The World Has Gone Virtual and So Has Much of Medicine: Stay-at-Home Doctors
(Second in a series)
I do house calls in my practice, but I also do remote work with follow-ups done via telemedicine and sometimes even see new patients for wellness visits with a medical assistant at the patient’s home doing vital signs, etc. I also do a weekly telemedicine Suboxone clinic for my old practice in Bucksport.
Remote physician work was once unthinkable. In very few specialties like psychiatry, it has been around for a long time because of the scarcity of providers and, I suppose, because there was no expectation of doing any sort of physical exam. But it was really the pandemic that opened this way of practicing up for other specialties.
I just took a screenshot from a Google search for remote physician jobs. LinkedIn has more than 2,000 of them.
From once unthinkable to now almost mainstream, we are finally at the point where physicians are paid for cognitive work. This means we listen to the patient’s story, we evaluate the testing they have done, or that we order, and formulate a diagnostic and treatment plan based on that in collaboration with our patient. To be honest, I’m not so sure today’s doctors are all that diligent or skilled in performing physical exams. And even if we do, imaging and laboratory testing provide a better documentation than a physical exam if we ever end up in a medicolegal situation. This is, sadly, particularly true when so many medical providers use templates in their documentation.
Imagine being asked in court: “Can you really swear before this jury that you checked all those elements in the physical exam and still missed that dreadful diagnosis? Especially since all your office notes seem to have the same, normal, exam documented, word for word.”
I can see telemedicine continuing to expand along with an increased reliance on laboratory and imaging as more “objective” than old fashioned physical exams. Paired with things like remote monitoring technologies for heart failure patients, and nurse/medical assistant facilitated video visits, my prediction is that more and more of us will be working from home, mitigating many of the obstacles and disparities of rural living, such as gas prices and lack of reliable of transportation as well as local physician shortages.
I haven’t had a real physical exam from any doctor, save the first one I saw who retired soon after I saw him, since I moved to New Mexico eight years ago. In Michigan, where I lived for 23 years prior, my doctor did a basic exam of at least listening to my heart, my lungs, and checking my reflexes, every time I went in to see her, regardless of why I was there. I do feel that I’m doctored by data now. Blood and urine tests are ordered, mammogram and colonoscopy reminders are made, vaccines are checked to see if up to date, a referral for a cardiology checkup is always submitted although I’m told to find the cardiologist…and I always choose an electrophysiologist as my only heart issues have pertained to heart rhythms and I’m educated about that from my time in Michigan. I’m then instructed to go to Urgent care for anything that comes up until next year’s “physical” or wellness exam.
I had a hip replacement a year ago (miracle surgery) but in trying to make haste like a 20 year old down our flagstone steps in our backyard, stumbled, fell downward hard, hit my new hip on the edge of a flagstone step, and although my hip x-rayed as fine, implant was fine, when two weeks later I was in more pain than when it happened, saw a PCP standing in for my doc for a suggestion of who I should see, what I should do, got a young woman doctor who examined me, listened to me, and sent me to get x-rays of my pelvis that day. I had fractured my pelvis: left superior pubic ramus. She immediately sent the x-ray to the orthopedic surgeon on call, he sent me for a CT scan which showed a fracture of left superior AND inferior pubic rami and a fracture of the left sacrum; probable fracture of the right sacrum. Saw orthopedist at week 5. Closed fracture with routine healing was his interpretation of the six x-rays they took that day. I will see him at week 11. I’m healing but it’s slow. I tried to see if I could drive here at the end of week 7 since I am now walking easily with a cane but I didn’t even make it out of the garage without pain, pushing on the brake and accelerator, so my husband will take me to the dentist tomorrow to reseat a crown that I flossed out. I say all this because I’ve seen such a change in medicine through the years (I’m 73.) From a family doctor who made house calls and set my broken ankle when I was pregnant, delivered my baby, inserted and later took out an IUD, gave me an adjustment during every visit (he was an OD who became an MD later on)…to being seen by a variety of doctors, specialists, more diagnostic tests than you can shake a stick at, and hurried, distracted visits with doctors who put things in my chart that we never discussed but that I’m sure have to be ticked off on the EMR in order to get paid. If I lived in a state that had a decent supply of doctors (which may be becoming rare everywhere) I would opt for one of those concierge doctors and pay out of pocket for care. I think, anyways. If I knew that I could get care when I needed it from a doctor who had time to get to know me and spend time with me, it would be worth it. But that’s because I can afford it. It’s not how I would wish to spend my hard saved retirement dollars but as one ages, health means everything that makes life worth living.
I have no problem having telemedicine appointments once a doctor knows me, or to get a specialist’s opinion if he/she has been given all the particulars. The doctor I had before my new one (he left NM) was only doing telemedicine appointments with me for his last two years here. Since he never touched me or looked at me when I had office visits, it wasn’t any different. He doctored by data also.
I subscribe to you in part because you remind me of the doctor I grew up with. I think that your patients are very lucky.