The most common mode of healthcare delivery is through personal, face-to-face contact between a provider, usually a physician, nurse, therapist, pharmacist or technologist and a beneficiary (patient). There is, however, an increasing trend towards provision of healthcare in the absence of a personal contact.
There are several ways of delivering health care: the commonest is through a personal, face-to-face encounter, another is via distance medicine where the patient and care giver are at different locations but still communicate by audio and video, and a third option is de novo care given without any personal contact. A face-to-face contact is often a necessary prelude to rendering health care. This, however, may not be necessary for care; in fact current technologies permit with no prior or concurrent contact. [1] [2] This type of in absentia medical care may derail the traditional sequences of narration, examination, diagnosis and treatment. Such a detour will challenge existent values of modern medicine. In absentia care assumes heightened relevance today because it is both convenient and risky. Easy questionnaire-based online access to healthcare is convenient. [3] [4] The same resources provide hazardous pharmaceuticals, addicting and life style altering drugs. [5][6]
We must temper some of the negative characterizations of care without personal contact with a glimpse at the past, because remote care is not a novel phenomenon endemic to the cyber era. The roots of in absentia care reach deeply to ancient times, mixing with medical lore over nearly two thousand years. On the one hand, aspects of online medicine have been described as an "asynchronous written exchange," and a "disembodied relationship," with "few analogues or precedents in medical practice." [7] This trend has also been viewed as perhaps "anarchic" with potential to "set off a revolution in remote care" and promote "self-diagnosis." [8](p144-145) The safety of online consultations by "Cyberdoctors" has also been seriously questioned.[9] On the other hand remote in absentia medical care has fulfilled an enduring human need over several centuries. What follows is a quick tour of the past in absentia medical practices.
Ancient Egypt emphasized a tripartite system which is extant even to this day. This system called for listening to the patient, before an examination. Only after an observation, or an examination, did a diagnosis follow. Treatment was undertaken as the last component. [10](p113-114) Observation and examination before treatment, had a central role that could not be easily circumvented. This sequence has been passed on as a tradition to us through Hippocrates and Galen. During the height of Arabic and Jewish medicine (732-1096AD), diagnosis called for an orderly sequence where examination, "by the feel of the hands," played an essential role.[11](p134) Ideally, healing entailed contact between the patient and a healer. Still, the practice of eliminating this personal contact as a prerequisite to healing was not unheard of. At a later time when astrology, animal products, magic and incantations were part of the healing arts, formal contact with healers may have gradually become unnecessary. Ill-health was often viewed as the result of malevolent external influences. Amulets and ligatures were worn as barriers to ward off such evil external visitations. Sufferers wore them, stuck them under their pillows or hung them on lintels and doorposts.[12](p89-90) Thus, care at a personal level by a physician was not the only means to regaining health; alternative practices were emerging.
No less a luminary than Claudius Galen (129-200 A.D.) chose, at times, to prescribe to patients without ever seeing them. Details about Galen's prodigious contributions to medicine and science may have subdued this little known facet of his practice. Apparently, Galen was so skilled in understanding symptomatology that there were times when he preferred to diagnose without questioning the patient. He then went on to prescribe by mail with confidence.[13](p172-174),[14](p505-506) His elevated status permitted him to offer consultations by letter. He would receive generous rewards for his postal consultations; in one instance, it is said that he had received 400 gold pieces for curing a woman in this fashion. [15](p172)[16](p121)
A diverse and illustrious cadre of English and European physicians had practiced medicine by post. Its ranks included William Cullen, Herman Boerhaave, Nathaniel Johnston, John Morgan and several others. The French physician and philanthropist Theophraste Renaudot (1584-1653) established a Paris practice that offered free treatment to the sick who were too poor to engage a physician. Renaudot's published a booklet titled, "La presence des absence," (The Presence of the Absent). This booklet listed a series of symptoms and carried diagrams of body parts. Patients were required to identify symptoms and check off body parts that hurt. This booklet, then, enabled a patient to receive a diagnosis and treatment by post without a personal visit to the physician. [17](p209)
In Europe and England between 1600 and 1800, dispensing and advising without direct contact with ailing persons had become a common practice. At that time, physical examination techniques were in their infancy. Auscultation (listening to the chest with a stethoscope) and ophthalmoscopy (examination of the interior of the eyes) had not found their way into the discipline of an examination until early to mid-1800s. At best, most physicians simply observed the patient's appearance and color, and palpated the pulse. Any further physical examination was perfunctory.[18](p74) Apparently, social etiquette also limited a hands-on approach to extensive examinations requiring physical contact.[19](p257). William Heberdeen (English, 1710-1801), of angina pectoris (chest pain indicative of impaired blood supply to the heart muscle, and an impending heart attack) fame, had a reputation for his diagnostic skills merely through his "expert gaze."[20](p45) Diagnosis depended heavily on the listener's interpretive skills, and treatment relied more on compassion than medicinal chemistry. The narrative conveyed by the ill revealed more clues than physician's tactile techniques.[21](p4) Thus, this was an environment which tolerated and even nurtured therapeutic initiatives without physical evaluation by physicians.
