Our Broken System #5: Riding Dinosaurs

I guess I am no longer \”old school.\”

In medical school I was repeatedly told of the importance the face-to-face encounter with patients, and how we avoid it at our peril.  The physical exam, I was told, is neglected by the younger physicians in lieu of scans and studies.  This, I was told, was a universally bad thing.  Medicine had to be done face-to-face, with attention given to the examination.  All other care is, to some extent, a cop-out.

I think this is a bunch of donkey dung. Patient face-to-face is overrated and overdone.

I know: my readers are probably asking themselves, What?  Dr. Rob is downplaying the importance of face-to-face encounters with patients?  This is the doctor who delights in the exam room?  This is the doctor who loves personal interaction?  Who is the impostor who has infiltrated his blog?  Does he have a lesion in his temporal lobe?  Is he having flash-backs from his years of eating those \”funny mushrooms?\”

First off, I don\’t even like mushrooms (too slimy).  Second, the lesion is in the pre-frontal cortex, not the temporal lobe.  Third, it really is me and I mean what I said: patient face-to-face is overrated and overdone.

The foundation of good care is communication and contact, but these two things do not have to be done in person.  After all, you are not with me right now.  As much as I like you folks, I am glad you are not sitting in my den while I am writing this (which is good, because I need a shower).  Communication is not only possible when not done face-to-face, it is often more effective when done that way.  You might get different things out of this post if I spoke it to you in person, but you would also possibly get distracted, not hear things correctly, or forget what I said altogether.  You\’d also wish I went ahead and took that shower.

Why is this any different in the exam room?  There is an ignoble reason why I insist on face-to-face encounters with my patients: it\’s the only way to get paid.  Our system leaves me no choice but to force the patient to take time away from life and sit around in my office waiting for me to spend my short time listening to them.  I do my best to make that time worthwhile for them (and think I do, most of the time), but I really wonder if this is the best way to do things.  No, that\’s not true: I don\’t wonder at all.  It is not the best way to do things.

Imagine this:

You or your child gets sick.  Which interaction would you rather have with your doctor:


  • Call the doctor\’s office, get put on hold or leave a message on voicemail.
  • Get an appointment with someone in the office (probably not your doctor, as their schedule will be full).
  • Take time away from normal life to go sign in at the office, fill out paperwork with information your doctor probably already has, and sit down and wait.
  • At a well-run office, you may end up being there 30-60 minutes total, but many/most offices will make the total visit time much more than that.
  • You finally get back to talk to the doctor (or other provider), and you tell the story of your problem.  Ideally, the doctor has all your previous information correctly in the chart and is up-to-date with all that has happened since you were last there.  This \”ideal\” is almost never true.  More likely, the doctor asks you about things you assumed he/she already knew about you.  Also, the doctor is probably rushed and distracted, trying to move through this visit as quickly as possible due to the long line of patients waiting after you.
  • You are given advice and/or prescriptions.  You may or may not remember what is said or why the prescription was written, as the doctor is going to be paid the same regardless of the length of time he/she spends explaining things.  Payment is based on how much documentation is put in the chart about the visit, not about how well the visit is done.


  • Send a message to the doctor that you have a problem.  Using a template to guide your questions, along with space for free-text, you give your best explanation of your concern about you or your child.  Alternatively, you record a video of your situation and your complaints that your doctor can view.
  • The doctor responds to your communication either by email, video conference, or phone, asking questions and clarifying the situation.
  • If the situation is obvious (your child is sick with a fever and you just need an excuse for school, or your blood pressure readings are up and you need to increase your dose of medications), your doctor handles this electronically.
  • If there is a need for seeing the doctor in person, 95% of the encounter is already done and documented, leaving only the physical exam to be done in person – something that can be accomplished in a few minutes for the vast majority of visits.

I am sure employers would prefer method B, as employees would spend far less time away from work.  I am also sure that the magazine collection in our office does not offset the hassle of coming in.  I also think that I would possibly give better care doing method B, as I could take more time than just the time I spend with the patient in the exam room to find out what\’s going on.  I also think my documentation would be easier, as I could use the electronic medium to record what is said while it\’s being said, rather than relying on my memory and obsessiveness to detail to get things right.  Documentation would be driven by the encounter, not by the need to bill.


