Telemedicine took MY Job!

I hear about Telemedicine often in the news and until recently had only casually glossed over the latest articles. The details I paid little attention to, but the headlines I would remember. Great for rural areas I would read! Extend physician reach to those who otherwise wouldn’t have access to a doctor! Get specialists with expertise to greater numbers of patients with rare or unique conditions!

As a nearly finished anesthesia resident, in a large city with an abundance of doctors – I didn’t think telemedicine would have much impact on my future in medicine. None of the above headlines applied. However, I would be surprised one morning to wake up to an email that roughly said: “Thank you for your service to our patients in the past, but we will now be covering your position with telemedicine doctors, effective (nearly) immediately.”

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You see I’m not JUST an anesthesia resident. I also spent several shifts a month serving as an in-house night physician at two long-term acute care (LTAC) facilities of the same company. In a long standing tradition called “moonlighting” residents in training often supplement their income by working night shifts in various medical positions. In fact, this second job can be so lucrative for residents, that (at the expense of sleep) residents can sometimes double or more their resident salary. Personally, with roughly 30 days notice, what amounts to 40% of my income was terminated.

In the new system, a single physician at home with a telemedicine interface will be covering the two LTACs that each previously had a physician on site at night. Each physician was previously paid $90-100 an hour, now the single telemedicine doctor will make $25/hour per hospital.  For the current two hospital system our moonlighting group was covering, this amounts to a cost savings of about 75%. Or using rough hourly wage amounts, our group was being paid ~$18,000 per week, $72,000 per month, $936,000 per year – to cover those two LTAC hospitals. The telemedicine group will be paid ~$4,800 per week, $19,200 per month, $249,600 per year to provide the same coverage. I cannot argue with the impressive financial savings that switching to telemedicine will provide for this small two hospital system. There is a third LTAC owned by the same parent company in the area, which is covered at night by a different system. They will also be eventually transitioning to telemedicine as well – making the cost savings even more dramatic.

The approach cannot be looked at any other way than a cost saving effort. There is not lack of physicians for the work, shifts were never unfilled, and frequently fought over. There are attending physicians of multiple specialties in our moonlighting group, as well as a few residents like myself training in specialities that are suited for critical care, airway management, and emergency response. The patients had no rural limitations, no particular special expertise needs, and no reason (other than what became a financial decision) that they couldn’t have access to a 24/7 in-house physician.

What kind of patients were we caring for? A great variety actually. Most made up of post surgical or intensive care patients requiring long-term IV antibiotics or rehabilitation that were too medically complex for a less acute rehabilitation center or skilled nursing facility. Admittedly, most of these patients do not need to be seen by a physician at night. But the 8 bed “ICU” unit at one of hospitals we covered was nearly always full as well – patients requiring a full range of intensive care needs from ventilator management to vasopressor support. And not entirely infrequently, our group was called in the middle of the night to run codes, intubate patients in respiratory failure, or place central and arterial lines. Despite our best efforts, sometimes patients died at night under our care.

Can telemedicine do all of that? Yes, and no. I must admit, in the last year I worked there I personally never had a situation arise during a shift that a telemedicine doctor/interface probably wouldn’t have been able to handle. The number of times I had to physically see a patient in the middle of the night (as opposed to the usual telephone calls for various small issues) was very small – and usually responding to falls. However, I was a bit of a “white cloud” in my group and while still rare, other members did have significant experiences requiring hands on skill to potentially save lives. Going forward, many of those tasks in emergencies will be handled by nursing or technical staff. Airways, including intubations, will be handled by Respiratory. Central and arterial lines will wait in until the morning. Codes will be run by the charge nurse, with telemedicine hopefully set up in time to assist with general direction. 

In one example, during the small window where both telemedicine was being used as the primary night coverage and there were still an in-house physician as back-up, a night physician was forced to intervene. A patient with impending respiratory failure was struggling on Bipap, and the decision was made via Telemedicine for respiratory to intubate. The night physician, trying to allow the telemedicine and RT to manage the situation, was only standing by and did not intervene….  until oxygen saturations went below 50% during the intubation attempt. That night the in-house physician likely saved that patients life (at least for another day).

