A second opinion, available from afar

  • Article by: MAURA LERNER , Star Tribune
  • Updated: June 8, 2008 - 10:31 PM

Although he had never met her, Dr. William Marshall knew a lot about Paulette Schlander.

He knew that Schlander, who lives in Duluth, had gone to Africa on safari with her husband last fall.

He knew, too, that the 58-year-old dental assistant started experiencing strange muscle pains about a month later.

Now he was trying to figure out whether the two events were connected.

In the past, Marshall, an infectious disease expert at the Mayo Clinic, would have invited her to Rochester for a full exam. This time, he didn't have to.

For the past year, he and other Mayo physicians have been offering "virtual consults," or second opinions by e-mail, to a Duluth clinic, SuperiorHealth Center, where Schlander is a patient.

As part of a pilot project, Marshall and his colleagues have tried to solve dozens of medical puzzles, sight unseen, involving patients with cancer, diabetes, heart disease and other disorders. They rely almost entirely on records, images and lab tests to answer specific questions about diagnosis and treatment posed by the Duluth doctors.

So far, the numbers have been small. But some say it's a preview of things to come, as technology makes it easier than ever to render a medical opinion from a distance.

"It's been a really remarkable learning experience," said Dr. Doug Wood, a cardiologist who leads the virtual consult program at Mayo. "We're learning that there are many more things that you could do [this way] than some people might have imagined."

For example, he said, many patients are sent to him for pre-op checkups to clear them for surgery. But most of the information he needs, he said, is available at the touch of a button, including MRIs and CT scans and batteries of lab tests. "I can certainly imagine, fairly soon, I would be spending more of my day working from the computer rather than in face-to-face visits."

Supporters readily admit that virtual consults don't work in every case. But when they do, they can save time and money, and spare patients the need to travel or take time off work to see a specialist. "[It's] a faster, better, cheaper way to deliver care," said MaryAnn Stump, chief innovation officer for Blue Cross Blue Shield of Minnesota, which is sponsoring the Mayo experiment.

Skeptics, though, worry about what might be missed. "It certainly creates a wide opportunity for negligence," said Thomas Malone, an Atlanta lawyer who heads a national group of malpractice attorneys. "The idea of any doctor making a diagnosis without seeing a patient is second best at best."

Stalking an illness

Last September, Schlander and her husband, Tom, arrived at a hunting lodge in South Africa for a long-planned adventure. For two weeks, they hiked in the bush, went on safari and had a "fabulous time."

The muscle aches began a month later, starting in her legs and spreading to her shoulders, arms and joints. Before long, Schlander, who had been in good health, was in so much pain she couldn't sleep. Her first thought: "Maybe I had picked up something in Africa."

Her family doctor, Dr. Carol Farchmin, ran tests for everything from malaria to muscular disorders. "Her illness didn't fit any clear picture," said Farchmin, who acknowledged she's "not real acquainted" with every travel-related illness in Africa.

She suggested Schlander try a virtual consult, at no extra charge. Schlander's reply: "That's great."

Her medical history and test results were sent to Mayo, along with a question: What other tests, if any, might shed light on her problem?

Ordinarily, it can take weeks or months to get an appointment with a Mayo specialist. But with virtual consults, the goal is to respond within 48 hours. The average is just over 26 hours, Wood said.

In this case, Mayo tapped two of its specialists, Marshall and Dr. Eric Matteson, a rheumatologist, to study Schlander's case. They said it took them each about 20 to 30 minutes to render an opinion, which was sent back to her family doctor in Duluth. The consensus: Schlander's symptoms didn't appear to fit a bug bite or other infectious disease, though that couldn't be ruled out completely. They suggested checking for other symptoms -- such as skin rashes -- and other clues that might lead to the culprit.

Eventually, the tests pointed to a probable muscle disorder. The Africa trip, it turned out, probably had nothing to do with it.

"It certainly was a help to me," said Farchmin, the family doctor, of the virtual consult. "It's helpful to bounce some ideas off of someone with a little more background, and help us feel a little more confident about the direction we were going."

Schlander said she was reassured as well. "I have total faith and trust in [Dr. Farchmin], she's such an excellent physician," she said. "But I thought it was a good idea to go through with this and see what they thought."

Valuable input from experts

Sometimes, the virtual consult has changed treatment decisions. In one case, Farchmin said, a patient was facing the possible loss of a kidney when his doctor decided to seek Mayo's advice. A Mayo specialist suggested an alternative treatment and now the patient is recovering, his kidneys intact, she said.

Still, the doctors admit they're cautious about the hands-off approach.

"We have to consider, do we have enough information about the patient to really make a reasonable judgment?" Matteson said.

If not, says his colleague Marshall, "we have to be very much willing to say, 'I can't answer this question without actually seeing the patient.'"

So far, only a small fraction of the patients have ended up at Mayo for a follow-up. But in those cases, the virtual consults "grease the skids" for their arrival, speeding up their treatment, clinic officials say.

The experiment with the Duluth clinic, which began in March 2007, was so successful that Mayo is planning to try it in the Twin Cities as well, said Barbara Spurrier, head of Mayo's Center for Health Innovation.

Some, though, say this is part of a trend that's making medicine even more impersonal. "I'm afraid you'll be moving further away from doctors spending time with patients, and they spend precious little now," said Malone, the malpractice lawyer, who is president of the American Board of Professional Liability Attorneys. "That would not make medicine better."

But health reformers say it could make it much easier for patients to get expert opinions. "It's exciting, quite frankly," said Dr. Ed Wagner, director of the MacColl Institute for Healthcare Innovation at Group Health Cooperative in Seattle. "Some folks have estimated that a significant percentage of those specialty visits ... could be avoided if there were other ways of getting those questions answered."

The big stumbling block, for now, is who will pay for virtual consults. While Blue Cross subsidized the Mayo experiment, that's still an open question.

Wood, of the Mayo Clinic, believes they'll find a way. "Even if you had to pay for it out of pocket, wouldn't that be preferable to taking a day off of work, driving all the way to Rochester and back with an overnight stay?" he said. "That's the piece that we're still trying to work on."

Maura Lerner • 612-673-7384

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