In this week's webinar, Dr. Klaper, Dr. Miller, and Dr. Marbas discuss the incredible opportunities of practicing lifestyle telemedicine and how patients can best partner with their doctor to get, and stay, healthy.
Questions Answered
- (00:52) – The complications of telemedicine
- (02:30) – The story of Yeshi Dhonden, and how doctors diagnose
- (11:38) – Not being able to feel your pulse…
- (14:27) – Help your doctor to help you
- (15:47) – Dr. Marbas's into to telemedicine.
- (20:00) – Tell your doctor everything there is to know about yourself.
- (23:18) – Please complete the check-in forms.
- (25:12) – Tell your doctor what you know.
- (27:19) – Plan your follow-up appointment with your doctor.
- (28:14) – Why are the appointments cash pay?
- (29:31) – How are follow-up appointments scheduled?
- (33:12) – Can patients provide prior medical records and lab results?
- (34:35) – Have you considered a subscription / concierge pricing model?
- (37:45) – What's the most important information for a patient to provide before their appointment?
- (40:15) – How to most effectively work with your doctor, especially when your case is complicated or tricky.
- (49:09) – Considering menopause and female hormones.
- (55:48) – Giving the power to the patient, and partnering in care.
Complete Transcript
Dr. Laurie Marbas
(00:04)
We appreciate everyone for being here and we have a really cool topic. Dr. Klaper had a great idea about speaking to you about telemedicine, especially in this world that we're living in now where telemedicine, the barriers and the concerns about telemedicine are really just kind of forced out of the way. For us, the silver lining of COVID has been allowing us to really launch this in a time where we need to focus on our health, not only to support our immune system and prevent, hopefully, long-term effects, if we do get COVID and maybe even fight off COVID earlier, but also just reaching so many people who looked for a plant-based doctor, but Dr. K, take it over and tell us how you'd like to start the telemedicine talk because I think it's an important topic.
Dr. Michael Klaper
(00:52)
Okay, well, thank you, Laurie, good to see everyone and Dr. Miller. This is a most remarkable medium that we're all working in telemedicine. We've all seen it appear, almost conjured out of the ether, and yet has become so powerful and integral to many people's healthcare depends on it. And the moment of transmission of information between the patient and the doctor in the telemedicine conference is a very important moment. The entire 20 minutes, half-hour that we spend together. We need to transmit to each other, both patient to physician and physician back to patient. So much information that it's got to be done clearly and time is limited, and it's a tenuous thread of connection that we have now with our patients that we would like to make as strong as possible.
Dr. Michael Klaper
(01:51)
And so we're going to be talking about things that people can do to make the telemedicine conference that you have with us, even more effective, things we need to hear and things that you are going to want to hear. Now, it should be clear in everybody's mind. So we're going to be talking about that during this hour. And to set the stage for the idea of getting lots of good information out of a very thin stream of data, I'd like to read you a story that I encountered a few years ago written by a doctor, written by a surgeon actually.
Dr. Michael Klaper
(02:30)
Dr. Richard Selzer was a general surgeon on the staff at Yale-New Haven Medical Center, but he was also a poet and he's also an author and a great storyteller. And he collected a lot of his medical stories into a book called Mortal Lessons. And this is a story from Dr. Richard Selzer, his book Mortal Lessons. It's the story of Yeshi Dhonden.
Dr. Michael Klaper
(02:58)
On the bulletin in the front hall of the hospital where I work, there appeared an announcement, Yeshi Dhonden, it read, will make rounds at six o'clock in the morning of Wednesday, June 10th. The particulars were then given, followed by a notation. Yeshi Dhonden, his personal physician to his holiness, the Dalai Lama.
Dr. Michael Klaper
(03:25)
On the appointed day, I joined the clutch of white coats waiting in the small conference room adjacent to the ward selected for the rounds. The air in the room is heavy with ill-concealed dubiety and suspicion of bamboozlement. At precisely six o'clock, he materializes, a short, intense barrel-like man dressed in a sleepless robe with a hood of saffron and maroon. His scalp is shaven, and the only visible hair is a skimpy black line above each hooded eye. He bows in greeting while his young interpreter makes the introduction. Yeshi Dhonden, we are told, will examine a patient selected by a member of the staff, the diagnosis is unknown to Yeshi Dhonden as it to us. The examination of the patient will take place in our presence after which we will reconvene in the conference room where Yeshi Dhonden will discuss the case.
Dr. Michael Klaper
(04:30)
We are further informed that for the past two hours, Yeshi Dhonden has purified himself by bathing, by fasting, and by prayer. I, having breakfasted well, performed only the most desultory of ablutions, and given no thought at all to my soul glanced furtively at my fellow, suddenly we see a soil uncouth flopped. The patient had been awakened early and told that she was to be examined by a foreign doctor and had been asked to produce a fresh specimen of urine, so when we enter the room, the woman shows no surprise. She has long ago taken on that mixture of compliance and resignation, that is the thesis of chronic illness. This was to be yet another and an endless series of tests and examinations.
Dr. Michael Klaper
(05:23)
Yeshi Dhonden steps to the bedside while the rest of us stand a perk, watching. For a long time, he gazes at the woman favoring no part of her body with his eyes, but seeming to fix his glance at a place just above her supine form. I too study her, no physical sign or obvious symptom gives a clue to the nature of her disease. At last, he takes her hand raising it in both of his own. Now, he bends over the bed and kind of a crouching stance. His head drawn down into the collar of his robe. His eyes are closed as he feels for her pulse. In a moment, he has found the spot and for the next half hour, he remains thus suspended above the patient, like some exotic bird with folded wings, holding the pulse of the woman beneath his fingers, cradling her hand in his. All the power of the man seems to have been drawn down into this one purpose. It is palpation of the pulse raised to the state of ritual.