Okay.  I confess that I am really running with this thing beyond what I actually believe.  I do value the exam room visit, and would not like care to be all electronic.  I know that some things would be missed that would be picked up in person.  Yet I do wonder about our clinging to the face-to-face paradigm of care being analogous to people who still insist on having newspapers delivered to their house to get information they could have gotten for free and in greater detail on the internet.  Are we riding dinosaurs?  Does our system of payment force us to use a method of interaction that is slow, wastes time, creates confusion and chaos, and yields worse care?


Wouldn\’t it be amazing if we could figure out a way to facilitate care that actually uses this wondrous thing called the information highway instead of plodding along on the back of a brontosaurus?  If we did, then maybe I would have time to spend with my patients who actually need to see me face-to-face.

6 thoughts on “Our Broken System #5: Riding Dinosaurs”

  1. As much as I like seeing you; when I am sick, I would love this, who feels like driving 50 miles when they are sick !!!!!

  2. Speaking from my own experiences as a patient, I can see the value in both types of interaction. Standard office visits certainly have their place, particularly when there’s a need for examination to get the full picture of a patient’s problems. Phone conversations can also have their place as well, since (as you wrote) there’s a bit less inconvenience for the patient in having to find time and transportation to the office, and still the opportunity to ask questions. (After all, a lot of the value in a physician is in their knowledge, which doesn’t always require their physical presence.)  E-mail/texting is a bit more iffy to me, for several reasons, but I would consider it in a pinch with the right provider. I discovered the value in the availability of information a couple of years ago, when I was able to do an extensive online search of reputable medical journals that helped me and my physician figure out which route to take for handling the problem I was seeing him for. The trick is knowing which information is legit and which is bunk.  And there is sometimes tremendous value in the one thing you’ll never get from an electronic encounter, which can only be had in person: the human touch. For all the fancy tools physicians have these days, there are still times when touch, in the appropriate circumstances, can be invaluable. The thing I like about the internet, though, is coming to know some truly fascinating individuals I never would have encountered otherwise; that would, of course, include you. That’s the upside to the electronic age. EMRs, however, can be another story (I do appreciate avoiding handwriting, however…).

  3. ‘Wouldn’t it be amazing if we could figure out a way to facilitate care that actually uses this wondrous thing called the information highway?”
    It’s already figured out and can be summed up in three words: pay for it.

  4. I love this proposed model of interaction.  It could simplify so many things on both sides of the encounter.  Especially with a well child in a waiting room full of sick children.  (Even those doctors who have a separate room for the poor little sick guys, you know those toys in the office are just teeming with germs).
    Having worked on both sides of the issue, on the delivery side and the managed care side, I know there are two major obstacles to establishing fair reimbursement codes for a virtual visit.

    One, people are idiots.  There are so, so many who will fill out the form wrong or ‘forget’ to give you essential information like Johnny is running a 103 degree fever or that pustular rash Mary has all over her back.   The liability factor just skyrockets for the innocent provider.

    Second, and probably the biggest issue, people are crooks.  For every honest person out there providing care, there is another who is looking to game the system.  Insurance fraud is rampant and difficult to uncover.  It costs all of us in the long run.

    So idiots and crooks ruin it for the rest of us.   Well, for the rest of you all at any rate.  Unfortunately, I cannot claim not to be an idiot.  I just ate a bowl of ice cream even though I was up all last night with a gall bladder attack.    A gall bladder attack I will ‘forget’ to mention to my doctor when I see him next.  I am one of those who will let it go until I am writhing in agony in the ER some day.  See what I mean?

  5. Both sides of your comment are correct. The idiots and crooks are a problem that will need to be handled. This is an obstacle, but not a barrier. It motivates me to make it work better than the “floating out on their own” that most patients experience.
    Systems need to take into account that people are just people: they do irrational things and try to find the easiest way out. If the system is designed to make it easiest to do the right thing (hypothetically), then it will get more things right than the current system. It won’t however, help people who enjoy writhing in the ER with gall bladder pain. Those folks have to fend for themselves.

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