The telemedicine lifestyle is wonderful because it allows me to manage patients without being in the clinic. Not all patients can be managed over an internet connection, some will need to go into the doctor.
It will take time for patients to learn which service is appropriate for what condition. In the meantime the worried-well, those who need medication refills or just need to be reassured make great candidates for this practice venue.
In future posts I’ll talk about the good and the bad with this kind of practice. For now it’s something that I am really interested in and I’m excited to learn about the different ways of doing it.
Recently the less pleasant parts of doing telemedicine have come to light which has mostly to do with technology, timing, the unique patient population, monotony and the sedentary work it come with.
The Different Forms Of Telemedicine
Whether you call it Virtual Medicine or Telemedicine or Online Care, the essence of this is that patients and doctors both can communicate with each other from the comfort of their own locations.
Some are done through text messaging such as Remedy where I exchange information with the patient through the Remedy app. Referrals and prescriptions can all be sent through their app making it overall fairly easy.
Others are done over the phone which is something all of us are familiar with. The culture around the telephone visit is still building but patients are getting used to it. I do the telephone work mostly for Kaiser Permanente and order any referrals or medications through their EHR. Patients use the KP app to book their appointments and to communicate with their doctor.
The last type is a web-based system such as JustAnswer, where I am giving expert opinion to clients seeking health advice. I am not treating them or managing their health but answering medical questions. This platform can be a bit risky for doctors, even online advice is considered medical care which can put us at risk for lawsuits. Most such “expert” site do not offer malpractice and the income is too low to justify purchasing such an insurance.
The Settings In Which I Practice
Well, I’m not in my PJ’s or at a bar when doing these and I will get into why in a moment. For the most part I’m dressing the part and doing these shifts from home, helps me stay in character.
I have done some of this work from coffee shops but there are limitations such as patient privacy, internet connection, having sufficient battery life and ambient noise and distractions.
Pulling up a picture of an oozing abscess on my MacBook Retina Display isn’t appetizing and not what the cafe patrons expected to see on their coffee run. Use your imagine and you know what other kinds of pictures I definitely can’t pull up on my screen out in public.
Another issue is when making phone calls. Most digital healthcare platforms offer patients the option of doing a live phone call. If I am in a loud environment then it’s either unprofessional or simply too distracting to carry a conversation with a patient.
The Kinds Of Patients I See
For the most part the clients are your traditional urgent care or clinic patients who are either a bit more tech savvy or have problems with transportation and prefer a virtual visit.
The main reasons I have identified for patients to choose this is:
- less exposure to other sick patients
- want an opinion on what the next step should be
- don’t have time to make it to a doctor
I have never viewed so many penis and vagina pictures on my laptop and phone screen… at least not for work. Patients naturally are a bit shy when it comes to addressing their medical issues involving their privates – even more so when they have to do it in-person.
Virtual medicine makes it a lot easier for patients to talk to a doctor about personal things. So expect a lot of genital rashes, concerns with STD’s and sexual performance disorders.
You repertoire of genital related dermatologic disorder will be tested. Bullous disorders, lichenoid lesions, normal anatomy, STD lesions, tinea, intertrigo and allergic reactions are just the basics.
I’ve discussed plenty of psyche issues with patients in the urgent care, in the primary care setting or in the ED. Depression and anxiety are the common ones. However, online it’s a whole different thing. You will have patients who are trying to understand why they have sexual feelings towards a family member, why they have olfactory hallucinations and if they can develop their telepathic powers to talk to a deceased relative.
1,001 questions About 1 Thing
I am very careful to never dismiss a patient or to make fun of their fears and concerns. I write this blog for other health care professionals and so we perceive our patient’s complaints in a broad spectrum of patient related issues. Online there will be an exhaustive number of patients who want to know why the edge of their nail has changed the way it has, why there is a tingling that comes and goes on their ear and why there are weird spots on their tongue.
Patient expect that you explain to them exactly why you are ruling one thing out and ruling something else in. They might have dry eyes but want to know why it couldn’t by organophosphate poisoning… and what the signs of organophosphate poisoning is… and how much experience you have with toxicology.
Patients will ask you the same question 800 different times. It is quite common to interact with the same patient over several days regarding the same issue. Depending on the kind of online platform you are using, you may not get paid extra for the duration of the interaction.