Dr. Michael Klaper
(06:50)
I cannot see their hands joined in a correspondence that is exclusive, intimate, his fingertips, receiving the voice of her sick body through the rhythm and throbs she offers at her wrist. All at once, I am envious, not of him, for his knowledge and his righteousness, but of her, I want to be held like that, touched so, received. And I know that I, who have palpated 100,000 pulses, yet not felt a single one. At last, Yeshi Dhonden straightens, places the woman's hand upon the bed and steps back. The interpreter produces a small wooden bowl and two sticks. Yeshi Dhonden pours a portion of the urine specimen into the bowl and proceeds to whip the liquid with the two sticks, this he does for several minutes until a foam is raised, then bowing above the bowl. He inhales the odor three times. He sets down the bow and turns to leave. All this while he has not uttered a single word.
Dr. Michael Klaper
(08:12)
As he nears the door, the woman raises her head and calls out to him, “Thank you, doctor.” She says and touches with her other hand, the place he had held on her wrist, as though to recapture something that had visited there. Yeshi Dhonden turns back for a moment to gaze at her, gives a slight nod of acknowledgment and then steps into the corridor, rounds are at an end.
Dr. Michael Klaper
(08:45)
We are seated once more in a conference room. Yeshi Dhonden speaks now for the first time and strange Tibetan sounds I had never heard before. His young interpreter's voice follows his, a bilingual feud. He speaks some winds coursing through the body of the woman, current that break against barriers, editing. These vortices are in her blood, he says, the last spendings of an imperfect heart. Between the chambers of her heart long, long before she was born, a wind had come and blown open a deep gate that must never be open through it charged the full waters of her river as the mountain stream cascades in the spring time, battering knocking loose the land and flooding her breath.
Dr. Michael Klaper
(09:50)
Thus, he speaks and is silent. “May we know the diagnosis?” The professor in the back of the room asked. The host of these rounds, the only man who knows answers. “Congenital heart disease,” he says, “Interventricular septal defect with resultant congestive heart failure. A gateway in the heart, I think, that must not be open. Through a charge, the full waters of a river that flood her breath.”
Dr. Michael Klaper
(10:31)
So here is the doctor listening to the sounds of the body to which the rest of us are deaf. He is more than doctor. He is priest. Now and then it happens as I make my own rounds in the hospital that I hear the sound of his voice, like an ancient Buddhist prayer, it's meaning long forgotten, only the music remaining. Then for a moment, it possesses me and I feel myself touched by something divine. Now, it's said that in ancient China, the final exam for the medical students is that they would be brought up to a silk curtain and a hand would come out with a wrist attached and it was up to the student to palpate the pulse and make the diagnosis of the patient behind the curtain there.
Dr. Michael Klaper
(11:38)
Every physician learns how to feel pulses, and we feel how, if it's regular and how rapid it is. And especially during anesthesia, when I was practicing anesthesia, I would feel the pulse for hours in the operating room. And you can feel when the surgeon has lost too much blood and the pulse gets thin and fast, you can feel when the patient's getting too deep as the pulse is getting slower and boggier, you can feel when the patient's getting light, as they're feeling the pain and you can feel the thump in it.
Dr. Michael Klaper
(12:15)
And when we work in the emergency room, every physician who walks up the bed and feels the pulse knows if there's a body in trouble there, you can feel distress in the pulse; when the patient's in pain, when they are in shock, when they are running a high temperature, when they are afraid, you can feel it in the pulse. And I tell the medical students, when you feel a pulse, close your eyes and ask yourself, is there any distress in this pulse? Is there any urgency in this pulse? If it's an easy regular Sunday afternoon pulse, probably nothing much happening in the body of imminent concern, but you feel that urgent frantic knock, knock, knock, you know that there's a stress happening in the body and up to the doctor to find out what the problem is and make it better.
Dr. Michael Klaper
(13:09)
Well, that was a long convoluted introduction to the topic today. But really we as telemedicine physicians, we can't feel your pulse and that's a frustration to us. I wish we could sometimes, it would give us so much information. But we can't, that's denied us. But, like Yeshi Dhonden like every physician who's feeling a pulse that's so far away from the body it's out in the periphery, but from this faint signal, you can deduce how serious the situation is, how much information is in that pulse.
Dr. Michael Klaper
(13:48)
And the telemedicine consultation we have has similar qualities to it. It's a thin of data that comes to us and we have to sense is there distress here? Is there something urgent that needs to be dealt with? Is there something under the surface and how can we amplify that stream of information so we can be confident in our diagnosis, so we can return the most valuable counsel to the person receiving our care.
Dr. Michael Klaper
(14:27)
So I'd like to open it up to my colleagues and to people who are listening in, but I know a telemedicine consultation is no time to be coy, it's no time to withhold information, it's no time to make your doctor guess, time is short and you want to be upfront. You want to know what's the main thing that made you make that appointment, is there any physical distress in your body, shortness of breath, pain, something not working right? What medications are you on? What supplements are you taking? And in general, what kind of food do you eat? What's your diet standard American, how do you eat? I, at least want to know those pieces of information. And I will ask that, but it's on our intake form. But there's a lot of other things that we would like to learn and things that could help us do a better job. So I'll turn it over to Dr. Marbas and Dr. Miller and have them paint their ideas of what an ideal patient giving us what we need to do an ideal telemedicine consultation would recall at least they would have.
Dr. Laurie Marbas
(15:47)
Wow, okay. So, Dr. Klaper, that was phenomenal. And I'm sure I'm speaking the sentiment of our audience and Chris, and say, thank you for such a valuable insight to a different way of looking at a patient. And when I was in training decades ago, the best advice I ever received and who I've given to my own daughter who's going to be newly minted doctor in May was, if you listen long enough and let the patient speak, they'll tell you what's wrong with you. And I can't tell you enough how that sage advice has held true over every course of every interaction I've ever had with a patient.
Dr. Laurie Marbas
(16:29)
And four years ago, when I started doing telemedicine out of circumstances that were not my own choosing. And I was seeing originally very acute typesetting or people calling for colds or UTI symptoms or whatever. I really learned to value one of my past experience, but also that listening skill of listening to the patient because I couldn't touch them. So that was the value of really just sitting back and watching and listening and learning from the patient because they're telling you what's wrong with you. They may not know that they are, but they are. And over time, besides the acute issue, what would also filter in and weave into those interactions are the chronic disease components, the diabetes, the COPD, the chronic digestive issues, the skin issues, and people feeling helpless and hopeless.
