A Country Doctor Writes:

The other day I had to handle an issue for another provider’s patient. In my conversation with the patient, I learned that they had gone through a relationship breakup and a major health crisis two months ago. One month later they had seen their PCP for a brief visit to recheck on a chronic problem. The note from that visit was full of details pertinent to that issue, but made no mention of the double crisis the patient had just gone through.

There are two forces behind situations like this. One is the time pressure in primary care practice and the other is the template driven documentation. So many EMRs have specific templates for specific problems. Most also let us providers create our own templates, which may not even have fill-in-the-blanks, but a whole normal visit that you can populate the chart with in just one click.

In today’s clinical documentation, the individuality of each patient tends to get lost. So much of the data in our office notes is structured and so much is boiler plate or copy and paste. The story is missing so much of the time.

Many if not most other “industries“ drill down on the uniqueness of their customers. Our social media feeds bring ads for things we have searched for on other websites, for example. Advertisers pay big money for such information so they can customize their approach to each of us. Medicine is the opposite: Doctors are encouraged or downright required to cover the same things in each office visit and to document it in the same, easily extractable, fashion. Narrative Medicine is a minority fringe, it seems. And this is in spite of everything we know about social determinants of health, genetics, epigenetics, mind-body medicine and psychoneuroimmunology.

My visit with this patient that I had never seen before lasted all of 10 minutes. You can learn a lot in such a short time. Why don’t we?

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.

We FaceTime or Messenger Video with friends and relatives, even with our loved ones. I do this with my American brother from my exchange student year every couple of weeks and with my lady friend almost every night. That does not take the place of time spent doing things together. But if we just want to talk, a video conversation is for most of us more satisfying and feels closer than a telephone call.

Since the pandemic and continuing now, one of the gastroenterology practices in Bangor has been very open to doing video consultations with new patients. In their specialty as in many others, the patient history provides 80% of the diagnosis. Their new patients have usually had a CT scan of their abdomen and sometimes even a local colonoscopy or upper endoscopy, so palpating their new patient’s abdomen is not usually necessary. If a procedure is necessary, it is almost never done at the initial consultation anyway, even if that is done in person, but will be scheduled later if it is needed.

Traditionally in medicine, procedures have paid much better than cognitive work. And the number of questions we asked and how many elements of our physical exam we documented helped determine our reimbursement. But for a long time, there has been a provision for charging for a visit where more than 50% was spent on counseling and education. As we move toward value-based care, clinical outcomes are mattering more than how exhaustive our investigation was.

The pandemic provided an opportunity to get paid for telemedicine and value based care does not incentivize us to start from scratch and turn every stone if we can tell right off the bat what ails our patient based on what has already been asked and documented.

Especially in remote and underserved areas like the one I practice in, it is such a blessing to be able to get a telemedicine consultation for a patient who can ill afford traveling hundreds of miles and perhaps staying overnight in a motel just to have a 30 minute consultation with a specialist.

I welcome seeing more of this for the benefit of my patients.

This morning I reposted a piece from 2017, A Lesson Learned, about my first case of Anaplasmosis, as a link in a new post about this disease and Lyme disease today according to the Maine CDC’s most recent report. I made reference to the fact that I had just posted the 2017 piece on my Substack, which I made my primary blog when WordPress no longer supported the theme (template) I have used here since I started this blog in 2008. Within a month or two of my migration, my old theme here started working again, but then I was already enamored with my growing viewer numbers on Substack.

I have found that Substack is a more immediate medium than my WordPress blog. If I go a couple of days without posting anything, almost nobody visits my Substack, whereas on WordPress, there’s always a trickle of people reading both the latest and prior posts. So even though I have half-neglected my WordPress blog, many of its readers have remained loyal, quickly reading my less frequent posts on this platform.

The lesson I have learned is not to put all my eggs in one basket. Some people have commented that they don’t like Substack and will only follow me here on WordPress. Therefore, I will put new material here when I put it on Substack and if I repost something old from here on Substack, I will only put it here if I have something new to say about that topic or perhaps the back story to that piece. In a way, this platform will be for my old friends who may have followed me since the beginning or at least longer than I have been on Substack.

If you are one of my old friends, I thank you for your patience while I figured this out and learned my lesson.

Today’s post on my Substack was first published here in 2017. It describes my first encounter with Anaplasmosis, one of the tick-borne illnesses that is slowly creeping north into Maine. When I wrote that piece, I was living and working in Hancock county, which has more tick-borne disease cases than most other counties in Maine. In Aroostook, way up north, where I now live, we hardly ever see Anaplasmosis (one case in 2022, compared to 78 in Hancock), and even Lyme disease is pretty rare here (12 cases in 2022, compared to 360 in Hancock).

A Lesson Learned