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   Duke Medical Ethics Journal   

Telemedicine: Convenient Communication at What Cost? Who Pays?

By: Shernice Martin

For a sizable portion of the US population, the proliferation of modern medicine is a resource that quite literally changes lives. It makes the impossible, possible. Day by day, the advancement of medical technology and enhanced training of medical professionals is defying odds, increasing health outcomes, and helping persons survive in the face of challenging illnesses. The battle against the COVID-19 virus has been no different. Healthcare providers employed prudent choices and tireless determination to ensure that, in the face of a deadly high transmission virus, everyone in need of care received it. Armed with their years of experiential knowledge and skill, cutting edge products of biomedical science and technology, and a full armor of PPE, they took to the frontline to defend their respective territories. One of the weapons that made this feat victorious was the use of telemedicine. With case numbers and death rates increasing exponentially during the pandemic, the ability to administer medical care virtually ensured that professional clinical consultation could be accessed without risking the health of both patients and physicians.

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However, we know that every battle leaves behind brutal bruises and scars to be healed, even when you’re on the winning side. In this case, the augmentation of medical mistrust and advanced impairment in the physician-patient relationship among minority populations is one of those. It has been a prominent phenomenon that “groups marginalized in society—due to race, behavior, or some other stigmatized status—are often more likely to be mistrustful about medical institutions and personnel based on personal experience, or vicarious experiences...” (Williamson & Bigman, 2018). Therefore, the continued use of telemedicine can easily erode the already endangered patient-provider relationships in minority communities by hindering the accessibility of clinical consultation and eroding the quality of interactive communication. 

“The continued use of telemedicine can easily erode the already endangered patient-provider relationships in minority communities by hindering the accessibility of clinical consultation and eroding the quality of interactive communication."

At first impression, it is difficult to disagree with the convenience of virtual communication in the context of clinical care. Patients can effortlessly acquire their healthcare provider’s insight from the comfort of their homes and flexibility of their schedule. This is the main rationale for its popularity in the post-Covid era. Benefits aside, however, it is important to ask: is telemedicine aligned with the human right to healthcare that is forged on principles of equity and accessibility? To utilize the convenience of such a service, one must first be able to access the fundamental resources upon which it is built––technology, a resource that many of us take for granted. Although technology is embedded in virtually every aspect of the modern world, we must understand that prominence is not always conducive to accessibility. The extensive costs of devices and software make technology a privilege only those with financial security can afford.

Most minority populations occupy the lower positions of the socioeconomic hierarchy. Hence, they have low financial stability and limited access to technological resources in comparison to other groups in society. This phenomenon, called the digital divide, has decreased slightly in the past decades. However, it has been more clearly exposed during the COVID-19 pandemic with the move of essential services such as education and health to virtual platforms (Lai & Widmar, 2021). There have been many minority communities, especially in rural areas, without internet access or many technological devices in the home, evidenced by low attendance to online classes and clinical appointments. Research has proven that, while internet use is becoming equal across ethnicities, there remains a disparity with regards to device access that mirrors that of

socioeconomic status (Anderson, 2015). Therefore, unless access to technological resources becomes universal, telemedicine will remain an infringement on the universal human right to healthcare, one of the major pillars of medical ethics. Its continued use as it is now will mean taking a step forward technologically but taking a step backward ethically. 

Even prior to the pandemic, researchers proposed that, with the increased frequency of telemedicine, “face to face clinical consultations will become increasingly expensive due to constraints on time and resources” (1996). The technological resources needed for virtual healthcare may be expensive, but the consultation itself will be delivered at a reduced cost. This should not be mistaken as a product of intentionally increasing accessibility but rather decreasing the resources expended by the healthcare industry. However, it may counterbalance the cost of technology, establishing an affordable model of care for minority patients. Even so, is it worthwhile for telemedicine to be made affordable to minority patients if the consultation is not efficient or effective? Should face-to-face consultation become a privilege in a profession that is at its core based on in-depth observation and analysis? It almost goes without saying that, if the cost of access to a service means a lower quality service in itself, then not much has been accomplished to make it equitable.