Dr. Laurie Marbas
(17:25)
And when I started using that platform for lifestyle medicine, I was a little unsure because nobody had taught me how to do that through telemedicine. And over time I found people found it such a refreshing message that they came back, and that's when we started seeing people drop their A1C from 14 to six in three to four months. People were graduating to a different life because I just listened and gave advice of the experience that I'd had treating other patients with lifestyle medicine. And I think that's so valuable. So it is, it's like you're feeling the pulse, but your ears are your hands and you're just listening to the pulse of their voice and what they're saying. And that is extremely important skill. When you're sitting on this side of it, when someone is literally delivering their care to you through this platform. And that's been my experience and I think your story shares that tremendously.
Dr. Laurie Marbas
(18:24)
So that's my experience. And that's why we started this, Anthony and I almost a year and a half ago, and his pushing and me going, “That's a lot of work.” And it's launched into this beautiful thing and we're growing and we're sharing and helping patients. And it's been a wonderful, wonderful experience. But Chris, tell us kind of on your side of things what you would like to share.
Dr. Chris Miller
(18:49)
It's hard to follow that you guys, well, you set the bar high for an introduction and then what you've done with telemedicine over the years, thank you for that. So I'm kind of new to telemedicine and I am definitely a hands-on physician. I actually taught physical exam to medical students for years in Denver. And so, to not have physical exam has been a challenge for me. So I actually didn't know how this was going to go to be just a telemedicine doctor, but I jumped on board because working with such great physicians and my friends, and also the opportunity to get into people's houses, to go across the country, to work with different people.
Dr. Chris Miller
(19:34)
And that's a thing that we noticed we were giving these talks and people would say, “Well, how can I find a plant-based doctor, there's nobody by me, I don't know how to reach anyone.” And so it became important like, “Well, gosh, I would be your doctor if I could.” And so to be able to do this, first of all, it's been the biggest honor for me to be here and to have patients that I'm meeting from all across the country. And those of you who worked with me, know that I love what I'm doing and this has been such a treat.
Dr. Chris Miller
(20:00)
And so, I do have a few tips to share that if you become a patient of ours or a patient of mine, something that really has helped me as I'm really honing my skills to maximize the visit with my patients. And one thing is, like the others have talked about, it is a time crunch, so we don't have a lot of time. And a brand new patient who has multiple things going on. And I love dealing with gut health, and inflammation and immunity, and all the chronic problems. I'm not in the ER anymore where I'm dealing with one thing. It is used to be you've got one complaint and then you're out of here, I didn't want to know everything.
Dr. Chris Miller
(20:38)
And now, it's the exact opposite. I literally want to know everything about you in that 30 minutes. I want to know what your job is, when you have time to prep food, what are your stressors in your life? How did you grow up? How much times are you on antibiotics when you were a kid? What are your favorite foods? Do you have food addictions? Do you overeat sometimes? Do you eat late at night? Do you even know how to cook? I had no idea how to cook when I started this journey myself.
Dr. Chris Miller
(21:05)
And then, of course, all the medical history, what medications are you on? What supplements, what medical problems do you have? What surgeries have you had? I want to know all of it, and I didn't want to know doses. And those of you who worked with me know that, I'll say, “What omega-3 fatty acid are you taking and how much? Which probiotics are you taking and when do you take it? I want details.
Dr. Chris Miller
(21:25)
So 30 minutes is really difficult for me. And so, I ask my patients to please do fill out all that paperwork. I will take the time to look at it before the visit and it really helps. Because then, I don't have to spend our short 30 minutes asking you what your medications are, what are your supplements? We can jump in to. I want to know what's really been going on, what's your life like? I'm trying to get to know you and get to know everything about you so we can build a comprehensive plan.
Dr. Chris Miller
(21:53)
And I build a plan with my patients that is holistic and integrative, it's everything it's going to cover your gut health and your inflammation, and when you sleep, and how much stress you have, and how you deal with your social issues, and if your job is stressful for you, we're going to look into all of these things while we're trying to lower your blood pressure and your cluster and get you off your diabetes medicines and treat your autoimmunity. So we're going to deal with all of it because they are very well all linked. And my goal is to get you to a healthy state where all of this all of this fall into place.
Dr. Chris Miller
(22:23)
So 30 minutes is tricky and it's been tricky for me. And you as my patients, those have worked with me know that I run a little bit late five, 10 minutes, especially my new visits. I save that extra time which I won't always have that, but I do right now on purpose as I'm honing it myself. So anything you can do to help me to get that information to me ahead of time is so helpful so that we can actually engage and get to know each other and formulate a plan and go from there.
Dr. Chris Miller
(22:50)
And it's been such a treat. People are having amazing results and even I am blown away because it's convenient, and it's flexible, and we're right there in each other's houses. This is my little office here and it feels like we're really getting to know each other, and it's been way better than I ever would have thought. So if you've never tried telemedicine, I encourage people to give it a shot. And it's been super fun establishing these relationships. So that is my little spiel on telemedicine.
Dr. Laurie Marbas
(23:18)
I think that's fabulous, Chris, and it's really interesting. So Christina mentioned some questions. She says, “Does the intake form allow for a written summary of history as well?” But she also says, “How does this work in conjunction with the primary care doctor as well? Do you communicate with them?” So that's some very good questions. So we do have an intake form that gets the basics. I have had patients, I've actually requested, can you write up a timeline? You were well until when? And then tell me this history because a lot of this is detective work. And if I can get that ahead of time, that really helps me narrow in on where we need to focus in that 30 minutes.
