Face-to-face care isn't always best

Many doctors contend that there’s no substitute for face-to-face interaction with patients. In some cases, this is true. But for most of modern medicine to be practiced rightly, a physician knows what the patient needs based on communication more than on physical exam findings. Doctors understand their ability to add value for a patient, to supervise their course of care, and to achieve good outcomes is based on knowledge of the human condition and how the health care system works. Unfortunately, doctors also understand, all too well, how they’re paid, and we often steer clinical care into pathways that allow us not only to be paid, but to maximize payments according to the rules of the game.

This weekend a childhood friend texted me, frustrated with her doctor. She takes a particular medicine daily and her doctor had recently switched her from one version of the drug to another. After the trial period, she preferred to go back to her original prescription, but the doctor wouldn’t switch her back without blood work. OK, I thought to myself, that’s certainly the doctor’s prerogative, but that’s not what annoyed her. She was upset because the doctor’s office is 40 minutes away and he was going to require two visits in order to accommodate the switch back. He wouldn’t order the blood work until she could come in for an exam (medically unnecessary in this case), after which he’d place the lab orders. Then she would be required to come back to the office for a second visit to review the results, at which time he’d re-prescribe her old medication. My friend is a mother and, like so many of us, she’s busy.

Where to begin? My friend has PPO insurance, the kind every doctor in a fee-for-service model hopes their patients have. He receives top dollar for every service he provides her, and his mechanism for providing service is an office visit. In fact, that’s this doctor’s only mechanism to collect fees from insurance and for his practice to thrive financially. The office visit is the required event for “care” to be quantified into a billable record. The doctor, in this case, managed to justify two encounters for something that could far more easily (for all involved) be handled remotely.

There are times when a patient needs to be seen and examined in-person in order for the doctor to provide the right care. Sometimes a procedure or a particular diagnostic exam are required for the best practice of medicine. But more often, in the world of modern medicine, the physician’s contribution to the patient’s care is purely cognitive.

For the physician to add value in a cognitive sense he or she must simply have an understanding of the body and what the patient needs, given their particular situation or disease-specific condition. But the physician’s ability to advance someone’s care without seeing them in person every time they need something is one of the most closely guarded secrets in clinical medicine.

If we consider the doctor-patient relationship as exactly that, a relationship, we must presume an ongoing interaction over time. The fee-for-service system introduces barriers into this relationship, creating a hindrance for bi-directional communication, adding frustration and delay to the best practices of medicine. In my friend’s case, the doctor could have simply asked his patient how she felt, received her feedback, asked a few pointed questions and then, if necessary, ordered the specific tests he needed. Then the doctor could make his decision on the re-prescription of her old medication with a plan to follow up and/or simply keep in touch.

The rationale for a face-to-face encounter every time the physician engages with the patient’s situation is not medically justified. But we justify it nonetheless, because without the face-to-face encounter, there is no transaction. I feel like my noble industry can do better.