We have all heard that 90 percent of the time, a patient’s history provides the diagnosis before we even perform a physical exam or order any tests. At the same time, much of our reimbursement used to hinge on how many body systems we examined. Like so many other things in the new reality we find ourselves in, what constitutes a proper medical visit has suddenly changed and will probably continue to evolve. I suspect, and hope, that the way we have now tried to work will bring a lasting shift in how we view the process, and the art, of medical diagnosis. Sitting in front of my laptop with both of us on the screen, I can maintain decent eye contact even if I look something up or type something into the medical record. The patient sees me as paying more attention than when I couldn’t effectively both maintain eye contact and look at the screen while talking to him or her (because I’m not that good at typing). Without the ability to do a physical exam, I have more time to listen and ask questions, and my patient is speaking to me from their home environment without the distractions of getting to my office, sitting in the waiting room and perhaps waiting in a sterile exam room longer than they should have. We are now perhaps a little more at ease as we begin our encounter. Without the trappings of the medical office, we are face to face, and our surroundings are less obvious and less able to distract us. We feel more on an equal playing field, each one of us in our own environment. At the same time, if the patient chooses to, they can show me a glimpse of theirs. Just the other day, a tough-looking ex-convict showed me his new cat, a surprising side of him that deepened my understanding of his new life and new level of responsibility and respectability. Thus far, televisits have also been unencumbered by many of the mandated screenings we always did, even if they were only required once a year (what if the patient moved away and we never did screen them?), infringing on the time available for diagnostic work. It is easy to order blood tests when all the patient has to do is walk down the hall to get it done. Now, it means asking them to leave their home and enter the hospital or office in spite of any concerns they may have of exposing themselves to infection. This raises the bar of necessity in testing. In my every day practice in Van Buren Maine, I have relatively few televisits, because the incidence of COVID-19 is low in Maine, particularly in the less densely populated areas, but the televisits I do have are always productive and quite brief when I look back on my time documentation. For about a year now, I have also seen Suboxone patients in my old practice 200 miles away once a week via telemedicine, and I found the same thing there: I accomplish a lot more in a very short time. So at least my personal conclusion and hope for the future is that the COVID-19 telemedicine experience will convince many stakeholders that if you leave the doctor and the patient alone they can accomplish quite a lot between the two of them in a limited amount of time with less interference and fewer resources immediately available than we used to think of as necessary. Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes:. Source
