My Problem(s) with Telemedicine

Veterinary medicine is increasingly leaning into aggressively-marketed telemedicine providers. We should be wary of the practice and the precedent.

“A VCPR cannot be established solely through telemedicine.” -FDA letter to the AVMA

“We deliver pet medications to your doorstep effortlessly.” -Headline on the Vetster’s landing page when I Googled “veterinary telemedicine” and Vetster’s sponsored advertisement appeared as the first result

“A veterinarian-client-patient relationship cannot be established solely by telephonic or other electronic means.” -AVMA Model Practice Act

“Cat or Dog experiencing UTI symptoms? Get prescriptions without costly vet visits” -Fuzzy advertisement

It’s apparent from these two messages that there is a widening gap between what the powers that be perceive about the role of telemedicine in veterinary care and what websites are advertising is possible, let alone legally and ethically appropriate. The aggressively-marketed alternatives to real patient care are alarming in their callous assertions of telemedicine and promises of prescription drugs. It’s not hard to perceive how these sorts of advertisements diminish the dignity and professionalism of veterinarians, as well as devalue the practice of medicine itself.

A screenshot of Vetster’s landing page.

The primary means of evaluation in primary care is the physical examination, it’s one of the earliest and most crucial skills taught to veterinary students. It is, wisely, mandatory for the establishment of the VCPR as well as the diagnosis, prognosis, and treatment of patients. It is also rather obviously not performed during a telemedicine consultation as no medical professional can physically examine the patient. But the visit to a veterinarian? It’s cast as costly, inconvenient, or stressful. 

A screenshot of Fuzzy’s landing page.

Without a physical exam, the subtleties and nuances of a pet’s status cannot be observed and appreciated. It dramatically limits the acuity and depth of a patient's evaluation, but you’d never know that from telemedicine providers like Dutch, Fuzzy, or Vetster. In fact, it’s hard not to get the sense from these pages that they’re happy to leave the diagnosis to the pet owner (decidedly not a “client”), seemingly inviting the diagnoses of “Allergies” or “UTI” to the user, rather than to a veterinarian. 

A page accessible without a veterinary consultation (or even human interaction).

A screenshot from Dutch Pet’s homepage.

How fortunate this pet owner would be to find Fuzzy or Dutch Pet! So they could “Get prescriptions without costly vet visits.” I bristle especially at the use of the word “costly” here, a word connoting not only financial expense, but a sense of loss, suffering, and disadvantage. How often, I think, that I’ve been able to detect bladder stones, urinary crystals, even cancer thanks to the opportunity offered by performing an actual physical examination at a “costly vet visit.” An awful lot of good medicine has been performed, as well as suffering and loss avoided, thanks to those “costly vet visits.” The author of the page also incorrectly uses the word “symptoms” rather than “clinical signs.” The symptoms are apparent to the patient, the clinical signs evident to the doctor, and, notably, there is a term commonly used for clinical signs observed by the pet owner: such observations are noted in the “History” or “Subjective” part of the physical examination. In this new advent of telemedicine without VCPRs, the “Subjective” aspect of the evaluation becomes the primary aspect of the evaluation and the responsible practice of veterinary medicine is derided as “costly” and we unfairly and improperly rely almost exclusively on the experience and expertise of a pet owner.

”As disruptive technologies and innovations develop, we will be forced to adjust our mindsets, clinical workflows, and businesses to meet the ever-evolving needs of our clients who want to use these technologies,” writes Jessica Trimble, DVM, in Veterinary Practice News. Dr. Trimble served as Fuzzy’s Chief Veterinary Officer and her husband, Robert Trimble, DVM, co-founded the company. She’s currently listed as Chief Veterinary Officer of another company selling telemedicine, though apparently one with a valid VCPR. I respectfully but emphatically disagree with what’s implied and alluded to in a statement like Dr. Trimble’s, especially when it comes from someone whose spent most of their career as corporate officer for telemedicine companies. Using consumer demand and advancing technology as justification for providing an inadequate, unsafe product is like selling leaded gas because it’s cheaper to manufacture and cars need gas to move. ("When leaded is gone, there is no question that one result will be higher costs for consumers," said Ron Jones, director of refining at the American Petroleum Institute, a trade organization, in an article in the Washington Post. Meanwhile, estimates have found that every year, leaded fuel bans save more than 1.2 million lives while helping the global economy avoid $2.4 trillion in healthcare expenses and other costs according the United Nations Environment Programme.) While a consumer might prefer a cheaper option, the provider’s professional ethical responsibility is to identify the risks associated with the product’s use and offer the consumer something better. Bizarrely, veterinary telemedicine companies are enthusiastically offering a worse product, a practice widely regarded as irresponsible and dangerous, and actively demeaning a better one as costly and inconvenient.

Telemedicine companies are using the same tactics employed for decades by the likes of petroleum producers as noted above, but also chemical companies, soft drink companies and sugar producers, and tobacco companies. Such self-serving behavior is not limited to telemedicine companies in veterinary medicine either. But we really ought to knock it off. And not just because it diminishes our profession - it does, or because it’s providing a lesser quality of veterinary care - it is, or because of any moralistic, self-righteous reason I’ve mentioned to date. It’s also because this sort of behavior exploits the most vulnerable populations of our clients. By offering lower prices and lower quality these companies prey on the desperation of those impoverished, elderly, disabled, or otherwise vulnerable individuals who may not have the resources to adequately identify the risks associated with these services or, worse, they may believe they have no other choice. Vulnerable populations often do not have ready access to the same information or resources, frequently making them more susceptible to unscrupulous “it’s better than nothing” marketing tactics.

“Telemedicine is a tool of practice, not a separate discipline within the profession,” states the AVMA webpage on telemedicine. The aggressive marketing of telemedicine providers like Fuzzy, Dutch, and others seems to have us believe that telemedicine is broadly legal and legitimate in every form. Technology and communication means have advanced there’s no doubt, with a booming need driving innovation and refinement during stay-at-home mandates during the Covid pandemic. We’ve certainly got the technological tools to do a consultation, and there seemingly exists the economic demand, but the addition of a “could” and a “would” doesn’t amount to a “should.” In a time when hard-earned professional expertise is under assault more often and in more ways than ever before, we should staunchly and vocally refuse to further diminish ourselves by participating in these telemedicine providers that openly demean the value of our service. We need to keep a real VCPR intact. Veterinary care cannot be provided only with a snapshot and a bottle of pills. The work necessitates hands-on, in-person evaluation and participation, a fact we’ve taken as gospel for more than a century until it became technologically possible and economically rewarding to do a much worse job in much less time. Then we suddenly see telemedicine providers describing the most basic practices of medicine as inconvenient and “costly.” Our professional expertise should not be sold off so cheaply, our life’s work should not be cast off so churlishly, and we ought to stand up for what’s right more resolutely.