So long, and thanks for all the fish

We recently had a discussion in the class I teach about the increasing popularity of telemedicine, and wondered if advances in telemedicine and e-communication would render the office visit as we know it extinct.

'Never!' proclaimed my students who were physicians, since the physical nature of the office encounter is critically essential to make the diagnosis. But is that really the case?

In the internal medicine universe that I live in, the emphasis is invariably on obtaining a good history, since most diagnoses can be made by the history alone; especially if relevant nuggets of information are unearthed during the process of history-taking. This then is the essence of the chase - the hunt for crucial information which can be processed to generate and modify a differential diagnosis; the clues on the treasure map that leads the clinician to the spot marked 'X'.

I remember my first attempts at videoconferencing, and how amazed I was by the tiny choppy pixelated images that would frequently stutter and freeze. Technology has advanced a great deal in the last couple of decades, and high quality video communication is now entirely feasible. A telemedicine interview is much easier to conduct today than it ever was in the past, and it might only a question of time before convenience trumps convention.

The title of this post is from Douglas Adams (I guess the dolphins are the telemedicine practitioners in this metaphor), but I was also thinking of the Arthurian legend of the Fisher King when I was writing this -- the Fisher King, much like the physician today, blights his kingdom because of his limited mobility and reach (unlike the promise of telemedicine, which truly offers clinicians an opportunity to practice as "médecins sans frontières").

Telemedicine is an upstart in the world of established medicine, but it has the potential to alter the delivery of patient care. Disruptive innovations like telemedicine will always displace the status quo to some extent, just like the concept of office visits displaced the status quo of home visits in the early 20th century.

And yes, I believe that the ultimate promise of HIT is that it will teach clinicians new ways to fish.


Christensen, Clayton M; Bohmer, Richard; Kenagy, John. "Will Disruptive Innovations Cure Health Care?" Harvard Business Review, September 2000.