 "Instant medicine")
"I feel unusually dizzy and nauseated, especially at night."
"Get investigation blood sugar (sic), liver function test. Check blood pressure. Take tablet Pantop D SOS (when feel nausea or abdominal discomfort)."
This online exchange took place between a doctor and me a few weeks ago. The physician, who described herself as a "specialist in psychiatry, general practitioner and sexology", had suggested a prescription drug without so much as a cursory examination, a look into my medical history, or even knowledge of my gender or age.
The advice - 130 characters, to be precise, in response to my 50 - was doled out free on a question-and-answer forum on iCliniq, a Coimbatore-based health portal.
Always wary of free advice, I turned to Sehat, a Hyderabad-based health portal. Here, I paid Rs 149 to post a similar question to a "general physician". More than an hour later, I received my diagnosis on email.
"The most common cause of dizziness in an otherwise healthy male is dehydration or hypotension which can subsequently initiate a feeling of nausea thereto." The nausea, I was told, can be aggravated with dyspepsia and gastritis as well. "You may take tablet Pantoprazole (40mg) once a day at 10 am in the morning for the next five days, which shall help you overcome your dyspepsia and tablet Perinorm (10mg) once a day for the next three days to overcome nausea."
If the doctor at iCliniq did not bother to ask me my gender, the one on Sehat got it wrong - I'm a 28-year-old woman. The advice did not carry the name of a doctor.
"There could be a thousand causes of dizziness and nausea," says Jitendra Mohan Hans, looking at the medical advice I received from the two health portals. At his office in the outpatient department at Saket City Hospital, a multispecialty facility in New Delhi, the ear-nose-throat specialist rattles off a list of what could possibly be wrong with me: it could be related to the brain, joint pain, thyroid, inner ear, spinal cord, eye problem, epilepsy, migraine.
"Diagnosing dizziness is so complicated that it can sometimes make the doctor dizzy," Hans provides some comic relief during our serious conversation, before advising caution. "Before prescribing that medicine, the doctor should have at least made sure you did not have a history of liver problem."
The doctors on the two portals suspected none of that before suggesting medication. Did I expose myself to medical risk by seeking their advice?
What is certain is that an increasing number of people in India, pressed for time, are turning to such portals for medical counsel. They cost much less to set up than brick-and-mortar clinics, and are a logical extension of the current fad of e-commerce: when diapers and potatoes can be sold online why not medical advice?
Delhi-based Lybrate, according to its co-founder, Saurabh Arora, is "larger than the largest healthcare facility in the country." In July this year, the Delhi-based health portal that lets users consult a doctor on the phone, email and even WhatsApp secured Rs 67 crore from Ratan Tata and other investors. More than 90,000 doctors serve on the platform.
With more than 100,000 registered users across 160 countries, iCliniq boasts more than 1,000 doctors available for online consultations. Sehat's founder Suresh Kanumuri says with more than 10,000 doctors, the portal is visited by 12,000 to 15,000 users every day.
In a country where there is only one doctor for every 1,700 people and where most people need to travel more than 20 km to reach a hospital, health portals' claim that they seek to bridge the doctor-patient gap cannot be faulted.
However, the nearly conclusive answers by two doctors to my vague query raise several questions. Where should a doctor draw the line in prescribing medicine online without an examination? Is it possible for a doctor to know what's wrong with a patient with so little evidence? Who will bear the legal liability if the treatment goes wrong: the technology platform or the doctor?
Those who swear by the online healthcare delivery model are quick to point out that in 70 per cent cases, a visit to the doctor is unnecessary - these problems can be resolved remotely.
"I'll give you a more optimistic number. Ninety per cent of health problems can be solved online," says Dhruv Kumar who founded iCliniq in 2010 soon after he graduated as a mechanical engineer from Guindy. "It's very easy. It's like finding something on Snapdeal, Amazon and Flipkart."
Kumar insists that there is no room for laxity when it comes to answering health queries online. "We have a pucca process," he says with confidence.
"We train doctors to put forth the right questions to the patients," explains Subha, a 27-year-old dentist - also, Kumar's wife - who makes sure that doctors registering with the website are competent enough to handle patients remotely. "We give them dummy queries at first and get those answered by doctors. And only once they are fully trained and we are satisfied with their answers do we let them answer real queries."
Is the training good enough?
In response to a post on iCliniq in which a 21-year-old woman has been "suffering from throat pain, headache, weakness and sickness for last two days," the doctor has deduced that the patient is suffering from a "simple viral infection" and advised the use of antibiotics, apart from an over-the-counter drug.
Similar prescriptions can be found on eVaidya, a Hyderabad-based health portal. A chronic headache accompanied by vomiting, described in about 60 words, is seen as indicative of "migraine", and so the patient has been prescribed a combination of anti-migraine drugs for "acute attacks." A query that reads "terrible headache and fever, it's worst in the morning" has received a brief response in which the doctor has prescribed two medicines without further questions.
