But I’m finding that I don’t miss them. And our patients shouldn’t, either.
Much of the actual work of primary care happens when patients aren’t in the office, whether doctors are coordinating with three specialists to tweak a complex medication regimen or finding a hospice agency for an ailing patient. The only reason we deliver almost all primary care through office visits is because that is what insurers will pay for.
It took a pandemic to get there, but covid-19 is giving us a sense of how much of our work we can do without tethering doctors to an exam room. At my hospital, we still run a daily “non-covid” clinic for patients who need to see a doctor in person. Any primary care physician in our large group can refer a patient to come in.
To my astonishment, no more than 5 percent of our hundreds of daily telemedicine visits are being referred for these in-person visits. No doubt the deadly virus lurking in any corner pushes down the number of referrals: It’s understandable that patients might want to avoid in-person visits and doctors might be reluctant to push them. But we never thought the number would be that low. When the non-covid clinic opened, we staffed it with six doctors, but only two patients showed up. Now, it turns out that a single doctor can manage the typical afternoon’s load, though we staff two so that there is no pressure to rush visits.
Good riddance. The dominance of the office visit, driven purely by how we pay for health care, distorts so much of what doctors do. Last year, a young woman scheduled an appointment with me solely to have her birth control pills refilled. Perplexed, I told her that next time she could just call in for her refill and save time. She looked confused and told me that her previous doctors would not refill birth control without an office visit, or even worse, a pelvic exam. Her reproductive health was basically held hostage to generate a bit more revenue, an infuriating perversity born of tying doctors’ paychecks to office visits.
The degree to which the system values doctor convenience over patient health leads to endless absurdities. Under current insurance rules, it’s easier to pay to transport a frail, immobile patient across town in a stretcher than to have a doctor visit them at home. Patients come to the office just to ask me to email their specialist because their appointment is weeks off and they can’t reach their other doctor any other way. Other patients on my worry list I almost never see because they can’t take two hours off work or child care to brave traffic, parking and the waiting room.
This is not to say that we should eliminate in-person conversations between doctors and patients. But finding the right combination of interactions — whether emails, home visits or in-office appointments — between doctors and patients should be the norm.
Healthy patients can mostly be managed by phone, or even with occasional patient portal messages. Much preventive care, including screening for colon cancer or even cervical cancer, can happen at home. Patients with chronic illness can use common devices such as home blood pressure cuffs and glucose monitors to gather basic data. And up to one-third of referrals to specialists could be resolved with “eConsults” without an additional appointment. All of this is possible with the right payment system that rewards doctors for providing the level of care that patients need, not what insurance will pay for.
Of course, seeing a doctor in person is still essential. We can’t transition to other methods of doctor-patient conversations until patients have access to and feel comfortable with the technology that makes those interactions possible. But the intimacy and rapport that can develop in an exam room can’t happen if the patient can’t come to an appointment at all.
I pray for the day I can finally see my patients in real life again — but only when they truly want or need to be there.