The Doctor is in…24/7?



Like many of my colleagues in medical education, I am a part-time clinician.  My time is split, spending less than half in my own clinical practice with the rest devoted to resident education.  This is precisely why I love my job.  The diversity of each day keeps me engaged, challenged, and excited about the work I do.  Unfortunately, this same thing that makes my job so fulfilling is often also a stumbling block for patients.  When your doctor is only in clinic part time with appointments booked out two months down the road, it can make scheduling a visit pretty challenging. This is an understandable frustration and has required both patients and doctors to be creative with work-arounds. One-such work-around is the use of tele-medicine.

The potential of tele-medicine is vast.  Daily, I message with patients regarding their health conditions; I send results, follow up on visits, and answer questions.  This provides a great way to connect with patients.  People’s schedules are busy (both patients and providers) and being able to communicate through a secure electronic portal allows both parties to connect when it works for them.  I have also used telemedicine, through Project ECHO, to connect with specialists and manage patients with complex disease in the primary care setting. Going further, many health care systems, including the University of Utah, are beginning to offer e-visits where a patient can connect with a provider electronically in real time to have an appointment without ever stepping foot in the office.

Yes, tele-medicine provides a wealth of possibilities for patient care.  Not only can it help bridge the gap between appointments, it can sometimes substitute for an appointment all together.  Why, then, does it also give me pause?  One of the great draws to family medicine for me was the chance to develop ongoing meaningful relationships with patients.  In my mind, these relationships were developed in a clinic, in person, over time. Facial expressions, nonverbal ques, the physical exam all help to build this doctor-patient relationship.  E-mailing and other electronic visits were not what I had in mind.

Secure patient portals were just being developed and were not part of the electronic medical record system used during my residency (yes, I’m dating myself here). And so, telemedicine was not really part of my training, and, thus far, there has not been a best-practice established for how to handle these electronic encounters. I struggle with finding the right balance, often asking myself (and my partners) “how much is too much to cover electronically?” I want to be flexible and meet the needs of my patients, but I also want to make sure I am not compromising their care.

Another part of the struggle with electronic patient care is when it should be done.  Understandably, patients want answers to their questions; they want to hear about their results.  Yet, there is not time scheduled into the day for this work and so it often happens between patient visits, at the end of a session, during other work, or at home. This sense that you can always get in touch with your doctor means that your doctor is potentially never off-duty.

Tele-medicine is here to stay and an important tool to offer excellent patient care.  I have seen its power and have been grateful to have it as an option for my patients. But, as it becomes more of the norm and we become more adept at providing care in this way, it is my hope that focus on the quadruple aim (improving population health, increasing patient satisfaction, reducing spending, and improving care provider’s well-being) will serve as a guide for our practice.



Kara Frame, MD is an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

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