The health portals follow different business models. Some allow doctors to register for free but take a cut from the fees. A few charge doctors money to join - with the promise that it will help them expand their practice. This is especially attractive for upcoming doctors.
"It's a market-oriented practice, where your qualification and experience don't matter much," says Hans. Seeing how some newly minted medical graduates were starting to see a surge in consultations owing to their presence on the internet, Hans decided to give it a shot. "But it hasn't made much of a difference to my practice," says Hans who sees 20 to 25 patients a day.
Online reputation does seem to matter, but only to an extent. "You obviously feel happy seeing your name come up on Google search," says Anshul Varshney, a Ghaziabad-based doctor. However, he admits that a virtual consultation cannot replace an in-person visit.
Others look at online consultations with a sense of misgiving.
"A very important aspect of the medical field is to see and touch the patient. You would look at the eyes, nails and tongue. Sometimes the person is not able to convey what exactly the problem is. A loss of appetite and dizziness could be anything from simple gastritis to brain tumour," says Dilip Bhalla, senior consultant (nephrology) at Max Super Speciality Hospital in Delhi's Patparganj. "It's very important to have the person in front so that it becomes a goal-directed investigation."
Doctors have used the digital medium for long but only with patients they know well and where physical examination is not required. (Doctors who receive queries from abroad on e-mail suggest just a broad line of treatment -no prescriptions.)
I, on the other hand, had far from an established relationship with any of the doctors on the portals. When asked what he thinks of those prescribing medicines on online health portals without examination, Krishan Kumar Aggarwal, secretary general of the Indian Medical Association, or IMA, doesn't mince words. "How do you know that the doctor who's prescribing medicines is not an agent of a pharmaceutical company?"
IMA is working on a code of ethics for telemedicine, although the extent to which it will cover health portals is not clear.
Those who have been in the business of long-distance healthcare before any of the online health portals came up understandably have reservations about the mushrooming of health websites.
"There is no organisational maturity," says Apollo Telehealth Services CEO Vikram Thaploo. "What has happened with some of these new forums is that a couple of engineers came out of college, spent a couple of months, created basic software, got a bit of funding here and there, and then did some marketing."
If something were to go wrong as a result of the medical advice I got on the health portals, what would be my legal recourse? Most portals that offer medical advice are careful to put out an elaborate disclaimer, the crux of which is: the risk lies with the user.
Moreover, it doesn't help that most portals, on the surface, claim to be meant purely for providing information and second opinion. "The onus would be on the patient to prove that he suffered the injury because of the drug that was prescribed on the online platform. The liability in such healthcare practices would be very important and proper documentation would be very vital in mitigating risk of liability for each stakeholder," says Milind Antani, partner-in-charge (pharmaceuticals and healthcare practice) at law firm Nishith Desai Associates.
The question of liability seems even more striking in the absence of a clear regulatory framework for digital healthcare delivery in India. At present, the country lacks a law that singularly deals with online healthcare delivery, let alone online medical advice.
The Information Technology Act, 2000; the Drugs and Cosmetics Act, 1940; and the Indian Medical Council Act, 1956 do address concerns about medical negligence, cyber security breach, manufacture and sale of drugs, and so on. Moreover, certain guidelines pertaining to registration of doctors under the Code of Ethics Regulations, 2002, issued by the Medical Council of India could also apply to online medical consultation.
"It is vital that all the stakeholders involved, right from the service provider to the doctors, must comply with the regulations that affect them," suggests Antani, emphasising that it is the responsibility of the service provider to develop a system of "checks and balances" on its website.
"We are only facilitators. The accountability clearly rests with the doctor and the patient," says P B N Choudary, chief operating officer of eVaidya.com.
Others insist their processes are robust enough to take care of all misdemeanors. Lybrates's Arora says he has made it clear to doctors on the health platform he co-founded in 2013 that they should not move ahead during online consultations if they feel they don't know enough about the patient to be able to form an opinion.
On Lybrate's mobile app, the user would not be able to get a reply from a doctor until the age, gender, height and weight are disclosed. In fact, Lybrate has also partnered with IMA to train doctors in using technology to communicate with their patients.
Suresh Kanumuri of Sehat says he is more confident about the other health portal he co-founded, AskTheDoctor, which provides paid medical advice through email. The website, Kanumuri tells me, has rigorous quality checks, especially because it "answers international patients. Most of the questions on AskTheDoctor come from the US."
With Sehat, however, Kanumuri is "a little lean as of now. There's no sugarcoating here. Sehat is a little bit flexible. We're not doing it to that [AskTheDoctor's] level."
That might explain the advice I got from his website.
