Myths and misconceptions about virtual primary health care - Kevin MD

Virtual primary care, unlike virtual urgent care, involves doctors who take the time to get to know their patients, creating (and nurturing) trusted doctor-patient relationships. Virtual primary care requires that doctors be consistently available for providing ongoing care to their patients.

Can doctors who meet their patients via video form an effective doctor-patient relationship, and does that relationship lead to appropriate and needed primary care?

The answer is a resounding "yes" on both counts.

Many people still believe that doctors must perform hands-on physical examinations in the office to deliver effective primary care. Some have gone so far as to say that "telemedicine is not medicine" and to assert that even when a physical examination is not needed, telemedicine is still ineffective — "Medicine … cannot be practiced through a screen between a doctor and a patient."

Both clinical experience over the past decade and more recently published research demonstrate that these assertions are simply wrong. Here are some common myths and misconceptions about virtual health care:

The most important, and often the only information that supports a doctor's diagnosis, is a thorough patient history, including all the relevant past medical, family, and social history, risk factors, and details of the presenting complaint(s). My mentor, Dr. Alan Hoffman, told me, "If you don't have a clear understanding of the patient's problem and a likely differential diagnosis after taking the history, then you aren't finished taking the history."

In practice, for people who do not have acute symptoms, the physical examination offers almost no additional information that informs care. As a result, the "routine" physical examination, when it is done at all, is done because it is expected and in a cursory manner.

However, as described by the department of Health and Human Services, the virtual examination includes perhaps the most important elements of the examination.

When a doctor does suspect a problem, they order appropriate laboratory tests and, in some settings, refer to a specialist (or office-based primary care provider) for definitive evaluation via in-person physical examination and review of test results. This is quite similar to what an office-based primary care physician does when they suspect a problem beyond the scope of their practice.

Myth: A doctor must meet a patient in person and perform a physical examination to create a relationship of caring and trust

Fortunately, with the advent of high-resolution video and audio technologies, doctors are able to create rapport and develop surprisingly strong doctor-patient relationships without ever meeting their patients in the office or performing a physical examination.

It is counterintuitive. But it turns out that when a doctor's only contact with their patient is via video, they pay increased attention to their patient. They are hyper-focusing on details of their patient's appearance and attire, mannerisms, affect, mood, voice, verbal tone, intonation, facial and eye movements, skin color and complexion, posture, and motor movements.

Patients who experience the longer-duration video visit are surprised — and delighted — when their doctor looks at them intently, listens to what they say, and responds directly to their concerns.

Myth: Virtual care is only good for minor, episodic health care needs

Virtual primary care has a greatly expanded scope of practice compared to virtual urgent care because doctors get to know their patients and are available to them for ongoing care. A virtual PCP can manage various ongoing health needs and help their patients even when multiple conditions and medications are involved.

Myth: Virtual care is inadequate because it fails to record vital signs at each visit

Patients take their temperature, weight, and blood pressure (BP) at home all the time, so doctors can and do record this information when appropriate at each visit. Doctors advise their patients on which home BP measurement devices they can get and how to record their readings at home or in the health care app.

Myth: Virtual care is lower quality care

Studies have shown equal or greater objective measures of primary care performance from remote visits compared with the same measures for in-office visits. For example, a recent study published in JAMA Network Open demonstrated that virtual visits were equal to or better than in-office visits for 13 of 16 objective quality measures of primary care performance.

Myth: Virtual primary care is only suitable for certain well-defined chronic conditions

Virtual care from a doctor who knows a patient is helpful for any problem almost all of the time. Even for new problems beyond the scope of virtual primary care, a visit with a patient's virtual PCP is indicated and helpful because the virtual doctor provides valuable assessment, reassurance, and triage to the right service with the right urgency. Patients follow through with appropriate and needed services when their doctor encourages them to.

Myth: Virtual primary care is only needed by people who have no PCP

The convenience, accessibility, and lower cost of virtual care make having a virtual PCP valuable for anyone, even those who already have an office-based PCP. A virtual PCP will coordinate their care with the in-office doctor, send copies of their virtual visits to the in-office doctor and refer to their in-office doctor when an office visit is needed. The virtual PCP can refer to their patient's in-office PCP when a physical examination or other in-person service is needed.

Myth: Virtual primary care is not good for seniors

Seniors over 65 are the fastest-growing group of users of virtual care. Modern virtual care platforms work on tablets, smartphones, and notebook/desktop computers, so seniors can access their virtual PCP on whatever device they are most comfortable with. Seniors who have mobility or transportation limitations or who live far from an office-based doctor derive even greater benefits from having a virtual PCP.

Myth: Giving virtual care increases a doctor's exposure to claims of medical malpractice

The initial concerns some doctors had about possible increases in malpractice liability associated with giving virtual care have turned out to be entirely unfounded. The actual rate of malpractice claims is dramatically lower for virtual visits compared to the rate for in-office visits with doctors of the same specialty.

Myth: Mainstream medical professional organizations oppose virtual health care

Some medical professional organizations, including the American Medical Association (AMA) and the Texas Medical Board, were initially hesitant to embrace virtual health care. However, this stance has dramatically changed. The AMA now publishes policies and guides to help doctors deliver virtual care and is actively lobbying to support telehealth; the Federation of State Medical Boards (FSMB) also strongly endorses virtual health care.

Geoff Rutledge is a physician executive.

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