Dr. Amy Nett: Let me explain the initial consult and the case review because we actually do require an in-person meeting for the case review, and that is a California State Medical Board requirement. I have to see a patient in person before I can legally make treatment recommendations, so here’s how that works.
We first do an initial consult, and that’s what’s over phone or Chiron. Chiron is just our video telemedicine platform. The initial consult for 30 minutes, which is phone or Chiron, I ask patients why they’re coming to CCFM, what their major complaints are, and again, a lot of your patients are probably going to be very complicated. They’re probably going to have a lot of details, so I tend to let people know we are going to have them complete case review documents where they’re going to have the chance to give me a very comprehensive past medical history. I want all of the details, the nuances, but not at the initial consult. The initial consult is a big-picture overview. So I get the general concerns and complaints, and I decide which tests we’re going to order. Then I also suggest if they haven’t followed a Paleo elimination diet, that I do want them to follow that. We’re going to give you a handout on what we suggest in terms of the Paleo reset diet that you’ll be able to customize, that sort of thing. We give them that, and during that time, if patients are overall healthy, I might ask them what their supplements are.
I feel a little bit limited in terms of making supplement recommendations during that time, so what we generally tell people is it’s nice to have testing at baseline, meaning, “What does your body look like when you’re not taking a lot of supplements?” It’s hard for me to tell people, “You should stop taking all of your supplements,” especially if they’re really sick, so what I tend to say is, “Well, if there are some supplements that you know you benefit from, definitely stick with those. If you’re taking cod liver oil, magnesium glycinate, some of the basic supplements,”—those two of my favorite, cod liver oil and magnesium glycinate—if they’re taking those, continue those. Otherwise, multivitamins, this impressive number of herbs that people come on, single-nutrient supplementation like selenium or iodine, these sorts of things, I might suggest people consider taking a break from those, and I sometimes let them know that once we get started, even though my long-term goal is to minimize supplements, the initial period of treatment does tend to be very supplement- heavy. So I tend to tell people, “Give yourself a break from taking supplements, because when we meet, we’re probably going to be starting a lot, unfortunately.” And what “a lot” looks like depends on what people can tolerate, what their tests look like. For some people, “a lot” might be six, and that’s where they hit their limit. For some people, we might be doing more like 10 or 14 different supplements for a defined period of time.
Again, this is the way we structure it. I only have an initial 30 minutes with someone, and that’s not always enough for me to tell people, “You should stop these,” because I don’t want them to feel worse during the time when we’re sort of waiting for the test results. So then what we do at the case review appointment is I always do a supplement review. At the case review, that’s where I have people list exactly what supplements they’re taking, what medications, and then I go over what they are taking, what I want them to take, and we sort of do a combined list, what feels important for them to continue and what I feel is important.
Hopefully that answered it for everyone. I do the supplement review mostly at that case review process. Bodie, the case review, again, Chris does 60 minutes, I do 75 minutes, and that’s an in-person appointment. I don’t know of any practitioners who do everything completely virtually. I think it’s really nice to have an in-person meeting with patients for a couple of reasons. One, it’s really nice to get the feedback and establish that connection with patients. It’s really not the same over phone or video, and I’m sure you know that intuitively, and I think, out of necessity because a lot of our patients do come from all over the country. It’s just not feasible to have in-person follow-up appointments. I’m so happy to be able to work with people across the country, and it’s great that they don’t have to come into the office, but I think at least one meeting in person really makes a big difference in terms of establishing a good working relationship. To really understand your patient and where they’re coming from, it’s helpful.
The second reason, and I don’t like practicing medicine from the sort of CYA perspective, but you still have to think about medical-legal issues. My formal training was as a radiologist, and radiologists, at least when I was training, at that time, statistics showed that radiologists were the second most commonly sued physicians. The reason it was thought that radiologists were commonly sued is because patients didn’t meet us. Our names would show up on a report, but for 98 percent of studies I was reading I never met the patient in person. It’s much easier for a person to sue someone that they don’t know. If you have a good relationship with your patient, you’re safer in a way, in part because when you actually meet your patient in person, they’re going to understand that you’re doing your best. Of course, mistakes are going to happen. We’re all going to make mistakes, so I think having a really good relationship with your patients—and part of that is meeting at least once in person—is incredibly important both for the therapeutic relationship, and then I don’t like thinking about being sued, but I think you have to keep it in mind, unfortunately. Personally, I wouldn’t advise doing a completely virtual practice. Some of our patients are sick and they definitely have concerns about travel, but aside from the California Medical Board requirement, it’s too important to me personally. I think that you really have to see a person at least once.