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Primary Care & The Advantage Of Continuous Communication

A Case Report: Even a Doctor Needs to Talk to His Doctor

I love the following battery of questions I hear from doctors and patients alike regarding telemedicine:  “Don’t you think it might be dangerous to answer a patient’s medical questions by phone or email?” and “Shouldn’t you handle all issues in the office with a face-to-face visits like most other primary care physicians (PCPs)?” and then “Isn’t medical care by phone or email impersonal, shoddy, and second rate?

I however argue that everyone with these assumptions is wrong, Wrong, WRONG!

To challenge this notion, I invite you to consider your own routine health care problems, and to count how many issues really have required a physical exam to determine the proper way to treat them. If you’re like most people, I bet you’ll say that more than half of the times you didn’t need a face-to-face visit.

Let’s take my own personal health as a case report. It’s been a year since my own heart attack and stent placement, which I blogged about this when I got home from the hospital last Christmas.

Since my heart attack, I’m exercising regularly (although admittedly not as often as I’d like), have maintained a constant weight (although fit the classic 95% failure to lose weight that plagues almost everyone), have had no further chest pain, and continue on all the meds I was started on when I left the hospital. All of my home blood pressure readings have been normal over the past year and my last cholesterol readings are close to ideal.  My body mass index (BMI) is 27 … so, yes, I know I should lose 12 pounds. I’ve been aware of this since before the heart attack and little, including a face-to-face visit with my doctor, magically will make this horse lose 12 pounds.

The cardiologist said she wanted to “see me” within a year after I passed my Thallium stress test.  So here are the issues she wanted to cover during the physical exam:

1.  Should I continue to stay on Plavix? I’ve been taking the drug for a year, and it’s expensive. Is there an advantage to my continuing to use it at this point instead of taking plain old inexpensive Aspirin? Since I have a high deductible health plan, I, like many Americans, worry about the cost of the medicine and would like to stop contributing to Pharmaceuticals’ profit margins.

2. Is there a different cholesterol regimen I should be following? My LDL cholesterol is 75 while my HDL is only 45 on maximum strength simvastatin (Zocor). I know more aerobic exercise and weight loss would help and I’m going to repeat to the cardiologist  the same excuse everyone gives me: “I’m busy working and trying to keep a semblance of a family life, so I do forego exercise from time to time.” Can seeing my doctor face-to-face help me prioritize, improve my exercise pattern, lose weight, or improve my cholesterol numbers?

3. Should I repeat a Thallium stress test? I’m on high deductible health insurance and this test costs me $1200. If a third party payer wants to pick up the tab, then no questions asked. Otherwise what information will a new test provide that my weekly ice hockey game isn’t already doing to inform me about my cardiovascular system …  I had exercise induced chest pain before my heart attack announced itself so assuming I’m not in denial again, is a thallium stress test really going to help guide any clinical changes?

4. What do my labs show (cholesterol, blood sugar, chemistry panel, liver function tests etc.)?

5. What is my random blood pressure and pulse and weight? Are my heart sounds any different?

Out of this entire list, the heart exam (which takes 10 seconds to do) is the only thing that a face-to-face visit with the cardiologist might need. Assuming most people don’t have a stethoscope and aren’t trained to understand what they are listening to, the next question is:  What are the value, yield and likelihood of the heart exam helping the cardiologist with any of the questions above in my case example?

The answer: nothing.  This entire visit should be conducted by telephone or videoconference. What the cardiologist needs is a progress report and what I need is to tap into her knowledge and expertise so that I can make the best informed decisions for me. I don’t need her listening to my heart or checking an EKG. These will provide no relevant data regarding my care. Instead the face-to-face visit with a 10 second heart exam satisfies a single objective. It justifies a billable service to the insurance company.  No heart exam, no billable service.

Instead what I need is a DocTalker cardiologist. Let me pay for 15 minutes of her time to answer the questions relevant to my care and keep me at work so I can get done in time to exercise. Speaking of which, it just snowed and it’s time to catch up on some cross-country skiing. I’ll carry my cell phone with me so in case one of my patients needs to reach me I’ll have an excuse to ski slowly.

Happy and safe holidays and may you too be able to talk with your doctor by phone or videoconferencing whenever want and from wherever you are in the following year. That truly might make all our health care a lot better quality and affordable.

Until next week, I remain yours in primary care,

Alan Dappen, MD



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One Response to “Primary Care & The Advantage Of Continuous Communication”

  1. Bob says:

    Your observation is absolutely correct. I did a rough lunchtime poll at my hospital regarding the need for face to face encounters for ambulatory medicine visits. The rough estimate that everyone had was 40% of the visits were not necessary.

    The driver of the face to face encounter is the payment system. It forces patients to waste remarkable amounts of time for criminally brief face to face encounters with their docs which serve little purpose other than to justify specific billing requirements.

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