What it's like to be a full-time telemedicine doctor

"My wife is in the room next door, my 2 year old is downstairs and my dog is at my feet."

Dr. Mike Hoaglin is a trained emergency medicine physician. But since the pandemic, he’s been seeing patients exclusively from the comfort of his California home. He starts his day at 7am and works until about 5pm with a few hour-long breaks. 

Currently, he’s juggling work with a few different digital health companies, including Brightside (behavioral health) and Oscar Health (urgent care). He’s previously worked with Hims & Hers and Doximity, so has experienced quite a broad spectrum of different telehealth companies and patient populations. 

Sometimes he misses banter with his colleagues, but there are definite upsides to a remote lifestyle. "My wife is in the room next door, my 2-year-old is downstairs and my dog is at my feet,” he told me. “Can’t say I’m lonely.”

Dr. Hoaglin is part of a growing trend of doctors moving out of hospitals and clinics and into remote work with venture-backed virtual care providers. Researchers at EAB, a consulting firm focused on education, found that in 2020 alone, demand for medical professionals with telehealth skills increased 14% per month, compared to 1.7% in 2019. None of that will be a surprise to those of us in the industry as there’s a huge need for clinicians willing to work in telehealth across the board. 

For those that are looking to make the jump either full-time or as a side gig, lots of companies are building up their internal care teams. Alternatively, telehealth staffing companies like SteadyMD, Wheel and OpenLoop are snapping up clinicians who have some additional hours to spend per week on telehealth work (and in some cases, take on a full workload of telehealth clients). In my work as a health-tech investor, I’m also seeing digitally-savvy, entrepreneurial clinicians shifting all - or a portion - of their brick-and-mortar practice virtual or starting one from scratch. 

Since I’ve been involved with digital health, I’ve wondered what it’s really like for telehealth doctors to work behind a screen. Do they miss the rush of the hospital? Or the experience of sitting with a patient in a clinic? And what new skill-sets do they need to develop to treat people online? It reminds me of many of the trends we’ve seen in the Gig Economy and I’ve wondered whether it’s contributing to burnout or offering a potential salve. And I’m not alone. When I mentioned that I’d be working on this piece on Twitter, dozens of you shared your own questions. 

Over the past few weeks, I’ve talked to half-a-dozen telehealth doctors. This is my best shot at getting you answers. 

Do you notice differences between telehealth and in person?

For Dr. Hoaglin, who spends most of his time with Brightside patients, it’s been a really positive experience. While he generally does feel in a solid position to treat people, some of his patients invariably need to be seen in-person. “Triage is an important skill,” he said. 

Other doctors I spoke to felt there were benefits with online consultations because the patients generally were more engaged in the conversation. A few theorized that it might be because there are fewer distractions when they’re in a quiet space at home. And Zoom is now viewed as a business medium so people have become used to it. 

Another added benefit: Fewer no-shows. And in cases where patients forget about the appointment, the clinician can call to remind them - and often they’ll find it’s a good time to connect anyways. The alternative is a missed appointment where the patient doesn’t get seen at all. And that’s lost revenue - and a missed opportunity to check in on a patient. 

Others say that it’s imperative that telehealth providers work on their bedside manner. Being distracted can come off even worse on a video consult. Your game has to be at “150%”, said Dr. Sina Haeri, founder of Ouma Health, a maternal health company. “You’ve got to return to relationship medicine to win hearts and minds.”

That said, not everyone felt that telemedicine-only was the right thing for their patients. For Dr. Ted Handler, a pediatrician who works part-time for Oath Care, an  OMERS Ventures portfolio company focusing on pediatrics and maternal health, it’s a balance. His goal, wherever possible, is to meet his patients in person at some point and perform a physical exam. 

Is it easy to work for more than one platform?

Dr. Matthew Sakumoto, an internal medicine physician, has been working in telehealth for the past few years, including for UC San Francisco’s Covid video triage clinic and companies like Plushcare (owned by Accolade). He notes that a lot of vendors will have non-competes so it makes it challenging from operating an Uber/Lyft model where it’s easy to swap around. 

The doctors that he sees with the most leverage to negotiate with companies - and work with more than one - tend to have 30+ state licenses. These are hard to get because it’s both a time commitment and it’s expensive. Some companies will help their clinical teams acquire licenses over time, effectively in exchange for loyalty, while others will tend to hire those who have lots of licenses already. To give you a sense of numbers, the last time I checked, which was back in 2019, there were only 14 doctors in the entire country with 50 state licenses. It’s likely more now but probably not by much. I’ve heard in the realm of 50/60 these days with a much smaller number also covering Washington D.C. 

How important is continuity of care versus access/speed?

