Options are abundant for physicians with a good ‘webside’ manner and willingness to adapt, but due diligence is essential

By Bonnie Darves, a Seattle-based freelance health care writer

Telemedicine, in the form of virtual patient visits using video platforms, has been making inroads into the broader physician practice realm for more than a decade, but when the pandemic hit, it exploded. Practically overnight, traditional practices and health systems scrambled to get technology in place to ensure that patients at risk for contracting the coronavirus — or experiencing poor outcomes if they did get COVID-19 — had some means of connecting with their physicians. Simultaneously, companies that were already in the virtual-visit business experienced exponential growth in demand for physicians to provide services.

“It’s been nothing short of a seismic effect,” said John Frey, founder of the National Coalition of Healthcare Recruiters (NCHR) in Washington, West Virginia. “Telemedicine was happening, but the coronavirus cracked the egg wide open.” NCHR members are reporting major increases in the number of clients, existing and new, seeking physicians to fill telemedicine positions.

Lou Anne Gonzales, president of Advanced Physician Recruitment in Overland Park, Kansas, who already had a solid footing in telehealth recruiting and consults on telehealth solutions, has seen a huge increase in demand from both sides of the picture: clients who need physicians to fill newly created positions and physicians who want to explore virtual-care practice opportunities. “I’m hearing from 10 to 12 physicians a week looking for positions where they can do some telemedicine — or do virtual practice exclusively,” Ms. Gonzales said. “This high level of physician interest is something I haven’t seen before.”

Regardless of whether physicians are seeking a full-time telemedicine position or a part-time opportunity to moonlight doing virtual visits, telehealth practice is here to stay, according to Joseph Kvedar, MD, who is president of the American Telemedicine Association and a virtual-care innovator at Partners HealthCare in Boston. “Wherever physicians practice, whether that’s in a clinic or with a digital-first primary care organization, they’ll be doing some telehealth now,” he said.

Telemedicine: It’s here to stay
A recent study by the COVID-19 Healthcare Coalition Impact Study Work Group, in which Dr. Kvedar participated, found that telehealth claims increased 50 to 100 times in several US states between July 2019 and July 2020, and grew significantly in all states. A companion survey of 1,594 physicians and health professionals last summer found that 83.6 percent had engaged in interactive video patient visits in 2020 and that nearly 40 percent averaged more than 20 virtual visits a week.

In Dr. Kvedar’s view, the issue now is not whether physicians will practice telemedicine but what their practice will look like. “We’re at the point now where it’s a question of how physicians will use it and how they’ll determine which clinical cases should be in office and which might be virtual,” he said. “I think we’ll see physicians joining practices where they’ll have 60 percent in-person and 40 percent telehealth visits. We’ll also see physicians who do 100 percent virtual practice with four or five companies — they’ll be the Uber drivers of health care.”

The model’s appeal is obvious for physicians seeking flexibility in their lives, to care for young children or aging parents, for example. Still others will seek part-time, limited telehealth opportunities to increase their income and pay off education debt more quickly. Some might choose the model out of pure preference, after trying it out and finding it a good fit.

That’s the case for Kurt Gilbert, MD, an internist in Cookeville, Tennessee. He was practicing as a hospitalist but then started seeing patients virtually when the pandemic hit. “I’ve always had an interest in telemedicine, and once I tried it, I really liked it. So, I’m now practicing telemedicine full time, from home,” said Dr. Gilbert, who works with Doctor On Demand, the company cofounded by the TV personality Dr. Phil. “The big difference for me now is that when my shift is over, I’m done. And when I want to see my 17-month-old on my lunch break, I can. For me, it’s a dream job, and the patients love it because they can choose the visit time.”

Dr. Gilbert sees patients in the numerous states where he is licensed. His care ranges from acute and urgent-care issues and chronic condition management to regular follow-up care for patients with whom he has established relationships. When a situation requires emergent medical attention, Doctor on Demand’s emergency support team steps in.

For Krista Grow, MD, a Kansas emergency medicine physician, telemedicine provided has proved an ideal solution to an intermediate-term family need. Her husband is doing his fellowship at the Cleveland Clinic, so the family moved to Ohio to stay together. Dr. Grow started doing some telehealth practice, about 12 hours a month, through Sycamore Independent Physicians of Alabama, and she also commutes to Kansas for ER shifts several days a month. “The [virtual-visit] care model is sort of slow-paced for me, but I find the work fulfilling. I’m often taking care of patients who can’t see their physician or who have lost their job and their benefits,” she said. “It’s rewarding to be able to help people when they need it.”

Larson Hicks, CEO of Sycamore Independent Physicians, reports a definite uptick in physicians seeking practice arrangements like Dr. Grow’s, either out of personal interest or because of declining patient volumes in the wake of the pandemic. “We have some independent physicians who practice telemedicine because they want to diversify their practice portfolio or gain a new revenue stream. Others like the platforms because they can build their own panel of patients or fill in a hole in their schedule,” said Mr. Hicks. His company, whose primary business is in emergency medicine locum tenens services, has placed 150 physicians in telemedicine positions in 2020. While many work in locums-type models, others are moving into more structured, permanent arrangements.

