Virtual MS clinics: The perks of being a digital nomad!

Neurology clinics anno 2020. Source:

As you might have experienced yourself when contacting your GP or consultant, the only tide that unfortunately has been turned so far is the NHS going fully digital. This means that I and all other Bart-MS consultants have been relying heavily – as in 99% of our clinic encounters – on virtual clinics to reach out to our MS patients since March 2020. People with MS are invited with an appointment letter (obviously delivered by the Royal Mail) to reserve a time slot in their agenda for a virtual clinic moment. This virtual clinic can be a telephone call or – less likely – a video clinic. The extent of this digital healthcare transition is huge, and it has become the new normal in every tier of the healthcare system. 

Imagine you are a person manifesting with symptoms suggestive of multiple sclerosis. Let’s say you noticed one week ago that you had a little bit less strength in your left leg while doing your weekly yoga class. The symptoms have evolved, and now you have difficulties doing stairs and your leg feels heavy all the time. You are really worried about this, and look for medical advice. The following scenario might be very common: 

  • You contact your GP who decides the symptoms are mild and already ongoing for more than a week. Your symptoms will be evaluated through a telephone clinic and, if interpreted correctly, you will be referred to the local neurology department.
  • You get a virtual appointment with a general neurology consultant in a couple of weeks/months. This consultant arranges a brain scan (MRI) and follow-up meeting. 
  • You come in to the hospital or MRI facility to have a brain scan. 
  • You get a new virtual appointment with the general neurology consultant who discusses the MRI findings and makes a referral to an MS consultant for a definite diagnosis/treatment. 
  • You get a virtual appointment with the MS consultant who decides the symptoms and MRI imaging findings are indeed compatible with multiple sclerosis. 
  • The MS consultant arranges for you to have one or more of the following: 
    • Bloods: done at your GP surgery or phlebotomy service of the hospital. Lab requests are made electronically. 
    • Lumbar puncture: done at the hospital by a younger doctor. 
    • Physiotherapy: not possible or potentially organised through a video-portal. 
    • Symptomatic treatments: you contact your GP surgery by phone and the drug is added to your chronic prescription.
    • A virtual encounter with an MS nurse to discuss about MS treatment options.
    • Treatment delivered at your home or administered at the infusion unit of the hospital.
  • A virtual follow-up appointment with the MS consultant/nurse in six/twelve months time.

In the COVID-19 epoch, you can thus be diagnosed with MS and treated for the condition without ever seeing an MS consultant or nurse in real-life. Admittedly, the diagnosis of MS is heavily reliant on the findings on MRI imaging and in the majority of the cases this is very indicative. However, this scenario also applies to other diseases such as Parkinson’s disease or dementia in which the role of MRI is much more modest.

The benefits of this policy are apparent and very quantifiable: 

  • Clinics can continue safely during COVID-19. No risk of COVID-19 transmission. 
  • Remote clinics are much more flexible and can happen anytime/anywhere independent of room reservations and presence/absence of other staff members. A beach in Morocco? An alpine hut (with good internet)? Neurologists and patients can essentially be digital nomads. 
  • Avoiding (unnecessary) transport of the patient (and consultant) on the tube/bus/car. Especially in the context of follow-up clinics in which case you already had a chance to get to know the patient, this is very true. Admittedly, healthcare systems around the world have been too reliant on face-to-face evaluations and familiarity with remote clinics opens up the possibility to reach out remote areas with no neurology coverage at the moment. A spin-off MS service in Wales, Isle of Wright, South-Africa? 
  • No (unnecessary) absence of work for the patient and employer. 
  • Cost-reduction in terms of NHS infrastructure (less clinic rooms, less parking facilities, less computers, less paper being printed, less energy use).
  • Cost-reduction in terms of NHS staff (less counter staff, less people involved in patient logistics, less phlebotomists, less cleaning staff, .. ).

Before you join “team remote”, some additional reflections. The disadvantages are namely less tangible and would require qualitative research: 

  • No clinical examination is possible. This implies that a diagnosis or management advice is mainly built on the medical history and the result of technical examinations. For a clinician, this feels like sitting on a chair with three legs. 
  • An unsatisfactory feeling after a virtual clinic for patients and clinicians. People are after all social animals, and there is a reason that for every group of mammals there is a specific term: flock, herd, school, drove, etc. 
  • Progressively considering coming into the hospital as dangerous and cumbersome. (Would it not be better to skip that next MRI …? Does the patient really needs to come in for this extra blood test?) Common and understandable logic might be: If your consultant not even sees you face-to-face, the hospital must be a real COVID-19 hotspot, better avoid it at all costs.. 
  • Apathy on both the consultant and the patient’s end. To which charity do you donate and why? Is it ALS because your cousin was diagnosed with it? Is it breast cancer because your sister died from it a young age? You relate to somebody’s faith because you have been confronted with the consequences. The possibility to – unconsciously – ignore an individual’s faith is intrinsically related to a ‘remote’ setting.  

