Abstract
There is a huge interest in human factors elements that are permissive or prohibitive for adoption of telemedicine technology by caregivers or patients. This is terribly important and to be encouraged. However, when something works it just works! In those instances perhaps a little more study of spontaneous acceptance might be informative.
There is a mobile surgical program in Ecuador developed by Dr. Edgar Rodas that has been bringing elective surgical care to remote and underserved populations since 1995. The program has always been deeply integrated into primary care, soundly based on protocols of acceptable indications, and supported consistently by quality data. The program became a test bed for telemedicine some years ago by reviewing the patients before deployment of the mobile unit to a distant site. In the telemedicine activity the patients were reviewed by store-and-forward and then interviewed by low bandwidth videoconference. The use of telemedicine allowed abbreviation of the screening of patients and expansion of the actual surgical service time when on site. In addition, the patients could be followed afterward by telemedicine. How was the program accepted by the patients?
It was another tropical day in Macas, Ecuador, on the high and serpentine banks of the Rio Upano rushing from the high Andes to the Amazon. Mt. Sangay was spewing a desultory cloud of ash from its elegant cone in the southwest, and the scudding clouds promised to gather for the afternoon rain later that day. The surgical truck had arrived the night before and was parked in front of the small hospital that served this provincial capital of a few thousand people and the surrounding jungle. There were no staff surgeons. The bus bringing the volunteers and staff pulled up to an awaiting crowd of patients, local doctors, nurses, family, and the curious. Juan stood waiting. He was barely 5 feet tall, and his squat frame showed not only his Shuar Indian ancestry but also the effects of 60 years of laboring on his small farm coaxing out crops of fruit and corn that supported his family and a few farm animals in a field that he moved from time to time in a slash and burn agriculture that had used this land prudently for thousands of years. He was muscular and somewhat bent from the labor. Radiographs of his long bones would have shown the damage of labor beyond the design of the human frame with calcifications of the tendons and irregularities at the muscular origins and insertions that had nearly avulsed from the powerful pull of muscle against the resistance of loads as heavy as he and more. He stood as tall as he might to see the arrival of the bus over the heads of the waiting doctors, nurses, and others. Juan had a disabling hernia that had been symptomatic for many years, but the long trip to the city for definitive care was not feasible. He could not leave his family or farm for the several weeks and could not afford the trip if he had had the time. So he suffered with his toil as the hernia protruded ever larger and painfully as he pulled weeds, hacked at unwanted plants with the machete strapped to his side, and carried enormous bundles of vegetation and supplies. The doctors coming off the bus amid cheers in their scrub suits and white coats might have been on their way to a conference at the academic medical center they called home back in the high cool Andes. But they were in the jungle, and stepped onto the volcanic dust of the road still wet from last night's heavy rain. They had been in the bus overnight driving down from the Sierra and should have been tired. However, they looked fresh and ready to go to work. The surgical truck had tents set up for perioperative care, and there was a satellite dish pointed at a reliable geostationary site that would connect during their work back to colleagues in the mountains or the United States for information support. Computers held the preoperative data and surgical plans for the next several days' endeavor. Birds in the tropical trees were in chorus as the people gathered, and the human noise level increased.
Juan looked intently at the emerging surgical team, and suddenly his face broadened into a smile of recognition. He turned to the person next to him and said, “That is my doctor!” The fellow he addressed knew that Juan had never been out of this area and that the doctors had never been here before. “How do you know?“ the fellow asked. Juan had had a videoconference with his surgeon for the physical exam and informed consent several weeks before, and he had completed all the instructions given him for preoperative care. He knew what to expect in the surgery, and his family was ready to care for him in the days following until he was ready to resume his work. “I met him on television!” Juan proudly proclaimed. He hurried forward and gave the surgeon a handshake and hug that spoke volumes about the trust, confidence, and familiarity that had been mediated by a simple videoconference. The surgeon recognized Juan and returned the greeting. Tomorrow Juan would have his hernia repaired with a safe anesthetic, in a surgical environment of proven effectiveness. His team knew he was a superb candidate and that the primary care doctors had done all the screening necessary. The surgical instruments were ready, and the supplies just for Juan had been sent forward. His electronic record would be populated with the next steps in his care, and he would be on his way to robust health again, supporting his family and making his life work.
In this tableau of recognition and affection, questions about technology acceptance models seem impertinent. Those questions are in fact of utmost importance in the process of putting telemedicine into the mainstream of global healthcare. However, Juan believed in the system that had come to provide care he could not otherwise expect. He was informed, empowered, and ready. The surgical team was confident in the plans, preparatory screening, and their work environment so carefully built around a telecommunications and information framework. They knew they were in an electronic continuity with their very sophisticated medical environment and full medical staff back home and that they could embrace Juan with all their skill and caring with complete confidence in the care continuum. Telemedicine works!! When we have the right application, as in this case, acceptance is more intuitive than contrived. Juan is ready. Are we?