A quick note here about customer service. Medicine has definitely taken on a retail approach as demanded by the patients, enforced by lawyers, taught by medical schools and given into by the medical soldiers on the floor. With retail works comes pleasing the customer and you can imagine that in the online market if you aren’t delivering perfect service with a smile you’re gonna get that 1 little lone star which will hurt your return customer base.
I’m actually pleasantly surprised that so many patients are opting to manage their own health instead of taking prescription medications. This means that you need to really build your knowledge base when it comes to alternative health management.
Is it bogus? That’s for you to judge. But if your patient is going to reach for something OTC then you owe it to the patient to help them make the best decision for their health.
Doctors & Technology
Whatever technology you work off of there will always be issues. I’ve mentioned the internet and device battery problems above. But there are other factors that can make it cumbersome to do your work.
Laptops can take forever to boot up which is why I switched recently to a Macbook, it set me back about $800 but hopefully it will be worth the investment in the long run. Kaiser Permanente has specific software which sort of forces me to use their PC laptop which is one of the main reasons I am doing less of their shifts.
When talking on the phone with a patient you will either need really good headphones or have to hold your phone to your head the entire time. I hate the feeling of the phone to my head so I have 2 headphones, a bluetooth model and a wired one. You think you don’t need it but there are reasons for both – total cost: $650. The speakerphone will be terrible for patients to hear your through and crappy headphones are just as bad.
If and when the software glitches on you the patient either won’t hear back from you timely or the conversation will be perpetually interrupted. This will make you look bad even if you didn’t design that particular platform.
Some programs are designed so poorly or have so many constant issues that it can make work on them seem 10x as hard. Just trying to get from one screen to the next could involve multiple keystrokes, clicking on dead links, restarting the program etc.
You would think internet connections are solid, you would be wrong. I have tried doing my work from cafes and there have been times when their internet and my own XFINITY hotspot (free with my home internet) has failed me. I’ve had the same issues from home. The only failsafe method is to be able to use your cell’s internet connection when all else fails.
Patients & Technology
As I mentioned before, if the tech breaks down then you will look bad. If the patient doesn’t know how to use a certain feature and you don’t know it, then they will assume that you don’t know what you’re doing – I have no idea why.
Whatever software or device you use make sure that you learn the patient-side of it. There are usually different apps and websites for the doctor side vs patient side – learn both because it will make your life easier.
90% of the pictures sent your way will be blurry. I don’t know what it is, but patients will take the blurriest images, quite consistently so. The fact that they send you the image is mind-numbing but I suspect in the future apps will have a little QA built into them so that a blurry image can be rejected.
I never try to blame the patient if a blurry image is sent my way, it can come across rude for some reason. Instead I give them some advice on how to take the image differently so that I can “see it from a better angle”.
The solution to the blurriness is usually to put their non-camera hand at the same level as the rash/lesion so that the autofocus can capture the appropriate distance, they can then remove their hand and snap away.
Typing on a laptop or a phone isn’t as easy as it used to be. With autocorrect and spelling programs and emoticons and abbreviations, you may find yourself needing to be an e-linguist to decipher what the fuck the patient is trying to tell you.
Ass Ulcers & Paresthesia
I thought blogging was hard on my ass but sitting down glued to a computer screen, waiting for the patient to reply will tear your ass up.
Some companies want you to do work for several hours, others let you pick the number of cases you want to handle. Either way you will spend long periods of time sitting in your chair or standing at your desk.
When doing telephone shifts you can walk around but there are limitations there as well. Patients can hear the microphone move when you’re walking which makes it hard for them to hear you.
When I’m working on the computer answering questions for patients I try to do some pushups and situps when I’m doing it from home so that my ass doesn’t get numb for 2 hours straight. Doing exercise when doing phone shifts isn’t possible because you’ll be out breath when talking to the patient.
Repetition & The Uber Complex
You will repeat yourself, have no doubt about it. Typing out the same thing over and over about how to manage a cold or deal with muscular back pains or what to do for insomnia is beyond mind-numbing – it will kill a part of you every time you have to do it.
On the other hand you will get some of the most interesting questions. Things I’ve never even thought of asking as a doctor and issues with wounds/post-op/follow-up that you will need to manage when the surgeon isn’t available.
You likely will come across patients from other continents, with different healthcare systems and different medications. Google is your best friend but it can suddenly become a lot of work trying to make a simple recommendation.
Language barriers are another major thing to take into consideration. With the advent of online medical care patients from other countries are utilizing US healthcare. Some use British English terminology or slang which can make communication hard. And when English is not their native language then it can be very tedious to communicate something to your patient.