Will telemedicine make us better diagnosticians? [PODCAST]

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“Sitting in front of my laptop with both of us on the screen, I can maintain decent eye contact even if I look something up or type something into the medical record. The patient sees me as paying more attention than when I couldn’t effectively both maintain eye contact and look at the screen while talking to him or her (because I’m not that good at typing).

Without the ability to do a physical exam, I have more time to listen and ask questions, and my patient is speaking to me from their home environment without the distractions of getting to my office, sitting in the waiting room and perhaps waiting in a sterile exam room longer than they should have. We are now perhaps a little more at ease as we begin our encounter.

Without the trappings of the medical office, we are face to face, and our surroundings are less obvious and less able to distract us. We feel more on an equal playing field, each one of us in our own environment. At the same time, if the patient chooses to, they can show me a glimpse of theirs. Just the other day, a tough-looking ex-convict showed me his new cat, a surprising side of him that deepened my understanding of his new life and new level of responsibility and respectability.”

Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes: and is the author of A Country Doctor Writes: CONDITIONS: Diseases and Other Life Circumstances.

He shares his story and why he writes, explores how the pandemic change primary care, and discusses his KevinMD article, “Will telemedicine make us better diagnosticians?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have a family medicine physician in rural Maine. He is a longtime KevinMD contributor. He’s contributed literally hundreds of articles, and he has his own site at A Country Doctor Writes. He’s Hans Duvefelt, and he’s coming out with an upcoming book, A Country Doctor Writes: Conditions: Diseases and Other Life Circumstances. I’m excited to have him on the show. Hans, welcome.

Hans Duvefelt: Thank you.

Kevin Pho: So we’ll get to your most recent KevinMD article and the book, but first, share your story with us and tell me your journey to where you are today.

Hans Duvefelt: I was born and raised in Sweden, and I went to medical school in Sweden. I was an exchange student in Massachusetts in high school, and I fell in love with a girl, and I fell in love with America. We were in Sweden, and I happened to read an article about this colony in northern Maine. When we moved back to the States, I made contact with the Swedish colony here, and this is where I ultimately ended up living, where I can celebrate Swedish holidays and things like that.

I always wanted to be a doctor. People tell me that when I was four years old, I said that I was going to be one, and here I am.

Kevin Pho: Fantastic. And how long have you been practicing in Maine?

Hans Duvefelt: I came to Maine in 1981 to do my residency. I graduated from medical school 40 years ago, which is a frightening number, but Maine in ’81, and I graduated from my residency in ’83. So my entire American medical career, I have been in.

Kevin Pho: So we’re now talking in the second week of June, and I’m curious to see how the pandemic has affected you and your practice in rural Maine.

Hans Duvefelt: Very little, surprisingly. We’ve had very little of the virus disease here. I would say I do in-person visits about 9 to 1 over telemedicine visits here. People don’t like technology. It’s an old-fashioned kind of culture here. Van Buren, where I am, is right on the Canadian border, and we have a fairly old population, and they’ll wear their masks, and they’ll come into the office.

I also worked for Bucksport Regional Health Center, where I spent a lot of my career, running a Suboxone group on Tuesday nights. We meet by Zoom, and that has worked very well. We have a breakout room and things like that where I see the patients. So I see more of an impact in my Bucksport activities than here in Van Buren.

Kevin Pho: One of the things that I love about your blog posts is the storytelling aspect. You tell wonderful, wonderful stories, and your most recent one on KevinMD is titled “Will telemedicine make us better diagnosticians?” A lot of us in primary care are now resorting to Zoom meetings with our patients in telemedicine. Can you share how that has affected the doctor-patient relationship?

Hans Duvefelt: I think it has eliminated a lot of the distractions that are built into the modern medical office. It is more one-on-one. You don’t have all the other people asking questions at check-in. And, you know, some of those mandated screening things, it’s kind of a pet peeve of mine, could be done outside of the valuable time that the provider and patient have together.

I think that we’re looking at things differently. When we are together, we have more of an opportunity to connect because the distractions are gone, at least for now. And going forward, I think virtual medicine or telemedicine, they’re both going to be here to stay.

Kevin Pho: So this is a rapid change for a lot of us in health care. What’s your number one tip that you could share with other primary clinicians on how to maintain that doctor-patient relationship virtually?

Hans Duvefelt: I think you have to show a little bit more humanity, a little bit more of yourself. I think that has helped me. For example, when I see patients in Bucksport, 200 miles away, that are new to the group, I tell them a little bit about where I’m sitting, you know, what the circumstances are like here, what the weather’s like, how much snow I shovel, and I tell them that I have certain interests and so forth. So I think that you have to go the extra mile to be a real person.

