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In Defense of Remote Access Medical Visits

Back in 1983, as a third year medical student, I read a study stating that 80% of medical visits were not needed.  After finishing the text, I remember thinking, “Hmm, there aren’t that many hypochondriacs in our office!”

It wasn’t until I had practiced medicine for 20 years that I finally understood this statement for what it really meant: doctors were not helping patients through remote means, instead insisting on seeing patients in the office for all medical issues, even the most routine of issues out of habit, out of fear, out of how to get paid.

In 1996, I set out to prove that allowing established patients to remotely access doctors for care would improve their medical outcomes. I convinced my medical partners to let me conduct an experiment: I would work a few half days on the phones, fielding medical-related calls from our HMO patients. Since HMO plans paid us a flat rate to take care of them, bringing these patients to the office cost us money and offering these patients medical consults by phone instead, for routine issues, would be more cost-effective for us and a lot more convenient for them.

At that time, the front desk fielded over 500 patient calls a day.  I sat next to the four receptionists, and the HMO screened patients with straightforward medical problems would be triaged to me. I then would speak to the patient, review their medical history and address their medical issue and get them what they needed.  I was able treat 90% of the screened patients I spoke over the phone, while determining that the other 10% needed face-to-face appointments. During a typical 3.5 hour shift, I routinely spoke to 25 patients, and immediately helped 23 of those patients with their medical issues thereby avoiding an office visit.

Unfortunately, the experiment didn’t last long.  To the business managers of the practice, we lost $500 in co-pays while I logged half days on the phone, not billing a single dollar for the practice.  Where I saw opportunity and a new paradigm, they saw lost income.

Thus, I returned to my routine day, seeing 25 patients a day in person, day after day. But drudgery of this led to deepening despair. So many unnecessary office visits, patients upset with their delays, apologies for running late, and meetings about how to see more patients, see them faster, charge the insurance companies more. In some cases all the delays had led to a complication that could have been avoided with more timely care.

Not undeterred, I discretely planned a study in 1999. For two weeks I collected data on each patient I saw. Recording data on a laptop during each visit, I analyzed three questions: How long did we talk, how long did the exam take, how often did I already know what to do through history alone and not due to findings from the face-to-face exam.

Here are the results: I saw an average of 23 patients a day. The longest office visit was 45 minutes, and the longest physical examination of a complicated patient took 10 minutes. Sixty-six percent of my patient visits had no reason to be in the office, with my diagnosis relying on patient history and not being influenced by my physical exam.

On reflection of the data, the implication of the data awoke me to a new realization. I must step outside the “Matrix” that I had been a part of: a healthcare system that often delayed and even held hostage 2 of 3 patients I saw each day.

But making the decision to step outside this system was not easy: why should I risk my medical career as I knew it, and my financial security to do what is best for my patients and deliver them the quality they care they needed?

It was my wife, who, in 2001, finally convinced me to move on. She wrote a resignation letter to my medical practice, a practice filled with respected friends and colleagues. As I sat pondering the risk I’d confront by handing in the letter, my wife reminded me of a familiar refrain, “Ships are safe at harbor, but that’s not what ships are for.”

And so, in 2002, I founded doctokr Family Medicine, a practice that does step outside the typical paradigm of healthcare. My patients control how and when they are seen by our medical team. At doctokr, all of the patients establish their care through a face-to- face visit at the office. We gather their history, review their records and do an exam. After that, all established patients are free to email or call the doctor directly, 24/7.  Over half of patients’ issues are resolved remotely, via phone or email.  Our medical team also sees patients if they want to be seen, or if we feel we need to see them 7 days a week.

As a medical practice with 3000 pioneering patients, we sail on empty oceans but with full faith that we will not have done so in vain. Our experience has shown happier and healthier patients, providers with a mission and passion again and pricing that is 50% less than the current system price of healthcare.

For doctors and patients, staying “safe” behind the many unexamined assumptions in health care makes such harbor risky indeed.

Until next week, I remain yours in primary care,

Alan Dappen, MD

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