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Risk: Virtual Visit vs Office Visit

I’m 39 years old and I am earning a solid income doing telemedicine as a per diem in the Urgent Care setting. In this post I’ll break down the difference between doing office medicine and virtual medicine and tell you why, for the time being, telemedicine is the clear winner.

The future of telemedicine seems to have already been cemented with the $6B which was invested by venture firms in 2017 alone.


The Current Office Visit

Patient calls to see if she can get an appointment the same day or the next, waiting on the phone for a rep, followed by waiting for days for the appointment. If none is available she is directed to a walk-in Urgent Care.

In the Urgent Care she’ll wait in line to check in, wait in the waiting room to get vitaled, and then wait in the secondary waiting room, the exam room, for the doctor to show up.

I walk in, talk to the patient, do a physical exam, order some tests, and dispense some medication. I need to finally discharge the patient or make sure my nurse does so.

While trying to focus on the office visit I will get interrupted by the radiologist, the clinic staff, the patient’s family members, the pharmacist, and a coworker who wants to run their case by me.

I’ll have to fumble to find the right equipment to do common Urgent Care procedures. I have to wait around to find a female chaperone and I have to review, confirm, and address the vitals which were entered in the chart.

I have to go back to my desk and document a lengthy SOAP note. This also involves referrals and ordering further testing.


The Current Virtual Visit

As of this writing in 2018, the patient opens an app, schedules an appointment for the same day that’s convenient for her or waits in a virtual queue to be seen.

I ask the patient some questions, I have them press on a few spots on their body or share some images with me. I order no tests and prescribe medications for a potential diagnosis.

I write a brief SOAP note and move on to the next patient.


Risks of Practicing Medicine

Practicing medicine involves taking on a fair amount of risk because we are intervening in the most precious thing which society has labeled the human life.

After my recent Professional Boundaries course I have become aware of certain risks which I wasn’t aware of previously.

Fortunately the stats are in our favor as far as the number of patients who could sue us and choose not to. Yay. But it’s not the ones that don’t sue me who put my career at risk but the ones who go through with it. Not to mention those who complain about me to my medical group or report me to the medical board.

Risk of an Office Visit

The worst risk is the kind we’re not even aware of.

I have to worry about vindictive supervisors and incompetent staff and pretty much any female individual with whom I interact with at work.

I came close to having a sexual harassment charge filed against me.

I have also been reported to HR for ‘harassment’ by a PA who didn’t like that I placed her on a work improvement plan.

Risk of a Virtual Visit

Such interactions would be decreased or eliminated with a virtual visit. I am certain that in the near future a hostile email sent to a subordinate can be held against a physician but for now this isn’t the norm.

The risk of making a clinical mistake during a virtual visit remains. I recently saw a patient who was given hydralazine for blood pressure by mistake instead of the hydroxyzine which was intended for her insomnia.

80% of what presents to the Urgent Care during an office visit is benign, likely resolving on its own. The same percentage, if not higher, will likely present on a virtual visit.

Decreasing the risk during a virtual visit can be achieved by not treating fragile patients virtually and instead directing them to the Urgent Care and having them follow up with their PCP.

The future virtual visit will be aimed at making sure that the doctor has the best and most pleasant experience which I suspect will be one of the tools used to tackle physician burnout.

Most virtual visits allow a physician to label a patient a ‘problem’ patient and this flagging allows the support staff to address these behaviours with the patient thereby protecting the physician.

Malpractice risk is also lower because patients are intelligent enough to self-select based on the acuity of their condition. It’s therefore more likely that a less-sick patient will connect with me through a virtual visit and the sicker patients will select an office visit.


Income Gap

To address the income matter I will focus on working as a per diem because the full-time model for a virtualist is in flux. There are some telemedicine companies who offer a solid full-time salary for virtual visits but most are still trying to focus on their per diem pool.

Doing Urgent Care medicine in the US should earn me somewhere around $125/hour on average for an office visit shift, gross.

A virtual visit shift pays per patient and not per hour, somewhere around $25/patient. At 5 patients-per-hour I could match the income from doing office medicine.

Seeing 4 patients per hour in the Urgent Care in the office setting is no easy task. Seeing 5-6/hour is brutal.

A virtual visit at 4 PPH is relaxed and almost too slow. At 5-6 PPH you can still feel quite productive without feeling overwhelmed. Sustaining 7-10 PPH for a 10-hour shift might be tough unless you are efficient at voice dictation and cut and paste techniques.

Income Per Effort

In the office visit setting at larger medical groups a physician earns a set salary regardless of the effort expended. We see however many patients come through the door. During slow times in the Urgent Care some physicians are even sent home while busy times are just handled by whoever is scheduled.

I rarely see more than 4 patients an hour during an office visit shift in the Urgent Care. During a virtual visit I might see as many as 10 patients.

Measuring the amount of effort per patient, 10 virtual visit patients are far easier than 4 Urgent Care patients in the same span of time for the reasons I pointed out above.


Our Skills As Urgent Care Doctors

It’s been 7 months since I have seen a patient in an Urgent Care for an office visit. Am I losing some of my office medicine skills? Absolutely. We all know how anxious we get before returning back to work after a few weeks off. There are so many little details and differential diagnosis to remember that being out of practice dulls our edge.

Volunteering can prevent some of this attrition which I have been able to do recently.

It’s important for me to maintain my skills of palpating an inguinal hernia or an enlarged ovary on the bimanual exam – it takes practice. Unfortunately it’s that practice that adds more risk to me as a physician exposed to office medicine.

A year ago I would have written the above paragraph then deleted it, telling myself that I’m just being paranoid. Now that I am going through my medical board investigation and after having completed the Professional Boundaries course, I am wondering what other risks I’m not adequately aware of.

Picking up on rotational nystagmus, a retracting TM, performing a proper shoulder exam, reducing a shoulder dislocation, setting a wrist fracture, removing a corneal lesion, placing sutures on the lips, and performing a cutaneous biopsy are all skills which require regular practice in order for us to be proficient at them.

Relearning the Skills

What I have noticed working in various Urgent Cares over the years is that the less you know the more the other doctors are willing to take on. If you haven’t don’t sutures in a long time then the staff will simply give that patient to another provider.

For the responsible clinician who wouldn’t want undue stress placed on their colleagues there are re-immersion courses which you can take in order to get you back up to speed if you’ve been out of the game for a few years.

I wouldn’t recommend this for a budding attending but for someone who has been in the trenches for a few years it would make sense to switch over and enjoy the fruits of telemedicine career.


The Big Picture

In summary I have concluded that earning your income doing telemedicine is a safer and more lucrative endeavor than seeing patient in an office visit.

Doing more virtual medicine than F2F medicine means that your clinical skills will dwindle but in the process you’ll earn the same if not a higher income by exposing yourself to less risk.

The facts in this post are going to be void just 6 months from now as the landscape for telemedicine is evolving. For now, it’s a great time to earn a living through virtual visits.


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