Patients Have Stopped Going to the Doctor

Patients have stopped going to the doctor.  Instead, the doctor is going to patients, intercepting them at work, at home and in grocery stores, malls, offices, shopping centers, drug stores, big box stores and on farms. In person and electronically, they’re showing up where patients live, work, shop and play.

They’re not alone.  They’ve got the whole team and more:  Nurse practitioners, physician assistants, nurses, pharmacists, community health workers, self-management trainers, iPhone app, cell phone text reminders, etc.

“Location, location, location,”

That’s how Direct Primary Care (DPC) pioneers Dr. Randy Robinson and Mason Reiner explained it in their recent Physician News Digest article:

“In today’s intense working environment where 85.8% of males and 66.5% of females work more than 40 hours per week, DPC addresses the burden of traveling for care. By locating near commercial centers, and integrating email, text messaging, and telemedicine capabilities into the practice, DPC can deliver convenient, time-efficient, high-quality care – a benefit for patients as well as employers.

When a hemoglobin A-1c lab test for a patient comes back grossly elevated, scheduling a 15-20 minute conversation about proactive diabetic management is a necessity. The only difference, utilizing DPC, the physician is in his or her office and the patient is at work as well as on a break. The vast majority of effective primary care is knowledge transfer, communication, and continuity.  The physical point of service is no longer necessary for billing purposes.”

Their characterization of primary care bears repeating:  “The vast majority of effective primary care is knowledge transfer, communication and continuity.” In other words – mutual learning for both the learning physician (about the patient) and the learning patient (about his or her condition). They emphasize that care will neither be patient centric nor physician centered but relationship centered.

The movement of care closer and closer to the patient can only accentuate this relationship-based learning.  In fact, the greatest long term value will come from patients learning to better care for their health and manage their conditions and from physicians and clinicians avoiding the inefficiency and misdirected care that can come from limited knowledge of their patient’s complete situation in context.

How can this closer relationship and mutual learning occur when, paradoxically, patient and physician are located miles apart, but joined by a high definition, telemedicine connection? In fact, patients and physicians are saying that virtual doctor visits may be better than in-person visits.  Reasons include greater convenience, a virtual waiting room that’s better than a real one, greater patient engagement from screen sharing, more convenient record keeping and a feeling by patients that their doctors pay more attention to them during virtual visits.

America’s military medical services have been using telemedicine extensively.  In fact, they are beginning to move from fixed base connections to using smart phones.

In Cleveland, physicians are examining patients remotely in connection with initiatives at University Hospitals, Cleveland Clinic and other institutions, according to a story in this week’s Cleveland Business.   Telemedicine candidates could include people in poor, urban centers or those in rural communities, according to the report.

One 77 year old patient was quoted in the story, saying “it was essentially the same experience as a visit to the doctor, but there was (my doctor) sitting at his desk, and here I was in my apartment.  It was amazing and very enlightening to me. The quality of the image is amazing.”

Meanwhile, in California, big agricultural companies have begun operating free clinics for workers on the farm. As California Healthline reported, “Paramount Agribusinesses, partnering with Kaiser Permanente, recently opened a 1,500-square-foot health and wellness center at its clementine plant in Delano and a temporary facility at its almond-processing plant in Lost Hills.”

“We’re backing up the healthy products we create by offering our employees much better than standard coverage,” said Danny Garcia, director of human resources at Paramount Citrus, according to the publication.

In Indianapolis, three employers are sharing a clinic set up in the Cumberland Crossing shopping center. Interviewed by Indiana Business, Dan Marchetti, Chief Financial Officer of Urschel Laboratories explained: “We see this as being both conveniently accessible and a great cost-savings to our workforce and their families.  Urschel is a global leader in food cutting machinery.

For rural areas across the country, Wal-Mart expects to install primary care clinics in its stores within five years. According to the Advisory Board’s Lisa Bielamowicz, MD, about a third of provider’ patients shop at Wal-Mart on a weekly basis. “It’s the cheapest place to buy groceries and ammunition, and it could become your most formidable competitor,” Dr. Bielamowicz said, as reported by Becker’s Hospital Review.

Already well known are clinics established by Walgreens, Target and CVS in their stores.  At Walgreens, the role of nurse practitioners will be expanded up the full level of education and licensure.

Taking medicine to patients is more than a US phenomenon; it is occurring worldwide, especially in developing countries.  The UN has just launched a campaign to recruit a million health care workers in sub-Saharan Africa. Already, these grassroots health advocates equipped with smart phones and other technology are making a difference in Rwanda and Tanzania. They are helping patients learn about and to manage their conditions – and to know when higher level care is needed.  And, in Zambia physicians from around the world are seeing patients via telemedicine connections.

So, whether you’re in the most remote areas of Africa, miles away from but connected the Cleveland Clinic, at an Indianapolis shopping center clinic, Dr. Robinson’s direct primary care practice in Elkins Park, Pennsylvania, or any number of pharmacy based clinics….you’ve stopped going to the doctor because the doctor, nurse or other clinician has come to you.

And, that means there’s a lot of learning to do.

Thank you for reading.

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