Back to In-Person Visits? Don't Give Away What We've Gained

Kenneth W. Lin, MD, MPH

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor.

Something remarkable happened in my clinic last week. I entered an examination room and greeted a new patient, who stood and extended her right hand in my direction. Without thinking, I reached out and shook it. I am fully vaccinated against COVID-19, of course, and as it turned out, so was she. Still, it was the first time I had shaken a patient's hand in more than a year. This commonplace act of courtesy between strangers, discouraged for most of the pandemic, marked a personal milestone on the return to normal.

In a previous Medscape commentary, I wrote about the challenges of building rapport with patients during video visits and stated that I was "looking forward to the time when patients and doctors can determine whether in-person, video, or telephone visits best meet their mutual needs, rather than having this dictated by public health emergencies or inflexible payment rules." As more and more Americans are vaccinated and the threat of COVID-19 recedes, it appears that this time has arrived.

In a recent Health Affairs blog post, Dr Chad Ellimoottil argued that payment parity for virtual visits should continue beyond the public health emergency because they require a similar amount of clinical effort as in-person care; provide equivalent care value to patients in most situations; don't increase fraud, abuse, or overuse; and don't reduce fixed expenses for brick-and-mortar practices. The legislative counsel for the American Medical Association called on Congress to protect Medicare beneficiaries against losing future access to telehealth services and to expand high-speed broadband programs that promote equitable access in rural and underserved communities. Telehealth's appeal extends across generations; virtual visits and secure online messaging with physicians are highly popular among millennials.

At the same time, I worry about the unintended consequences of employers and insurers pushing patients into "virtual first" care plans. Telehealth is not always an appropriate substitute for office visits; the Robert Graham Center estimated that two thirds of all primary care visits in 2016 required at least one in-person service such as a vaccination or laboratory tests. Although there is some evidence that diagnostic accuracy for common conditions is similar between virtual and in-person visits, I agree with Dr David Blumenthal's assertion that "well-trained clinicians use all their senses — not just hearing and vision."

Regarding preventive care, though it is probably safe to measure cholesterol profiles less often than we have in the past, a national study of primary care visits during the early months of the pandemic found sharp declines in blood pressure measurement during telehealth visits. If we can't do blood pressure screening or monitor patients taking antihypertensive medications, we will be flying blind and increase their risk for poor outcomes.

Regardless of our personal preferences for in-person vs virtual visits, family physicians should exercise caution so that these visits' respective advantages and limitations do not reduce quality of care. For example, it is easy to perform an ECG and order blood and urine tests for a patient who is in the office for a physical and may even expect to receive these tests; but are they necessary or will they only increase costs and risk exposing the patient to unnecessary interventions? The pandemic forced most of us to alter our practices to some degree; we should take a thoughtful approach to restoring in-person care that does not give away what we gained in the telehealth transition.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

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