I started Dignity Integrative in early 2021, amid huge changes in healthcare. The one advantage to these last few years of struggling through COVID was that healthcare systems finally broke free from the antiquated view that a doctor must see every patient in person to provide high-quality healthcare.
As I launched my practice, I knew I would have an office in Rockville in Maryland, near my home and close to big population centers in Germantown and Bethesda. But I still had a momentous decision to make: would my integrative medicine practice be primarily in-person, primarily, telehealth, or some mix of both?
In many areas of healthcare, the advent of high-speed internet and reliable audio now allows many interactions which were previously in person to switch to telehealth. But what did that mean for my own practice? And, what would it mean for my patients? Let’s say you live in the Rockville, Bethesda, or Germantown area (or in Washington DC), and you are searching for an integrative medicine doctor—does it even matter where they are located? Should you be willing to see a doctor who is out of reasonable driving distance, or is it important to find one located nearby so you can see them in person at least some of the time?
Shifting attitudes on telemedicine
For a period during this pandemic, I was part of our acute care company’s effort to partner with a telemedicine provider to deliver care for urgent medical conditions. In the beginning, many physicians and healthcare leaders were skeptical of this effort. I was not one of them.
As most doctors will tell you, making a correct diagnosis comes predominantly from talking to the patient about their medical history. Certainly, a good physical exam is helpful in many situations to confirm or rule out serious conditions. There are also labs, radiographic and other diagnostic testing to confirm a final diagnosis, all of which must be done in person.
The real question though is whether a physical exam is needed at all as part of the modern healthcare interaction, including integrative or functional medicine visits. While I agree that the patient history is the key in medical diagnosis, the physical exam should be part of a complete evaluation.
Reasons why your integrative medicine journey should include an in-person visit
First, the physical exam can be critical to diagnosing certain types of conditions. Examples range from being able to assess edema (swelling) in the legs for signs of heart issues to feeling thyroid nodules, to assessing subtle decreases in sensation in a person’s legs reflecting micronutrient deficiencies like B12 to observing the conjunctiva (area inside your lower eyelid) to look for clues of anemia.
Second, biometric assessments are a critical part of most medical practices. Details such as blood pressure, waist-to-hip ratios, and simple height and weight, while they can certainly be done at home, are subject to error if you do not know how to do them properly, which can influence your doctor’s decision-making.
Third, there is something timeless about sitting across from a patient in person and having that conversation about their history. The physical exam is a time-honored tradition as not only part of a complete evaluation of a patient, more importantly as part of the sacred bond that connects patient and doctor.
Fourth, there are certain regulatory requirements, including performing a physical exam, if you are prescribing certain medications.
I realize as I write this, I bring my own biases into the conversation. I trained at Georgetown University Hospital and attended lectures by Dr. W Harvey Proctor who was a legend in diagnosing cardiac conditions based on subtle differences in heart sounds. Admittedly, much of the magic of the physical exam is a lost art, though some especially gifted and practiced Internists, Pediatricians, Family Practitioners, Neurologists, and others still carry those talents into a patient’s room with them. But for most, it has been replaced by diagnostic testing such as CT and MRI as well as advanced lab testing.
This perspective is also a generational reflection as younger people are much more comfortable seeing their doctor virtually. They have existed, from an early age, with a smartphone as an extension of their being. They are more likely to consume information differently and their comfort level with a telehealth provider is just another ‘normal’ in their world. That is all well and good as the general expansion of telemedicine has brought expertise to areas of the country, and world, where it was not possible in the past.
A blended model for integrative medicine
This is why I chose to structure my integrative medicine practice as a blended model. The initial evaluation, for all the reasons listed above, is designed to be in person. Follow-up visits have the option of being in person or virtual. The choice is the patient’s. All the health coaching visits are virtual.
I believe this provides the right balance of in-person and virtual care. As the technology continues to improve and more and more biometric data can be obtained at home that calculus may change.