Dr. Laurie Marbas
(23:55)
And you could see my patients, we say, hi, and then like, okay, let's talk about [inaudible 00:24:00] and bump right into it. And I think that's really important. A far as it comes to the primary care doctor, we are not replacing your primary care doctor. I like to consider us consultants to the primary care doctor. So we take those tough cases and help them navigate those waters and help them actually get to a healthier state more time than the regular primary care doctor can. We are happy to speak to a primary care doctor, should they feel so inclined to speak to us.
Dr. Laurie Marbas
(24:27)
In all the years I've done this, I have not had one reach out to me. Now, there could be various reasons for that. Some do not agree with the plant-based diet, there's a lot of people in the ketogenic type diet, there are others who are just like, “Okay, keep doing what you're doing, I don't have time for that.” And then, sometimes they do ask some questions and the patient will fill them in on what we're doing, and maybe they'll do some research on their own, but I've not really had anyone reach out and say, “I really need to speak to you.” Because oftentimes, we're decreasing medications. The patient's feeling better, the patients losing weight. So unless they're curious to learn what we're doing, oftentimes, they're just like, “Yo, keep it up.” So Dr. Klaper, any thoughts on any of that?
Dr. Michael Klaper
(25:12)
Well, I was really delighted by what Dr. Miller said, how welcoming she is to all this information. And she's absolutely right, and she's a good doc, and she knows that how the person's living, and who's doing the shopping and the cooking in your house, and do you cook at all, and how often do we eat out in restaurants? All this is so important, especially these days. That she really painted an important picture that I hope people are listening, “Oh, okay, she's interested in that kind of stuff, okay.” And so that alone I'm sure will help.
Dr. Michael Klaper
(25:49)
I had to smile when Dr. Marbas was mentioning the tissue she got out. There's some things in medicine that are so universal that it's guaranteed to find its way into the heads of just about every medical student. I still remember my chief medical resident at the University of Illinois [inaudible 00:26:08] if you just shut up and listen to the patient, 90% of the time, they're telling you the diagnosis, and if you keep listening, they'll tell you what treatment they need too, and how right that's turned out to be and the same truth. Obviously, I'm sure Dr. Miller ran into the that in some form or another as well.
Dr. Michael Klaper
(26:28)
So again, this is definitely a 50/50 exchange here. You're paying us for our time and expertise, but the more information you can give us as far as what's really bothering you… And people really do know. I often ask the patient, “What do you think is going on? Well, of the different doctors you've seen for this, whose ideas resonated best with you? Who do you think? Was it the endocrinologist or the dermatologist, who do you think was closest to their actual diagnosis?” And so, we want to know what you're thinking and feeling, but then we have some ideas as well that we'll certainly share with you. Medicine is getting just extremely powerful these days and what we're able to ascertain.
Dr. Michael Klaper
(27:19)
Dr. Marbas and Dr. Miller, I'm curious about your philosophy, and I know the answer depends on the patient, we all know that, but as far as follow-up visits, because we know it's going to cost the patient cash, at the end of the visit, what is your criteria for saying, “I want to talk to you next week or in three weeks or whatever versus call me if you have any problems?” And are you ever hesitant to ask for a follow-up for the patient?
Dr. Laurie Marbas
(27:51)
I follow up with probably 95% or more. And the reason is, most of the time there's medications that need to be monitored. And sometimes, it's maybe one week, sometimes it's two weeks, three weeks, three months. So oftentimes, I'm like, “Okay, let's just schedule…” Well, I've asked, “When do you want to follow-up?” Or if there's someone I'm more concerned about, like, “How are you cool with next week?” That would be one thing.
Dr. Laurie Marbas
(28:14)
And then try to be conscious of the cost. We have tried here to keep the costs, trust me, Anthony and I went around in circles trying to figure out the least amount we could charge and yet still run a business. So this is still a business, we don't have this platform for free, we don't spend our time for free, I literally cut down my other day job that I have to see patients. So there has to be some cost.
Dr. Laurie Marbas
(28:42)
Unfortunately, insurance does not give you the money back in Medicare, especially, it's on average $15-$40 per visit, if you get anything back. So we don't accept insurance, all the pricing information is on our website at plantbasedhealth.com. We can give you a super bill or receipt, which would allow you to submit to insurance companies. And we've actually had people get three fourths back of the actual cost of the visit, which is amazing. Unfortunately, our Medicare patients are not allowed to do that. It's actually against the law to submit for some type of reimbursement because we don't accept Medicare. And that's unfortunate and it's unfortunate we have to be this way, but that's the only way we can survive and still offer the services.
Dr. Laurie Marbas
(29:31)
So as far as follow-up, I look at the urgency of the patient, where they're at. I do a lot of portal messaging back and forth with patients, I probably 15-20 messages a day. And I always say, “If you need to reschedule, we'll just reschedule, but at least I have that slot saved for you.” It's just a kind of a fluid thing. But now we're getting people. I've had people like last night, I had a patient who's literally versus diabetes in the three months we've worked together. His labs look amazing, his A1C is normal and he's just like, “This is amazing.” Now we follow-up in three months just like I would with a regular patient if I was seeing you in brick and mortar place.
Dr. Laurie Marbas
(30:14)
So those are the types of things that we're seeing now. And yeah, so that's the urgency of medications, this is a big one, or if I feel someone needs an accountability to say, “Okay, they're really struggling, let's follow up a little bit sooner.” But I try to be judicious in that because I do understand the cost, Chris.
Dr. Chris Miller
(30:33)
Yeah, that's a good question too. And I definitely, I follow up pretty much with everyone as well and it varies depending on what's going on. So same thing, if they're on medications or if I'm worried about their blood pressure, blood sugar, or doing some tricky interventions, we'll follow up more frequently. So one week, maybe two weeks, depending on how they're doing. And they know how to reach me if they need me anytime, because I always want to be involved if they could fall to with low blood pressure or with blood sugar too fast. And so, those people follow up pretty quickly.