For all these reasons I am convinced that a healthcare system that is largely reliant on virtual clinics is detrimental to a nation’s health status. I am convinced that when this ‘new’ normal lands as the future standard-of-care in NHS, we will see a decrease in life expectancy 20 to 30 years from now. The problem is that in 20 to 30 years from now, we will have forgotten about the ‘old’ normal and the link between the switch from face-to-face to remote virtual clinics will not be that clear. Young bright epidemiologists and statisticians will look into smoking habits, BMI, environmental pollution, virus pandemics etc. as an explanation for the decrease in life expectancy as – again – those are obvious and quantifiable explanations. The same trap has been set for researchers in the United States. For years, researchers tried to explain which policy change (read: Republicans ‘law and order’ vs. Democrats ‘Tender, Love & Care’) might have explained the steep reduction in youth crime in the early nineties. Was it the number of police officers? Was it the severity of the punishment? Was it the money spent on reintegration facilities? In the end, the most solid explanation was the legalisation of abortion twenty years before. 

Therefore, I would like to advocate a diversified healthcare system in which virtual clinics exist in a healthy symbiosis with face-to-face clinics, and in which each of them are used because they are complimentary to each other and, most importantly, to the patient’s needs at that specific stage in his/her disease. 

About the author

Ide Smets


  • Completely agree. My six-monthly consultation with my neurologist which usually lasts at least 30 minutes was won’t up by him in 14 minutes.
    Video consultations are better than telephone conversations as it feels more like the normal consultation which is adequate if if it genuinely is just a catch-up rather than a discussion of new symptoms but the telephone consultation feels very remote and I believe give them a religious and excuse for a quick clinic.

    • We’ve not had the option of a video call – it is telephone or nothing. It is very difficult to see anyone in the medical world right now, virtually or otherwise. I think it must be especially difficult for anyone presenting with symptoms for something like MS to get an appointment which leads to thorough investigation. GP appointments are impossible right now. I really hope this isn’t a stepping stone to this approach in the hopefully post-Covid future.

  • Thoughtful post. ‘Diversified’, ‘healthy symbiosis’, ‘complimentary’ and ‘most importantly focused on the patient’s specific needs’. Great last paragraph, sounds such a perfect world 🙂.

    I can’t imagine virtual ever being suitable for those early diagnostic appointments.

    Later on, I’m sure many of us would happily save the travel and hassle in favour of virtual.

    Save the face to face clinic time for those who need it most.

  • Thoughtful post. ‘Diversified’, ‘healthy symbiosis’, ‘complimentary’ and ‘most importantly focused on the patient’s specific needs’. Great last paragraph, sounds such a perfect world 🙂.

    I can’t imagine virtual ever being suitable for those early diagnostic appointments.

    Later on, I’m sure many of us would happily save the travel and hassle in favour of virtual.

    Save the face to face clinic time for those who need it most.

    • Yes, that would already be a start. But I also don’t think years and years of virtual follow-up appointments is the solution. Maybe alternating one virtual one face-to-face? But that will be up to the NHS management to decide.

  • Thank you, Dr. Smets, for calling attention to a very real and disturbing prospect. For some time physicians have been retreating from the bustling clinic where physical examination and careful history-taking are the norm. COVID-19 has accelerated the process and it is unlikely to be rolled back to the pre-pandemic state. Yet in the case of MS, while it’s true that diagnosis is largely based on imaging and other studies, progression, disability and symptom management depend on evaluation involving physical contact.

    Here in Canada, a GP told me: “Eighty per cent of what I do can be done on the phone.” The general practice where my wife and I are rostered will book an in-person visit only when considered necessary after a telephone or video consultation. Follow-up specialist neurology consultations are done by video. A spouse, partner or friend, if available, performs simple elements of standard tests with guidance from the neurologist: touch my finger, touch your nose; don’t let me push down, et cetera.

    Some data can perhaps be obtained this way, but not the kind that depends on the specialist’s sensory knowledge, close-up judgment or intuition. High ratios of virtual to in-person care will diminish the quality of patient experience, devalue public investment in clinician experience and increase the risk of poor outcomes. Not only patient care but also the quality of local and registry data will be affected. It will become harder to test the validity of proposed scales, assessment tools and measuring techniques.

    MS-related referrals such as ophthalmology, physiatry and urology may be impossible to conduct without in-person assessment. Virtual follow-ups in psychiatry can be envisioned, but only after rapport is established face to face. A limited form of physiotherapy is possible via virtual connection, but at the cost of drastically reducing the scope of that vital discipline. Other MS-related procedures with proven clinical application requiring in-person attendance include evoked potentials, electromyography, neuropsychological testing, massage and sleep studies.

    None of this is to deny that remote access brings benefits. It takes the clinic to geographically isolated and other underserved populations. It can save time for patients and clinicians through ease of scheduling and elementary triage. As part of a secure digital health platform it can help empower patients by making clinical records available, improving transparency of decision rationales and providing educational resources.

    It will, however, be a serious blow to health care if the cost-cutting impulse drives authorities to expand virtual care beyond its clinical usefulness. Physicians, paramedicals and patients must insist, as Dr. Smets suggests, on evidence-based complementarity as the principle that guides its development. Those who care for us should get to know us as thoroughly as possible, and we should get to know them, through the irreplaceable experience of in-person encounters.

    • Dear Paul, I only read you comment just know, but I could not have said it better and I entirely agree with all your reflections. We are focusing on the wrong kind of ‘remote’ or ‘digital’ medicine. It should not replace clinical evaluations but facilitate them. Thank you for sharing!

By Ide Smets



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