Three months ago, none of us thought we would be shifting our practices from office visits and hospital rounds to telemedicine and virtual check-ins. In fact, we would have not only denied it was possible, but touted concern for the decline in patient care. As pandemic concerns reached the United States in March, telemedicine visits began to climb, and many practices have reported increases of 500 percent or more for virtual visits. Spurred by necessity given stay at home orders, as well as public fear of venturing out, the decision by CMS to reimburse at rates comparable to in-office visits was really the catalyst for this explosion in telemedicine, which involves synchronous audiovisual communication. After addressing cost and availability, the final barrier in the adoption of telemedicine was, of course, the doctor-patient relationship.
Pause and think about where you were last year. Perhaps struggling to see patients with an ever-increasing template volume, struggling to chart efficiently while paying attention to what the patient is saying and trying to maintain eye contact all the while. Don’t forget to nod and smile. Now think about your recent telemedicine visit. Full eye contact, decreased templates to account for tech delays, and less checking of boxes to reach MIPS/PQRS/MACRA/CMS (feel free to insert your own acronym) requirements.
You know what I found? I listened better. More fully.
Remember when we all started medical school, and one of the first lectures was “How to Take a Patient History”? Some of us rolled eyes, eager to move on to the anatomy, physiology, and pharmacology subjects, but if you listened to your instructor, they told us you could diagnose many illnesses by just listening to the patient’s story. In fact, Nobel Peace Prize laureate Bernard Lown revealed that the medical history provides sufficient information in nearly 75 percent of patient encounters to make the diagnosis (before even performing a physical exam or additional testing).
We also know that sometimes the “chief complaint” is not really what’s bothering the patient. I have had many encounters that started with a complaint of throat tightness but evolve into a conversation about the additional stress and anxiety the patient is currently feeling trying to balance work from home or loss of a job, homeschooling children, caring for an elderly parent; sometimes all at the same time.
Listening is one of the first executive skills learned by children and often where so much parental instruction is spent. It must also be said that active listening is key. Being able to observe a patient’s face as they tell their story can provide clues (and also provide a significant portion of the physical exam). The more physicians develop active listening skills, the more intuition is nurtured as pauses, inflections, and eye movements begin to take on meaning. Active listening is almost impossible when you are simultaneously clicking through an EMR.
As an otolaryngologist, I worried about not being able to visualize the tympanic membrane or the larynx, but I found that by carefully listening to the course of events leading to their concern and how the symptoms evolved I felt much more confident in my assessment. In cases where I felt patients needed to be seen in clinic, I found my suspicion was often confirmed, whether it was head and neck cancer, fungal otitis externa, or temporomandibular joint pain. I am certainly not saying that we no longer need the physical exam but in cases where a pandemic makes access more difficult telemedicine visits have certainly become a legitimate alternative. One could even advocate as we move forward that patients who travel from afar or have difficulty finding transportation could consider using telemedicine when participating in a planned check-up for chronic but stable conditions.
As restrictions are lifted, and we ease back into our practices, let us not forget the valuable lessons learned during this time; not only with regards to disaster planning and preparation, but on a personal level with our individual patient interactions.
Let this be the time where health care providers regain the confidence to speak up in operational decision making and ensure that patients do not get crowded out by administrative requirements. Let this be the time we speak up for true patient care, including more time to build relationships with our patients.
Maybe it is not so much about returning to “normal” as it is about finding a new rhythm and remembering that the most important part of our day simply involves listening.
Jessica Lee is an otolaryngologist.
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