I guess I am no longer "old school."

In medical school I was repeatedly told of the importance the face-to-face encounter with patients, and how we avoid it at our peril.  The physical exam, I was told, is neglected by the younger physicians in lieu of scans and studies.  This, I was told, was a universally bad thing.  Medicine had to be done face-to-face, with attention given to the examination.  All other care is, to some extent, a cop-out.

I think this is a bunch of donkey dung. Patient face-to-face is overrated and overdone.

I know: my readers are probably asking themselves, What?  Dr. Rob is downplaying the importance of face-to-face encounters with patients?  This is the doctor who delights in the exam room?  This is the doctor who loves personal interaction?  Who is the impostor who has infiltrated his blog?  Does he have a lesion in his temporal lobe?  Is he having flash-backs from his years of eating those "funny mushrooms?"

First off, I don't even like mushrooms (too slimy).  Second, the lesion is in the pre-frontal cortex, not the temporal lobe.  Third, it really is me and I mean what I said: patient face-to-face is overrated and overdone.

The foundation of good care is communication and contact, but these two things do not have to be done in person.  After all, you are not with me right now.  As much as I like you folks, I am glad you are not sitting in my den while I am writing this (which is good, because I need a shower).  Communication is not only possible when not done face-to-face, it is often more effective when done that way.  You might get different things out of this post if I spoke it to you in person, but you would also possibly get distracted, not hear things correctly, or forget what I said altogether.  You'd also wish I went ahead and took that shower.

Why is this any different in the exam room?  There is an ignoble reason why I insist on face-to-face encounters with my patients: it's the only way to get paid.  Our system leaves me no choice but to force the patient to take time away from life and sit around in my office waiting for me to spend my short time listening to them.  I do my best to make that time worthwhile for them (and think I do, most of the time), but I really wonder if this is the best way to do things.  No, that's not true: I don't wonder at all.  It is not the best way to do things.

Imagine this:

You or your child gets sick.  Which interaction would you rather have with your doctor:

A:

  • Call the doctor's office, get put on hold or leave a message on voicemail.
  • Get an appointment with someone in the office (probably not your doctor, as their schedule will be full).
  • Take time away from normal life to go sign in at the office, fill out paperwork with information your doctor probably already has, and sit down and wait.
  • At a well-run office, you may end up being there 30-60 minutes total, but many/most offices will make the total visit time much more than that.
  • You finally get back to talk to the doctor (or other provider), and you tell the story of your problem.  Ideally, the doctor has all your previous information correctly in the chart and is up-to-date with all that has happened since you were last there.  This "ideal" is almost never true.  More likely, the doctor asks you about things you assumed he/she already knew about you.  Also, the doctor is probably rushed and distracted, trying to move through this visit as quickly as possible due to the long line of patients waiting after you.
  • You are given advice and/or prescriptions.  You may or may not remember what is said or why the prescription was written, as the doctor is going to be paid the same regardless of the length of time he/she spends explaining things.  Payment is based on how much documentation is put in the chart about the visit, not about how well the visit is done.

B

  • Send a message to the doctor that you have a problem.  Using a template to guide your questions, along with space for free-text, you give your best explanation of your concern about you or your child.  Alternatively, you record a video of your situation and your complaints that your doctor can view.
  • The doctor responds to your communication either by email, video conference, or phone, asking questions and clarifying the situation.
  • If the situation is obvious (your child is sick with a fever and you just need an excuse for school, or your blood pressure readings are up and you need to increase your dose of medications), your doctor handles this electronically.
  • If there is a need for seeing the doctor in person, 95% of the encounter is already done and documented, leaving only the physical exam to be done in person - something that can be accomplished in a few minutes for the vast majority of visits.

I am sure employers would prefer method B, as employees would spend far less time away from work.  I am also sure that the magazine collection in our office does not offset the hassle of coming in.  I also think that I would possibly give better care doing method B, as I could take more time than just the time I spend with the patient in the exam room to find out what's going on.  I also think my documentation would be easier, as I could use the electronic medium to record what is said while it's being said, rather than relying on my memory and obsessiveness to detail to get things right.  Documentation would be driven by the encounter, not by the need to bill.

Okay.  I confess that I am really running with this thing beyond what I actually believe.  I do value the exam room visit, and would not like care to be all electronic.  I know that some things would be missed that would be picked up in person.  Yet I do wonder about our clinging to the face-to-face paradigm of care being analogous to people who still insist on having newspapers delivered to their house to get information they could have gotten for free and in greater detail on the internet.  Are we riding dinosaurs?  Does our system of payment force us to use a method of interaction that is slow, wastes time, creates confusion and chaos, and yields worse care?

Absolutely.

Wouldn't it be amazing if we could figure out a way to facilitate care that actually uses this wondrous thing called the information highway instead of plodding along on the back of a brontosaurus?  If we did, then maybe I would have time to spend with my patients who actually need to see me face-to-face.

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