December 30th, 2009 by AlanDappenMD in Primary Care Wednesdays
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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!
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April 15th, 2009 by AlanDappenMD in Primary Care Wednesdays
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The most revolutionary tool in primary health care, for almost all out patient care for that matter, is something so common, so mundane, so overlooked that it’s like the nose on your face, you never see it. This tool is not the computer, the internet or a killer software application.
It’s the phone. Why? The answer is equally as simple: The phone allows for 24/7 communication between a doctor and patient who know each other. Likewise, the patient can access the health system with an expert from anywhere and most of the time get what they need.
The American Telemedicine Association (ATA) estimates that 70% of medical problems can be resolved with phones. Almost everyone thinks phone medicine is reserved for an arctic explorer or a poor citizens living in Timbuktu. This assumption ignores how life transforming it would be for every American citizen to pick up a phone, and expect to speak to their doctor anytime from anywhere, at work, on the metro, even on travel, or vacation and expect to resolve their issue instantaneously! No wait, no hassle, no waiting room, no bureaucracy. At least 70% of the time it should be that easy!
Telephone medicine is not to be misconstrued for talking to a stranger. It is not impersonal, nor meant to avoid seeing patients. In reality, it is simply one way of many to get good health care. Sometimes you need a hospital, an emergency room, a specialist, an office visit. However, more than half the time you only need a phone visit, preferably with a doctor or medical practice you know and trust. Even emails are appropriate at times.
That telephones could so easily replace more than 50% of all office visits is so unexamined, so foreign, so shocking, that a predictable series of objections arise:
1. If it was so safe why isn’t it being done already? Of course this begs the reality that our health care system doesn’t pay — or underpays — a doctor to do this. It’s as simple as following the money. Right now the money is in seeing you, so an office visit it must be.
Doctors also answer phones on weekends and night. In fact more than half of the week they are practicing “free telemedicine care,” and that means phone medicine has more real time, more experience in any week than office visit time. It’s just been always deemed “free.” No money means no mission. The doctor, saying, “We’ll schedule you an office visit,” is code for, “Come on in so I can get paid.” That’s a business fact!
2. Isn’t the doctor afraid that he/she’ll miss something? First, office visits miss things all the time. For the sake of not missing something, shouldn’t it mean every problem needs doing a full body scan, complete blood work, and parading every medical problem in front of three separate specialists. If each problem was hospitalized too, maybe that would mean not missing something.
The answer of course, is that to every problem there is a season of reasoning; a triage of appropriateness. Many problems arise where physical exam is irrelevant. If you or the doctor thinks you should be seen, then a face-to-face visit should be arranged but when both people agree what’s going on and that an office visit is not needed, then a phone visit makes sense, which is true over 50% of the time.
3. Isn’t it dangerous for a doctor to answer the phone? To which no one asks the converse question: What’s the experience when the doctor doesn’t answer the phone? If this occurs, then the most knowledgeable person about healthcare, becomes the LAST person to know. This means exposure to the Hippocrates business model of care: long delays, hassled waits, rushed visits. Illness is not a static problem but evolves. The reality of how you feel this minute in front of the doctor often is rendered irrelevant tomorrow when something dramatically changes “Waiting and communicating change” is critical to medical decision making and treatment. Most doctors bring you back in to “see how you’re doing” and make sure they get paid again. It’s not the doctors’ fault, It’s the way the system pays them.
4. Telemedicine, doesn’t that mean higher chances for malpractice? You’ll love the answer to this, but that will need to wait ‘til next week.
Until next time, I remain yours in primary care,
Alan Dappen, MD
