In the past, physicians enjoyed the luxury of having a small volume of patients and a large margin of profits. But as we make the transition from fee-for-service to managed care, the reverse is becoming the norm. That is, the American physician can anticipate that in the future his or her practice will have a large volume of patients and a small profit margin.
The result is that physicians will feel pressured to spend less time with each patient. One way they may be able to do that -- and yet still retain quality of care -- is telephone medicine. Following patients by telephone allows physicians to treat patients who are hundreds or even thousands of miles away.
Numerous pilot projects are underway to determine whether quality of care is preserved with tele-medicine, and whether patients will accept this new method of healthcare delivery. Advanced communication technology makes possible not only efficient, but also effective, treatment.
The purpose of the tele-medicine pilot project I have undertaken is to evaluate the efficiency and effectiveness of treating patients with symptomatic benign prostatic hyperplasia (BPH) with either alpha-blockers or finasteride. Some of the patients are followed by telephone; others make traditional follow-up visits to my office.
At the end of the study we will be able to evaluate the merit of using tele-medicine to monitor patients with BPH. This information will be very important for urologists who will be caring for more capitated patients in the near future. The same method can be applied to other chronic diseases such as hypertension and diabetes.
According to the tele-medicine protocol I developed, patients with lower urinary tract symptoms initially are seen in the office, given physical exams and interviewed about their histories. All of the men who are treated are asked to complete the American Urologic Association's symptom score (AUASS) questionnaire, which contains seven questions about lower urinary tract function. Those men with symptomatic BPH, a normal digital rectal exam, a normal urinalysis and a normal PSA are offered medical management with either alpha blockers or finasteride.
All of the patients, regardless of the medical management they receive, are assigned randomly to either the tele-medicine follow-up protocol or the in-office follow-up.
The patients in the tele-medicine arm receive a call from the nurse coordinator every three months and are asked about symptoms and any side effects from the medications. The summary of the symptom score and any side effects, such as postural hypotension, nasal congestion, decrease in volume of ejaculation, or impotence, are noted in the chart.
The physician then makes the appropriate adjustments in the medication and the nurse coordinator contacts the patient and informs him or her about any changes.
The patients in the traditional arm return to the office every three months for a symptom check by the physician and are queried about the side effects of their medication. The doctor makes necessary medication adjustments at the time of the office visit.
So far, 46 patients have been assigned to the pilot project. A total of 30 patients have been placed on alpha blockers and 16 patients on finasteride. Of the overall group, 23 patients have been followed using the tele-medicine technique.
In the tele-medicine arm of the study, the patients are asked by the nurse coordinator, when he or she calls, whether they would like to speak to the physician or make an appointment to see him. Only four of the 23 patients have asked to speak to the physician. None has requested an appointment.
The other 23 patients, who are in the traditional follow-up, are seen in the doctor's office every three months.
After 12 months on the tele-medicine protocol, the patients are reminded to return to the doctor for a follow-up appointment.
Also at the 12-month point, all of the patients are surveyed for their satisfaction with the protocol. Although only 12 patients have been followed for an entire year, none of the tele-medicine patients were dissatisfied with the management process. Of the patients in the traditional follow-up branch, most indicated they would rather be managed by the nurse coordinator at home with the opportunity to have access to the physician if necessary.
This pilot project demonstrates that patients are willing to accept tele-medicine monitoring as long as they know they have access to their physicians.
If capitation becomes a medical certainty, then physicians will have to find methods of managing large populations of patients. It may be necessary to practice medicine without being "eyeball to eyeball" with the patient.
For example, with the development of new computer technologies, patients can complete a computerized questionnaire and the physician can receive the summary and make adjustments in the medication through a computerized call-back.
Patients also can receive a daily reminder to take their medication, to call back for refills and to contact the office for their annual examination and blood tests.
All of my colleagues might not embrace this methodology, but they have found no fault with the quality of care offered to a large volume of patients when this technique is used. More detailed results will be submitted to the AUA annual meeting in 1999.
Although very few of us went to medical school to learn to "see" patients over the telephone, nearly all of us will have to make significant adjustments in the way we practice in the future. Integrating tele-medicine into our practices likely will be one of those adjustments.
Baum, a New Orleans-based urologist, is associate clinical professor of urology at Tulane University School of Medicine and Lousiana State University School of Medicine. He also is author of Take Charge of Your Medical Practice -- Practical Practice Management for the Managed Care Market (Aspen Publishers).