The inchoate state of physical diagnosis was not the only reason for 17th and 18th century in absentia practice. Another major obstacle to face-to-face contact was the difficulty posed by distance and poor travel conditions. Because of this it was convenient for patients and their caregivers to seek medical help by writing to physicians of repute.[22](p76-78) Letters bearing detailed accounts of a patient's symptoms were delivered by post or courier to physicians practicing at a distance. Hermann Boerhaave (Dutch, 1668-1738) was at ease with such a concept and practice. He dispensed advice to other colleagues and apothecaries by mail.[23](p300-301) There is an example of an apothecary having consulted Boerhaave on the status of his patient, a 23-year-old male merchant. His letter describes, in language appropriate to those times, a patient with relentless cough, spitting of blood, weight loss, sweating, tenacious green sputum and malaise. Boerhaave's written response had offered a diagnosis of "suppuration (pus) of the lungs." The tone of the letter conveyed a less than optimistic prognosis; but nevertheless the letter had made several therapeutic suggestions. Erasmus Darwin (English, 1731-1802), grandfather of Charles Darwin, similarly treated a patient with dizziness, not by seeing him but by recommending "scarifications" (making scars) on the back.[24](p77-78)
William Cullen (1710-1790) of Edinburgh, Scotland had engaged in a flourishing mail order practice.[25]135-139 In his early years of practice between 1764 and 1774, Cullen wrote approximately 20 consultation letters per year. This number jumped markedly to almost 200 a year from 1774 till his death in 1790. He had used an amanuensis and an early version of a copying machine to facilitate and expedite his responses.[26](p136) His consultation letters were often directed to wealthy patients to whom he had advocated an authoritative agenda for moderate living. Perhaps this was his attempt at preventive medicine for patients with indulgent life styles. Most of the letters were written to patients residing at a distance from Edinburgh. If he did not know the condition well, he cautiously avoided making a diagnosis.[27](p145) For the acutely ill, he preferred hospital admission and personal care. Cullen had recognized long ago the limitations of in absentia care.
John Morgan (1735-1789) of Philadelphia, a founder of the University of Pennsylvania medical school in 1765, was equally active with regard to postal consultations. Morgan had studied under Cullen in Edinburgh between 1761 and 1764. He had announced his willingness to consult by post for those patients residing at a distance from Philadelphia.[28](p6) Regardless of the location or the period of practice, in absentia mail order treatments were all compensable and led to lucrative practices. There is no obvious evidence to indicate that there was any serious professional opposition to compensation for this type of practice. Patients' letters contained details of their symptoms, written either by the sufferer or a family member. The bulk of mail order practice depended on the strength of these descriptions.
In addition to these narratives, early physicians may also have recognized the importance of examining bodily excretions in establishing a diagnosis. A Yorkshire physician by the name of Nathaniel Johnston (1627-1705) had carried out an extensive correspondence practice with his patients. In one instance a writer had sent a letter to him enclosing specimens of his wife's "phleagme" (sputum) and "water" (urine) as samples. He had hoped that Johnston might use the specimens to narrow the diagnosis of his wife's chronic cough.[29]
Even as early as the 1830s, there was an attempt at reducing the subjectivity of findings and narrations. Julius Herisson, an early inventor of sphygmomanometer (blood pressure measuring apparatus) in 1834, recommended that numerical aspects (quantitative data such as beats per minute) of pulse were more informative than their descriptive characteristics.[30](p199) He had realized that the bodily presence of the ailing was not an absolute requirement for information exchange leading to a diagnosis. This may well have been the prelude to data exchange that is now a common practice. These early endeavors at sharing quantitative and graphic data had culminated in the eventual transmission of ECG signals in 1954 over a leased commercial phone line. This remote exchange served its purpose well in distant diagnosis of chest pains, arrhythmias and electrolyte (sodium or potassium) imbalances.[31] Not all remote practices were based on honorable intentions. A foul facet of in absentia medicine surfaced in the first third of the 20th century. It arrived in the form of radio advertising. Radio, much like the internet now, was a nascent medium then. It presented novel opportunities for technophiles of that period. A Kansas physician by the name of John R Brinkley(1885-1942) exploited this new medium to maximum advantage between the years 1928 and 1941.
