Three weeks ago, I received an email from my medical office chief saying that our clinic had cancelled all regularly scheduled appointments for the next 2 months.  I knew the reason why, and I had anticipated something like this happening, but I was still shocked when I got the news.  A rush of questions raced through my mind:  “What will I be doing instead?  How will I adapt to virtual doctoring?  How long is this going to last for?”  Over the past 3 weeks, the answers to these questions have evolved, although I still feel that the last question remains unanswered.  This is a fascinating time to be practicing medicine.  I am astonished at the adaptability of both healthcare workers and health care organizations and I would like to share my perspective on that today.

Social distancing has completely changed how my partners and I are practicing medicine for the time being.  Although we have limited the face-to-face contact that we have with patients, we are still able to deliver quality virtual care through a variety of other tools and methods.  In speaking with other colleagues that work for other companies, it sounds like the whole medical community is adopting similar practice changes.  I was rather impressed when my dad, who has been in private practice for 40 years, told me he started doing virtual care with his patients.

What is Virtual Doctoring?

Virtual doctoring is the ability to remotely interact with patients, including emails, phone calls, video encounters, etc.  I have been doing this to some degree for the past 4 years, but now this is 100% of my practice.  I haven’t seen a patient in person for 3 weeks.  There was growing demand for this type of service prior to the pandemic, but now it is a necessity.  I have been impressed by what my patients and I have been able to accomplish virtually and my hope is that this trend will continue even after social distancing is over.

I think the way we have practiced medicine in the past has been inefficient and cumbersome.  Let me give you an example:  I’m seeing a patient in my office for a 2-week follow up. At our last visit 2 weeks ago, I started the patient on an antidepressant.  The appointment is scheduled at 4:30pm.  The patient lives across town.  At 4pm, the Denver traffic has already picked up so it takes her half an hour to get here.  Upon arrival, she sits in the waiting room with other potentially sick patients for a few minutes before my nurse comes to take her vital signs (by the way, vital signs are really not needed for a visit like this, but it’s standard protocol so it has to be done).  My face-to-face time with this patient consists of a 5 min discussion to check-in to see if she is having and side effects and to determine if she is having any perceived benefit.  A physical examination is not needed. Everything seems appropriate so I order a 3 month supply of the medication that the patient picks up at our pharmacy on the first floor.  The wait at the pharmacy will be about 10 minutes. She then heads home and arrives at about 5:30.

Better Ways

To be honest, I got a little exhausted just typing out that 90 min scenario.  An alternative and superior encounter goes like this:  I simply call the patient at 4:30 and have a 5 min discussion and then send her a 90 day supply of her medication through a mail order pharmacy.  This saves the patient 85 min of her time and saves her from potential ill exposures in our waiting room.  The best virtual visits are the ones that require no vital signs and no physical exam.  There are several scenarios that I think are perfect for virtual visits:

• Mental health: depression/anxiety follow up

• Diabetes: review a glucometer log and adjusting medication doses

• Follow up on simple test results like labs and imaging reports

Video visits are becoming more popular.  They are just as useful as a phone visit with the added benefit of being able to see a few things.  Video can’t give you the quality you need to identify a mole versus skin cancer but it can help with some things:

• The ability to see a rash

• Evaluating a joint for swelling and range of motion

• Watching a patient breathe to determine if they are in respiratory distress

Chat is another interesting way to deliver virtual care.  I just recently started doing “chat with a doctor” shifts for my company.  Chat services are being offered by large healthcare organizations and by some independent “chat-only” services.  Chat is best when you need a quick answer to an easy question or just need advice about where to go next.  No appointment needed.  You just log on to the service website and type your question.  You won’t know the doctor you are corresponding with, it will just be random.  Some great examples of chat appropriate cases are:

• Simple urinary tract infections or yeast infections

• A request for asymptomatic STD testing

• Confirming a medication dose

Why Aren’t We Doing More of It?

One of the biggest barriers to implementing more virtual medicine has been the reimbursement.  In-person visits are reimbursed at a much better rate than virtual visits.  Some conditions or tests require an in-person visit before paying for a test or service.  This is mostly driven by Medicare and then adopted by other private insurance companies.  For example, I must have had a face-to-face visit with my patient in order to have Medicare pay for a sleep study to diagnose sleep apnea.  However, most of the information that I need in order to determine if a sleep study is needed or not, I can get from a phone call.

My Hope For the Future

Perhaps there is one good thing that can come out of this pandemic: a more broadly accepted transition to virtual doctoring.  My hope is that this pandemic will teach us what our virtual capabilities really are.  While I know there will always be a need for in-person evaluations, we should really use this time to explore what is able to be done remotely.  Right now we are discovering what has to be done in-person and what can be done faster and easier via telemedicine.  This will have to be adopted by doctors and patients and insurance companies alike in order to work. But, I believe this pandemic will catalyze the transition to virtual doctoring, and as wise patients and practitioners, I want you to be prepared for these new ways that we can practice medicine in the future.

Want to read more? Check out the recent stats on coronavirus. Or prepare yourself for what a trip to the hospital might look like.

For more information on how to prepare for a virtual visit I recommend reading this article in US News and World Report.