Anecdotally, I’ve heard of a lot of telehealth companies starting out by building for speed - “talk to a nurse (meaning any available nurse) in 5m or less!” - but many have now moved away from that model. Helping patients see the same clinician wherever possible can be more expensive, but it often also results in higher lifetime patient value. That means patients tend to stick around versus moving between platforms. 

But of course, it totally depends on the type of care being provided. For urgent care, it is typically more important to take to any provider as quickly as possible, as long as they’re equipped to support the patient and help triage them if needed.

Another related trend is companies starting to focus a lot more on provider experience, and not just the patients. Some are creating community with regular group chats and meetups to help clinicians feel less lonely.

How do you find opportunities and is the money good?

For most of the physicians, it’s a mix of networking, Facebook groups and some ads. Salaries tend to be a bit less stable than brick & mortar, but that’s offset by greater flexibility around remote work and living in more affordable parts of the country. Some of the doctors preferred models where they get paid hourly versus on a per patient basis. The latter can make them feel rushed when seeing patients.

Have you missed any diagnoses or gotten it wrong because the care wasn’t provided in person? 

This is a tricky one because it’s not always possible to track outcomes post consultation.

Dr. Sakumoto shared that he’s “over called” a couple encounters. He’s had a few cases where he was concerned about a stroke or acute glaucoma but the patient was in fact experiencing a migraine with aura. He notes that one of the challenging parts of telemedicine is sometimes you don’t actually know if you’ve missed something because there aren’t always feedback loops, unless you’re the patient’s virtual PCP. 

Dr. Handler, a pediatrician, notes that triage is just as important with telemedicine as it is with in person care. “As doctors, we need to do a better job of telling patients how sure we are of a diagnosis, because we are rarely 100%.”

Are there access gaps? Do you feel that patients are being excluded?

Most of the doctors didn’t see many - and in fact, they felt they were accessing patients that they wouldn’t have otherwise in a brick-and-mortar setting. Dr. Haeri, for instance, noted that there are maternity deserts across the country, but that “every mom should have 24/7” access to an expert in this day and age.” So telemedicine can help fill some of those gaps.

Most platforms these days will also have an audio-only option for users who don’t have reliable bandwidth. Some states are starting to reimburse for that too. And increasingly, as more companies focus on treating diverse patient populations, there’s access to interpreters.

Although it’s important to note that not all companies have built out those capabilities yet so it’s not really fair to say that telemedicine is changing the game when it comes to access.

What are the benefits to full-time telehealth versus part-time? 

Most companies will tell you that working with full-time physicians allows them to offer more continuity of care for their patients. This is especially true for those in primary care and behavioral health.

For his part, Dr. Sakumoto notes however that there’s benefits to part-time or flexible work. He refers to a new kind of medical specialization called the “availabilists.” He describes that as this new cohort of clinical experts available to give advice on-demand. This could start with a nurse triage line but as care gets more complex, doctors with a bit of extra time could be called upon to provide treatment and cover any off hours. 

Dr. Sakumoto is looking for more flexible options at present because of a new puppy. But he thinks it’s also an ideal gig for those who otherwise would have retired but want to see patients without administrative overhead. It’s not just the millennial docs!

 Of course I included a photo of the puppy in question!

Are virtual waiting rooms going to be a thing?

This one is surprisingly controversial. Dr. Sakumoto is not a fan. In his view, the last thing that telehealth companies should be doing is re-creating the clinic experience online. And that’s not just true for waiting rooms. 

“Once you move to asynchronous chatting and monitoring, the number of patient lives touched per day goes up dramatically,” he said. Like in our new world of remote work, ‘This meeting could have been an email’ is now ‘this clinic visit could have been a MyChart message’." 

On the other hand, it’s something we all know and recognize. And as a patient who’s sat holding a phone with nothing but an endlessly rotating circle on a screen to let me know that I might see a doctor at some point, we need to do better.

How do you make sure you can trust telehealth companies?

Haoglin has a checklist he works through before working with any new company:

1. He makes sure the company follows corporate practice of medicine laws

2. He asks questions to ensure there are ethical billing practices

3. He checks to see if the team is mindful about the needs of both the patients and the providers. 

Other doctors, like Sakumoto, will dig in to understand what happens if there’s a disagreement between what an individual provider might want and the internal operations team. He also looks to see whether there’s a strong Chief Medical Officer at the company and what kind of power this person has to make decisions and overrule those on the business side. 

Do you check in on patients between visits? 

Many of the doctors are routinely checking in on their patients, particularly if they’re providing long-term care versus treating them episodically.

Dr. Hoaglin checks in with his behavioral health patients every few weeks. In between visits, he asks them to fill out PHQ-9 and GAD-7 survey questions so they can understand how the treatment is progressing. That also helps dictate whether a medication regimen needs to get tweaked. 

What percent of the telemedicine visits you have done have been what you would deem “medically unnecessary”? In other words, the problem would have gone away on its own. 