Brinkley's life and career have been the subject of several books and theses.[32][33][34] Born in Beta, North Carolina, Brinkley moved to North Central Kansas early in the 20th century. Armed with a love of technology and a questionable medical degree, he set up practice in Milford, Kansas in 1917. Early in his practice, on the brink of poverty, he acceded to a rejuvenating surgical procedure of shady merit. He transplanted goat testicles into the scrotal sac of a pleading farmer whose sexual performance and "pep" had waned. Within a year, the farmer's wife bore a healthy male child, whose paternity may never be verifiable. Soon, the demand for his procedure grew greatly. International fame and enormous wealth followed. The validity and value of this surgery came under understandable scrutiny only a decade later. Organized medicine, through the efforts of the Kansas Medical Society and the American Medical Association, put an end to this practice in 1930. His transplant surgery had earned him worldwide reputation, as "The Goat Gland Doctor." His popularity was such that he ran for the Governor's position thrice in Kansas, winning the first time in 1930 by vote count, but losing on a technicality. Undaunted, after losing his medical license in Kansas, Brinkley moved to Texas and later to Arkansas, to practice medicine.
Meanwhile, perceiving an opportunity to advertise his skills, he exploited the emerging medium of radio broadcasting.[35](p61-89) Radio allowed him to spread the news of his surgery and also to start a "Medical Question Box." His live radio broadcasts diagnosed diseases on patients who wrote to him describing their symptoms. He then prescribed nostrums to his patients, sight unseen, through a chain of pharmacies. Through flagrant advertising and kickbacks from druggists, he enlarged his wealth further. The clamor of his powerful megawatt stations provoked punitive actions by the Federal Radio Commission, and later the Federal Communications Commission. He mounted formidable protests, legal and otherwise, against such controls. Eventually, Government regulations silenced him in Kansas, Texas and Mexico serially. In 1941 his radio broadcasts ended for good. His health, wealth and fame eroded rapidly. Brinkley died in 1942 leaving behind impressive fodder for historians, writers and analysts.
His radio career started with ostensibly noble objectives of education and entertainment for his hospitalized patients. Gradually, he subverted this objective to unabashed self-promotion. He received a large number of questions from his admiring listeners from near and far. Several times a day, on a regular basis, he would read questions by dipping into a "question box," containing mail that he had received. These were from persons whom he had never seen, but who nevertheless, wrote to him inspired by his broadcasts.[36],[37](p76) From a suffering patient's point of view this type of one-stop approach was eminently convenient. One was never sure if the letters were genuine, fictitious or both. Based on his interpretation of symptoms he would provide an on-air diagnosis and prescribe proprietary medicines. These medicines were identifiable only by numbers. A typical patient may be advised to purchase combinations of several numbered nostrums. These were obtainable only through a network of Brinkley owned pharmacies. The network participants had to pay a percentage of their sales back to Brinkley.[38](p77) Brinkley justified his in absentia practice using his own interpretation of the history of medicine. He cited the practice of an 18th century Swiss mountain doctor by the name of Michael Schuppach,(1707-1781). Schuppach had practiced diagnosis and treatment by drawing on the powers of nature. His reputation was such that he could diagnose illnesses by the smell of a patient's shirt, or a flask of patient's urine mailed to him.[39](p99) Brinkley drew from history selectively to bolster his convictions.
In absentia healthcare has probably existed for more than 1500 years. This enduring practice owes its longevity to need fulfillment, convenience and greed. When viewed in the context of slow travel, healing in absentia was eminently suited to fulfill a need during certain periods in history. Fame and repute were partly responsible for encouraging the ill to write to physicians practicing at a distance from them. Healers of fame, from Galen to Cullen, engaged in mail order practice even though they rendered in person care primarily. They had used the leading technological innovations of their days to facilitate diagnoses, enhance communication speed and mass reach - no different from what we do today. Physical examination itself had a lesser role than narration in arriving at a diagnosis. Therapy was more often a ritual than a scientific exercise of logic. Thus, personal contact, while desirable, may have been unessential.
Contemporary technology allows transmission of images and data to distant sites.[40] This may remove the need for a spatially proximate contact. It is not yet clear if this would eliminate the need for a physical examination also. Remote viewing of images and data are acceptable, but incomplete proxies for physical contact. This is especially the case with telemedicine when a physician may consult with a remotely sited,and sighted, consultant. Here, however, a patient-physician relationship already exists between two parties. Indeed, data exchange serves as latter day equivalent of a third party physical examination in such instances.
Technology permits de novo healthcare also without any primary contact with a qualified caregivers. This type of care, "between strangers," is of uncertain merit. It is less expensive, speedy and convenient at a time when traditional health insurance and the cost of drugs are straying beyond the reach of many. Mental health and specialist-care are not readily available under some health plans. The worried-well may seek care for discomfiture that past generations would have dismissed as trivial or inevitable. [41](p684-7) The same electronic information technologies that aid the health-providers also empower the health-seekers who can gain easier access, with inherent anonymity.[42](p143) While anonymity encourages transactional candor, it can also veil substandard care and greed. Over time, barrier to access has been one of the stimuli that has encouraged patients to seek and preserve remote care. The ultimate balance sheet of risks and benefits of remote care is yet to emerge. What is clear, however, is that our times have not spawned a fundamentally new phenomenon. They have brought about only variations, more technological and less thematic, on an old entrenched practice, both honorable and venal, for in absentia care.