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Job Review: Virtual Medicine With Large Medical Group

A Critique Of My Virtual Medicine Work With My Medical Group

This is a post in a series reviewing various jobs and gigs that I’m doing. Now that I’m no longer tied to my full-time job with my medical group and trying different things, I want to give some feedback for those of you who might pursue something similar.

For the past 2 years I have been doing virtual medicine with my medical group. We have thousands of physicians in the Pacific Northwest, a large medical group with a ton of patients.

The urgent care department consists of 60+ providers, a mix of MD, DO, NP and PA’s. We see everything including pediatric patients. We have MRI, CT and ultrasound on site along with a full laboratory so there are no limitations as to pathology.

Our medical group is all about access and they push virtual medicine hard because we have built a solid infrastructure for it. We have a few exclusion criteria such as infants and chest pain or major trauma – otherwise everything else is fair game.

Our Work-Flow

The providers have 5-hour or 10-hour shifts. Patients are scheduled into appointment slots at 5 per hour, a fairly busy shift.

Patients call the advice line and are triaged by RN’s to determine if the patient can be managed at home, needs to go to the ED, can get a virtual visit or needs an in-person appointment.

The chief complaint and phone number of the patient is written into their appointment slot and we simply dial up the patient and start the interaction.

Patient Management On The Telephone

Sometimes all the patient needs is a strep test, a urine test or an ear lavage. These are things we can arrange over phone by sending patient to our dedicated Nurse Treatment Rooms.

When imaging or lab work is needed we send patients to the lab and radiology centers and view the results on our work laptops. The workflow is quite streamlined. There are some limitations which I’ll mention later.

Most of the time we provide reassurance though every patient needs triaging and some will need medical management. A few of our providers have a hard time with prioritizing their workflow, I’ll talk about that in another section as well.

How Patients Perceive The Service

We don’t charge our patients for this service, it’s a huge satisfier because they are able to book the appointment themselves on their app. They are able to do a telephone or video visit through the app from any location.

The majority are quite satisfied with being simply being reassured, they don’t have an expectation to get the exact diagnosis over the phone. Just knowing that their diarrhea and abdominal pain is unlikely to be appendicitis will make them quite happy.

Income And Shift Availability

They only allow associates to do telephone visits at my medical group, per diems are shit out of luck – which is gonna be me in a couple of months.

Associate urgent care providers make a little over $100 per hour after factoring in the benefits packages. A 10-hour shift would be a gross of $1,300. That’s a decent amount of cash for being able to sit at home and do you work on your laptop.

There are always a few rogue shifts available that don’t get picked up. If we are desperate enough we’ll let providers do just 2-4 hours instead of a full 5 or 10 hours. Is there enough to go around for per diem doctors? Yes, I believe in the next few months we will need to open up the virtual shifts up to the per diem doctors as well

A typical shift will be from 8am-7pm or 10am-9pm with a 1-hour break.

Downside With This Practice

It can get really busy when you are talking to 5 patients per hour since you are documenting as you go along and ordering a few tests which you need to follow up on.

Speaking of tests, when you order them you have to remember to follow up with the patient regarding the results. You have to call the patient back and review results. And since they are stat labs you want to make sure you discuss the results with the patient while they are still at the facility – if they need a cast or a medication and they went home already they might be upset.

The hypochondriacs can be high utilizers, creating multiple visits and unfortunately latching on to the nicer providers which can be draining for that clinician.

Seeing 50 patients in 10 hours is no easy task. Some patients will be hard of hearing, some phone numbers will be entered incorrectly. Others will need lab orders or need follow-up arranged. On occasion we have to call in medications to outside pharmacies which means another phone call.

Video visits seem sexy but in reality they aren’t all that helpful. The quality is shit, looking at a rash is useless on a video visit. Do you think a patient can actually hold a camera steady? Most of my patients still can’t send me a non-blurry photo with their fancy auto-focus 10 megapixel cameras.

If you send a patient in for a test and they decide to go in towards the end of your shift it becomes a mess. Are you going to sign it out to someone? Are you going to call them on your off-time? It takes some coordination to make sure that the patients you call towards the end of your shifts don’t become time-consuming.

Prescribing antibiotics over the phone. I’ve always been stingy when it comes to pain medications, specifically controlled ones. I reserve opioid pain medication for fractures, urolithiasis, cancers and a few other rare processes. Antibiotics prescribed over the phone can cross that fine line of antibiotic stewardship.

What I Really Enjoy

Patients are exceedingly grateful, being able to talk to a doctor within minutes of making their appointment. They don’t have to pay for our service, they don’t have to get into their car, sit in a waiting room full of sick patients and have a nurse ask them a ton of irrelevant questions which they then have to repeat back to the doctor.

The tech-savvy patient can send me pictures of pretty much anything on their body. They can take a video or upload documents.

Once I have their phone number I can text them for follow-up. If they sent me images of a rash/infection I can ask for follow-up images, a great way to know if they are improving or doing worse.

How To Succeed In This Setting

The successful providers know that there is a process to this madness. Trying to diagnose exactly what the patient has is a futile effort and generally leads to frustration on both ends of the line.

First, triage the patient. If they have cardiac risk factors and left arm pain and SOB on exertion it doesn’t matter how many questions you ask them, they need to go to the ED – this could either be your easiest visit if you understand this or you can beat your bald head against the wall and complain left and right as to how this patient ended up on your schedule.

Rule out emergent and urgent issues. After you do the triaging you need to rule out anything that’s immediately life threatening. If you can reassure the patient that their headache is likely not a brain tumor/bleed then you met the demands of the patient – no exact diagnosis needed.

I am not saying to do a half-assed job. But I’m not going to diagnose someone with a tension headache or migraine without doing a full neurologic exam. Conversely, I am not going to bring a patient into the urgent care the same day just because they have a mild headache with no red-flag symptoms.

Don’t just reassure and hang up. Because there is no eye contact over the phone and the patient can’t read your body language it’s easy to come across as a robot. So it’s important to be a little extra nice, explain your thought process and give them good return or return precautions.

Recognize the needy patient. You will almost never succeed in reassuring a patient that’s paranoid or a hypochondriac. Collect the pertinent information, redirect the patient when they get off track and create an endpoint otherwise you’ll be talking for hours.

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