Whatever telemedicine model physicians are interested in, they’ll find opportunities, said Ateev Mehrotra, MD, MPH, a Harvard health care policy researcher and hospitalist at Beth Israel Deaconess Medical Center in Boston. “If physicians want to be free spirits, they can do 100 percent telemedicine,” he said. At companies like Blue Sky Neurology, physicians do virtual consults on stroke or neurological disorders. In radiology, an early telemedicine entrant, the market for all-remote positions has expanded dramatically, Dr. Mehrotra added, and psychiatry has seen major growth in all-virtual and hybrid models. “We’re seeing psychiatrists whose schedules include in-person clinic one or two days a week and tele-psychiatry visits at home in the evenings, for example,” he said. “Moving forward, physicians across all specialties will be engaging in more remote patient monitoring, especially for patients with chronic conditions. The innovations we’re seeing will give physicians a lot more flexibility than they’ve had before.”

Even hospitalist medicine is moving into remote care. Sound Physicians, a long-established hospitalist company, now offers tele-hospitalist positions in which home-stationed hospitalists work collaboratively with onsite hospital nurses and physicians to triage patients and create care plans. “Our tele-hospitalists might be supporting five to eight hospitals on a shift, and they have more control over how they manage the requests and alerts in their queue than they might in the hospital,” said Brian Carpenter, MD, the company’s national medical director. Sound Physicians is also moving into tele-SNF (skilled nursing facility) and virtual transitional care for discharged patients, providing a new range of telemedicine physician practice opportunities.

What telemedicine organizations look for
All sources interviewed for this article agreed that practicing telemedicine requires a change of mindset and that physicians who want to do virtual practice need a few years of post-training practice experience before making the shift. Moving from in-office visits to virtual ones is a definite adjustment because video visits obviously don’t allow for a traditional physical exam. Physicians who need to listen to the heart and lungs, check a patient’s ears, or examine a rash must use technology. They’ll also have to be extra diligent in obtaining a history in new patients and adept at establishing rapport quickly. “Not everyone can communicate effectively virtually, so that’s one of the qualities we screen for, in addition to solid experience,” Dr. Carpenter said. His company seeks hospitalists with at least three years of onsite practice experience, for example, as well as a strong critical care comfort level.

“Beyond practice experience, telemedicine organizations are looking for is physicians who are personable, adaptable, and willing to learn something new,” Mr. Hicks said. It also helps when physicians have licenses in multiple states. That’s become easier with the advent of the Interstate Medical Licensure Compact, which expedites licensing among its 30 participating states.

Tony Yuan, MD, medical director at Doctor On Demand, which employs 600 physicians and has seen a dramatic spike in demand in 2020, boils it down to what he calls good “webside” manner. “Anyone can learn the skills and pick up the technology, but we’re looking for physicians who present themselves well, who are compassionate and approachable,” Dr. Yuan said, “and who can adapt to the volume.” Most video visits are scheduled for 15 minutes, with a short buffer between visits. Doctor on Demand physicians may take as much time as they need or extend a visit when necessary, but the basic expectation is that they’ll see four patients an hour. The company provides extensive training, a robust support system, and an integrated electronic health record.

Doctor on Demand has two primary models, a 32-hour work week and a 40-hour schedule, with some flexibility to break up visit “blocks” to suit personal or family needs. The company looks for a minimum commitment of 60 hours a month. Compensation, Dr. Yuan said, is “on par” with the income physicians would receive in a traditional care model. The virtual practice model, he added, is ideal for primary care physicians, emergency medicine physicians, pediatricians, and psychiatrists. “We can’t hire people fast enough, and we’re hearing from physicians who tell us that they didn’t even know these options existed,” Dr. Yuan said.

Tyler Covey, CPA, who is CEO of the national firm MDstaffers in Rancho Cordova, California, echoes that demand-versus-supply dilemma. His company filled 900 telemedicine positions (for physicians and advance practice clinicians) in a single month and has seen the demand for behavioral health professionals and primary care clinicians “pretty much explode.” The physicians that MDstaffers has placed practice in a variety of settings, from dedicated virtual clinics to call centers to their own homes.

“There’s a lot of variation, but for physicians, I think the important thing is ensuring the organization is well equipped to support virtual care,” Mr. Covey said. Ideally, that means having dedicated support personnel, top-notch technology, a system for ensuring patients are prepared for the visit, and a platform in which the electronic health record (EHR) is integrated. “Not all telemedicine jobs are created equally,” he said.

