An online doctor can be your best option for a personal primary care physician

by Geoffrey W. Rutledge MD, PhD, FACMI  

Previously virtual care, or telemedicine, was limited to urgent care problems — it involved episodic visits with a primary, urgent, or emergency care provider (usually an allopathic or osteopathic physician) who did not already know the patient at each visit. Such episodic care is more transactional, inherently less complex, and often driven by the patient's desire or request for a specific treatment. In the urgent care setting, doctors often do not have the time or the ability to get to know their patients, and are often encouraged to identify a problem quickly, give the patient what they are asking for (or not), and move on to the next patient. 

Virtual primary care (VPC) is very different from virtual urgent care. VPC requires that a doctor see the same patient repeatedly, and take the time to get to know each patient, creating (and nurturing) a trusting doctor-patient relationship. VPC also requires that doctors be consistently available for their patients' needs, as long as their patients remain on their panel. 

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 in order to deliver effective primary care, doctors (and other healthcare providers) must meet and interact with their patients in the office setting. Traditionally, doctors have performed hands-on physical examinations routinely as part of what they do. 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."[1]

Both clinical experience over the past decade, and more recent published research[2] demonstrate that these assertions are simply wrong. Here are some common myths and misconceptions about virtual healthcare: 

Myths about virtual primary care:

1. A doctor must perform an in-person physical examination to evaluate a patient.
2. A doctor must meet a patient in person and perform a physical examination to create a relationship of caring and trust.
3. Virtual care is only good for minor, episodic healthcare needs.
4. Virtual care is inadequate because it fails to record vital signs at each visit. 
5. Virtual care is lower quality care.
6. Virtual primary care is only suitable for certain well-defined chronic conditions. 
7. Virtual primary care is only needed by people who have no PCP.
8. Virtual primary care is not good for seniors.
9. Giving virtual care increases a doctor's exposure to claims of medical malpractice.
10. Mainstream medical professional organizations oppose virtual healthcare.

Here is why these beliefs are myths, and a description of how VPC actually works. 

Myth: A doctor must perform an in-person physical examination to evaluate a patient  

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 history, social history, risk factors and details and timeline of the presenting complaint(s). As my mentor Dr. Alan Hoffman was fond of saying, "If you don't have a clear understanding of what the patient's problem is and a likely differential diagnosis after taking the history, then you aren't finished taking the history."

In fact, for routine in-office visits, doctors do not usually perform a physical examination. When doctors do examine the patient, it often is little more than the "laying on of hands." It's done to connect with the patient and establish a rapport — and because it is expected. In routine practice, and when there is no suspicion of a specific problem, the percussion, palpation and auscultation elements of the physical examination are rarely done in a thorough manner, and almost never provide information that has any impact on the care delivered. 

What's more, as described by the U.S. Health and Human Services (HHS), there are many aspects of the traditional physical examination that can be performed via video consultation.[3]

When a doctor giving a virtual consultation does suspect a problem, they may first perform an initial physical examination via video, then order appropriate laboratory tests. A doctor may also "order" an in-person physical examination, by referring their patient for an office visit. The physical examination can then be performed as part of the follow-up visit to review the test results. 

Myth: A doctor must meet a patient in person and perform a physical examination to 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, hyper-focusing on details of their patient's appearance and attire, mannerism, affect, mood, voice, verbal tone, intonation, facial and eye movements, skin color and complexion, posture, and motor movements. 

Patients tell us they are delighted when during a video visit, their doctor looks at them intently, listens to what they say, and responds directly to their concerns. This doctor-patient interaction is greatly enhanced by the lack of other distractions in the typical busy office. Doctors giving video consultations are able to focus intently on the video and concentrate on the image of their patient. Also, doctors giving virtual care are able to offer longer visits, which helps to develop greatly enhanced doctor-patient relationships.

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

Telemedicine got started by offering short online visits to people who could not reach (or afford) a doctor for an in-office visit. This type of on-demand virtual urgent care is quite good at managing minor episodic healthcare needs of people who are otherwise well, and who may not have or perceive the need for their own dedicated primary care physician (PCP). Virtual primary care has a greatly expanded scope of practice when you are cared for by a physician who knows you, undertakes your care, and is available to you on an ongoing basis. A virtual PCP can manage a wide variety of ongoing health needs and help you even when multiple conditions and multiple 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, and so doctors can and do record temperature, pulse, and BP 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 healthcare app. So the need for vital sign measurements alone isn't a reason to require an office visit.

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 demonstrated that virtual visits were equal to or better than in-office visits for 13 of 16 objective quality measures of primary care performance.[3] 

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 when a higher level of service or referral is required for a new concern, a virtual visit with a PCP who has a trusted relationship with their patient is indicated and helpful, because it guides them to the right service with the right urgency, and provides reassurance from a doctor they trust that they should follow through with the appropriate and needed services. 

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

People who already have a good relationship with an in-office PCP can also benefit from having a virtual 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 in-person visit is needed. The in-office PCP can continue to provide an annual physical examination when that is indicated. 

Myth: Virtual primary care is not good for seniors 

Seniors over 65 are the fastest growing 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.[4] 

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. Of course, doctors always need to deliver appropriate care, document their care, follow regulatory guidelines, and guard their patients' privacy regardless of the venue of care. 

However, the rate of claims arising from virtual care has been dramatically lower than some predicted, and lower than the rate for in-office care. A research report in JAMA in 2019 reported that there was not a single case of a judgment or other judicial action related to telehealth in 2019.[7] As of this writing, despite offering a large and growing nationwide virtual care service since 2014, HealthTap has not seen a single malpractice allegation, let alone a successful claim. Our experience is not unique; according to one large insurance broker providing telehealth malpractice coverage to more than 70 clients over six years, they have seen only one paid medical claim — and that claim arose from the inappropriate involvement of a therapist with their patient.[5]

Myth: Mainstream medical professional organizations oppose virtual healthcare 

Some medical professional organizations, including the American Medical Association (AMA)[6] and the Texas Medical Board, were initially hesitant to embrace virtual healthcare. However, this stance has dramatically changed. In November 2017, Texas became the last state to remove restrictions that prevented doctors from delivering virtual healthcare with no prior in-person examination.[8] The AMA now publishes policies and guides to help doctors deliver virtual care,[9] and is actively lobbying to support telehealth, saying:

Comprehensive telehealth reform is critical to the future of health care.[10] 

The AMA also recognizes that virtual primary care improves physician satisfaction even as it helps people who need ongoing access to care: 

The AMA is focused on helping confront the increasing chronic disease burden, especially preventing or managing diabetes, blood pressure, and substance use, and helping increase patient care and physician satisfaction by leveraging telehealth technology as an asset, not a burden.[10]

In April 2022, the Federation of State Medical Boards (FSMB) issued policy recommendations for all state medical boards, which included this endorsement of virtual healthcare: 
When utilized appropriately, telemedicine technologies can enhance connection between patients and physicians, and reduce inequities in the delivery of care. Telemedicine technology can facilitate patient examinations and permit diagnosis, if acceptable under the standard of care. Telemedicine technologies also enable remote patient monitoring and permit physicians to obtain medical histories, give medical advice and counseling, and prescribe medication and other treatments.[12]

Summary

Virtual primary care is now established as a high quality, convenient and accessible form of effective medical care. 

Dr. Rutledge is Chief Medical Officer and Co-founder of HealthTap.