Kevin Pho: So in addition to everything that you do, you’re also a prolific writer. You have close to a thousand blog entries over the past 10 years. So tell me about your background in writing, and why you decided to start your blog and why you decided to share those stories.

Hans Duvefelt: I always liked to write. I remember I did a monthly newsletter for the Boy Scouts and things like that earlier in life. In 2008, I started to write because there were a lot of frustrations in medicine, and I felt that I needed to put into words those feelings that were kind of coming in second place.

Looking at all my frustrations, I said, “Wait a minute. I am here doing this because of this long-standing passion I have.” If I express that, I will focus my thoughts on it. Maybe I can inspire other people, either to become physicians after all or to stay with it and find joy in it, with all the bad stuff going around outside.

Kevin Pho: Well, I can say, speaking as a primary care physician myself, your writings have always been inspiring. I always look up to your wisdom and experience through your years and years of blogging.

Hans Duvefelt: Thank you.

Kevin Pho: So I understand you’re coming out with a book in the next few weeks or so. It’s called A Country Doctor Writes: Conditions: Diseases and Other Life Circumstances. Tell my audience a little bit about that book.

Hans Duvefelt: So I have selected things that either describe interesting or surprising diagnoses that I’ve either made or missed in my career, and also some of the things that people live with that may not have a medical term for them but still frame their existence. When you meet people and when you get to know them, you become awed and inspired at what people have to deal with and still carry on their lives.

Kevin Pho: Give us a little bit of a sneak preview. Is there a story that particularly is outstanding?

Hans Duvefelt: I think the very first one is a very short one, but I think it is cute. It describes a middle-aged woman who, at the end of the visit, starts pulling down her jeans, and she says, “Can you tell me what this rash is?” It was a kind of brown, lace-like, reticular rash on her thigh, and it didn’t blanch when you pressed on it. I wasn’t sure what it was. I thought, “I’ve seen this before,” but I couldn’t remember.

So I minimized my EMR, and I googled “brown reticular rash,” and it’s called erythema ab igne. It was right there, the first thing, you know, on the Google search. As I said, I read about it, and it’s basically a rash that develops when you have something hot there. It used to be hot water bottles back in the old days, or standing too close to the wood stove.

So I said to this woman, “Do you have anything warm touching there?” And she said, “Yeah, my laptop computer.” So I told her to put a towel between her and the computer. And I thought, “Isn’t this odd? This is a disease that we really don’t see anymore. It was caused by a computer, and I used the computer to figure out what it was.” I think that’s kind of a short sample of storytelling and medical factoids kind of wrapped up.

Kevin Pho: So you’ve been a primary care doctor for decades now, and on my own site, there is a lot of anxiety about the state of primary care. So if you could give us a prediction over the next 5 to 10 years, what do you see the future of primary care to be?

Hans Duvefelt: I do think that the genie is out of the bottle when it comes to telemedicine. I think that we will interact with our patients on more fronts than we have so far, and I think that’s a good thing. I mean, the only reason we didn’t do that much before was there was no reimbursement for it. It was basically a loss for the practice to let the doctors do this. So I think we will communicate more virtually, email, all kinds of apps and things like that. I think that’ll be a good thing. I think the challenge is, as I kind of hinted before, to maintain that personal relationship in that.

And I think the other thing: Payment mechanisms have to change. You have direct primary care now. Who knows what Google and Amazon and all these other businesses are going to do? But I think that in primary care, we don’t spend a lot of money in our office. We control, perhaps, through our orders, expensive testing and so forth. But I think that it’s too complicated to look at: A patient goes to a primary care doctor, has a few things done, and we spend huge amounts of money billing for what we do. If that money could be spent providing better care, I think everybody would be better off. And I think we’re going to have to realize that primary care may not require that same kind of micromanagement that big, expensive procedures might require in the health insurance system.

Kevin Pho: Well, thank you for sharing that. We are talking to Hans Duvefelt, who is a family physician in Maine. He is otherwise known as “A Country Doctor,” a longtime physician blogger. And my final question to you, Hans: What’s your take-home message for the KevinMD audience?

Hans Duvefelt: I think the take-home message is to focus on the true meaning of doctoring, the historical role that we have. It may seem corny, but I think when times are hard and when change is happening, if you see yourself as carrying on a historical tradition of doctoring, you might keep the focus better, get frustrated less often, and focus on the patients that you are here to serve.

Kevin Pho: Excellent advice. Hans Duvefelt is a family physician in Maine. He’s coming out with a new book, A Country Doctor Writes: Conditions: Diseases and Other Life Circumstances. Hans, how can people find you, and how can we find the book?

Hans Duvefelt: So I don’t write regularly on my blog now, but I put links to where I am published. So acountrydoctorwrites.com is the place to find me.

Kevin Pho: Hans, thank you so much for joining us on the show.

Hans Duvefelt: My pleasure. Thank you.

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