Kurt Schussler, a managing partner of Medical Advantage Recruiters in Addison, Texas, whose company is seeing skyrocketing demand for telemedicine physicians, urges physicians to thoroughly research both the position and the organization offering it. “It’s important to know how the organization is structured, how much support they’ll receive, and whether the entity is financially solid,” Mr. Schussler said. That due diligence includes obtaining credit reports and speaking to physicians who work for the organization to ensure that compensation is equitable, as advertised, and paid timely.

Kaiser: the ‘gold standard’ keeps innovating
Organizations that want to do virtual care right might look to Kaiser Permanente for expert instruction. Kaiser has been delivering telemedicine services and virtual care for more than 15 years, in a highly organized, orchestrated, and integrated manner. All physicians who practice with The Permanente Medical Group — with 9,000 physicians, TPMG is the country’s largest — are equipped with video cameras, state-of-the-art information technology, dedicated smartphones, and a system that enables physicians to quickly “accelerate” care when specialists are needed. Even with those components in place, Kaiser had to adjust to accommodate the new environment after the coronavirus hit, said Richard S. Isaacs, MD, TPMG’s CEO and executive director.

“When the shelter-in-place mandate came, we had to move to a video-care-first strategy almost overnight and we quickly converted to conducting 90 percent of all exams on video,” Dr. Isaacs said. “What we’re seeing is that patients really love video visits, both the convenience and the personalization.” By August 2020, Kaiser was conducting nearly 25,000 video visits daily in its Northern California region alone and provided four million in the first three quarters of 2020 across all eight Permanente Medical Groups.

Although Kaiser had long been using virtual visits for preventive care and some follow-up care, behavioral health, and dermatology, the pandemic spurred innovations in other clinical areas. A Kaiser pilot in tele-critical care, for example, has become part of a sophisticated hybrid-care model going forward, in which specialists perform remote monitoring and proceduralists provide direct patient care in the ICUs. “Our physicians are really enjoying this — it’s as if they’re part of a team like the Navy SEALS,” Dr. Isaacs said.

A more recent innovation involves virtual cancer care. Kaiser oncologists recently began using primarily video visits for oncology patients, who, because of their compromised immune systems, may be especially vulnerable to COVID-19 infection and poor outcomes. Tatjana Kolevska, MD, chair of the Kaiser Permanente Northern California Oncology and Hematology Chiefs Group, spearheaded the effort to move almost all oncology care to phone or video appointments, in very short order. “We moved from 15 percent before the pandemic to 98 percent [virtual visits] within a week, and it’s been very successful,” she said. “We’ve discovered that physicians find it easier to act on issues that patients are experiencing. And the video visits make it easier for caregivers to participate.”

Dr. Kolevska said that somewhat surprisingly, the majority of Kaiser oncology patients, based on survey findings, have proved amenable to having even sensitive issues such as a new diagnosis or a treatment failure discussed using virtual visits. “We’ve seen a significant increase in patient satisfaction overall with the video visits,” said Dr. Kolevska. Kaiser is also convening multidisciplinary patient conferences and tumor boards completely virtually now, enabling oncologists and other specialists from across the organization to review and guide care.

In Dr. Kvedar’s vision of the future, virtual care and telehealth will play an increasingly larger role in most physicians’ lives, with mostly beneficial results, especially when physicians manage patients who can’t readily get to care facilities. But telemedicine won’t supplant face-to-face visits, he said, or obviate onsite physical exams. “Most of us chose this career path because we want to help people and form that bond, which might be harder in a virtual setting,” he said. “At the same time, I see telemedicine and its flexible work environment as extremely liberating for physicians.”

Considering a Telemedicine Job? Ask the Important Questions
There’s so much going on in telemedicine today that it can be daunting to physicians trying to explore the fast-evolving marketplace and compare different practice opportunities that are wholly or predominately virtual. Because there are so many new players in the market and organizations offering positions differ widely, it’s a bit of a Wild West out there. For that reason, it’s very important for physicians considering telemedicine practice to obtain as much information as possible before making a commitment.

Sources interviewed for this article offered tips for navigating the telemedicine market and making informed decisions:

• “It’s important to ask how patients will be prepared for virtual visits, whether there’s a dedicated virtual exam room, and whether they’ll have a well-trained assistant to help support them. Physicians practicing telemedicine will have the highest satisfaction if all these components are in place.” — Lou Ann Gonzales, Advanced Physician Recruitment
• “Physicians need to know the types of patients they’ll see, what the volume expectations are, and what’s required in terms of schedule and call to reach the stated compensation levels.” — Kurt Schussler, Medical Advantage Recruiters
• “Ask whether the EHR is fully integrated with the virtual-care platform, where you’re permitted to work from, and what the payment models are: is it hourly, salaried, per consult, or productivity based?” — Joseph Kvedar, MD, American Telemedicine Association
• “Make sure any organization you consider has an acceptable standard of care and that they’re compliant with CMS [Centers for Medicare and Medicaid Services] rules and state regulations.” – Tyler Covey, MDstaffers