Dr. Chris Miller
(31:04)
The others will follow up depending on what they need. There is some data showing that the more you see a doctor, the better results you get with lifestyle medicine, so we know that. And so, and I see that in my patients, I put them on. Some of them are on pretty complicated plans or we don't have time to finish it all. So usually, I'll do about two weeks or a month out and people will come back and come back with their questions, maybe their food journal for me, food symptom journal, I ask about how their bowel habits are, that's just a gateway to me in how their gut's working. And so, we've started going through that. What are the symptoms now? What's changed? Medication supplements, all of that.
Dr. Chris Miller
(31:44)
And I want to know what obstacles they're meeting, how is this working for them? And is it taking too much time? Do they not like the food? Are they jamming with it? Or a lot of people with IBS and gut issues, we're advancing the diet according to kind of a protocol and following them. And so, I want to know how they're doing with that, and if we can move forward or step back, answer their questions. So I'm also mindful of cost. And so, it's kind of up to the person. So I always ask them, unless we're cutting back on medications and I'm worried, then, I'm a little more like let's follow up next week.
Dr. Chris Miller
(32:20)
But other than that, it kind of depends on the patient. Some people see me once a week, some people, every other week, some people, once a month, some people will be three months, some people, they'll say, “I'll see you in six months,” and that's fine because their labs are normal. So it kind of varies, but, yeah, it's helpful to stay in touch with each other.
Dr. Laurie Marbas
(32:38)
Yeah, absolutely. And I think the messaging too. And someone asks, can we upload labs or other documents? Yes, so we have a patient portal, it's a HIPAA compliant patient portal or EHR, we can order labs medications across the country. I'm in 40 States right now, working on the last 10, and DC, so much things I got to do. But anyway, yes, you can upload documents, you can upload your labs. You can upload your blood pressure log, your food log, all of those things very simply, you just need to have them in a PDF format and we upload them, or even photos, but it's easier if it's PDF.
Dr. Laurie Marbas
(33:12)
We can upload information to you many times, or actually, every single day that I see patients spending time afterwards sending a follow-up message saying, “Here are the links that we talked about. I've uploaded this information. This is your diet plan and I'm making notations as we're talking about the plan.” So I definitely want to keep track of all that. So there is that two-way communication, which is very helpful.
Dr. Chris Miller
(33:39)
And I know Kim. Kim, I can email you that information on that link from Anthony and it'll kind of walk you through the steps so you can get anything uploaded.
Dr. Laurie Marbas
(33:49)
Yeah, she can go to plantbasedtelehealth.com and under how-to videos, it's under the information link and you can see Anthony, that's Anthony's voice guiding you through the EHR. And we're trying to make that as simple as possible and remove as many barriers as possible, but we appreciate people's patients as we grow this and the growing pains with us, so thank you.
Dr. Chris Miller
(34:13)
And for anyone out there, if you guys are listening, I know a few of you guys, it's been really nice to see you there today, but if you have any thoughts about it, what's working, what's not working, please share with us too, because we'd love to learn, and grow, and improve on it as well, so.
Dr. Laurie Marbas
(34:29)
Absolutely, Dr. K, any other thoughts there on that?
Dr. Michael Klaper
(34:35)
Well, looking at the chat here from Trudy Jones, it's fascinating idea where she says, “A subscription model that I'm seeing in direct primary care here in Denver is an interesting idea, have you considered that?”
Dr. Laurie Marbas
(34:51)
Yes, so we've played around with a few different ways and the only caveat is the cost of how much would we charge, how many visits would that mean? So it's a real balance. Most physicians these days are not solo practitioners or even in a private practice, they are employees of usually larger hospitals, someone's paying them a salary, so they don't worry about that. So a lot of, some physicians, I shouldn't say a lot, some physicians have moved to this direct primary care where you're paying kind of like a subscription, just like if you would go to a gym.
Dr. Laurie Marbas
(35:30)
So you would pay anywhere from 49-159 or whatever per month, and you would have complete access or a certain amount of access to your physician and they'd have a smaller practice. But there's two things that benefit that, one, the patient knows how much it's going to cost per month, they understand what that access entails, and two, it provides a basic continual income for the physician. So that gives them some security in going out and branching into that.
Dr. Laurie Marbas
(36:00)
So there is some benefits, but there's also the waving back and forth. So it's a challenge on the business side of things. I've learned so much, I've been listening to a lot of business podcast, I have an MBA, but it's not quite the same. But there's marketing involved and there's all these amazing things, there's legal stuff. Medicine is a very special field. It's not just like starting any business, there are some very tricky laws and we're in a lot of different states and everything is very, very different. So there's a lot of lawyer fees involved. So when we look at it, we have to calculate it, we have to look at the cost, the benefits, the time involved, is it going to be worth it to the patient and to the physician?
Dr. Laurie Marbas
(36:43)
Because we also want to make this a place where the physician wants to do this. We don't want someone to do lifestyle medicine after their big gig and they're exhausted, we want then this to be their thing. And so, they can give you the full attention and the energy you deserve as a patient. So yes, we thought about it, we're still young, we're just six months old, so we're still crawling. So maybe that will be something that we or maybe even a model that contains two things, people who just pay as they go or someone who has a subscription model. So we'll see, we just have to balance that with the cost of running a business and all the things that entails, so yeah.
Dr. Michael Klaper
(37:23)
Well answered.
Dr. Laurie Marbas
(37:27)
Let's see here. “I don't even feel better yet,” Kim says, “And this has been life-changing for me.” So that's great. Sounds like we're appreciative of that. So we'll open that up. Now we have a few more minutes. Does anyone have any questions about telemedicine or anything else? Any other thoughts on maybe patients that you've seen that you feel would be maybe inspirational to an audience member who's thinking “Well, is this something that I want to do?”
Dr. Michael Klaper
(37:54)
Just let people know when I'm sitting down from my work session to see patients in the electronic office these days, I sign on about 15 minutes early and I see who's on my schedule. And I go to each of your charts, for the folks who are listening, and the first thing I click on is chief complaint. I want to know, what is the major thing that made you make this appointment?
Dr. Michael Klaper
(38:20)
And so, there is a place to pour your heart out or list the major things that have you concerned that always grabs the doctor's eyes when you see chief complaint, that's not a trivial line to fill in, and that's of most important things we put a lot of import on. So if you don't have a lot of time to fill that out, please, at least go the chief complaint area there be as specific as you can, as far as what your medical concerns are.
