Apr 8, 2020 9:00 AM

That Weird Pain in Your Nuts and the Limits of Telemedicine

Patients often don't know their own anatomy. Doctors often don't know how to talk about it over a screen.

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.

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.

Every field has its ball pain. That burden that cannot be described except with in-person presence. In-person presence is needed to get those bits of information that we still cannot transmit by text, voice, or video. Perhaps it’s the aura of trust and understanding that is built from presence, the “water cooler” moment camaraderie for which a pet-related Slack channel is a poor substitution.

No one should ever hesitate to call their doctor. But reaching out to see if a matter deserves more evaluation is not a technological revolution; it’s been a professional courtesy since the 19th century. The innovation is compensation for this in the modern health care system.

But at this moment, assuming you unfortunately suffer from the described affliction, should you schedule that telemedicine visit or go into a hospital? The advice today is the same advice as yesterday and tomorrow: Talk to your doctor. Though we really don’t want anyone leaving their house today, remember, as we have learned from online delivery, behind the webpage are real people who may be overwhelmed with workflow right now. Doctors still run late, even in telemedicine clinics. For now, treat telehealth as you would treat any health care during a pandemic: Save it for emergencies. If the problem existed many months before the pandemic and you can continue with your day to day, then it can wait until after the pandemic. If there is a sudden change or you have any worry, call your doctor, get the telemedicine appointment. But manage the expectations of results, you may still have ball pain at the end of the visit.

Indeed, we need to accept that we cannot do everything remotely and we need to stop pretending like universal remote work is the new permanent normal, especially after the crisis passes. Failing to understand the limits of remote care is nuts, and would leave countless sets of them in pain.

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