Having delivered a lifetime’s worth of remote care, I’ve seen the limits of telemedicine, and it’s ball pain.
In the era of social distancing, telemedicine has fully arrived. It promises to solve the ills of health care, both immediate needs during the present crisis and endemic faults beyond. Rural communities gain access to distant experts, waiting rooms disappear, you can remain sheltered-in-place, and almost everything is cheaper. Legacy HMOs and startups proudly trumpet how they give 24/7 access to a smiling person in a white coat through a smartphone. Amid the pandemic, insurers have dramatically changed payment regulations, making telemedicine financially workable.
Dr. Robert Lurvey is a urologist in private practice in California. He has provided health care through telemedicine in government, private, and academic institutions.
I too once believed in telemedicine’s universal promise. I am a urologist, and years ago, I eagerly developed scripts, triage algorithms, and the right amount of inflection to make a phone call about urination into the most sincere expression of human compassion one can muster through a landline.
To be sure, telemedicine has incredible value in the reaches of mental health, in which human connection is the foundation of treatment. A doctor can also reliably share a lab result or medical image and help patients make decisions based on them over the screen. Tele-pathology, tele-dermatology, tele-radiology—all were doing handsomely long before entire health systems tried to conserve the resource of physical distance.
But telehealth has its limits, some of them user-generated. Beyond basic technological illiteracy, many doctors and patients are just not good on a phone or webcam. Some don’t know how to fill awkward silences, others don’t know how to stop filling them. In person, we can use the indescribable cues that come from physical presence to regulate the back and forth. But on the phone, here we sit, alone, with our words.
Sure, users can be trained, and technology can get more user-friendly. But there remains a fundamental flaw in delivery of care from afar, and ball pain exposes it.
The urgency scrotal disquiet causes needs little explanation to half the population, nor the other half that generously listens to the complaints. Medically speaking, even in a pandemic, ball pain demands attention because of the vast differential diagnosis that includes threats to life or limb. Is it a cancer, testicular torsion, herpes?
When I try to address ball pain with telemedicine, I can’t solve it. The worst is ruled out through objective medical history, labs, and ultrasounds, but then the pain persists and I remain stumped. Video doesn’t help; even in a clinical realm, a man gesticulating over his scrotum on a webcam is of limited informational value. For some reason, I just need to be there.
For one, we lack a common language for the location of pain. Many men have a hard time articulating their own scrotal anatomy, let alone in standard terms. For the purpose of “localization,” the scrotum is a vast playing field from the penis to the thigh. Complicating this is the fact that the scrotum hangs. When the object of interest can find itself overwhelmed by other hanging things, like hernias or a skin flap, is it pain in the balls or somewhere else? The map is fluid.
We also lack a common language for pain itself. Pain is real, but also subjective. One man’s scrotal vice is another man’s pleasure. And when one seeks objective advice on a subjective matter, there needs to be some kind of standardizing metric. What one means by pain cannot be communicated well over the internet. Instead, and I wish that there was a workaround here, an exam of the “the area of concern” is surprisingly necessary to frame the patient’s ailment into the language of the doctor’s clinical experience. Is there a wince or stoicism with a touch here or there? I need to examine in order to say, “The pain is coming from inside … that cyst that is small and benign.”
Finally, for treating ball pain, reassurance is a common treatment, and here too physical presence communicates a common language better than any webcam. Incidentally, this is also true of other aspects of medicine and life, from cancer discussions to airline customer service. Perhaps physical presence reassures so much better because when you occupy a space with another, you know they cannot abandon your cause except by force or sneaking out the back, both choices curbed by some innate guilt.