Dr. Laurie Marbas
(38:47)
Perfect, yeah. It's just like any type of practice, you have to learn to be efficient, otherwise, you're going to be exhausted. So it's just translating things, I think, efficiency, and time management. And I've learned even in the last six months, and I've been doing this a long time, how to streamline that process. So there's about an hour involved before every night, before I see patients, and there's another hour after that, making sure everybody has everything that they want and answering questions.
Dr. Laurie Marbas
(39:16)
So it's not just the time we're spending with you, there's timing before, making sure we're prepared for the interactions that they're efficient for you and that we're not searching for things. I have about six things open when we're talking, I do a lot of continuous glucose monitor, I'm looking at your blood sugars before we talk. So there's a lot of stuff going on. And I'm sure, Chris, you have something that you do as well, a schedule before you're seeing patients.
Dr. Chris Miller
(39:42)
Yeah, for sure. This is what I'm figuring out right now because I look up, same thing as Dr. Klaper too, what everyone's chief complaint is. And if I haven't seen a lot of it, I want to know what's modern medicine regular treatment for it and I want to know lifestyle medicine, is there anything specific? Is there data on it yet? I have my own ideas. I could start to figure out whether [inaudible 00:40:04] inflammation or gut health or what we're going to deal with, but I want to know, is there any data on it yet and what is modern medicine I'm going to recommend? And where does this progress? What's going on with you?
Dr. Chris Miller
(40:15)
So there are some things that I haven't seen a lot of, and I am looking it up and I'm reading and some of you know when we work together that I go and read more about it. I'm like, “All right, let's get to the bottom of this. Let's figure this out. Or if you're not getting better, why aren't you getting better? What else is going on? Or if we need to talk to a specialist or get other imaging done or take it to the next level, absolutely.” So I do put plenty of time in looking that up as well so that when on our time or visit I'm knowledgeable and I have something to talk about, and then afterward I'll keep pursuing and we'll work together. We're going to get to the bottom of it until people get better, I won't give up on you. And that's been the fun of it.
Dr. Chris Miller
(40:51)
So I have seen people with all sorts of just interesting, weird symptoms. So neurologic things, like numbness and tingling that hasn't gone away for years or pain in their fingertips that they were losing sensation. And nobody was able to diagnose it or it wasn't related to anything, they had no idea what was going on. And I've done research on it, we work together and symptoms are resolving and people are getting their sensation back. And the numbness [inaudible 00:41:19] even gone, the weakness in their legs that's been for years. One of my patients is able to walk, improved walking when she was using a cane before and now, she's told me she did it a couple of times without it. And this is the power of working together, forming a relationship and we're in each other's houses again. And I'm learning and as we go and researching and we're figuring it out and we're applying these concepts. And so it's been really powerful and it is adjustment, I'm learning as well so I'm figuring this out because this is new to me. What I've only been here since May, so I'm figuring it out as well.
Dr. Laurie Marbas
(41:58)
Yeah, Absolutely. I would say I had, even just a recently in the last couple of months, I had a patient who had some very odd symptoms and she had been to multiple specialists, had been in the ER, very ill. And I was like, “Okay.” I said, “Let me do some research.” And I spent about actually two hours after the appointments were done. And I found something and we implemented this treatment and she is doing fabulous. So that's the beauty of being able to have these types of interactions and comfortable. You're comfortable in your home more than going to a doctor's office, we're also in our home, we can do whatever. And so that is really cool stuff that you can do with this type of power of the telemedicine visit. And I'm not saying that other doctors don't do that outside of telemedicine, but it is been a really unique experience. Dr. K, any thoughts there?
Dr. Michael Klaper
(42:50)
It reflects on how important the medical history is. 90% of our diagnoses are made by history and even on a phone call after, by the time you get to the end of the call, you know what the patient's lungs sound like. You have a pretty good idea what's happening in the patient's body. And so, expect us to ask questions that… We want this information just how your body's doing in general, as well as the specific issue that you have in mind.
Dr. Michael Klaper
(43:32)
A question I always ask or usually find that paints a big part of the puzzle picture is when's the last time you felt really good when last time when problem X was not in your life, the fatigue, the pain, the limp, the whatever it is? When was the last time you were just good old Mary or Joe? Oh, three years ago. Where were you three years ago? What happened three years ago? Tell me about their transition into pain or more patient who went there and because something happened there, body's not capricious. It doesn't decide I'm going to whip up lupus today. I'm going to whip up your colitis today, I don't this.
Dr. Michael Klaper
(44:21)
So something happens that has to do with how we are treating their body, how we are caring for the machinery that usually sets this off. So we're always going to be very interested in that kind of the last time that you weren't a medical patient that you felt really good or we're very interested in that transition. So be prepared to help us drill down on that a bit because there's often pearls of information there that help us make the diagnosis.
Dr. Laurie Marbas
(44:47)
I literally have people write down a timeline. So you were fine until exactly, that's kind of how I phrase it and then write down everything symptoms, things that you don't think are important maybe I will think important. Who you saw, what did they treat you with? And as things go through that is gold. And honestly, you take it to any of your doctors if you're not going to see us, but do something like that because it's going to give you insights and you may forget sometimes or maybe it'll jog your memory to do something else, a very important hint or a clue. And that is just so very, very important. So absolutely the history, your history, your interpretation of the history is so very important. But Chris, anything else you'd like to say to any of that?
Dr. Chris Miller
(45:35)
Well, speaking of one question that I always ask everyone is when I'm first meeting you is I want to know what you want to get out of this visit. It's been interesting, so people with rheumatoid arthritis who come to me and say, “I want to break my sugar addiction.” “Great, that's an awesome goal, let's work on that.” And I might say something like, “Well, we could work towards maybe lowering your rheumatoid arthritis medications or possibly not even needing them one day.” That's always my goal. And she was like, “No, I feel good on those. I'm not really interested in that. I just want to get off my sugar addiction, it's really limiting my life.” And I was like, “Perfect, if that's what your goal is, that's where we're going to go for.”
