Chris Kresser: The answer is both. For me personally, I prefer to see patients in person for the initial visit at least, but the reason that we transitioned to that is because we believe it is mandated by state law and the California Medical Board. Now that I am working in practice with physicians, we are governed by that as well as the Acupuncture Board regulations. Before I started CCFM and started working with Sunjya and Amy, I did occasionally do case reviews virtually, so I had in some cases patients that I worked with virtually the entire time and I never met in person because my healthcare attorney looked at the Acupuncture Board regulations since I was doing lab testing and I was making nutritional recommendations and supplement recommendations and there wasn’t any medication being prescribed, my attorney felt like that was probably permissible to not see the patient in person for the first time. But the Medical Board in California has pretty clear regulations about that and about prescribing medication, so if you want to be able to prescribe medication to a patient and you’re a physician, I think in most, if not all states, but certainly in California, you have to see that patient in person for the initial visit.
After that it is a little more murky. Medicare requires that in order to continue to prescribe medication to a patient, you have to see that patient once a year in person. There is no similar provision by the Medical Board outside of medical care, but our attorney felt like if you want to take a very conservative approach, it might be good to just kind of replicate the Medicare requirement and have a patient come see you in person once a year at least if you are prescribing medication. We haven’t done that. We have chosen to be a little more flexible about that requirement. I have a feeling that in the near future things are going to change and it will be possible to do a case review appointment virtually if you choose to do that because I’m sure most of you have already noticed that there are some very large medical groups now that are doing that. They’re offering virtual appointments, even for new patients, and the patients get prescribed medication after that appointment and they’ve never seen the practitioner in person. I think the laws are probably going to be changed in the next three to five years to where video consultation is viewed as being equivalent to an in-person visit.
To be honest, I have mixed feelings about that. I certainly am a big fan of applying technology in practice, as you know, and a believer in the potential for that. I certainly see how the benefits of an entirely virtual practice for both patients and providers. Again, maybe I am a little bit old school too. I also see the benefit of a real human face-to-face connection. I know that I develop a kind of relationship with patients that I have seen in person and continue to see in person that I don’t develop with patients that I’ve only had phone consultations with or video consultations with. Certainly video is better than phone, but I would rank it as in person, video, and then phone last.
To be perfectly honest, the other day I had what seemed kind of like a crazy idea to me because I’ve emphasized the virtual element in my practice from day one. I could even imagine at some point going really old school and going back to only seeing patients in person, including for follow-ups. I mean, I’m not planning to make that change any time soon and I may never make it, but I just really appreciate how I feel at the end of a day when I’ve been sitting in a room and having face-to-face meetings with patients compared to when I’m sitting in my office by myself looking at a computer and talking on the phone. I mean, I do a lot of that as it is with developing ADAPT and writing my blog and doing my podcast, and I like that and I love it, but for me because I do so much of that work I actually find the contrast of being in a room in person with a real live human connection to be a nice shift out of my more habitual experience of doing a solo thing.
So that was maybe a little more information than you bargained for, Anthony, but hopefully that’s helpful. I do think that a completely virtual practice will be entirely legal in the next three to five years, but as far as I know in most states now if you’re going to be prescribing medication and even if you’re doing what might be construed as diagnosis, which means lab work and interpreting that lab work and making recommendations based on that lab work, for most of the healthcare attorneys I’ve spoken to, you’d be safer doing that initial appointment in person.
Yea, you’re right, Anthony. We don’t want to become characters from the movie WALL-E. Actually, what I think of is George Lucas’ film that he made in film school. I think it’s … I might get the title wrong, THX 1138, or something. It’s really worth watching if you haven’t seen it before. There’s a scene where Robert Duvall, who’s a very young actor in this film, it was a long time ago, basically the plot is it’s in the future, the not too distant future, and everyone has their head shaved and wears these white jumpsuits. They’re all kind of working as automaton kind of factory assembly line workers, and they’re heavily medicated to keep them from questioning that existence. Robert Duvall somehow stops taking his medication and wakes up and realizes how oppressive the society is and starts to try to escape and get out of it. At one point when he is still in that transition and he’s questioning what’s going on, he goes and sits in a little box, like in a mall that looks kind of like those photo booths that you go into and you put some coins in the machine and it’s a therapist. The therapist says, “Hi, how can I help you?” He’s trying to have a conversation with the therapist and the machine keeps interrupting and saying inappropriate things. It’s a funny scene, but it’s actually kind of an important point. I want to say a little bit more about that before we move on.
Last weekend we had our first annual CCFM retreat. We have about 13 employees now and many of them are virtual. We have admin people in Pennsylvania, in southern California, Las Vegas, and Colorado. Many of us had never actually met in person so we rented a big house in Tahoe and hired a chef, Zenbelly’s Simone, if you know her cookbooks, and we had a great time together. One of the things that we talked about is that my vision with Sunjya has always been for this clinic and this model has been to automate the things that don’t require human interaction to make them as efficient as possible, so like filling out forms, onboarding, and doing all of that kind of stuff to free up more time for human contact.
The purpose of a lean distributed model is not to remove the human contact. It’s actually to add more back in. The way that happens is by automating the things that can be automated. That’s the difference between like a conventional clinic is they’re so busy with all of the day-to-day operational stuff that is so inefficient that the level of human contact and service you get in that model is really poor, often, and so what we’re trying to do in this model is the opposite. We’re trying to automate the heck out of things that can be made more efficient so that we can actually have a deeper and more meaningful and supportive relationship with the patient.