If you were to walk into the Mount Sinai medical centre in Harlem, New York, you’d be forgiven for thinking you’d accidently entered a stereotypical American sports bar instead of a clinic.
The male patients in the waiting room are sitting on plush couches and watching live sports on giant flat-screen TVs while the walls are lined with memorabilia featuring the local hockey team.
It’s more “man cave” than doctor’s office, and that’s the point. The clinic offers a relaxed place for men charge up their smartphones, help themselves to hot drinks, and most importantly, wait to see a doctor.
And this new style of clinic isn’t the only model vying to capture a slice of the male health market. In the online space, men are being swamped with advertisements for online services offering “real doctors” and “real treatments” the instant they enter their health concerns into a browser.
The advertising focuses predominantly on a select suite of issues: hair loss, erectile dysfunction, sleep problems, herpes and mental health and capitalises on the relative reluctance of men, particularly younger males, to attend GP surgeries compared with women.
Earlier this year, the Australian Institute of Health and Welfare reported that almost 20% of Australian men felt they had to wait an unacceptable amount of time to get an appointment with a GP.
It’s these men, seemingly, who are turning to private companies offering on-demand GPs via telehealth consults and the discreet home delivery of prescribed medications.
WHO ARE THE PLAYERS?
The “bro-ification” of men’s health has existed in different forms for decades, unfortunately often by unscrupulous operators presenting a façade of medical professionalism while really just being entrepreneurial ventures.
In July this year, the Federal Court ordered Peptide Clinics Australia pay the Commonwealth $10 million for breaching mandatory rules for advertising prescription medicines.
The federal Department of Health said the penalty was due to the clinic: “Giving the impression that medical practitioners were involved in the business and misleading consumers to think that those practitioners were acting in their best interests”.
Another clinic which came under public scrutiny was the Advanced Medical Institute, notorious for their giant yellow billboards asking ‘Want Sex Longer?’ which littered Australian highways until being banned in 2008 by the Advertising Standards Bureau.
However, in more recent years, the start-ups offering online consults and discreet scripts are increasingly marketing themselves as offering a genuine medical service, using skilled GPs and state-of-the-art technology to ensure a high-level of patient safety.
In Australia, some of the newest players include MOSH and Pilot.
Both of these companies employ Australian GPs who perform telehealth consults with patients.
The way both these players operate is similar: patients pay a fee to talk to a doctor, and, if treatment is recommended, the patient signs up to a monthly subscription to receive medications delivered to their door.
Both companies are modelled on a successful UK-based company called Hims, which has been valued at $1 billion earlier this year.
These subscription-based medication services have proved so successful, a number of these companies are now expanding into women’s health as well.
But while the telehealth service might be proving popular with patients, some health professionals have expressed reservations.
Dr Michael Lowy, a sexual-health physician based in Sydney, says it is a concern that men are choosing to talk to doctors online rather than face-to-face.
Given the complex nature of some patients’ conditions, just how effective could a consult really be when you don’t see the patient face-to-face, says Dr Lowy who runs a men’s health clinic which treats conditions also commonly being treated in these online clinics.
“I find most of my patients come to me after finding my clinic on Google, but the difference is that I don’t treat the patients online or by phone. I need to see my patient and perform an examination, if that is required.”
It was also troubling almost all of the male telehealth clinics asked their patients to sign up to a subscription service in order to receive medications.
Dr Lowy says this could be troublesome for patients who don’t understand the financial arrangement they may be entering into.
Charlie Gearside, a co-founder of the online men’s health platform called Pilot, says his platform is trying to be vigilant in only accepting patients which it deems to be suitable for telehealth consults.
LEAVE IT TO THE EXPERT
“We leave it completely up to the treating doctor to make a decision on whether they choose to treat the patient or refer them on to a local GP,” he tells The Medical Republic.
Patients who use the Pilot telehealth platform must create a medical profile before selecting the area of treatment they seek such as hair, sex, skin, sleep or mental health.
They are then required to answer a long medical questionnaire, not dissimilar to the paperwork required by some GP practices when they accept a new patient. To book a telehealth consult with a GP, the patient pays a fee of $20, after which they will hear from a GP within 24 hours.
“From there, the doctor determines whether the patient’s right for telehealth or not,” Mr Gearside says. “In the case that it’s suitable and safe to do telehealth, the doctor will create a treatment plan which includes a script and the medication is mailed to them.”
It’s the discreet nature of telehealth, and the home delivery of medication, which makes it attractive for men wanting to manage health conditions which may be stigmatised.
Most of the patient feedback on these telehealth sites commend the fact the companies provide a simple consult with a GP without facing the embarrassment of having to visit a clinic in person or pick up an easily identifiable medication at the local pharmacy.
And there also seems to be a level on honesty conveyed through men’s telehealth consults which may not always occur in-person consults.
“Our doctors tell us that people are a lot more open and transparent because they don’t have to be face to face,” says Pilot co-founder Tim Doyle.
Users seem to tell the (online) GPs more about their lifestyle habits, including drinking, drug taking and problems with sexual function, with less hesitation experienced in face-to-face consults.
“There’s also the convenience element of patients being able to seek healthcare on their own time, which is important when people are shift workers or busy office workers,” Mr Doyle says. “Some have said this also helped them adhere to treatments, where otherwise they would have let the prescription lapse, or not sought treatment for conditions that have affected them.”
CONVENIENCE VERSUS BEST PRACTICE
When it comes to safe and effective healthcare, convenience doesn’t always coincide with gold standard care. Most concerns about private telehealth platforms arise because the service is isolated from a usual doctor-patient relationship.
