Despite the changes around us, the training of physicians has stayed much the same. Sure, there are new work hour limitations and a push to move towards competency-based assessments, but the overall structure of our training remains largely untouched. We spend the vast majority of our time training in hospitals, with the remaining time spent practicing in traditional outpatient clinics.
However, health care is being increasingly delivered outside these two arenas. I recently conducted a home visit for one of my primary care patients. While some physicians may view the home visit as the most traditional of venues to deliver care, it is not a model by which we are currently trained to deliver care. In fact, the home visit is only one of many nontraditional settings through which patients are receiving health care.
Traditional episodic care
The trend towards receiving health services in nontraditional ways stands in contrast to the largely unchanged manner in which we are being taught to deliver and think about health care. During our time training, we learn how to provide care in a largely episodic manner, either for the course of a patient’s hospitalization or during a clinic visit. Although some patients are proactive about reaching out to us between visits, we are not taught to think about how to continue provision of care and promotion of health outside of the face-to-face time we have with them.
Nontraditional modes of health care
As the landscape of health care delivery changes, more and more patients are receiving health care and health services outside of their face-to-face time with physicians. We often do not train for (and sometimes are not even made aware of) these alternative venues for providing care. Many patients now receive health care at pharmacies or clinics unconnected to traditional health care providers. Google Helpouts offer individuals a way to receive expert health advice. Uber (through UberHEALTH) recently delivered flu vaccines to patients’ homes. Through many advances in telemedicine, expert health advice is now more available than ever before.
The demand for community care models
It is clear that more patients are seeking care in these alternative ways, and I find that our profession is often wary of these other health care services. But instead of being so wary, I think we need to ask ourselves why patients are seeking care from other venues. To me, it seems to be a clear message that we are not meeting our patients’ health care needs. Should this really be surprising though? Patients encounter health issues all the time, but due to our rigid schedules they could often only access us every two to three months. It’s no wonder many have sought care from alternative sources. We ask our chronically ill patients to come see us every month or two — can you imagine how inconvenient this is? In the age of high-quality video and imaging services, the face-to-face encounter seems increasingly less important. Patients can collect much of the data we need to offer health advice. Photos and videos capturing physical exam findings outside the office setting often provide more helpful information than what we can gain in a single moment of time during the clinic visit.
Moments outside the face-to-face visit are valuable times that we should dynamically use to promote our patients’ health. Instead of asking our patients with heart failure to weigh themselves and look over the findings every two to three months, it probably makes sense to look at that data in real time. This also applies to our patients with hypertension and diabetes. The current reimbursement model makes it difficult for physicians to devote time to their patients in this continuous, dispersed (rather than episodic, concentrated) way. Furthermore, we are often not taught to think about ways to maintain health outside the episodic times during which we interact with patients, but we should be.
As payment models move health care towards a more integrated system, we should start thinking more systematically about how care can be provided more continuously and moved into the community. This is clearly something that patients want. So whether or not we think this is a good idea, it is likely going to happen. We might as well start preparing providers to think about efficiently utilizing time between face-to-face encounters to provide care in a less episodic manner.
Elaine Khoong is an internal medicine resident. This article originally appeared in The American Resident Project.
