What does telehealth have in common with pornography?

And what does it tell us about the future of medicine?

The COVID-19 pandemic has accelerated the adoption of telehealth across the country. I wrote a newsletter a couple of weeks ago about my initial experience in telehealth, highlighting some of the promise, such as easier access to care, along with some of the perils, like the inadequacy of evaluation for patients who are quite sick.

The more time I’ve had to reflect on telehealth, the more potential opportunity I see. The improved access to care coupled with constantly improving home data collection options holds the promise of many advances in care delivery.

But every time I get excited about telehealth, there’s an internal voice nagging me about the possibilities of a dystopian medical future:

• Virtual visits are turned into a battle to complete a checklist based on whether care fits an administrator’s arbitrary definition for “quality.”

• We’re forced to see more and more patients over video chat with shorter and shorter appointment times because of financial pressures. I’m talking less than 10 minutes for each visit, plus notifying patients of results, plus documenting in the chart

• All of my work happens in front of a computer screen with a patient who is miles away and we miss out on the most important part of medicine - the human connection.

But your title said there would be something about pornography. Was that just your dumb version of clickbait?

I’ll get there. Hear me out.

Axios just published an article about how the COVID pandemic has resulted in a shift of power from big porn producers and distributors to thousands of individual performers and models.

"Porn is free on the internet, nobody needs to pay to see sex video or nudity," IsMyGirl CEO Evan Seinfeld tells Axios. "But people will pay to have an interactive experience and to feel acknowledged and to be engaged."

The isolation that people are facing due to social distancing has led to an acute exacerbation of a chronic crisis of loneliness. COVID didn’t create this problem, but it did intensify it.

As the Axios story suggests, the easy availability of pornography has turned it into a commodity, something that people value less in 2020 than they did even 10 years ago, even though their access has increased exponentially.

So while people have easy access to pornography, it’s not clear that it’s improving their lives - or how much they even value the easy access.

This reminds me of the notion that access to medical care isn’t the same as high quality medical care.

The commoditization of medical care really worries me

Telemedicine’s most immediately apparent advantage is access to a doctor for patients who have difficulty getting to the office. I don’t mean to discount the importance there - that access can have incalculable value for many patients.

But telemedicine doesn’t fundamentally improve the actual medical care for the patient - and there are likely unintended long term consequences when we skip physical examinations.

The faster visits also mean more appointments, and coupling higher volume with increasing electronic clicks promises more burnout for physicians as we spend a greater proportion of our time with the electronic medical record.

As insurers, administrators, and regulators see that televisits can take less time with less overhead than regular visits, the financial pressure to squeeze more visits in will start, doubling down on these challenges.

The sum total of this makes me worry about a situation where access to care is ubiquitous, but the interactions are superficial and commoditized. As with pornography, increased access doesn’t necessarily mean better outcomes or better quality.

I’m sure you’ve already seen the results of increased commoditization of your doctor’s visits - less time with a doctor who has quicker draw to pull out the prescription pad or make a referral, more cookbook medicine, a relationship replaced with an algorithm.

Our current situation is an opportunity to re-imagine the experience of healthcare for the digital age

If all we do is translate the current experience of the doctor’s office to a Zoom call minus a nurse taking vital signs, we’ve missed the boat.

Telehealth hasn’t solved any of the problems that exist in our current medical system - it doesn’t fix our high costs, procedures of questionable necessity, and it certainly doesn’t address any of the things that frustrate doctors with our jobs. If anything, telehealth just augments the annoying EMR clicks, orders to fill in, and results to sign.

With change comes opportunity. I’m hopeful that we can imagine a future that doesn’t accelerate the continued commoditization of medicine where the big, entrenched players dictate an environment that works for them at the expense of patients and doctors.

Perhaps doctors should be looking to the pornography industry for some inspiration with innovating to a more personalized experience that’s best with a human touch.