Dr. Chris Miller
(46:15)
And so we formulated a plan that would work for her. And my second question follow up is what are you willing to do to reach that goal? Because it's one thing to say, “Oh, I want to break my sugar addictions.” It's another thing to say, “I don't want to give up any of my favorite foods. These are foods I love, these are the foods that my family, I am so busy, I don't have time, I'm stressed out.” We have all of our things in our head that drive us to keep doing the same thing. So I want to know, one, what is it that you want out of this visit? What's your goal? And two, what are you willing to do for it? Are you willing to go the extra way? And so then we develop an approach.
Dr. Chris Miller
(46:49)
So for some people we're going to jump right in, for other people we're going to take the tiny steps and go a little bit at a time and build a plan for them. And so what happened with that patient is over time, she was awesome. We built a plan and we made little changes for the first two weeks. And then we said, “Let's go for it.” She stopped her sugar for those first two weeks. And in the meantime, I was like, “Well, add in a little bit of this. This is going to help you, add in, I want you to fill yourself with this. The fiber will take away your cravings. It's going to keep your blood sugar flat.”
Dr. Chris Miller
(47:18)
And so we were adding in these different foods and we were pushing up the sugar, we kind of crowded it out, pushed it out, push it out. And then we finally made… we're ready. And we went for it and she got off and she felt amazing. She said, “Chris, I don't even crave it anymore.” She's like, “I don't even want it.” And I hadn't even said 100% no sugar yet, we were just crowding out at this point. And she goes, “I chose not to eat a brownie. I didn't even want it, my brain was not going crazy anymore.”
Dr. Chris Miller
(47:43)
And at the end of it when she followed up, she followed up in two weeks and she was like, “Oh my God, I have no joint pains.” So in a way, we were adding in the right foods without even really thinking about it. And she was getting her goal which was getting rid of the sugar cravings. And we were able to take her off her meds over the next three months. So it all worked, we both got our goals, but we were following her goal with what she wanted and what she was willing to do. So we built a plan for her. So that's one of my approaches.
Dr. Laurie Marbas
(48:14)
That's a beautiful example of what lifestyle medicine does. So you will focus, people are like, “I need to fix my diabetes.” But they have hypertension, joint pain, fatigue, insomnia, the emotional distress, or mood disturbances. All these things, but if we focus on the big part of what are we feeding our body, how are we getting some rest, those small goals, everything gets better. And before you know it, they're looking at you a whole different person than three months ago. So that is really a beautiful example, Chris, exactly what we do, I think so. And someone did ask a question, are there doctors in your network of people that deal with hormones? And I think all of us deal with hormones just as a physician. So I think hormones are the content, one of the biggies. I'm not sure if you meant female hormones in particular or stress hormones, or anything too but do either of you have any thoughts or expertise in a specific area of hormones that you'd like to speak to?
Dr. Chris Miller
(49:09)
No, but I've been reading a lot about menopause lately because I'm getting to that age myself. So I have dealt a lot with female hormones just over the years, just randomly. And of course we deal with thyroid, we all deal with insulin, these are all hormones, we all deal with stress. I love talking about stress and things that we can do for it and stress hormones. So I feel I think you're right, Laurie, that this is something we all feel comfortable with and we all see quite a bit of in deal with.
Dr. Laurie Marbas
(49:38)
Menopause, I have a whole new appreciation because I'll be 50 next month and I'm entering this pre menopausal phase. And like, “Life was different five years ago and I really am beginning to understand it.” And not that it's severe, but it's certainly different enough to be going, “Well, okay, now I get it.” So yeah, it's just a different perspective, which I think as we all grow and live life, I think that happens. But Dr. K, any thoughts and anything in particular that you'd like to work with?
Dr. Michael Klaper
(50:08)
Well, first of all, I definitely, I picked up a good pearl from you today, thank you. It sounds so obvious but I'm going to start asking my patients right off the bat. What do you want to get out of this particular visit here before we focus in on your blood pressure, whatever? Because they may have something else all together or their blood pressures are peripheral to them, they got something else happening. So thank you, I'm going to start asking that question more frequently. I am curious, I think behind that last questioner's question was the issue of bioidentical hormones and do we prescribe that? Are we the kind of people who, if a woman's having this really severe hot flashes, vaginal dryness, et cetera, would we prescribe those kinds of hormones? How are you two physicians feeling about that?
Dr. Laurie Marbas
(51:03)
She mentioned again, female hormones, AKA getting off of birth control. Yeah, I can definitely, [inaudible 00:51:08]. I mean, I've been writing birth control since I was a resident physician. So for sure we can talk to you about coming off or whatever you need. Female hormones, I'm not a huge fan of bioidentical hormones because menopause is not a medical diagnosis in the sense that it's a crisis or a disease, it's a natural phase of life. So we have taken the medicine and made it something to fight and something that is not an… we think of it as something's wrong because you're entering menopause and you're having these symptoms when actually this is a normal phase of life. Now, are you very symptomatic and are there things we can do? Absolutely, write prescriptions to treat that other things you can do.
Dr. Laurie Marbas
(51:49)
But we also have to look at this as a natural stage of life. And I think with men and testosterone, unfortunately we have to be very careful with that because testosterone is considered a controlled substance and you cannot write those types of prescriptions via telemedicine. So that would need to be taken up with either an endocrinologist, or your primary care doctor, or urologist sometimes they'll do that. But for females, there's certain things that we can talk about for sure. And if you're really suffering 100% there are things we can write for. But then it goes back to lifestyle medicine, why are you suffering so much?
Dr. Laurie Marbas
(52:25)
I've lost count of number of women, who do better going through this menopausal transition, which can last for one time, they stop having their period and they're done never have hot flashes to women who suffer for years. I would say some very interesting transitions. And many, many, many, many get better with just paying attention to their lifestyle.But yeah, Chris, any thoughts on?
