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Location Independent Physician

Because of telemedicine I am able to sit at Powell’s bookstore in Portland, sip my coffee, and make money as a physician.

laptop-coffee-mug-powells-bookstore

This post is about telemedicine, or virtual medicine, that’s being widely adopted and becoming the new trend in medicine. My medical group is aiming to have 60% of its patient encounters be virtual in as little as 2.5 years.

I’ve been doing telemedicine for the past 2 years. As residents we all did some sort of telemedicine – we triaged patients on the phone when on call, we have made recommendations and even prescribed meds over the phone.

Specialists have done telemedicine by taking calls from family docs or from their PA’s. They have viewed studies and made recommendations and clinical decisions based on that data.

The difference now is that we can finally get paid for the work we were doing, work we assumed was part of the job.

Same Shit, New Name

We made phone calls to patients way back in the day but didn’t call it telemedicine. Now that companies can bill for it, it’s got a new name.

I think patient’s lives are getting more and more complex, there is less and less free time and health is quickly falling down the list of priorities in someone’s life.

The general public has an impressively misguided faith in medications, tests, surgeries and imaging.

This creates an opening for medicine to go from in-person visits to a digital form. Patients rely more on lab work and imaging to get the right diagnosis and prefer medications over conservative management. This is a perfect environment for virtual medicine to flourish in.

Patient Preference

There are still quite a few people out there who don’t think medicine can be practiced through a screen or a phone line. They prefer an in-person interaction and usually prefer to have their regular doctor be the person they interact with.

This group will probably only use virtual medicine to get a medicine refilled or relay some information to their doctor.

Telemedicine In 2016

There are 2 main forms of this right now, telephone/video or using artificial intelligence for data collection.

The first and most common is where the doctor calls the patient and triages, orders tests and manages the illness. Video is sometimes used instead of voice but it seems to be wonky still, limited by technology.

The second form is usually over text, this is where artificial intelligence (AI) gets integrated to collect the pertinent information for the clinician. No decision-making takes place but less data collection has to be done by the doc, expediting the decision-making, usually.

This text-interaction takes place either through an app, through text messaging or on the web.

Text-based interactions are less intrusive. A question can be asked, an image posted, each party has time to think about the next answer/question and there is less pressure on the doctor to come up with a diagnosis right away. The patient isn’t forced to ask all the right questions and give all the right answers in one setting.

Some of the virtual medicine visits I perform in this form go on for several days and believe it or not, they are quite pleasant.

Location Independent Physician

The best thing about virtual medicine is that I get to practice it anywhere I like, anytime I like. I don’t need a nurse nor my own lab/imaging center.

A location independent physician can be in any country. In a coffee shop or from my apartment at an AirBnb. I can control the volume of patients and the hours I want to work fairly easily since the demand is high.

Part-Time and Retired Physicians

If you have your own practice or job then you are not likely to work a full day and go home and do more virtual work. The reason is that reimbursement is higher per-hour for in-person medicine.

Older docs who are retired will do this, but their limitation will be technology. Let’s face it, the older docs don’t stay up on technology like younger ones and getting some of these programs to work can be a huge pain in the ass.

It’s also unlikely that doctors will do well in this if they try to go into it straight out of residency. I think to excel in virtual medicine it’s really important to have a good solid base with actual clinical medicine and then either do it on the side or transition into it slowly.

Trend in Medicine

The future of medicine is most definitely AI. It’s quite likely that AI will do most of the triaging and data collection to the point that the doctor can review the information and make the next decision.

Some illnesses and chief complaints will completely outsmart AI, those will need the doctor 100% at the helm. Think psychotherapy.

Video is more of a gimmick and doesn’t seem to be an efficient way for a clinician to communicate with a patient. Internet connection is still the limiting factor and software rendering and manipulation of images/videos is still too slow to make video a good substitute for an in-person exam.

Several companies are working on developing intelligent software that will examine an image, adjust colors based on whatever device you’re using, make an initial diagnosis and even build a differential diagnosis list.

Post-op wounds, melanomas, lid disorders, stroke evaluation, genital evaluation for STI related rashes, oral lesions and goiter evaluation are all now being worked on by software companies trying to design a program that can not only diagnose these things but also learn from a wrong diagnosis by input from the clinician.

 

Artificial Intelligence & TeleMedicine

In order for lawyers and politicians to keep their job, doctors will never be hands-off when it comes to healthcare delivery. No matter how intelligent an AI component is, it will still have to be reviewed by a clinician.

AI is now being built into phones, software, devices, EKG’s etc. Devices are being built that will be advertised to consumers that can do EEG’s, EMG’s, EKG’s, measuring eye pressure, skin turgor, blood tests etc.

Someone please work on a self-disimpacting AI device! Not for myself but just so I don’t have to do it anymore.

Making Money

I am doing virtual medicine now on 3 different platforms.

I am doing a mostly phone-based one which is quite busy, with 5 patients an hour, but very easy. Patients have low acuity and it’s mostly triaging and deciding what the next step is. I usually prescribe some NSAIDs or non-opioid cough medications. I order imaging and place referrals for very straightforward cases.

I am also doing a web-based gig where I am answering medical questions posted by those wanting a second opinion or who are too anxious to wait to be seen by their doctor. Others are asking for information to take to their doctor before their visit.

In this web-based program I can do as many questions as I want and I can take my time doing the questions. It’s generally easy but the questions are often quite detailed. Either you have to be a specialist and answer only the question posed in that field or you have to know a little about a lot, family medicine. There aren’t quite enough oncology or ortho questions on this website to make it worthwhile for a specialist, but plenty of questions for a general practice doctor.

The last one I’m doing is an AI-based texting platform. Patients interact mostly with a computer, all the pertinent information is obtained and I come in to decide on management. Much lower volume, higher end clientele.

Telemedicine Income

A specialist can make over $150/hour looking at images. Dermatology will probably end up being one of the highest paid in this group. Ophthalmology is gonna be up there as well.

Psychiatry will do pretty well too, but they are already doing a lot of their work over the phone.

Because a lot of the care is based around triaging and providing second opinions or providing a specialist’s perspective, it’s unlikely that an interaction will profit a clinician more than $20-30 right now.

A few months/years down the road each respective specialty might see their normal hourly rate translated into an e-rate. For now, the general practice specialties (family, peds, OB) will get the biggest slice of the health-pie.

Answering only questions and not prescribing any medications or ordering tests makes me about $3,000/month for 2-3 hours per day, 6 days a week. I could make more but there is quite a bit of competition for these questions.

I probably could ask to get dibs on the questions if I was willing to commit to a certain number of hours daily… but I don’t want to.

Doing full-scope urgent care through telemedicine pays me around $100/hour. The volumes are high but the acuity isn’t bad, as I mentioned before. I can get tedious but a 10-hour shift would pay me around $1,000, not bad.

Telemedicine Companies

I thought I would include a few of the better-known companies out there for anyone interested in doing some telemedicine. I think it’s the wave of the future, not to replace in-person visits, but to take the burden off of the excess visits which many specialties face.

HealthTap, they are using a monthly subscription model which appears to be $50/month. They are advertising a wait-time of only 2 minutes, not bad.

Amwell, American Well Corporation, charges $50 or less for an urgent care visit, $100 for therapy and $200 for psych visits.

Doctors On Demand, amazing marketing, I’ve seen ads for these guys everywhere. Charging $50 for each visit.

Providence Virtual Express, a large medical group which is offering their virtual services to the public for $40 per visit.

 

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