According to the RACGP position statementon telehealth services, digital consults should be provided according to these principles:
- That on-demand telehealth services are ideally provided by a patient’s usual GP or practice and only provided when deemed appropriate by the GP
- That a patient has a stable and ongoing relationship with their general practice, which provides continuous and comprehensive care
- A GP should only provide on-demand telehealth services to a patient when appropriate (e.g. if physical examination is required for effective assessment an on-demand telehealth service should be avoided)
- That on-demand telehealth services can complement traditional consultation methods, helping to facilitate the partnership between individual patients, their usual GP and extended healthcare team
The RACGP also said that many of the risks associated with telehealth are reduced by doctors having prior knowledge of the patient history and access to complete medical records.
But when asked how the company is ensuring patient safety, Pilot says it is able to pause the consult at any time to direct patients to a pharmacist for a blood pressure reading which may be required before a doctor prescribes some erectile dysfunction drugs.
“We understand telehealth isn’t for everyone and we think, in reality, there is a huge gamut of conditions that can only be properly dealt with in a physical examination environment,” Mr Doyle says. “We’ve tried to remain very narrow about what we do, and then build deep experiences around very specific conditions where there is pre-questioning and a discussion around mental health has been a fundamental part of the experience.”
But the GPs who work for these men’s health companies also have to rely on patient honesty as well. Dr Matt Vickers, a GP at Harold Park Medical Centre in Sydney and working for the telehealth company Pilot, says that at first he was hesitant about being able to ensure patient safety on the platform.
But within a couple of months, he was pleasantly surprised by how comprehensively patients filled out the pre-consult information forms and well they actively participated in the text-based consultations, asking relevant questions and expressing any concerns.
“Some patients definitely need prompting. You get similar issues in face-to-face consultations where patients just don’t really say anything, and via text that sometimes happens as well,” he says.
“[But] it’s been structured in a way that most people are quite comfortable divulging quite a huge amount of information including issues they’ve had for 30 years but never discussed with anyone before.”
Dr Vickers says he has full clinical autonomy in his telehealth practice.
“GPs are not being forced into providing treatment or continuing with consultations where it’s not appropriate,” he says.
While some people may be sceptical of online treatment, it is providing another line of protection for patients who may otherwise try and source prescription medications from illegal online pharmacies, he says.
If you type ‘buy Viagra online’ into a search engine, you will be bombarded by hundreds of faux pharmacies based in countries such as India and Indonesia which will sell and ship generic erectile dysfunction drugs to your door, no doctor required.
These companies, unlike men’s telehealth services, are entirely in the business of selling medication directly to consumers, with all the risks inherent in this practice, such as medications containing either not enough, or too much, of the active ingredient.
To try and crack down on this black market, countries such as the UK and New Zealand have down-scheduled Viagra, allowing it to be purchased over the counter.
But in Australia, the TGA rejected the latest application to have the well-known erectile dysfunction drug reclassified, saying it was unsure if the risks surrounding these drugs could be managed in a pharmacy setting.
At the very least, these telehealth services play a role in helping to mitigate some of the risks for men sourcing pharmaceutical treatments via
RISK TO TRADITIONAL GENERAL PRACTICE
And while telehealth proponents are keen to list all of the advantages of this new model of healthcare, how do they address concerns about telehealth services encroaching on general practice.
“I don’t think these [telehealth] companies are taking away from regular general practice, but instead providing just another avenue for treatment,” Dr Vickers says.
Telehealth, he says, can be useful in a variety of consults which are unlikely to take place in your traditional nine-to-five general practice anyway.
“In my face-to-face clinical practice, the vast majority of our patients are young professionals and young families who struggle to get in to see us during business hours, and so we have quite a lot of quiet time in the day.”
And as well as the convenience factor, there are many other reasons who would not have otherwise presented to a face-to-face general practice might employ telehealth services.
Dr Vickers thinks everyday clinical practice could be enhanced, rather than replaced, by online care models. And he isn’t alone.
RECLAIMING THE MARKET
Dr Amandeep Hansra, a GP and digital health consultant, says GPs can’t ignore the reasons men are seeking help from online health clinics in the first place.
“These companies have a consumer-centred approach that we are missing in healthcare and they have found a niche in young men who are disengaged from primary care,” Dr Hansra says.
“What we should be doing as GPs is asking ourselves what is driving that need for consumers to turn to these services? What are we not doing as a profession to engage with young men and make them realise they can get those services from us? How do we convince them that we will do all the things we need to do in terms of anonymity and convenience and provide a good seamless customer experience?
“The reality is that some of these patients, without these services, would not see a GP at all. So, we can’t get angry at these start-ups unless we are willing to solve these problems ourselves.”
One solution, Dr Hansra says, could be for the RACGP to start campaigns which tell patients the types of services their community GP can offer, which includes treatment for erectile dysfunction.
In addition, there was a need to cater for patients who were unable to afford private telehealth services. Existing item numbers for telehealth are only available on the MBS for consults with patients living in isolated rural and remote settings, despite GP advocacy of its usefulness in everyday practice.
The Department of Health told The Medical Republic it was examining possibilities of expanding telehealth services through their Primary Health Care 10 Year Plan.
But while this strategy will involve helping GPs deliver timely telehealth care to people aged from 70 years, it was unclear how GPs would be remunerated for the additional services, or if there were plans to expand these consults to include younger patients.
There’s no doubt, given their ever-increasing popularity, these online telehealth services are addressing a real gap in the market. They look set to continue to flourish and expand beyond the current men’s health model, but only for those who can afford it.
For better or worse, unless these services become Medicare-rebateable or the regulations change, it is likely online GP services will remain the success story of the patchily regulated, but entrepreneurial, private sector.