A Country Doctor Writes:

It’s been three years. Three years of sanity, three years of road trips for house calls, instantly learning more about each patient than you could ever learn in an office visit, making friends with their dogs and having all their cats climb into my leather house call bag, three years of virtual visits from home with the dogs sleeping at my feet. But it is all coming to an end very soon. Read on and I’ll tell you…

The nitty gritty details are for my paid Substack subscribers. I need to figure out how to level the reader playing field for my WordPress subscribers.

Here’s some more from behind the Substack paywall, telling more of the story:

A couple of weeks ago, I found out that our practice lost its contract with our major (insurance) payer. Without them, we couldn’t possibly continue operating in Maine. So by the end of the year, our practice will cease to exist. My hours are, as of Monday, reduced from full time to 0.8 full time equivalents and I am slotted to go down to 0.6 FTE by November 1.

In the coming days, my quit date with Galileo and start date with two of Northern Light’s primary care offices in Caribou and Fort Fairfield will be nailed down. Each one is about 10 minutes from my house, so my driving will go from one extreme to another. My home territory with Galileo, Aroostook County, is as big as Connecticut and Rhode Island combined. And since last November I have also been serving, mostly remotely, the Bangor market which stretches 80 miles west, south and east of our Bangor office.

https://acdw.substack.com/p/no-choice-but-to-move-on?r=254ice&utm_campaign=post-expanded-share&utm_medium=web

This weeks New England Journal of Medicine has an article titled Physical examination for asymptomatic adults.

It describes a clinical scenario where a 60-year-old male presents for a routine visit with normal vital signs, up-to-date screening history and no concerns or symptoms. I think we all know that the evidence favoring in depth routine physical exams in people with a negative review of symptoms is by now fairly nonexistent. But the article includes opinions from two different doctors about the overall benefit, including which approach Fosters the best Doctor, patient relationship.

Allan Goroll, MD writes in favor of doing an exam. He summarizes:

Time is in short supply in modern clinical practice, particularly in primary care. Reducing low-value administrative tasks to free up time for a 10-minute thoughtfully directed physical examination that generates trust, addresses concerns, and picks up potentially important findings warrants serious consideration. The payoff in terms of relationship building, patient satisfaction, and risk reduction represents an excellent investment in time.

My eminent fellow substacker, Adam Cifu, MD, writes in favor of not doing an exam. He says

Forsaking the routine physical examination will be difficult because it has become a standard part of an annual visit and is expected by patients. There is, however, precedence for abandoning common practices when their clinical value is deemed to be marginal. Routine prostate examinations, pelvic examinations when Papanicolaou (Pap) smears are not warranted, and testicular examinations have been abandoned. We should focus on providing patient care that is necessary, evidence-based, and value-based, instead of care that is expected but potentially harmful.

I am a stickler for not doing a physical exam during a Medicare Annual Wellness Visit, because it was never meant to include an exam. If a patient raises concerns that require attention during that visit, which normally is free, they will have a bill for what amounts to an additional service.

During routine visits for a medical problem or with a new patient I have to confess I do at least a limited exam. My personal belief and opinion, as well as experience, is that patients more or less expect it and I do believe it helps establish rapport. It also adds to the perceived value of the visit. The literature now less and less supports doing much of a physical exam during routine visits, but the literature also has established very clearly that the patient’s trust in the physician greatly impacts the success of any prescribed treatment.

Here are a couple of pieces I have published before about doing an exam on your patient, in large part to establish the clinical scenario and the trust it can build. I have also included a piece about a life-saving auscultation of the carotid arteries on a high risk person.

How Much Should Physicians Touch?

A Quick Listen