Communication and physical examination as basic aspects of global telemedicine

Amsterdam 22 April 1998 Before starting to talk about telemedicine, we should realise ourselves that good medical practice starts with diagnosis, treatment, and possibly prevention of human diseases of the body as well as the mind. Some millenaries ago, Hippocrates proclaimed the rules of the medical act and the procedures of the clinical examination. Professor Jean-François Moreau, who is chairman of the Department of Radiology in the Hospital Necker of Paris, warned the ITIS'98 participants that these principles still keep their content and value, even and especially in the telecommunication era. He held an ardent plea for the "use of the five senses" in the contact between physician and patient.

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Before starting to talk about telemedicine, we should realise ourselves that good medical practice starts with diagnosis, treatment, and possibly prevention of human diseases of the body as well as the mind. Some millenaries ago, Hippocrates proclaimed the rules of the medical act and the procedures of the clinical examination. Professor Jean-François Moreau, who is chairman of the Department of Radiology in the Hospital Necker of Paris, warned the ITIS'98 participants that these principles still keep their content and value, even and especially in the telecommunication era. He held an ardent plea for the "use of the five senses" in the contact between physician and patient.

The basic elements of a clinical examination consist in an interrogatory through profound communication with the patient and in a physical examination through inspection, palpation, percussion for chest and abdomen, and auscultation. How can they be integrated in the concept of telemedicine, both parties being at a distance from each other? Both the interrogatory and inspection processes can be enhanced and complemented with biological examinations, analogue or digital imaging procedures, such as X rays, ultrasound, MRI, radiography, or nuclear medicine, and sometimes intervention by means of punctures and imaging procedures under guidance with use of CT scan.

Once the diagnosis has been determined, the physicians enter in therapeutic discussion to decide whether yes or no, treatment has to follow. If so, it can be performed by means of drugs, surgery or interventional procedures under guidance. As a result, the patient might fully recover, start to suffer from complications, or the physician can make prognosis on possible sequelae or abnormalities which will last after recovery. The final cost-effectiveness of health care therefore depends both on the competence of the physician and the population's level of education. In telemedicine, the balance between the medical experts and the referent physicians has to be constantly evaluated. Professor Moreau stresses the importance of permanent academic knowledge training as well as practical training of the paramedical staff.

Today, we witness the appearance of spectacular advances in diagnostic telemedicine, such as the deployment of Picture Archival Computer Systems (PACS) or Image Management and Archiving Communication Systems (IMACS) in the various radiology departments of hospitals. Technological handicaps no longer seem to form a problem anymore. Political strains with relationship to industrial development are a different story. Another controversial issue constitutes the cost-effectiveness since at this point, we have no clear idea about the balance between cost and savings of telemedical applications.

The aspect of tele-teaching includes the birth of a new vocabulary, similar to show business. Indeed, teleconferencing comprises video-technologies as well as virtual workshops by means of talk- and reality shows. The use of standard telephone lines is insufficient in this regard, according to the experience of Professor Moreau. In the nineties, his hospital has performed some experiments with Asynchronous Transfer Mode (ATM) links between Paris and several regions of the world through the application of ISDN lines. Tests have proven that at least four ISDN lines are necessary to provide the required transmission power.

It is impossible to transmit the clinical examination's elements of palpation and percussion and even the broadcasting of analogue imaging processes is difficult. The interest of Virtual Reality of course is capital but not easy to apply for the moment. Yet, there remain plenty of possibilities to perform telemedical activities if we consider the components of interrogation, inspection, auscultation, biological examinations, digital imaging procedures, and endoscopy, which are already successfully being broadcast. The concept of tele-proctoring for ultra-sonography for instance, constitutes an excellent knowledge application, developed by the astronauts in space. Currently, digital ultrasonograph data can be directly connected to the network.

We have no actual evaluation of the cost-effectiveness of remote data transfer through ISDN yet. If we use tele-transmission only for teaching purposes, a considerable level of maturity has been raised. Tele-teaching is going to benefit from the deregulation of the global telecom facilities. English has been installed as the official transmission language but the vernacular should not be ignored as a discussion and promotion tool to allow easy and fruitful communication between the physician and the patient. Only in this way, Hippocrates will smile approval.


Leslie Versweyveld

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