Dr. Chris Miller
(52:47)
Yeah, that's a good point, Dr. Klaper, because that's probably what people are wondering about us. So I'm glad you brought that up. I personally do not prescribe bioidentical hormones. I'm a little nervous for them, I just am first do no harm. And I don't want to be giving extra hormones because hormones are in a fine balance, it's like a web and they balance each other. One goes up, the other goes down, they're very finely balanced. And so if we start giving one fixed amount of one, it kind of throws everything off and so I will do everything I can with lifestyle medicine to help someone improve.
Dr. Chris Miller
(53:20)
And I have some supplements that are very effective for people going through a tough menopause time that I've used and as well as diet and lifestyle, and there's a lot actually that we can be doing. But I have delved into the research. So I have a few patients that are just really struggling. And so I've done quite a bit of research for them trying to figure out, is it safe? What are the risks? And knowing that specific patient, what are the risks and then talking about it with them. So they have a very good understanding and then they've taken it to someone else. And If they feel like they need to go on for a short time, and I always say with medications, if you're going to go on something it's always for short time, our goal is never to be on something for life.
Dr. Chris Miller
(53:59)
So sometimes maybe someone does, is really struggling and is just not doing very well. And so I'll help them do the research and if they go on for a short time, then they keep working with me and we're really going to step it up and do everything we can so they can hopefully get off of that and not need it for too long. But, so that's yeah, I mean, some people just really have a tough time.
Dr. Laurie Marbas
(54:21)
Yeah, absolutely. So women who are being prescribed testosterone for example, no, that's just, there's so many side effects and I've had people come in with high blood pressure, chest pain, all sorts of issues from someone prescribing testosterone and some other things or prescribing thyroid hormone and they have normal thyroid function. So these are dangerous drugs. You just can't throw a wrench and the monkey doesn't respond. So the monkey wrench really does something. You're a body as a system. So when you start throwing in hormones or medication, be it high blood pressure meds, or different types of any type of medications, you're going to have a response. And there's multiple things that occur. It's not just fixing your blood pressure for example, sometimes you can get a side effect from a cough or you can have your heart rate too low that you feel dizzy upon saying.
Dr. Laurie Marbas
(55:10)
So there's so many different things and hormones are a beautiful example of that because they touch so many things, your thyroid hormone touches every cell in your body. So it some big deal to be putting someone on these type of medications. So we should be walking it cautiously. I've had men say, “I don't know why I take testosterone. The doctors said I had low T and that's what I need.” I'm like, “Well, why do you have low T, what is their definition of low testosterone? What was the diagnosis?” And they're like, “I don't know, nobody ever told me.” I was like, “Okay, so we're going to talk about why that's important for you to understand what you're treating. You're not just throwing a medication at something.”
Dr. Laurie Marbas
(55:48)
So I think we need to give the power back to the patient to ask the questions of like, “What is wrong with me and let me understand why you're doing what you're doing.” You got to be your biggest advocate. You've got to be for yourself. And if your doctor should come aside along you as your partner in your health and be your advocate with you. So that is my philosophy. Again, like Chris said, it's so very important, do no harm. It boggles my mind, I've had a patient walk in before I even went on a plant-based diet, the lifestyle medicine, 85 years old, still on female hormones, I'm like, “You're 85.” We had quite the conversation. I was like, “Why are you still on these increased risks for all different things?” And sorry, but I've I can go on a rampage about that because I think it's harmful.
Dr. Chris Miller
(56:36)
Actually, Laurie, that reminds me, I just recently saw a Dr. Klaper little video and Dr. Klaper was talking about the Amazon forest and how you block up a dam thinking you're just blocking up the dam, but you're changing the amount of mosquitoes, you're altering everything downstream. You can't just do one thing. That was his point of that talk, you can't do just one thing. So these medications, you're not doing just one thing. And it's very intricately related like you said, every cell in the body. So I always keep that in mind too. So if you have to take something it's very short term and really you can affect your hormones by what you eat, and how you live and maybe a few supplements, you really can, we can change that. So yeah, anyway.
Dr. Laurie Marbas
(57:17)
That's a great example. So look at the world around us, we live in the world, the systems. So for example, in Yellowstone, they took out the predator, the gray wolf. And before it, over the course of decades, you actually would see things happen, like trees begin to disappear, birds disappeared. The river is actually changed course. And all of these consequences, they introduced back in the gray wolf and things start going back in balance. So everything is important and everything should be looked at in the system since and I absolutely get that. Dr. Klaper, anything that you'd like to speak to about that?
Dr. Michael Klaper
(57:54)
That was a beautiful example. For those who couldn't understand why taking the wolves out, made the trees disappear because of the elk population blossomed and the elk were eating everything in sight, including little saplings that came up, when you introduced the wolves back and things stabilized again. And it's a symbol for our everything's connected in the body. You can't do one thing, everything sets off cascades of reactions. Well, it looks like we're getting at the end of the hour. So I hope this has been worthwhile. We're here for you and we're interested in everything you say as a patient, it helps us. And don't be shy, don't be coy, tell us what you need. Now, I'm going to ask, what do you want to get out of this appointment? But tell us what you need and tell us what's in your mind, in your heart. And we'll do the best we can to make things as healing as possible for you, that's what we're here for.
Dr. Laurie Marbas
(58:56)
Absolutely, I think that's a great way. And I just want to answer this one quick question real quick from Dali, I know you just asked this question. She's asking my endocrinologist called to change my Levothyroxine from 88-50. And I ask why, but nobody's giving me an answer. It's probably because your thyroid is working better, so you need less medication, so that's why they're lowering it, which is a good thing, so. All right, thank you guys. We appreciate you and you can find us at plantbasedtelehealth.com, Dr. Miller, Dr. Klaper and myself. And thank you for sharing your hour with us. We know it's an honor to be here with you and again, have a great day.
Dr. Chris Miller
(59:35)
Bye guys, take care.
Dr. Michael Klaper
(59:36)
Bye-bye.
*Recorded on 9.17.20