AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. March 2001, Volume 3, Number 3.

Historical Postmortem

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Being There

The use of telemedicine technology, while convenient, can at times be inadequate, as shown in the portrait painting entitled The Doctor, where the physician stays at the bedside of a gravely ill child and offers his presence as comfort to the family.

Karen Geraghty

The following warning was issued through the Lancet regarding the use of telemedicine technology in the diagnosis and treatment of patients:

"The phrase 'medical advice' ... should imply that the recipient has been seen and examined ... so as to leave no reasonable doubt as to his illness ... and appropriate mode of treatment. In order to arrive at this degree of security ... it is commonly necessary and always advisable that a practitioner should be at the time in attendance on his patient .... Practice conducted [without direct contact with the patient] is no better than a name ... its systematic exercise even in trifles is at best the harmless shadow of a dangerous custom, and does not accord the true ideal of professional duty" [1].

The year is 1887. The technology that threatens the professional ideal of medical practice is the rudimentary telegraph.

By the end of the nineteenth century, communication technologies were opening new possibilities for the care and treatment of patients, as well as for more effective management of expanding medical practices. In 1876, a patent was issued to Alexander Graham Bell for the invention of the telephone and within months, physicians adopted the new invention as a means for treating patients over long distances. Public and professional opinion on the use of the device, however, was mixed. Although the physician was now more readily available to patients, the telephone encounter denied the physical contact so integral to the traditional model of the patient-physician relationship.

Several medical journals enthusiastically reported the experience of a physician in Cincinnati, who was awakened

"during the night by a summons through his telephone to go at once to the house of the caller, who stated that his child had croup and was coughing violently. As the house was several distant miles, and the doctor very tired, he requested the father to hold his child for a few moments before his telephone. This was done, and the practised ear of the physician at once convinced him that there was no fear of true croup. After informing the father of this, and giving the necessary directions regarding the management of the patient, the doctor again retired. When he saw the infant the next morning, all symptoms of laryngismus stridulus had disappeared, and the child was apparently quite well" [2].

JAMA however, reported a similar story that provoked a different reaction from a worried parent:

"A St. Paul doctor... was requested over the wire to visit a sick child two miles away the other night, and not wanting to go, prescribed over the 'phone and went back to bed. On making the call the next day he found the patient doing very well under the care of another doctor, and went back with a change of mind regarding the usefulness of Professor Bell's invention" [3].

Sir Luke Fildes. The Doctor(1891)
Image courtesy of the National Library of Medicine

The professional ideal of medical practice, unarticulated but challenged by these two stories, can be illustrated by Sir Luke Fildes' famous portrait The Doctor. Although painted in the waning years of the nineteenth century, well before the technological innovations of the twentieth century made the house call obsolete, there is already something wistful captured in the portrait - something intangible that - while not yet lost - threatens to slip imperceptibly away.

The child lies desperately ill while the parents huddle in the background, fearful, helpless and grief-stricken. There is nothing more the physician can do medically to save the child. Why, then, is he still there? He can only keep vigil - watching as the girl's delicate breath grows ever more shallow.

Now picture a different scene - one with the physician's chair empty, and the two distraught parents clutching a telephone receiver.



References

  1. Consultation by telegraph. Lancet . 1887;1:230.
  2. The telephone as a medium of consultation and medical diagnosis. British Medical Journal. 1879;2:897.
  3. The telephone. AMA . 1888;11; 791.

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