The other noteworthy issue is the decrease in physical interaction caused by telemedicine. The physical component of a consultation is imperative in the consultation and diagnostic process. In this virtual model of clinical care, patients would typically interact with providers via video or messaging software, thereby eliminating many essential components. As a result, the effectiveness of a clinical consultation may be compromised in multiple ways. Diagnostic accuracy may decline severely without the ability to inspect affected areas, perform physical examinations, and collect real-time vital data, which would inform the patient’s presented symptomology. Without the necessary data required to make the best diagnosis, there will be a cascade of faulty clinical care. This may include ineffective prescriptions, prolonged illness and suffering, and, most importantly, a propagation of the medical mistrust that most minority patients already experience.

Additionally, removal of the in-person component of consultations would most likely increase the need for the patient’s awareness and description of their symptoms to be more accurate, especially for externally presenting symptoms. In this case, the lack of fundamental medical knowledge may be a compounded barrier to minority patients in the context of telemedicine, where verbal communication is the major tool of effective exchange. For decades, research has been conducted on the correlation between poor educational outcomes of minority populations and poor health outcomes (Agee, 1989; Ngo & Lee, 2007; Connell, 1994; Kickbusch, 2001; Eide & Showalter, 2011). The lack of health literacy may make virtual consultations ineffective and perhaps even frustrating for minority patients. Without the ability to communicate their needs precisely, they will not be able to receive the clinical insight they need. The use of messaging software as a form of medical care administration may also be a detrimental factor in the physician-patient relationship. Patients may not be able to always receive responses from physicians in a timely fashion. This may lend itself to feelings of helplessness and hopelessness in a health care system that was designed to give help and hope in moments of vulnerability. Consequently, patients will be discouraged from using this resource even if they do have the technological means to do so.

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While there are many drawbacks to the use of telemedicine in the context of the physician-patient relationship, there are multiple benefits in other aspects of healthcare that are too important to be ignored. These include improved access to care and services not previously available. There would be more efficient storage and use of patient data leading to improved patient monitoring, especially for those with chronic illnesses. Furthermore, the use of virtual conference room technology and increased appointment availability will make it easier to schedule multiple simultaneous consultations with specialist physicians. This technological advancement would also improve professional education for health care providers, quality control of screening programmes, and reduce overall health care costs (NJ Hjelm, 2005).

Like all human advancements, telemedicine will have advantages and disadvantages alike. With both the benefits and drawbacks considered, we must now decide as a society where our priority lies and with whom. It is the duty of the citizens to play a role in the democracy of designing a health care system that would meet their needs the best: both the majority and minority of the population. It starts with gathering the information and voicing a well-informed decision. It starts by asking the necessary questions: Do we eliminate effectiveness for efficiency? Should there be a more emphasized focus on sustaining relationships or resources? Which aspects of health care should be a privilege to access, if any at all? As we transition out of the COVID-19 era, the ethical questions surrounding the use of telemedicine will continue to linger. I propose, however, that our aim is not so much in finding an answer but, rather, finding the rightful place for telemedicine in the healthcare system to capitalize on its strengths. When addressing its weaknesses, there should be no hesitation to return to the model that has served us throughout

history: face-to-face consultations. Sometimes finding the way forward means not being afraid to retrace one’s steps.

Review Editor: Jennifer Xu
Design Editor: Shanzeh Sheikh

1. Williamson, L. D., & Bigman, C. A. (2018). A systematic review of medical mistrust measures. Patient education and counseling, 101(10), 1786-1794. 

2. Lai, J., & Widmar, N. O. (2021). Revisiting the digital divide in the COVID‐19 era. Applied Economic Perspectives and Policy, 43(1), 458-464. 

3. Agee, E. M. (1989). A Portrait of Older Minorities. 

4. Connell, R. (1994). Poverty and education. Harvard educational review, 64(2), 125-150. 

5. Ngo, B., & Lee, S. J. (2007). Complicating the image of model minority success: A review of Southeast Asian American education. Review of educational research, 77(4), 415-453. 

6. Kickbusch, I. S. (2001). Health literacy: addressing the health and education divide. Health promotion international, 16(3), 289-297. 

7. Eide, E. R., & Showalter, M. H. (2011). Estimating the relation between health and education: What do we know and what do we need to know? Economics of Education Review, 30(5), 778-791. 

8. Benefits and drawbacks of telemedicine. (2005). Journal of Telemedicine and Telecare, 11(2), 60–70. 

9. Wootton R. Telemedicine: a cautious welcome BMJ 1996; 313 :1375

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