Caveat emptor

I’m depressingly traditional as a physician, I realize as I see my distressed reaction to most ‘new trends’ in healthcare, like this one. A Virginia family practice MD scoffs at the idea of seeing the patients in his practice when he can deal with them by phone or email instead. He reportedly feels that ‘the need to physically examine each patient is quickly becoming an anomaly.’

The article focuses on the financial rather than the ethical implications of his practice, which is of course cash-only — he could not accept insurance reimbursement since, silly them, the insurance companies expect their patients to be seen for the provision of medical care. Prominent physician groups such as the AMA and the American College of Physicians have recently taken the position that physicians ought to be able to bill for patient communication connected to providing care, but not as an altenative to seeing them! I’m certain that this physician played hookey in medical school on the days they gave the classes on physician-patient interactions and the value of the therapeutic alliance in the healing process. Is he affording added respect to his patients by relying on their perceptions of what is going on with them —

“The notion that you have to see every cough that walks in the door because it may be pulmonary edema or tuberculosis — give me a break,” (he) said.

— or profoundly disrespectful and devaluing? I think the latter. If patients could diagnose themselves and assess all the factors and observations necessary for treatment, why would they hire doctors in the first place? Actually, it is clear from his fee structure that he does not value so much the patient’s perception as his own omniscience. He charges almost as much — $20 — for every five-minute block he spends on the phone with a patient as he does — $25 — if the time is spent face-to-face in the office. In fact, the reason everyone needs to be seen is precisely that sooner or later something of equivalent severity to a cough turning out to be pulmonary edema will, not may, will, happen. You can be sure that, when it does, this guy will not accept that his practice model was to blame. Some fatuous rationalization about the inevitability of adverse outcomes would follow — no cocksure omniscience at that point! The other classes this guy must have skipped out on in medical school were about game theory and risk-benefit analysis, because he fails to grasp a basic fact about how one weighs the importance of medical actions. The value of an intervention to prevent an adverse outcome is not simply a function of the estimated frequency of a disaster but the product of its frequency and its severity.

His other rationalization for this practice model is that it

is no different from what he did for years as part of a large group, when he would cover night and weekend calls for his partners and treat patients whom he had never met over the phone. Even his liability insurance premium is about what it was when he was with his former practice, he said.

To argue that, because medical care has already become impersonal and exploitative, one ought to accelerate the trend, adds insult to the potential injury he may do. The malpractice insurance provider that covers him ought to drastically increase his premiums — or refuse to cover him all together — for his cockiness and recklessness. And the patients who get snookered into believing that the quality of the medical care this guy could provide was comparable to that they would get from any other doctor who would interact with them face-to-face ought to have their heads examined — in person. —American Medical News