This was a tough one to answer for the doctors. 

Dr. Hoaglin feels that urgent care is more binary: Either it’s a problem that needs treatment or it might resolve on its own. Even in the latter case, it was probably the right thing that the patient got care. In behavioral health, he notes that he rarely sees patients who would not benefit from treatment of some kind. 

One problem - and also a benefit - associated with telemedicine is that it is easier to get care online versus taking time off of work to drive to a clinic. So sometimes telemedicine doctors end up seeing more patients whose symptoms haven’t progressed all that much. In other words, they’re earlier in the course of their disease. And perhaps that problem would be resolved on its own; perhaps not. So it can be more challenging to spot symptoms and determine the right course of treatment. “The symptoms are often much less differentiated than the patients I would see in the clinic,” said Sakumoto. But telehealth also allows for more follow-up care so he can also check in and see whether the patient has gotten better or worse or the same. And he can make a more informed decision from there. 

According to Dr. Sakumoto, there’s also a benefit to what he calls “therapeutic listening.” Perhaps he can even talk a patient out of going into the emergency room who doesn’t need to be there. And that’s a win: win for everyone including their insurer. 

If he had to put a number on it, he’d say about 20% of the consultations he does are unnecessary and would resolve on their own, which is no higher for him as a percentage than in-person urgent care visits. 

What does it take to be a good telemedicine clinician?

I heard three things consistently outside of the obvious one - being digitally savvy: 

1. Being comfortable with inconsistency and uncertainty because sometimes symptoms might be less clear than in person 

2. Having a really good bedside manner that translates to audio, video or SMS

3. Inherently trusting their patients as they’re often relying on self-reported vitals, symptoms and so on 

4. Having a high EQ because it might not be as easy to pick up on social cues and other tells online 

I hear from a lot of women, particularly those on the more diminutive side (my people!), that telemedicine can feel like a leveller versus in-person settings. There’s been well reported bias on both sides and I’d be intrigued to see more studies here on the effect of video vs. in person. Another interesting set of studies that Midi’s Chief Medical Officer Kathleen Jordan flagged to me in a recent chat: Patients prefer doctors who sit versus stand in in-person interactions. So I’m curious about how different styles of conducting telemedicine calls will resonate.

How do you schedule visits?

A few of the doctors use a Calendly-like application for his behavioral health consults. For urgent care, it’s oftentimes a queue and patients get seen as they pop in. Some also hired a part-time coordinator to help them out with scheduling visits.

Dr. Josh Emdur, the Chief Medical Officer for SteadyMD, tells me he shares lessons learned with clinicians he hires to ensure they have enough time for the important things in their personal life and they’re not overbooked. 

How do you help patients connect to local resources, including emergency departments? 

One thing that telemedicine doctors are commonly told to do at the outset of a conversation is to confirm the patient’s current address.

That allows them to make sure they have the current state licenses to treat the patient.

But it’s also to make sure they can route them to emergency services when needed. 

When do you chart? 

Hoaglin makes notes in the consult and jots down additional information in the chart in the transition period between calls. The rest of it he does on Tuesdays, which he uses as an administration-only day. 

Many of the doctors share pre-visit questionnaires with their patients and most will fill it out. For Dr. Sakumoto, these tend to be more thorough and less rushed when it’s a telehealth appointment. In person, patients tend to write out their answers in the 15 or so minutes while they’re sitting in the waiting room.

Do you have any issues with pharmacists? 

None of the doctors I talked to had significant issues, except in cases where there was a drug interaction that needed to be flagged. Many companies will have integrations with Surescripts for e-prescribing, similarly to Brick & Mortar practices.

Is telemedicine too fragmented?

Dr. Sakumoto thinks patients want fewer apps and certainly not more. “Between having to download Zoom, WebEx, Vidyo, and/or MyChart, Teladoc, PlushCare, AmWell apps, the virtual care ecosystem is becoming as fragmented as our brick-and-mortar health environment,” he notes.

And as we all know, when there’s more fragmentation, information systems don’t integrate well. So if a patient sees a doctor via a telehealth app and is told to go to the emergency room, they may need to re-share their story because the ER doctor or nurse may not have access to the doctor’s notes from the telehealth consult. 

Any tips on the EHR integration?

Dr. Sakumoto thinks that doctors make too big a deal out of this. “For a video visit, you need something for talking, something for typing,” he explained. “If they’re an all-in-one solution, great. If not, using Doximity Video as the communications conduit and documenting in the regular EHR is fine.” 

So that’s it for this week’s edition. I hope it was helpful! And as always, please share your thoughts. Up next, my colleague Marissa is putting together a deep dive on lab tests’ evolving role in virtual care, so if you have strong thoughts on where that trend is going, drop her a line.