How many times would a similar situation come up per year? It’s hard to say, but I’d guess about one every month or two. That’s a small number, unless of course you are that patient in need. But I’ll admit I have no idea if we are really “saving” any of those patients, as the mortality of requiring a significant intervention when already sick enough to require LTAC care is likely very high. 

It brings the telemedicine movement forward as part of the bigger issue of cost saving in medicine. At some point we cannot continue to spend every dollar all the time to save every patient, especially when there may be little long-term benefit. In our case, I have to admit I see the move as justified, even if my own pocket book takes a painful hit. The question will be where the line is drawn, as the proliferation of telemedicine continues. How many lives are worth saving with the added expense of physicians in person? Could telemedicine even replace the more permanent day physicians at locations like these? Surely not.. But I never thought I’d lose my own job to telemedicine either.

What do you think of telemedicine? Are there places it is a good option? Is this situation described one of them? Give us your thoughts in the comments. 


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11 Comments

    • Alabama was first alphabetically :
      Alabama Medicaid reimburses for live video for the following services:
      Consults;
      Office or other outpatient visits;
      Individual psychotherapy;
      Psychiatric diagnostic services;
      Neurobehavioral status exams.
      For all telemedicine services, an appropriately trained staff member or employee familiar with the patient or the treatment plan must be immediately available in person to the patient.

      And some more:
      Originating and distant sites must be located in Alabama.
      For rehabilitative services, the originating site must be:
      Physician’s office;
      Hospital;
      Critical Access Hospital;
      Rural Health Clinic;
      Federally Qualified Health Center;
      Community mental health center (to include co-located sites with partnering agencies);
      Public health department.
      Source: AL Medicaid Management Information System Provider Manual, p. 833 (105-12), (Jan. 2017).

      All this is located on center for connected health policy’s website:
      http://www.cchpca.org

  1. From a safety standpoint, that would be interesting to know.

    As a fellow physician/anesthesiologist, I appreciate what you’ve done with your blog.

    Strong work!

    • Very interesting, I doubt there are restrictions at this time, but that certainly will be a discussion of patient safety to come as the service grows. In this example, the telemedicine doc was covering the two LTACs for a total of about 60-80 patients.

      Thank you for the kind words, and for reading!

  2. This is all very interesting, and you’re right — a bigger discussion is about cost-cutting and at what cost to the patients.

    I lamented the fact that moonlighting wasn’t an option in our program, but in hindsight, I was busy enough without it. Opportunities to make more money doing what you were trained to do will be there soon enough.

    Best,
    -PoF

  3. Telemedicine is starting to creep into our hospital in the place of certain specialties. Its a win for the hospital in terms of money spent at the cost of decreasing some individuals hours in house. This has mainly only been done on weekends and holidays so far. I think telemedicine is growing quickly but there is a limit since there will always be a need for face to face consults for many specialties. Sorry to hear that your job got taken. Your gig sounds sweeter than my moonlighting gig in residency. We made 100 bucks an hour but had to cross cover 200 patients while admitting up to 12 patients overnight. I don’t think I got sleep once during one of my moonlighting gigs.

    ID

    • It was a sweet gig, about 80% of the time I wouldn’t have to leave my call room and simply answer about 5 phone calls. Our admissions were “tuck-ins” and usually only 1-2 at about 20min spent with each. I can’t blame them for wanting to replace us, but we did occasionally do emergent hands on work for sick patients – that will no longer be available.

      As far as my finances, luckily I started this job about the time I got into personal finance reading and mainly just used the money to max a his/her roth and successfully fill a 3-6mo Emergency fund… we will just ride the latter out til residency ends in July! +1 to the finance blogging world!

  4. I wonder about the potential for liability for the telemed doc when the outcome is less than satisfactory and amid claims that more could have been done had a doc been in-house. Is hospital to “blame?” or is telemed doc going to be held to account?

    • Great thought! Theoretically, the hospital – as for example, they would be employing the RTs to manage airways to a minimum standard, and thus liable for failure to meet that… but in real life it certainly is a slippery slope!

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