners, and one of the reasons we wanted to work with Leicester was to find out what features and improvements they needed. The faculty and students gave useful and specific feedback and our developers made the improvements based on their conversations with them. We are looking forward to the next round of feedback as the program is rolled out to more students in more settings.”

Dr Hsu said early feedback involved tweaks to the doctor-facing interface of the system: he suggested that the ‘patient-first’ philosophy of PKB was so deeply ingrained that some aspects did not work so well for a student medic using it. He  said: “His system was built to have, say, half a million patients and a few thousand doctors. We had 12 patients, effectively, and 240 doctors! We made suggestions, which Mohammad has implemented in the full system. He’s developing a screen that’s more doctor-friendly. Systems like EMIS and SystmOne were specifically designed for doctors: Mohammad, of course, was doing it from the patient’s perspective.”

But the overall feedback was positive, he said. “The students liked the idea that they were interacting with someone; the volunteers liked that they were helping students learn how to explain things in simple language; the academics liked being able to see what the students thought of what they’d recently been lectured on.”

Improvements were suggested to the way the teaching works. The students wanted it to be easier to talk naturally with the avatars, the volunteers wanted more support, and the academics wanted more time devoted to it and timetabled for it.

The project will definitely continue at Leicester, Dr Hsu told us, but they are still discussing which of two roads to go down.

It can either be kept as a way of teaching basic science and the principle of online consultations. Or it could become more like a real diagnostic consultation, with specific symptoms and patient problems. That could be more difficult, especially at such an early stage of the medical students’ education. It’s evolving, and there’s a tension in where it evolves to,” he said.

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